Pain arising from the sacroiliac joint is one of the potential causes of axial low back pain. A quarter of low back pain could be originating from the sacroiliac joint. Sacroiliac joint pain can be from trauma, pregnancy, repetitive stress, sports, and following spinal surgery. This article hopes to provide a short review of sacroiliac joint pain and management options.
The potential causes of sacroiliac joint pain can either traumatic or atraumatic.
The traumatic causes of pain are
The atraumatic causes of sacroiliac joint pain are
Repetitive shear and torsional forces may arise from various sports like figure skating, golf, and bowling. Pregnancy causes sacroiliac joint pain from weight gain, increased lumbar lordosis, hormone-induced laxity in the third trimester, and the trauma associated with delivery. Rear-end collisions cause sacroiliac joint injury from an indirect torsional strain on the joint. As the body is thrown forward on impact, a torsional strain acts on the sacroiliac joint of the leg that is fixed to one of the foot pedals. Previous spinal surgery is a poorly recognized cause of sacroiliac joint dysfunction. Finite element analysis show increased stresses that occur at the sacroiliac joint following fusion surgery. Results from the study by Ha and co-workers showed a two-fold increase in sacroiliac joint degeneration following fusion as compared to controls.
The lifetime prevalence of low back pain is 85% . In 25% of these patients, the sacroiliac joint may be the cause of the pain. The majority of SI joint pathologies affect the adult patient population. However, there is a bimodal distribution with two peaks—younger adults following sporting injury and pregnancy and older adults from degeneration. Both genders and people of all races present with Sacroiliac joint dysfunction.
The sacroiliac joints are usually considered as synovial joints but can also be classified as a diarthrosis-amphiarthrosis joint. The superior and dorsal portion of the joint is an amphiarthrosis. In this portion, fibrocartilage fills the joint space. The joint's inferior and ventral portion is a diarthrosis with hyaline cartilage covering the joint surfaces and possesses a synovial cavity. The sacroiliac joint is the largest joint in the body, with a surface area of approximately 17.5 cms. This joint is relatively immobile, and its primary function is to transfer weight to and from the lower limbs to the axial skeleton. There are three large lever arms, the trunk and each of the lower limbs whose movements transmit significant force through the sacroiliac joint. The bony contours and the strong interconnecting ligaments allow only minimal motion at the joint surfaces.
Anterior innervation of the sacroiliac joint is from the ventral rami of the L5 to S2 nerve roots. The lateral branches of the dorsal rami of the S1 to S4 nerve roots innervate the posterior part. Immunohistological studies have demonstrated nociceptors throughout the joint capsule, ligaments, and the subchondral bone. An injury or inflammation in any of these structures can potentially cause pain.
Sacroiliac joint pain can arise from a variety of clinical conditions. A thorough history of clinical symptoms and past medical conditions should be a routine part of the comprehensive evaluation of a patient presenting with SI joint disorders:
Patients usually complain of deep-seated pain, which extends down the posterior thigh and up to the knee. Pain can frequently mimic and be misdiagnosed as radicular pain. Patients are also likely to complain of pain while sitting down, lying on the ipsilateral side or when climbing stairs. Pain from the sacroiliac joint usually follows an inciting event and does not arise insidiously. The inciting event helps to differentiate between pain arising from the sacroiliac joint and pain arising from the facet joints or the disc. Facetogenic or discogenic pain tends to be of insidious onset, whereas patients with sacroiliac joint dysfunction can identify a precipitating event. The usual precipitating events are Motor vehicle collisions, falls, repetitive stress, or pregnancy.
Patients with isolated SI joint dysfunction often localize their pain inferior and medial to the PSIS. Pointing the finger to this area is the Fortin finger test. Localized pain is not always a reliable presentation, as a 2000 study reported 18 different pain referral patterns from the SI joint. Among these other patterns included pain down the posterior/lateral thigh (50%), pain distal to the knee (28%), and pain in the foot (14%).
