Author(s): Nathan Robert Badillo, DO, Justin Sup Hong, MD
Originally published: December 9, 2011 Last updated: November 21, 2024
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Disease/Disorder

Definition

The International Association for the Study of Pain defines three criteria for diagnosing sacroiliac (SI) pain: localized pain in the sacroiliac region, pain produced by tension with several maneuvers, and pain that decreases with local infiltration of anesthetics to the articulation.1

Etiology

SI joint pain may arise from traumatic or atraumatic sources.2 Traumatic sources include axial loading, abrupt rotation, falls, and motor vehicle accidents.2 Nontraumatic sources include inflammatory arthropathies (seronegative and HLA-B27 associated), osteomyelitis secondary to infection, lumbar spinal surgery, pregnancy (i.e. weight gain, enhanced lordosis, and hormone-related ligamentous laxity), degenerative changes (osteoarthritis), and joint stress (i.e. obesity, leg length discrepancy, gait abnormalities, in setting of scoliosis, prolonged strenuous exercise, etc.).2,3

Epidemiology including risk factors and primary prevention

Among patients complaining of back pain, 15-30% were found to have pain with origin in the SI joint.2,4 Risk factors that increase stress borne by the SI joint include leg length discrepancy, gait abnormalities, and scoliosis5 While younger adults typically suffer SI joint pain via sports with repetitive or asymmetric loading, or pregnancy, older adults typically suffer SI joint pain via aging-related degenerative changes or from previous spinal fixation, with fixation causing SI joint pain in  40-75% of those surgical patients after 5 years.3,6 Once the pain improves, daily ambulation is important to prevent recurrence. Other primary prevention strategies that patients should be educated on include weight loss, exercise, and maintenance of proper back ergonomics.3 In those affected by systemic inflammatory conditions, the utilization of systemic NSAIDs can treat flares and disease modifying agents can prevent later worsening of pain.7,8

Patho-anatomy/physiology

The SI joint is a unique diarthrodial joint and is the largest axial joint in the body. The joint is relatively immobile and functions to transfer weight from the lower extremities to the axial skeleton.2 The anterior third, the interface of the sacrum and the ilium, is a true synovial joint while the posterior two-thirds is composed of fibrocartilage and ligamentous connections. The connections become increasingly complex moving posteriorly along the joint, becoming a syndesmosis of the sacroiliac ligament, gluteus medius/minimus, and the piriformis muscle. The posterior elements function to limit motion in all three planes. The innervation of the joint remains controversial with multiple contradicting studies. These include strictly dorsal rami innervation, ventral rami involvement, nearby dorsal root ganglia innervation, spinal nerve involvement, etc. Overall, research opinion suggests that innervation arises from an area between L2 and S3, with the lateral branches of L4-S3 dorsal rami supplying the posterior SI joint (some studies saying contribution of L3-S4), and L2-S2 supplying the anterior SI joint. 9,10

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  • New onset/acute – (dysfunction). Duration: 1 to 4 weeks. Characterized by minor pathology causing abnormal motion and resultant pain. Clinical features include pain, spasm of surrounding musculature, and abnormal SI joint motion.
  • Subacute – (instability or intermediate). Duration: 1 to 3 months. There is further disruption in SI joint stability with potential gait dysfunction and persistent pain. Features include pain with functional impairment.
  • Chronic/stable (stabilization). Duration: more than 3 months.11

Specific secondary or associated conditions and complications

SI pain due to isolated joint dysfunction or sacroiliitis is often a diagnosis of exclusion. Evaluating for other inflammatory diseases such as ankylosing spondylitis, Reiter syndrome, psoriatic arthritis, enteropathic arthropathies, or other spondyloarthropathies is necessary. Anatomic abnormalities such as leg length discrepancies or scoliosis, soft tissue or bone malignancies, post-surgical changes after lumbar spinal fusion surgery, or traumatic events must also be ruled out if clinical suspicion is present.

