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Sacroiliac Joint Dysfunction

Dysfunction in the sacroiliac joint, or SI joint, is thought to cause low back and/or leg pain. The leg pain can be particularly difficult, and may feel similar to sciatica or pain caused by a lumbar disc herniation.

Anatomical Source of Sacroiliac Joint Pain

The sacroiliac joint lies next to the bottom of the spine – below the lumbar spine and above the tailbone (coccyx). It connects the sacrum (the triangular bone at the bottom of the spine) with the pelvis (iliac crest). The joint typically has the following characteristics:

  • Small and very strong, reinforced by strong ligaments that surround it
     
  • Does not have much motion
     
  • Transmits all the forces of the upper body to the pelvis (hips) and legs
     
  • Acts as a shock-absorbing structure

While it is not clear how the pain is caused, it is thought that an alteration in the normal joint motion may be the culprit that causes sacroiliac pain. This source of pain can be caused by either:

  • Too much movement — hypermobility or instability. The pain is typically felt in the lower back and/or hip and may radiate into groin area.
     
  • Too little movement — hypomobility or fixation. The pain is typically felt on one side of the low back or buttocks, and can radiate down the leg. The pain usually remains above the knee, but at times pain can extend to the ankle or foot. The pain is similar to sciatica, or pain that radiates down the sciatic nerve and is caused by a radiculopathy.

This condition is generally more common in young and middle age women.

Background on Sacroiliac Joint Dysfunction

For decades, the sacroiliac joint was suspected to be a common cause of low back and/or leg pain, although difficulty in proving it with standard diagnostic tests left many in the medical profession skeptical.

Also, over the last twenty to thirty years, the medical profession has focused more on discogenic pain (herniated disc, degenerative disc disease) as a common cause of low back and/or leg pain. In fact, to this day sacroiliac joint dysfunction remains difficult to diagnose as no non-invasive diagnostic test has been found to be able to isolate the sacroiliac joint (short of anesthetic injection blocks specifically applied to the SI joint).

Signs and Symptoms of Sacroiliac Joint Dysfunction

A clear understanding of the difference in the signs and symptoms of sacroiliac joint dysfunction and other pathologies is key in making the proper diagnosis. Because the diagnosis of SI joint dysfunction is made primarily from the patient's subjective complaints and the physical evaluation, it's diagnosis is somewhat problematic for the clinician.



The most common manifestation of sacroiliac joint dysfunction is acute pain in the low back, in the area of the Posterior Superior Iliac Spine (PSIS) positioned approximately 2 inches from the midline and very deep-seated. Usually, tenderness is found near the lumbo-sacral promontory and in the PSIS area, one more pronounced than the other. Radiating pain into the buttock, hip, groin and thigh is often experienced. The pain is frequently increased by prolonged sitting, standing, walking or lying. The patient reports that frequent position changes are needed to maintain any degree of comfort.


 

List of Common Sacroiliac Joint Dysfunction Symptoms

1. Lumbosacral pain
2. Buttock Pain
3. Pain radiating to the leg
4. Hip pain
5. Groin pain
6. Urinary frequency
7. Iliac crest pain
8. Transient numbness, prickling or tingling
9. Increased pain with menstruation
10. Increased pain with sexual intercourse
11. Increased pain with stair climbing
12. Increased pain with sustained positions (i.e., sitting, walking, lying)



Patient self-evaluation of symptoms revealed the following:

96% Increased discomfort with sustained positions (i.e., standing, sitting, lying)
66% Radiating buttock pain
39% Discomfort with stair climbing and/or hill climbing
26% Groin pain
23% Radiating leg pain
20% Pain with forward flexion
15% Loss of strength in the legs
10% Urinary frequency

The most commonly reported position of comfort by patients in the study was side lying (left or right), with a pillow between the knees.

The most frequent complaint from patients with sacroiliac joint dysfunction is increased discomfort with sustained positions such as standing, sitting and lying, with the inability to attain a position of comfort. A disc patient can often find a position of comfort, especially when lying down. Sacroiliac joint symptoms will intensify with activity and decrease with rest, while disc symptoms will usually be worse upon rising in the A.M.

The second most common symptom of sacroiliac joint dysfunction is radiating buttock pain. This is reported as a generalized distribution of "achiness" which can radiate into the thigh.

The third most common symptom is increased discomfort with stair or hill climbing. This is a result of increased demands on the skeletal and soft tissue system of the pelvic girdle during these activities. This symptom may also be present in disc pathologies but is primarily reported as increased discomfort with forward trunk flexion.

Diagnosis of Sacroiliac Joint Dysfunction

Accurately diagnosing sacroiliac joint dysfunction can be difficult because the symptoms mimic other common conditions, including other mechanical back pain conditions like facet syndrome as well as other lumbar spine conditions including disc herniation and radiculopathy (pain along the sciatic nerve that radiates down the leg).

A diagnosis is usually arrived at through physical examination (eliminating other causes) and/or an injection (utilized to block the pain).