A comprehensive physical examination should consider alternate pathology in the thoracolumbar spine, pelvic organs, or hip that could refer pain to the posterior hip region. Test the range of movement and tenderness in these areas. Perform a neurological examination encompassing sensory (pinprick and light touch), motor power, deep tendon reflexes, and Babinski on both lower limbs. Leg length should be measured as unequal leg lengths can lead to sacroiliac joint dysfunction.
Numerous stress tests to identify sacroiliac joint dysfunction are available. Unfortunately, there is no single test that is both sensitive and specific in identifying sacroiliac joint dysfunction. A few of these maneuvers are
Patrick's or FABER's (flexion, abduction, and external rotation) test
The patient lies supine on the exam table. Flex and externally rotate the hip and knee of one leg to rest the lateral malleolus just proximal to the contralateral patella. Pain in the sacroiliac joint region is considered positive for sacroiliac joint dysfunction. Pain in the hip or groin suggests hip pathology.
The patient lies supine on the exam table. Flex the contralateral hip and knee towards the patient's chest while the opposite leg is allowed to drop off the table's side. Pain in the sacroiliac joint region of the lowered leg suggests sacroiliac joint dysfunction.
The patient lies supine on the exam table. The examiner applies outward rotatory stress on both the anterior superior iliac spines. Pain in the sacroiliac joint region is suggestive of sacroiliac joint dysfunction.
The patient lies supine on the exam table. The examiner flexes the hip and knee on one side till the thigh is vertical to the exam table. The examiner wraps an arm around the flexed thigh and knee and provides a posteriorly directed force. The opposite hand of the examiner supports the hip and the sacroiliac joint. Pain in the sacroiliac joint region is suggestive of sacroiliac joint dysfunction.
The patient lies on his / her side. A downward directed compression force is applied with the heel of the hand to the iliac crest on the top. Pain in the sacroiliac joint region is suggestive of sacroiliac joint dysfunction.
The patient lies prone on the exam table. A downward directed force is applied with the heel of the examiners hand centrally over the sacrum. Pain in the sacroiliac joint region is suggestive of sacroiliac joint dysfunction.
The presence of three or more of the provocative tests will increase diagnostic accuracy.
Imaging studies help rule out other possible sources of pain. Plain radiographs will identify pathology in the hip and also changes in the sacroiliac joint.
The changes in ankylosing spondylitis are
CT scans provide a more detailed anatomy of the bony architecture. Radionuclide imaging is not a useful tool in identifying sacroiliac joint dysfunction. MRI scans have a 90% sensitivity in identifying spondyloarthritis but not valuable for non-inflammatory conditions.
Image-guided injections are the gold standard to identify sacroiliac joint dysfunction—document both the provocation of symptoms when inflated and relief following local anesthetic infiltration. Image modalities in decreasing order of efficacy are CT guided, Fluoroscopy guided, and ultrasound-guided. When performing injections, direct the needle towards the inferior portion of the joint. Inflate the joint only with 1-2 ml of injectate.
diofrThe initial step in the treatment of sacroiliac joint syndrome is similar to the management of any axial low back pain. This would be an exercise orientated spinal stabilization/stretching program. Belts applied to hold the sacroiliac joints in place has equal benefit as a home exercise program or a structured clinical exercise program in pregnancy-induced sacroiliac joint dysfunction. Analgesics and NSAIDs can help with symptom relief. If there is a triggering mechanism, then the patient needs to be counseled on modifying this sport or activity. Therapeutic manipulation, osteopathic manual treatment, and chiropractic adjustments are beneficial. Kinesio taping has also shown positive results.
Interventional treatments include the following .
