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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]
  • 15-25% of axial low back pain arises from the SI Joint[4]

Introduction

Illustration of the sacroiliac joint[5]
Illustration of the sacroiliac joint with labeled ligaments[6]

General

  • Patients typically present with deep pain radiating down posterior thigh and up to knee
    • Worse/reproduced when sitting down, lying on ipsilateral side, climbing stairs
  • 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
  • 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

Pathophysiology

  • Thought to be caused by inflammation or injury to the joint capsule, ligaments or subachondral bone in the SI Joint[7]
  • Pathologic changes can be broken down into intra-articular and extra-articular[8]
    • 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

Etiology

Anatomy of the 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, transfer weight from lower extremities to axial skeleton

Risk Factors

  • Intrinsic[9]
    • Length discrepancies[10]
    • Scoliosis[11]
    • Hypermobility
    • Variability in articular surface
  • Extrinsic
    • Gait or biomechanical dysfunction[12]
    • Biomechanical abnormalities
  • Spondyloarthropathies
  • Other
    • Low Bone Mineral Density
    • Persistent or prolonged microtrauma or repetitive exercise (e.g., running)[13]
    • Pregnancy[14]
    • History of spine surgery[15]
    • Advanced Age
    • Obesity
  • Sports
    • Football
    • Basketball
    • Powerlifting
    • Gymnastics
    • Golf
    • Cross country skiing[16]
    • Rowing
    • Use of eliptical, stair stepper

Differential Diagnosis

Differential Diagnosis Back Pain


Clinical Features

Illustration of FABER test[17]

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[18]
  • 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, lying on ipsilateral side

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 (flexion, abduction, external rotation)
  • 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
  • Fortins Sign: Patient points to pain source with one finger, localizes to PSIS
  • Cranial Shear Test: Patient prone, apply cranial directed force to sacrum
  • Sacral Thrust Test: patient prone, apply anteriorly directed force to sacrum
  • Active Straight Leg Raise Test: Patient holds straight leg a few inches off examination table

Evaluation

Spectrum of sacroiliitis severity on radiographs graded according to the New York criteria. (A) Grade 1 changes with subtle blurring of the joint margins. (B) Grade 2 changes in left sacroiliac joint with erosions and mild periarticular sclerosis. More severe Grade 3 changes are present on the right with partial ankylosis evident. (C) Grade 3 changes bilaterally with severe joint erosions, sclerosis, and joint space widening. (D) Grade 4 changes demonstrating complete ankylosis of both sacroiliac joints.[19]
Findings compatible with acute sacroiliitis on MRI of the sacroiliac joints. Source: the authors (2019). Coronal STIR sequence: high signal intensity consistent with synovitis (white arrows) on the left and capsulitis (blue arrows) on the right (a). Coronal STIR sequence: high signal intensity bilaterally consistent with bone marrow edema (white arrows) (b). Coronal T1 post-contrast with fat suppression: high signal intensity bilaterally consistent with bone marrow edema (white arrows) and suggestive of capsulitis (blue arrows) on the right and enthesitis on the left (green arrows) (c). Coronal STIR sequence: high signal intensities on the right compatible with bone marrow edema (white arrows) and enthesitis (blue arrows) (d). R: right side, L: left side.[20]

Diagnostic Sacroiliac Joint Injection

  • Diagnostic gold standard
    • History, exam and imaging are generally not enough to make diagnosis of SI joint pain
  • Diagnostic confidence is 90%[21]
  • Some variability to 'positive' test
    • Most commonly accepted is at least 75% reduction if symptoms with injection[22]
    • If less than 50%, consider other etiologies
  • Reported success rates based on approach
    • Landmark based approach: 12% - 22%[23]
    • Ultrasound: 40% to 90%[24]
    • Fluoroscopy: 97% to 98%<
    • CT: 100%[25]
  • Injectant is typically anesthetic plus/minus corticosteroids

Radiographs

MRI

  • Sensitivity >90%[26]
  • Indicated if inflammatory condition is suspected
    • Not useful in identifying non-inflammatory conditions

CT

  • Elgafy et al: Using injection confirmed SI Joint Pain[27]
    • Sensitivity 57.5%
    • Specificity 69%

Radionuclide Imaging

  • Sensitivity 13% - 46.1%[28]
  • Specificity 89.5% - 100%

Classification

  • Needs to be updated

Management

Nonoperative

  • Indications
    • First line therapy for nearly all cases
  • Medications
  • Activity Modification
  • Physical Therapy
    • First line treatment, should include acute phase and recovery phase
    • Up to 95% of patients improve with PT[29]
    • Emphasis: improve mechanics of lumbar spine, pelvis, hip
    • No adverse effects are associated with PT if done properly and under supervision[30]
  • Spinal Manipulation Therapy
    • Includes manual therapy, osteopathic manual treatment, chiropractic adjustments
    • Well designed studies fail to show benefit[31]
    • Needs to be updated
  • Prolotherapy
    • Kim et al: Significant difference in symptoms at 15 minutes in prolotherapy arm vs steroid arm (control)[32]
  • Platelet Rich Plasma (PRP)
    • Efficacy remains uncertain
    • Singla et a: PRP superior to CSI at 6, 12 weeks but similar at 2-4 weeks[33]
    • Wallace et al: Single arm study found the most benefit at 4 weeks[34]
  • Mesenchymal Stem Cells
    • According to the American Society of Interventional Pain Physicians (ASIPP) Guidelines, the literature is currently limited[35]
  • Sacroiliac Joint Injection with corticosteroids
    • Typically indicated when NSAIDS and PT have failed
    • Performed with ultrasound or fluoroscopic guidance
    • Benefit increases when combined with PT[36]
    • Intra-articular injections generate more pain relief compared to peri-articular injections[37]
    • Can also be used diagnostically (see evaluation)
    • Extra-articular (EA): Appear to be superior to placebo[38]
    • Intra-articular (IA): Appear to be superior to placebo[39]
    • EA injections may be superior to IA according to Murakami et al[40]
  • Neurolysis/ Radiofrequency Ablation
    • 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
    • One retrospective study showed reduced opioid use, pain and disability relief[41]
  • 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[42]
  • Most physical therapy protocols emphasize on core strengthening[43]
    • 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
  • Techniques: direct manipulation, direct mobilization, indirect methods[44]

Return to Play

  • Prior to beginning RTP, ahlete should be[45]
    • 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

Prognosis and Complications

Prognosis

  • Vanaclocha etal: study with up to 6 years follow up[46]
    • Patients treated with conservative management had no long term improvement in pain, disability scores
    • Increased use of opioids, poor long term work status
  • Minimally invasive surgical techniques[47]
    • Compared to open fusion: less tissue damage, blood loss, duration of hospitalization
    • Better outcomes
  • Operative complications occur in 21% of open, 18% of minimally invasive patients[48]
    • Minimally invasive group had better pain scores at 12 and 24 months

Complications


See Also

Internal

External


References

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Created by:
John Kiel on 17 June 2019 16:43:32
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