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Sacroilliac Joint Pain

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Other Names

  • SI Joint Pain
  • Sacroiliitis
  • SIJ Pain
  • Sacroiliac Joint Dysfunction

Background

History

Epidemiology

  • Prevalence
    • Bimodal, highest rates in young athletes and elderly[1]
    • True prevalence is difficult to assess based on diagnostic criteria, but likely ranges from 15-21%[2]
    • Bernard et al: 22.5% in a retrospective study of 1293 patients[3]

Pathophysiology

  • Mechanism is often involves a combination of twisting/rotation and axial loading
  • Between 40 and 50% of patients with injection-confirmed SIJ pain can identify a specific precipitating event
    • Most frequently cited include motor vehicle collisions, falls, repetitive stress and pregnancy
  • Pathologic changes can be broken down into intra-articular and extra-articular[4]
    • Intra-articular: capsular or synovial disruption, capsular and ligamentous tension, abnormal joint mechanics, microfractures or macrofractures, chondromalacia,
    • Extra-articular: hypomobility or hypermobility, extraneous compression or shearing forces soft tissue injury, and inflammation
  • There is a paucity of literature on SIJ pain in athletes
    • Asymmetric loading is likely a risk factor including kicking, swinging, throwing and single leg stance

Etiology

  • Osteoarthritis
  • Spondyloarthropathies

Pathoanatomy

  • Sacroiliac Joint
    • Articulation of Sacrum and Ilium
    • Diarthrodial Joint with fibrous capsule and synovial fluid
    • Function: support the upper body, dampen the impact of ambulation

Risk Factors

  • Intrinsic[5]
  • Extrinsic
    • Gait or biomechanical dysfunction[8]
    • Biomechanical abnormalities
  • Spondyloarthropathies
  • Other
    • Persistent or prolonged microtrauma or repetitive exercise (e.g., running)[9]
    • Pregnancy[10]
    • History of spine surgery[11]
  • Sports
    • Football
    • Basketball
    • Powerlifting
    • Gymnastics
    • Golf
    • Cross country skiing[12]
    • Rowing
    • Use of eliptical, stair stepper

Differential Diagnosis


Clinical Features

  • History
    • Pain patterns are highly variable, which makes clinical diagnosis challenging
    • Although it can be traumatic, generally insidious from overuse
    • Some patients endorse buttock pain extending into the posterolateral thigh[13]
    • Slipman et al found patients reported buttock pain (94%), lumbar pain (72%), radiating into lower extremity (50%), pain below the knee (28%), and groin pain (14%)
    • Worse with running, climbing stairs, standing from a seated position
  • Physical Exam: Physical Exam Back
    • May be tender over sacral sulcus
  • Special Tests
    • FABER Test: Patient supine,, affected limb is placed in figure 4 position
    • Posterior Shear Test: Patient supine, stabilize SI joint, hip and knee flexed to 90° and posterior load applied
    • Resisted Abduction Test: Patient supine, leg abducted about 30°, knee slightly flexed, asked to abduct against resistance
    • Standing Flexion Test: Patient standing and flexes forward while examiner palpates PSIS and also on the S2 spinous process
    • Stork Test: Patient stand on one leg while flexing the ipsilateral hip to 90° while examiner palpates PSIS and sacrum
    • One Legged Hyperextension: Patient patient hyperextends backwards, examinar may help stabilize patient
    • Sacroiliac Compression Test: Lateral decubitus on affected side, apply compression of SI joint
    • Sacroiliac Distraction Test: Supine patient, apply force at bilateral ASIS
    • Gaenslens Test: Supine, flex contralateral leg to chest, hang ipsilateral leg off the examination table

Evaluation

Diagnostic Injection

  • Diagnostic gold standard
    • History, exam and imaging are generally not enough to make diagnosis of SI joint pain
  • Diagnostic confidence is 90%[14]
  • Some variability to 'positive' test
    • Most commonly accepted is at least 75% reduction if symptoms with injection[15]
    • If less than 50%, consider other etiologies
  • Reported success rates based on approach
    • Landmark based approach: 12% - 22%[16]
    • Ultrasound: 40% to 90%[17]
    • Fluoroscopy: 97% to 98%<
    • CT: 100%[18]
  • Injectant is typically anesthetic plus/minus corticosteroids

