Sacroiliac Joint Dysfunction – the essentials
Please note –
the following does NOT discuss inflammatory sacroiliac joint pathology (sacroilitis)
- Females >> Males (aged 45 to 65)
- Nulliparous or exclusively c-sectioned women are less frequently affected.
- Consider in patients with S1 radicular symptoms or persistent gluteal pain without convincing evidence of impingement on imaging.
- Consider in patients with a history of failed medical or manual treatments.
- There is no need to image the SI joint (unless you are considering an inflammatory joint arthropathy). X-rays, CT’s MRI or bone scans provide no useful information to enable the diagnosis or treatment of sacroiliac movement disorders.
- Consider in patients with lumbar fusions (Surgical or anatomical – particularly L5/S1).
- Consider in both genders with significant leg length discrepancy or history of significant pelvic trauma (eg MBA).
- Patients may give a poor history or a vague summary of their symptoms.
- Prolonged sitting is a common aggravating factor.
- Over-diagnosed by physiotherapists and under-diagnosed by doctors.
- Tenderness over the SI margin – this alone does NOT confirm the diagnosis. Push firmly over the superior and inferior margins of the joint ensuring to direct pressure over the ilium (not the sacrum) in a PA direction.
- Gluteal, PSIS or lumbar pain with prolonged sit or stand.
- Chronic, unilateral/asymmetrical lumbar or gluteal pain. (Do NOT exclude bilateral presentations).
- Usually no causative event although chronic lumbar pain from other sources may precede the onset of SI joint pain. Acute presentations (although rare) can present very much like lumbar disc pathologies – imaging may be of benefit to differentiate.
- Tenderness inferior to the PSIS and medial iliac crest (medial gluteal tendonoses)
- Patients will have a preferred side upon which they sit or stand.
- Imaging, including bone scan, rarely reveals SI issues (not so in sacroilitis)
- Poor response to oral SAIDs or NSAIDs.
- Short-term and incomplete relief with manual therapies.
The only definitive diagnosis is obtained by local anaesthetic injection into the joint. The addition of steroid rarely improves outcomes. If concerns for bilateral SI dysfunction exist, each side should be injected at least one week apart.
NOTE – relief of symptoms following this procedure is nearly always very short lived (hours, days or 1 to 2 weeks maximum). It is vital that a patient keep a very accurate pain-diary in the hours and days immediately after their injection.
Patients should be provided with an hourly pain-diary to complete and rate their pre and post procedure pain levels out of 10. (“Better” “same” or “worse” is not sufficient)
- Asymmetrical iliac movement with lumbar flexion or extension is suggestive but not clinically sensitive enough to diagnose SIJ dysfunction and such asymmetry in movement is extraordinarily hard to assess in obese patients.
- Sacroiliac compression test, sacroiliac distraction test, thigh thrust test, sacral thrust test and Gaenslen’s test are quick tests. Pain reproduction on 3 or more of these is highly diagnostic for SI joint dysfunction.
- Accurate sacroiliac injection (under CT guidance) is the gold-standard. Be warned – this is usually a painful injection and radiologists (who are likely pressured by a patient in pain) frequently ‘miss’ the joint. Ask the radiologists to provide ALL imaging so you can confirm accurate needle placement.
- S1 radiculopathy
- Medial gluteal tendonoses
- Pelvic congestion syndrome/pelvic vein incompetence (pelvic CT venogram/transvaginal doppler)
- L5/S1 facet arthropathy
- L5/S1 spondylosis
- Ankylosing spondylitis (other inflammatory arthropathies)
- Trochanteric bursal ‘syndrome’.
- Piriformis syndrome – a rare and generally poor diagnosis.
Physiotherapy intervention is most effective in early presentations of SI dysfunction (where symptoms have been present for less than 3 months). Beyond this time physiotherapy treatment is likely to be prohibitively expensive (in excess of 6 treatments) and the rehabilitation required has an extraordinary low compliance rate.
Physiotherapists are often the first to diagnose SIJ dysfunction (and frequently over-diagnose it). Treatment may include:
- Release of proximal gluteal musculature. Usually done very poorly by physiotherapists resulting in painful treatments that leave the patient feeling bruised. Such treatment is fundamental to recovery and should be painless.
- Lumbar and sacroiliac joint mobilisations.
- Appropriate sacroiliac brace fitting
- Core strengthening and pelvic floor exercises have some weak evidence behind them (remember compliance is poor and it is usually unreasonable to expect third-party insurers to fund this type of rehabilitation.
Note – there is no evidence to support the use of ultrasound for ANY pathology.
Be wary of the therapist who advocates expensive rehabilitation programmes. The evidence to support efficacy is poor and patient compliance is poorer.
- SI joint steroid injection –request that long-acting local anaesthetic be used in combination with long-acting steroid (eg Depo-medrol)
It is VITAL that patients keep an hour-by-hour ‘pain-diary’ following this procedure. Only short-term relief (hours or days) is expected. The aim is to diagnose the pathology and justify rhizotomy, prolotherapy or SI fusion.
- SI joint rhizotomy/radio-frequency ablation (RFA) L5, S1, S2 and S3 – This is a difficult procedure (compared to facet rhizotomies) and is best followed up (6 weeks later) with steroid injection to the medial gluteal tendons/medial iliac rim and gluteal release. Chronic SIJ dysfunction frequently has gluteal tendonopathic pathology (medial and lateral tendons) +/- trochanteric bursitis. Hence rhizotomy alone is unlikely to provide full resolution of symptoms.
- Of the several prolotherapy options available Platelet Rich Plasma shows the most promise for CONFIRMED SIJ dysfunction. Usually two injections are required, 4 to 6 weeks apart (approximately $500per injection). Results take 8 to 12 weeks.
- Hyperosmolar sugar solutions can also be injected.
SI joint fusion is successful but rarely performed – even minimally invasive approaches are complex high-risk surgeries with 9 to 12-month recovery.
Take home message
- Over-diagnosed by physiotherapists and under-diagnosed by doctors.
- Physiotherapy is helpful to treat concomitant sources of lumbar pain
- Local anaesthetic (+/- steroid) is the gold standard for diagnosis – will provide short-term relief only.
- An accurate pain-diary following SI steroid/long-acting local anaesthetic injection is vital.
- Radiologists OFTEN do not place the injection within the join so it is vital that the GP view and confirm an accurate injection.
- Imaging is a poor diagnostic indicator.
- Extremely rare in males and nulliparous women.
- Work with a Pain Physician to coordinate rhizotomy and follow up injections and physiotherapy. Quality after-care is essential to achieve full recovery.
- Consider this diagnosis in mothers with persistent lumbar (+/- radicular) pain and benign imaging.
- Treat early presentations (less than 12 weeks) aggressively. Short-term, high-dose oral corticosteroids, NSAIDs and physiotherapy together often work extremely well in this period.
To discuss your lumbar pain with one of the doctors at Kingsley Medical please be sure to bring ALL imaging to your consultation. It is important that you understand our fees before making a booking. Click here for an outline of our fees. Please understand that Kingsley Medical is not a bulk billing clinic. Please do not ask to be bulk billed.
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