Correct diagnosis is paramount. History of a precipitating event, repetitive strain, or previous lumbar surgery should be ascertained. Three or more provocative tests should identify the sacroiliac joint as the source of pain. Physical therapy using a stretching/stabilization exercise program is the first line of treatment. Correct any anatomical leg length discrepancy with adjustments to footwear. Pelvic stabilization belts can be useful in pregnancy-induced sacroiliac joint dysfunction. If non-interventional techniques fail to provide benefit, attempt an image-guided injection of a local anesthetic with or without steroid. Injections can be either intraarticular, extra-articular, or combined. The injection should provide pain relief, and provocative tests should become negative following injection. Treat any persistent pain with radiofrequency denervation. The majority of patients can achieve adequate pain relief with these techniques. In recalcitrant cases, minimally invasive trans sacroiliac fusion surgery is an option.
Injections carry the risk of introducing infection into the joint and inducing bleeding. Ensure strict asepsis and fine epidural needles decrease the chance of bleeding. During image guidance targeting the inferior portion of the joint is essential. Radiofrequency denervation may cause numbness. Wrongly placed electrodes can cause damage to sacral nerves resulting in incontinence, further pain, or limb weakness. Surgery can cause increased pain and neurological damage. Two plane radiography is paramount during percutaneous fusion procedures.
Sacroiliac joint pain like most mechanical low back pain has a good prognosis. Patients should avoid bed rest and continue mobilization. Stabilization and stretching exercises are beneficial. Pregnancy-induced sacroiliac joint dysfunction is usually self-limiting and resolves within12 months postpartum. Expert and specialist advice is required if the pain persists. However, any neurological deficit, bowel or bladder involvement, severe pain even at rest, or pain that disturbs sleep requires urgent medical attention for assessment.
Sacroiliac joint pain can be a difficult diagnosis to make. Identification of inciting events or the history of single-sided pain below the posterior superior iliac spine should alert the physician of pain originating from the SI joint. Lifestyle modification with weight reduction and exercise is key. Injections with steroids and radiofrequency denervation has a good track record. Surgery is the last resort and is not always associated with good outcomes.
|||Cohen SP, Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesthesia and analgesia. 2005 Nov; [PubMed PMID: 16244008]|
|||Chuang CW,Hung SK,Pan PT,Kao MC, Diagnosis and interventional pain management options for sacroiliac joint pain. Ci ji yi xue za zhi = Tzu-chi medical journal. 2019 Oct-Dec; [PubMed PMID: 31867247]|
|||Slipman CW,Whyte WS 2nd,Chow DW,Chou L,Lenrow D,Ellen M, Sacroiliac joint syndrome. Pain physician. 2001 Apr; [PubMed PMID: 16902687]|
|||Fortin JD, Sacroiliac Joint DysfunctionA New Perspective. Journal of back and musculoskeletal rehabilitation. 1993 Jan 1; [PubMed PMID: 24573095]|
|||Ivanov AA,Kiapour A,Ebraheim NA,Goel V, Lumbar fusion leads to increases in angular motion and stress across sacroiliac joint: a finite element study. Spine. 2009 Mar 1; [PubMed PMID: 19247155]|
|||Ha KY,Lee JS,Kim KW, Degeneration of sacroiliac joint after instrumented lumbar or lumbosacral fusion: a prospective cohort study over five-year follow-up. Spine. 2008 May 15; [PubMed PMID: 18469692]|
|||Simopoulos TT,Manchikanti L,Gupta S,Aydin SM,Kim CH,Solanki D,Nampiaparampil DE,Singh V,Staats PS,Hirsch JA, Systematic Review of the Diagnostic Accuracy and Therapeutic Effectiveness of Sacroiliac Joint Interventions. Pain physician. 2015 Sep-Oct; [PubMed PMID: 26431129]|