Physical Examination to Determine the Source of Pain

In physical examination, the doctor may try to determine if the sacroiliac joint is the cause of pain through movement of the joint. If the movement recreates the patient’s pain, and no other cause of pain can explain the patient's pain and symptoms (such as a disc herniation on an MRI scan), the sacroiliac joint may be the cause of the pain.

There are several orthopedic provocative tests that can be used in an attempt to reproduce the symptoms associated with sacroiliac joint dysfunction. As a rule, several positive tests that reproduce pain specifically located at the sacroiliac joint improves the probability of the diagnosis of sacroiliac joint dysfunction.

Injections to Determine the Source of Pain

A sacroiliac joint injection – sometimes called a sacroiliac joint block – can be a useful diagnostic test.  It takes a highly skilled and experienced physician to be able to insert a needle into the correct portion of the sacroiliac joint. Because of this, the injection is usually guided by an x-ray to make sure the joint is properly injected. Sometimes a dye is injected so that the joint is better visualized, which is called an arthrogram.

In this test, a physician uses fluoroscopic guidance (live X-ray) and inserts a needle into the sacroiliac joint to inject lidocaine (a numbing solution). If the injection relieves the patient’s pain, it can be inferred that the sacroiliac joint is the source of the pain. Usually, a steroid solution is injected at the same time to decrease inflammation in the sacroiliac joint and decrease pain.

Treatments for Sacroiliac Joint Dysfunction

Treatments for sacroiliac joint dysfunction are usually conservative (meaning non-surgical) and focus on trying to restore normal motion in the joint.

Typical treatments for sacroiliac joint dysfunction include:

  • Ice, heat and rest
    Initial treatment recommendations will typically include use of ice or cold packs, applied in 15 to 20 minute intervals as needed to reduce inflammation in the area, along with rest to reduce irritation. Depending on the duration of sharp, intense pain, ice can be continued anywhere between 2 days to 2 weeks. Once the inflammation is less, gradual return to normal activities may be advisable. Application of heat (such as a heat wrap or hot bath) may help the healing process, but not during the acute, high intense pain time frame.
     
  • Medications
    First line of treatment often may include pain medications (such as acetaminophen), as well as anti-inflammatory medications (such as ibuprofen or naproxen) to reduce the swelling that is usually contributing to the patient's pain.
     
  • Chiropractic manipulations
    Manual manipulation provided by a chiropractor, osteopath, or other qualified health practitioner may help. This can be highly effective when the SI joint is fixated or “stuck.” It may be irritating if the SI joint is hypermobile. This is accomplished by a number of methods including (but not limited to): side-posture manipulation, drop technique, blocking techniques, and instrument guided methods. Your health care provider will choose a method they feel is most appropriate for your specific case.
     
  • Supports or braces
    When the SI joint is "hypermobile" or too loose, an "orthotic" or brace about the size of a rather wide belt can be wrapped around the waist and pulled snuggly to stabilize the area. This can sometimes be very helpful at times when the joint is inflamed or painful. When it calms down, the orthotic can be weaned away.
     
  • Physical therapy and exercise
    Controlled, gradual physical therapy may be helpful to strengthen the muscles around the sacroiliac joint and appropriately increase range of motion. In addition, any type of gentle, low impact aerobic exercise will help increase the flow of blood to the area, which in turn stimulates a healing response. For severe pain, water therapy may be a reasonable option, as the water provides buoyancy for the body and reduces stress on the painful joint. Read more with Exercise for Sciatic Pain from Sacroiliac Joint Dysfunction
     
  • Sacroiliac joint injections
    While the primary reason for sacroiliac joint injections is to determine whether or not the sacroiliac joint is the cause of the patient’s pain, it is also useful in providing immediate pain relief. As part of the injection, an anesthetic is typically injected along with an anti-inflammatory medication (such as a corticosteroid) to help reduce inflammation around the joint, which in turn will help alleviate the pain. The immediate pain relief can help the patient start with a physical therapy program and return to normal activity levels.

For severe cases of pain that are not addressed by several weeks or months of one or a combination of the above treatments, surgery may be a possible option. In surgery, one or both of the sacroiliac joints may be fused with the goal of eliminating any abnormal motion.

Surgery for Sacroiliac Joint Dysfunction

Fixation: To stabilization the sacroiliac joint, cannulated screws will be placed through the ilium and sacrum. The cannulated screws that your physician will use for stabilization are approved by the U.S. Food and Drug Administration (FDA) for fixation of fractures of large bones. It is inferred from this that they are solid enough for sacroiliac stabilization for which they are commonly used.

Fusion: Fusion between the sacrum and the ilium may also be necessary. This is done by scraping the bone on both sides and placing a graft taken from the iliac crest at the surgical site between the two sides. Artificial graft can also be used. If your physician determines that a fusion is not necessary in your case, the joint will be fixed in place using only the screws.

 

 

     

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