Radiographs

MRI

  • Sensitivity >90%[19]
  • Indicated if inflammatory condition is suspected
    • Not useful in identifying non-inflammatory conditions

CT

  • Elgafy et al: Using injection confirmed SI Joint Pain[20]
    • Sensitivity 57.5%
    • Specificity 69%

Radionuclide Imaging

  • Sensitivity 13% - 46.1%[21]
  • Specificity 89.5% - 100%

Classification


Management

Prognosis

  • Most cases of SI joint pain have a favorable prognosis.

Nonoperative

  • Medications
  • Activity Modification
  • Physical Therapy
    • Up to 95% of patients improve with PT[22]
  • Spinal Manipulation Therapy
    • Includes manual therapy, osteopathic manual treatment, chiropractic adjustments
    • Well designed studies fail to show benefit[23]
    • Needs to be updated
  • Prolotherapy
    • Kim et al: Significant difference in symptoms at 15 minutes in prolotherapy arm vs steroid arm (control)[24]
  • Corticosteroid Injections
    • Extra-articular (EA): Appear to be superior to placebo[25]
    • Intra-articular (IA): Appear to be superior to placebo[26]
    • EA injections may be superior to IA according to Murakami et al[27]
  • Neurolysis
    • Best candidates are those that have obtained relief from SI joint blocks
    • Technique include heat (convential radiofrequency), bipolar, cold (cryoneurolysis), chemical (alcohol/phenol), pulsed, combined
    • Convential RF: No controlled studies published, two retrospective reviews show mixed results
  • Consider Orthosis
    • Shoe inserts for pes planus or pes cavus
    • Heel Lift for leg length discrepancy
    • Sacroiliac Brace if dysfunction is due to hypermobility

Operative

  • Indications unclear
    • Refractory to conservative measures? At least 6 months
    • Must have had positive diagnostic injection
    • In the setting of trauma
  • Technique
    • Open SIJ Fusion
    • Minimally invasive SIJ Fusion

Rehab and Return to Play

Rehabilitation

  • If present, correct maladaptive biomechanics</ref>Prather H, Hunt D. Conservative management of low back pain, part I. Sacroiliac joint pain. Dis. Mon. 50(12), 670-683 (2004).</ref>
  • Most physical therapy protocols emphasize on core strengthening</ref>Mens JM, Snijders CJ, Stam HJ. Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial. Phys. Ther. 80(12), 1164-1173 (2000).</ref>
    • Including correction of muscle imbalances, retraining of posture and proprioception
  • In peri- and post-partum women, emphasis on strengthening the pelvic girdle
  • Emphasis on improving range of motion of hip flexors, glutes, adductors
  • Proposed program
    • Closed, kinetic chain strength training to strengthen core, lumbo-pelvic musculature
    • Progression to multiplanar strengthening exercises
  • Consider gait analysis

Return to Play

  • Prior to beginning RTP, ahlete should be[28]
    • Relatively pain free, off medications
    • Have no correctable biomechanical dysfunction
    • Have successfully initiated rehabilitative program
    • Achieved at least 75% of their baseline strength and flexibility
  • If athlete has ankylosing spondylitis
    • Screen for cardiac abnormalities