|||Kiapour A,Joukar A,Elgafy H,Erbulut DU,Agarwal AK,Goel VK, Biomechanics of the Sacroiliac Joint: Anatomy, Function, Biomechanics, Sexual Dimorphism, and Causes of Pain. International journal of spine surgery. 2020 Feb; [PubMed PMID: 32123652]|
|||Vleeming A,Schuenke MD,Masi AT,Carreiro JE,Danneels L,Willard FH, The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of anatomy. 2012 Dec; [PubMed PMID: 22994881]|
|||Poilliot AJ,Zwirner J,Doyle T,Hammer N, A Systematic Review of the Normal Sacroiliac Joint Anatomy and Adjacent Tissues for Pain Physicians. Pain physician. 2019 Jul [PubMed PMID: 31337164]|
|||Szadek KM,Hoogland PV,Zuurmond WW,De Lange JJ,Perez RS, Possible nociceptive structures in the sacroiliac joint cartilage: An immunohistochemical study. Clinical anatomy (New York, N.Y.). 2010 Mar [PubMed PMID: 20014392]|
|||Chou LH,Slipman CW,Bhagia SM,Tsaur L,Bhat AL,Isaac Z,Gilchrist R,El Abd OH,Lenrow DA, Inciting events initiating injection-proven sacroiliac joint syndrome. Pain medicine (Malden, Mass.). 2004 Mar; [PubMed PMID: 14996234]|
|||Fortin JD,Falco FJ, The Fortin finger test: an indicator of sacroiliac pain. American journal of orthopedics (Belle Mead, N.J.). 1997 Jul [PubMed PMID: 9247654]|
|||Thawrani DP,Agabegi SS,Asghar F, Diagnosing Sacroiliac Joint Pain. The Journal of the American Academy of Orthopaedic Surgeons. 2018 Oct 1 [PubMed PMID: 30278010]|
|||Dreyfuss P,Michaelsen M,Pauza K,McLarty J,Bogduk N, The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996 Nov 15 [PubMed PMID: 8961447]|
|||Laslett M,Young SB,Aprill CN,McDonald B, Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. The Australian journal of physiotherapy. 2003; [PubMed PMID: 12775204]|
|||Szadek KM,van der Wurff P,van Tulder MW,Zuurmond WW,Perez RS, Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. The journal of pain : official journal of the American Pain Society. 2009 Apr; [PubMed PMID: 19101212]|
|||Cohen SP,Chen Y,Neufeld NJ, Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert review of neurotherapeutics. 2013 Jan [PubMed PMID: 23253394]|
|||Le Huec JC,Tsoupras A,Leglise A,Heraudet P,Celarier G,Sturresson B, The sacro-iliac joint: A potentially painful enigma. Update on the diagnosis and treatment of pain from micro-trauma. Orthopaedics & traumatology, surgery & research : OTSR. 2019 Feb [PubMed PMID: 30616942]|
|||Nilsson-Wikmar L,Holm K,Oijerstedt R,Harms-Ringdahl K, Effect of three different physical therapy treatments on pain and activity in pregnant women with pelvic girdle pain: a randomized clinical trial with 3, 6, and 12 months follow-up postpartum. Spine. 2005 Apr 15 [PubMed PMID: 15834325]|
|||Kamali F,Shokri E, The effect of two manipulative therapy techniques and their outcome in patients with sacroiliac joint syndrome. Journal of bodywork and movement therapies. 2012 Jan [PubMed PMID: 22196424]|
|||Al-Subahi M,Alayat M,Alshehri MA,Helal O,Alhasan H,Alalawi A,Takrouni A,Alfaqeh A, The effectiveness of physiotherapy interventions for sacroiliac joint dysfunction: a systematic review. Journal of physical therapy science. 2017 Sep [PubMed PMID: 28932014]|
|||Schütz U,Grob D, Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome. Acta orthopaedica Belgica. 2006 Jun [PubMed PMID: 16889141]|
|||Dengler J,Kools D,Pflugmacher R,Gasbarrini A,Prestamburgo D,Gaetani P,Cher D,Van Eeckhoven E,Annertz M,Sturesson B, Randomized Trial of Sacroiliac Joint Arthrodesis Compared with Conservative Management for Chronic Low Back Pain Attributed to the Sacroiliac Joint. The Journal of bone and joint surgery. American volume. 2019 Mar 6 [PubMed PMID: 30845034]|