Sacral fractures can also be a source of SI joint pain. Most of the time they occur due to high-impact injuries such as motor vehicle accidents.12 However, certain patient populations may be prone to sacral insufficiency fractures. Risk factors include osteoporosis, bone cancer, long-term corticosteroid use, local irradiation, and metabolic bone disorders.13 These patients have inadequate cortical integrity at baseline and can be at higher risk of fracture from low-impact injuries. A high index of suspicion of fracture should remain in patients with ecchymosis, swelling, or bruising at or near the sacrum.11 Sacral fractures can often be overlooked as they may be masked by concurrent injuries, but prompt diagnosis with the proper imaging and treatment is important.12,13

Essentials of Assessment

History

History for lower back pain, including SI joint pain, is often variable. The pain is typically unilateral, below L5, and distal medial to the posterior superior iliac spine (PSIS).3 It can be described as sharp, dull, or shooting and can often mimic radicular pain. Patients may notice a worsening of pain with prolonged sitting, standing from a seated position, lying on the affected side, or most commonly, with sudden spinal/pelvic rotational motions such as climbing stairs.3 Rheumatologic etiologies of SI joint pain should be considered if the patient has morning stiffness, pain improves with exercise, and/or pain is worse at night. Red flag diagnoses should be considered in cases of reported bowel or bladder dysfunction.

Physical examination

A comprehensive physical examination should be done to rule out other pathology causing low back pain. The physical examination begins as one analyses the patient’s gait as they ambulate into the exam room and may exhibit slight forward flexion of the body away from the painful SI joint (if unilateral involvement) or with a slow, methodical pace with short strides (if bilateral involvement).14 Afterwards, diagnosis can be made by assessing pain localization and provocative manual testing. Leg length should also be assessed due to the contribution of discrepancies being a cause of SI joint dysfunction. Of note, there is no one physical examination test that is pathognomonic for SI joint pain.

The Fortin Finger Sign test is positive when the patient reports maximal pain elicitation upon palpation along the inferomedial border of the PSIS. Testing for sensation and muscle group strength should be performed to evaluate for other pathology as these should remain relatively normal with isolated SI joint involvement.15

Numerous stress tests to identify SI joint dysfunction are available. Individual sensitivity and specificity of SI joint provocative tests are relatively poor, but when at least three or more of the tests are positive, with at least one being from the thigh thrust or compression test, the sensitivity is 94% and specificity is 78%.15

  • Distraction test is performed by having the patient lie supine on the exam table and then having the examiner apply a posteriorly directed pressure to the anterior superior iliac spine, which is positive if pain is reproduced to the affected side.15
  • Thigh thrust test is performed by having the patient lie supine on the exam table. The examiner has the patient flex the hip on the affected side to 90 degrees. The examiner places one hand on the fixed PSIS and the other hand applies a downward force along the axis of the femur to create a shearing force of the SI joint on the affected side. A positive test will reproduce the patient’s symptoms on the affected side.15
  • Gaenslen test is performed by having the patient supine on the exam table with the affected side on the edge of the table. The patient is then asked to flex their hip and knee on the unaffected side while the examiner extends the affected hip while it is still off of the table. A downward force is applied on the affected side to create a shearing mechanism of the SI joint on the affected side. A positive test will reproduce the patient’s pain on the affected side.16
  • Compression test is performed by having the patient side lying with the affected side facing upward. The examiner will use both hands stacked on one another, with elbows fully extended, to apply a downward pressure upon the upward facing iliac crest. The test is considered positive if it reproduces the patient’s symptoms.16
  • The Patrick’s or FABER (flexion, abduction, external rotation) test is performed with the patient supine on the exam table. On the affected side, the hip and knee are flexed, with the foot positioned over the opposite knee to place the hip in abduction and external rotation. The examiner then stabilizes the ASIS on the unaffected side. Test is positive if pain is elicited upon downward pressure of the knee on the affected side.16

Functional assessment

Typical assessment of impairments as a structural abnormality regarding impaired joint mobility, motor function, muscle performance, range-of-motion, and sensation should be performed. Self-reporting measures are also employed to understand the patient’s viewpoint of their functional limitations and may be helpful to predict favorable outcomes of both conservative and interventional treatment.17,18 Physical performance measures (PPMs) are increasingly popular as some believe they demonstrate causal relationships between physical performance post injury and calculation of fall risk.19

Laboratory studies

Routine laboratory studies do not provide any diagnostic benefit unless suspicion is raised for malignancy or systemic inflammatory disease. If suspicions are high for systemic disease then consider ordering a complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), antinuclear antibody profile (ANA), human leukocyte antigen status (HLA-B27), and rheumatoid factor.15

Imaging

Imaging does not reliably determine the source of pain in SI joint dysfunction, nor is it typically utilized in all cases of SI joint dysfunction. However, imaging can be useful if there is high clinical suspicion for mimickers of SI joint dysfunction.3,15 MRI or CT can rule out malignancies, spinal stenosis, lumbar radiculopathy, fracture, and disk herniation. SPECT can also be utilized to localize areas of abnormal metabolic activity; however, this is not standard of care.