Complications

  • Chronic pain
  • Inability to return to sport/ work

See Also


References


  1. Depalma MJ, Ketchum JM, Trussell BS, Saullo TR, Slipman CW. Does the location of low back pain predict its source? PM R. 3(1), 33-39 (2011).
  2. Simopoulos TT, Manchikanti L, Singh V et al . A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician 15(3), 305-344 (2012).
  3. Bernard TN, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop 1987;217: 266 – 80.
  4. Cohen, S. P. (2005). Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment. Anesthesia & Analgesia, 101(5), 1440–1453. doi:10.1213/01.ane.0000180831.60169.ea
  5. Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth. Analg. 101(5), 1440-1453 (2005).
  6. Schuit D, McPoil TG, Mulesa P. Incidence of sacroiliac joint malalignment in leg length discrepancies. J Am Podiatr Med Assoc 1989;79:380 –3.
  7. Schoenberger M, Hellmich K. Sacroiliac dislocation and scoliosis. Hippokrates 1964;35:476 –9.
  8. Herzog W, Conway PJ. Gait analysis of sacroiliac joint patients. J Manipulative Physiol Ther 1994;17:124 –7
  9. Marymont JV, Lynch MA, Henning CE. Exercise-related stress reaction of the sacroiliac joint: an unusual cause of low back pain in athletes. Am J Sports Med 1986;14:320 –3.
  10. Ostgaard HC, Andersson GB, Karlsson K. Prevalence of back pain in pregnancy. Spine 16(5), 549-552 (1991).
  11. Katz V, Schofferman J, Reynolds J. The sacroiliac joint: a potential cause of pain after lumbar fusion to the sacrum. J Spinal Disord Tech 2003;16:96 –9
  12. Butcher JD. Cross-country ski injuries. In: O’Connor F, Casa D, Davis B, et al. editors. ACSM’s Sports Medicine: A Comprehensive Review. 1st ed. Philadelphia (PA): Wolters Kluwer Lippincott Williams and Wilkins; 2013. p. 598.
  13. Fortin JD, Aprill CN, Ponthieux B, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation. Spine 19(13), 1483-1489 (1994).
  14. Szadek KM, van der Wurff P, van Tulder MW, et al. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. J. Pain. 2009; 10:354–68.
  15. Rashbaum RF, Ohnmeiss DD, Lindley EM, et al. Sacroiliac joint pain and its treatment. Clin. Spine Surg. 2016; 29:42–8.
  16. D'Orazio F, Gregori LM, Gallucci M. Spine epidural and sacroiliac joints injections — when and how to perform. Eur. J. Radiol. 2014; 84:777–82.
  17. Chang WH, Lew HL, Chen CP. Ultrasound-guided sacroiliac joint injection technique. Am. J. of Phys. Med. Rehab. 2013; 92:278–9.
  18. D'Orazio F, Gregori LM, Gallucci M. Spine epidural and sacroiliac joints injections — when and how to perform. Eur. J. Radiol. 2014; 84:777–82.
  19. Puhakka KB, Jurik AG, Schiøttz-Christensen B et al . MRI abnormalities of sacroiliac joints in early spondylarthropathy: a 1-year follow-up study. Scand. J. Rheumatol. 33(5), 332-338 (2004).
  20. 50 Elgafy H, Semaan HB, Ebraheim NA, Coombs RJ. Computed tomography findings in patients with sacroiliac pain. Clin. Orthop. Relat. Res. 382, 112-118 (2001).
  21. Maigne JY, Boulahdour H, Chatellier G. Value of quantitative radionuclide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain. Eur. Spine J. 7(4), 328-331 (1998).
  22. Zelle BA, Gruen GS, Brown S, et al. Sacroiliac joint dysfunction: evaluation and management. Clin. J. Pain. 2005; 21:446–55.
  23. Flynn T, Fritz J, Whitman J et al . A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 27(24), 2835-2843 (2002).
  24. Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J. Altern. Complement. Med. 16(12), 1285-1290 (2010).
  25. Luukkainen R, Nissilä M, Asikainen E et al . Periarticular corticosteroid treatment of the sacroiliac joint in patients with seronegative spondylarthropathy. Clin. Exp. Rheumatol. 17(1), 88-90 (1999).
  26. Maugars Y, Mathis C, Berthelot JM, Charlier C, Prost A. Assessment of the efficacy of sacroiliac corticosteroid injections in spondylarthropathies: a double-blind study. Br. J. Rheumatol. 35(8), 767-770 (1996).
  27. Murakami E, Tanaka Y, Aizawa T, Ishizuka M, Kokubun S. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. J. Orthop. Sci. 12(3), 274-280 (2007).
  28. Peebles, Rebecca, and Christopher E. Jonas. "Sacroiliac joint dysfunction in the athlete: diagnosis and management." Current sports medicine reports 16.5 (2017): 336-342.
Created by:
John Kiel on 17 June 2019 16:43:32
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Last edited:
23 November 2020 15:47:12
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