Sacroiliac Joint Pain

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Summary

Sacroiliac Joint PainThe sacroiliac joints connect the sacrum to the right and left iliac parts of the pelvic bones. They are an integral part of both the lumbar spine and the pelvic girdle (Cusi, 2010). Painful conditions of the sacroiliac joint are often called sacroiliac joint dysfunction (Cusi, 2010). Sacroiliac joint pain may account for 10-30% of cases of low back and posterior (rear) pelvic pain (Kim & Moon, 2010).

Pathology

Like the knees or the shoulders, the sacroiliac joints are diarthrodial, or maximally mobile, and synovial, meaning they are constructed with a cartilaginous joint capsule. They are anchored by three flexible, fibrous ligaments which hold the bones in place.

Since the bones and ligaments of the sacroiliac joints bear weight and are in constant use, they are prone to gradual degenerative changes. These changes, known as mechanical changes, often stem from overuse, aging, and osteoarthritis and may cause pain and inflammation of the joint, or sacroiliitis. Pain originating in the sacroiliac joint is predominantly felt in the gluteal region, although pain may be referred into the lumbar region, groin, abdomen, and lower limbs (Vanelderen et al, 2010).

Another route to sacroiliac joint problems is development of autoimmune disorders. Rheumatoid arthritis (Pagnini et al, 2010); inflammatory bowel diseases such as Crohn’s (Peeters et al, 2008); and psoriasis (Kaçar et al, 2010), a skin disorder associated with arthritis, are a few of the autoimmune conditions that can induce painful inflammatory alterations in the sacroiliac joints.

Sacroiliac joint pain is also caused by ankylosing spondylitis, a form of spondyloarthritis, a chronic, inflammatory arthritis and autoimmune disease that predominantly affects the spine (Malaviya & Ostor, 2011). In this disorder, the irregular, interlocking joint surfaces of the sacrum and iliac bones may gradually fuse, or become ossified (Appel et al, 2009).

Pregnancy is another reason for development of pain in the sacroiliac joints. The hormone relaxin, produced in large quantities during pregnancy, relaxes the connective tissues of the body primarily to enhance the elasticity of the female pelvis to allow birth. The ligaments stabilizing the sacroiliac joints are often affected, causing excessive laxity and mobility in this area. Moreover, the weight gain and changes in gait during pregnancy can cause significant mechanical strain on the sacroiliac joints, leading to inflammation and pain in the posterior pelvis. Further, the mechanical changes in the sacroiliac joint sustained during pregnancy can lead to osteoarthritis of this joint later in life, particularly in women who have had multiple pregnancies.

Diagnosis

One of the most challenging aspects of treating sacroiliac joint pain is the complexity of diagnosis (García Díez et al, 2009). In fact, presently, there are no widely accepted guidelines in the literature for diagnosis and treatment of the condition (Zelle et al, 2005), as no diagnostic method is completely infallible (Rupert et al, 2009). Pain in the sacroiliac joint is common to numerous conditions, including other mechanical back pain conditions like facet syndrome and other conditions in the lumbar region of the spine including disc herniation and sciatica. 

In order to diagnose sacroiliac joint problems, practitioner may perform certain physical manipulations to see if they produce pain in the sacroiliac area (Vanelderen, 2010). For example, a meta-analysis showed that the thigh thrust test, compression test, and three or more positive stressing tests have discriminative power for diagnosing sacroiliac joint pain (Szadek et al, 2009). Such “provocative maneuvers” may be followed by imaging studies. Radiological imaging (x-ray) is important to exclude “red flags” but contributes little in the diagnosis (Szadek et al, 2009)  since the sacroiliac joint has several unique anatomical features that make it one of the more challenging joints to image (Vanelderen, 2010).  For this reason, CT scan and MRI are more likely to be used to screen for abnormalities in the sacroiliac joint. In fact, MRI performed with proper sequences is excellent for diagnosing even very early sacroiliitis as well as following treatment (Tuite, 2008).

Another way to diagnose sacroiliac joint pain is through a diagnostic block, which may reveal whether the sacroiliac joint is the source of a patient’s pain. Diagnostic blocks are formulations of anesthetic, corticosteroid, or other medications injected into the sacroiliac joint under fluoroscopic (live X-ray) guidance.  If the diagnostic block produces analgesia (pain relief), it implicates the injected joint as the pain source. Diagnostic blocks are the diagnostic gold standard for sacroiliac joint pain but must be interpreted with caution, since false-positive as well as false-negative results occur frequently (Vanelderen et al, 2010).

Treatment

Most patients with sacroiliac joint pain respond well to non-operative treatment. Conservative treatments address the underlying causes (posture and gait disturbances) of sacroiliac joint pain and may consist of exercise therapy and manipulation (Vanelderen et al, 2010). In the literature, physical therapy alone has been reported to completely eradicate sacroiliac joint pain (Boyle, 2011).

Other initial measures may include rest, application of cold or heat, and anti-inflammatory medications before more aggressive interventions are undertaken. Sometimes, patients may find relief through a removable orthotic brace used to stabilize the sacroiliac area. The brace, fitted securely around the waist, can be used until inflammation and pain in the sacroiliac joints are reduced.

Patients with sacroiliac joint pain often experience immediate relief from image-guided therapeutic injections into the affected joint (Hart et al, 2011). These injections are similar to diagnostic blocks and hold the highest evidence rating (of demonstrated efficacy) (Vanelderen et al, 2010). Another type of injection administered for relief of sacroiliac joint pain is botulinum toxin A (Botox). A study examining the clinical effectiveness of botulinum toxin A as a treatment for sacroiliac joint pain compared to a traditional mixture of medications found Botox was equally effective to the customary formulation of local anesthetic and steroid (Lee et al, 2010). In fact, at two and three months after injection, patients who were injected with Botox had significantly lower scores on a pain assessment scale (Numerical Rating Scale), than patients who received the traditional anesthetic and corticosteroid medications.

If therapeutic injections fail to bring relief or produce only short-term effects, denervation procedures may be recommended (Stone & Bartynski, 2009). One such procedure is cooled radiofrequency ablation. A randomized, placebo-controlled study showed that 47% of treated patients with sacroiliac joint pain obtained significant improvements in pain, disability, physical function, and quality of life through this procedure (Patel et al, 2012).

Patients who do not respond to non-operative treatment may be considered for operative sacroiliac joint stabilization (Zelle et al, 2005). The goal of surgical treatment may be stabilization of one or both of the sacroiliac joints in order to eliminate excessive motion. However, surgery is typically reserved as a last-resort measure for serious and intractable cases. This is because open surgery is associated with risks such as damage to structures in the sacroiliac region and post-operative complications such as infection.

As with many painful conditions, early treatment of sacroiliac joint conditions is preferable. Arresting the progression of joint pain and degeneration is easier to accomplish before the condition becomes severe.

Resources:

  • Sacroiliac Joint Injections – PainDoctor.com
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