Supplemental assessment tools

Performing diagnostic injections (local anesthetic with or without steroid) with appropriate relief of pain (greater than or equal to 50-75%) can help to localize pain to the SI peri- or intra-articular region. This can be performed in preparation for further local blocks or more definitive treatment with lateral branch neurotomy or SI joint fusion surgery.

Pain symptoms should be monitored utilizing one of the commonly accepted validated pain scales such as the Dallas Pain Questionnaire (DPQ), McGill Pain Questionnaire (MPQ), Oswestry Disability Index, Roland-Morris Back Pain Questionnaire, or the Visual Analog Scale (VAS). Chronic pain patients may also have signs of depression or post-traumatic stress disorder so assessing symptoms using the Patient Health Questionnaire (PHQ-9) or Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).20,21,22

Early predictions of outcomes

Factors associated with outcomes in musculoskeletal pain include: anxiety, belief in personal control, mood, coping style, fatigue, education level, and gender. Psychiatric comorbid conditions are also associated with decreased therapeutic efficacy after interventional pain techniques.23,24

Environmental

Low back pain is commonly associated with poor ergonomics and workplace-related exposures, especially physical labor. Lifting heavy objects without external support, such as a brace, or with poor posture, is strongly associated with low back pain. Additional workplace factors include: psychosocial stressors, time pressure, pressure to contribute positively, and conflicts with co-workers and superiors. Poor diet, minimal exercise, obesity, lower socioeconomic status, and unfavorable attitudes towards health status are associated with higher pain levels and rate of disability.25

Social role and social support system

A sense of social and emotional support is reported to have a positive impact on participation in activities of daily living. Avoidance behaviors developed in response to pain frequently lead to increased levels of pain, depression, and disability.25 Higher levels of overall functional social support are associated with recovery from low back pain and other associated symptoms. Patient self-reporting also indicates that tangible support is rated as “helpful,” particularly when provided by family members and physical therapists.26, 27

Professional issues

Low back pain is the leading cause of worldwide productivity loss and the lead cause of years living in disability in over 100 countries, with an economic burden of $100 billion in the United States alone.28 Low back pain, particularly in the chronic setting, is often associated with motor vehicle accidents, workplace injuries, disability compensation, and various other medicolegal concerns. Appropriately assessing pain pathophysiology, setting realistic outcome goals, and addressing patients’ social and emotional concerns related to the functional status of their pain are effective techniques to ethically treat non-radicular, non-malignant low back pain.29,30

Rehabilitation Management and Treatments

Available or current treatment guidelines

In the initial stages of treatment for SI joint pain, conservative management comes first. Physical therapy demonstrates intermediate and long-term benefits, in which the proper muscles can be treated to prevent the recurrence of disease. These include the abdominals, pelvic floor muscles, ipsilateral gluteal muscles, contralateral latissimus muscles, and the thoracolumbar fascia.15 Osteopathic manipulative therapy in combination with exercise has been shown to help in the short-term. In terms of oral medications, NSAIDs are typically utilized to achieve pain relief. Once that is attained, the previous modalities described are utilized to prevent recurrence.3,15 If unresponsive to NSAIDs, Other conservative modalities include heat/ice, transcutaneous electrical nerve stimulation, yoga, and cognitive behavioral therapy. Patients must also be educated on lifestyle modifications, such as healthy eating and routine exercise.3

If conservative management fails after six weeks, interventional treatment may be considered. These include intra- and peri-articular corticosteroid injections and diagnostic blocks/radiofrequency ablations. Most RCTs evaluating intra-articular injections reported pain relief for up to 6 months.12 There appears to be stronger evidence supporting peri-articular (i.e. tendons, bursas, muscle bellies) injections over intra-articular injections, while the studies addressing the efficacy of radiofrequency ablations are varied. To address anatomical variations in the innervations of the SI joint, some advocate for the use of  utilized i cooled radiofrequency treatment, which increase the ablative area by minimizing the effect of tissue charring that limits lesion expansion.15

The last case scenario for refractory SI joint dysfunction is SI joint fusion, however there has been a growth of minimally invasive SI joint arthrodesis techniques.31

Potential complications of interventional management include sequelae from neural or structural damage, infection, and hematomas.

At different disease stages

  • New onset/acute – During the first one to three days, initial treatment emphasizes education (postural awareness, pelvic/spinal body mechanics, and activity modification), superficial heat, massage, spinal manipulation, ice, electrical stimulation, and topical creams. NSAIDs and muscle relaxants may prove beneficial if previous methods have failed.11
  • Subacute (Recovery phase) – During the next three to eight weeks, the focus of this phase is to increase mobility, flexibility, and stability, correct leg length discrepancy, and restore healthy gait. Rehabilitation exercises, including pelvic and spine stabilization, core strengthening, and postural education coupled with osteopathic manipulative therapy should be utilized. This should be followed by a maintenance exercise program, with education on self-exercise provided to the patient. If residual pain limits function, an SI joint injection may be considered.11
  • Chronic/stable (Maintenance phase) – After eight weeks, the focus is to restore muscle balance, strengthen appropriate muscles, and initiate functional exercises. If pain persists and there have been positive responses to diagnostic and therapeutic SI joint injections on 2 occasions (>50% relief), then radiofrequency neurotomy may be indicated. If radiofrequency neurotomy is not helpful, regenerative therapy or SI joint fusion surgery may be considered.11

Patient & family education

Patients and their families must act as an extension of the multi-disciplinary therapeutic team and should continue to practice appropriate postural techniques and stretching exercises. Adherence to activity modification as well as healthy workplace hygiene and ergonomics should be emphasized to the patient and their family. For patients with chronic pain, the patient should be reminded of the need to continue with physical activity to prevent increasing pain levels. Additionally, addressing socioeconomic concerns and sleep hygiene represent effective techniques to offset other factors to SI joint dysfunction.32

Emerging/unique interventions

Prolotherapy, an injection technique that introduces a small amount of an irritant solution to painful joint spaces, ligaments, or tendon insertions, to promote healing of the targeted site, has seen increased utilization and review over the past ten years. Some researchers postulate that refractory SI joint dysfunction is related to degeneration of posterior ligaments of the SI joint and that prolotherapy is efficacious in stimulating the production of collagen fibers, thereby stabilizing the joint. Current research has been limited due to potentially biased patient selection and small sample sizes; however, some studies suggest non-inferiority of prolotherapy when compared to local anesthetic/corticosteroid injections with regards to pain and disability improvement.33, 34 Platelet rich plasma (PRP), a supernatant of growth factors obtained from a cell separating process applied to the patient’s own blood, is an injection technique being utilized for certain musculoskeletal conditions. Like prolotherapy, the current literature is lacking regarding definitive recommendations about PRP injections, but some case series and prospective studies have shown long lasting improvement from SI joint PRP injections and some have proposed that PRP provides superior pain relief and functional improvement as compared to corticosteroid injection.35,36

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Patients with SI joint pain should be managed in a multi-modal approach that utilizes exercise, manual therapy, non-opioid pharmacologic agents, and procedural intervention when warranted. Special consideration should be given to the psychologic, workplace, socioeconomic, and other environmental factors that influence chronic pain. Adherence to guidelines and avoidance of overly aggressive treatment regimens maintains ethical practice measures.

Cutting Edge/Emerging and Unique Concepts and Practice

The interventional armamentarium has expanded recently with literature suggesting benefits from peripheral nerve stimulation for therapy-refractory SI joint pain. Surgical studies have exhibited some benefit of minimally invasive sacroiliac joint fusion for the relief of pain and restoration of functional status. Other proponents for injections have suggested an increased utilization of ultrasound guided needle placement to decrease radiation exposure. Further research into the appropriateness of these techniques is currently needed.37,38

Gaps in the Evidence-Based Knowledge

A variety of topics related to pain management require further research to refine the guidelines of the current practices of evaluating and treating different causes of back pain. Prolotherapy, corticosteroid injections, and surgical fixation all have research that espouse the benefits of these techniques; however, further research is needed to develop an appropriate algorithm on utilizing these treatments for patients. Further quantification of the role of socioeconomic status, peer support, and psychologic intervention may provide insight into a more holistic patient approach for overall pain improvement.

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Original Version of the Topic

Ricardo Nieves, MD. SI Joint Pain. Original Publication date: 12/9/2011

Previous Revision(s) of the Topic

Travis Coats, MD and Xiaoli Dong, MD. SI Joint Pain. 5/29/2018

Ajay K. Patel, MD, Jaspal Ricky Singh, MD, Sumeet Prasad, MS. SI Joint Pain. 2/9/2022

Author Disclosure

Nathan Robert Badillo, DO
Nothing to Disclose

Justin Sup Hong, MD
Nothing to Disclose