You are in: eMedicine Specialties > Sports Medicine > Spine Sacroiliac Joint InjuryArticle Last Updated: Apr 28, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Andrew L Sherman, MD, Assistant Professor, Departments of Neurological Surgery, Orthopedics, and Rehabilitation, University of Miami Andrew L Sherman is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, and American Medical Association Coauthor(s): Robert Gotlin, DO, Director of Orthopaedic and Sports Rehabilitation, Assistant Professor, Department of Physical Medicine and Rehabilitation, Beth Israel Medical Center, Albert Einstein College of Medicine Editors: Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Henry T Goitz, MD, Chief, Sports Medicine, Associate Professor, Department of Orthopaedic Surgery, Medical College of Ohio; Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital; Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Author and Editor Disclosure Synonyms and related keywords: sacroiliitis, SIJ injury, lower back pain, low back pain, LBP, back pain, low back injuries, lower back injuries INTRODUCTIONSection 2 of 11
  BackgroundLower back pain is one of the most prevalent sports maladies, affecting athletes in nearly every sport. Diagnosing the cause of a back injury is quite difficult and challenging because multiple structures in the lower back region can cause pain. However, an accurate diagnosis is paramount to providing successful treatment of the spine injury. For excellent patient education resources, visit eMedicine's Osteoporosis and Bone Health Center and Back, Neck, and Head Injury Center. Also, see eMedicine's patient education articles Back Pain and Lumbar Disc Disease. FrequencyUnited StatesThe incidence of lower back pain in humans parallels the incidence of the common cold, with a lifetime rate approaching 95%. Goldwaith and Osgood first discussed the possibility that SIJ injury could cause low back pain as early as 1905.1 In the decades since then, several attempts have been made to establish the prevalence of SIJ syndrome in persons with back pain, and the results of these reports vary widely. Functional AnatomyThe SIJ is a true diarthrodial joint that joins the sacrum to the pelvis.4, 5, 6 In this joint, hyaline cartilage on the sacral side moves against fibrocartilage on the iliac side. The joint is generally C shaped with 2 lever arms that interlock at the second sacral level. The joint contains numerous ridges and depressions, indicating its function for stability more than motion. However, studies have documented that motion does occur at the joint; therefore, slightly subluxed and even locked positions can occur.2, 7 Stability is provided by the ridges present in the joint and by the presence of generously sized ligaments. The ligamentous structures offer resistance to shear and loading. The deep anterior, posterior, and interosseous ligaments resist the load of the sacrum relative to the ilium. More superficial ligaments (eg, sacrotuberous ligament) react to dynamic motions (eg, straight-leg raising during physical motion). The long dorsal sacroiliac ligament can become stretched in periods of reduced lumbar lordosis (eg, pregnancy). Many large and small muscles have relationships with these ligaments and the SIJ, including the piriformis, biceps femoris, gluteus maximus and minimus, erector spinae, latissimus dorsi, thoracolumbar fascia, and iliacus. Any of these muscles can be involved with a painful SIJ. As a true joint, the SIJ is a pain-sensitive structure richly innervated by a combination of unmyelinated free nerve endings and the posterior primary rami of L2-S3. The wide possibility of innervation may explain why pain emanation from the joint can manifest in so many various ways, with different and unique referral patterns for individual patients. Sport-Specific BiomechanicsThe function of the SIJ is to dissipate loads of the torso through the pelvis to the lower extremities and vice versa. The pelvis acts as a central base through which large forces are accepted and dissipated. Although the main role of the joint is to provide stability, the SIJ has limited motion that allows it to dissipate and transfer significant loads and stresses. Studies by Weisel indicate that most movement occurs when rising from the sitting to the standing position. However, the amount of motion is small, making assessment of sacroiliac motion during physical examination quite difficult. Selvik suggested that hyperextension produces the greatest degree of motion (2° on average, with only minimal translation of 0.5-1.6 mm). If the motion in the pelvis is asymmetric, then dysfunction can occur. Some conditions that cause asymmetric motion include leg-length inequalities, a unilaterally weak lower limb (eg, polio), tight myofascial structures (eg, iliopsoas), and scoliosis. Hip osteoarthritis can lead to leg-length shortening and SIJ pain. Women may be at increased risk for SIJ problems because their broader pelvises, greater femoral neck anteversion, and shorter limb lengths lead to different, possibly predisposing, biomechanics. In addition, pregnancy often leads to stretching of the pelvis, specifically targeting the sacroiliac ligaments and possibly leading to dysfunction, hypermobility syndromes, and chronic pain. Innervation The nerve supply of the SIJ originates from multiple lumbosacral root levels with partial innervation from L2 (anterior joint) to S3 (posterior joint). Because the root innervation can vary so widely, the pain referral patterns from primary sacroiliac pain can also vary. Fortin et al interviewed multiple patients documented to have sacroiliac pain by anesthetizing the joint with lidocaine injections under fluoroscopic guidance.8, 9 He found referral patterns ranging from localized buttocks pain to frank radicular leg pain and many other descriptions in between. CLINICALSection 3 of 11
HistoryThe key element in the diagnosis of sacroiliac dysfunction is pain. Many authors have attempted to define a typical pain pattern associated with the SIJ. Several of these reports describe patients reporting pain in one or both buttocks at or near the posterior superior iliac spine (PSIS). However, pain radiating to the hip, posterior thigh, or even calf has been described.
PhysicalThe reliability of the physical examination findings to diagnose SIJ dysfunction has been addressed in several articles. The usual pattern of examination is discussed, as follows:
CausesMany patients state that their pain began spontaneously, whereas others can cite a specific inciting event. Bernard and Kirkaldy-Willis reported that 58% of patients diagnosed with SIJ pain based on clinical examination findings had some inciting traumatic injury.3 Many risk factors are associated with lower back pain, and many are directly associated with lumbar disk injury. These include, but are not limited to, smoking, poor physical condition, positive family history, and occupational lifting. Factors that specifically increase the likelihood of mechanical injury to the SIJ have not been identified. Pregnancy is one particular condition attributed to SIJ dysfunction. In the authors’ experience, certain biomechanical or muscle length imbalances may ultimately predispose a person to sacroiliac dysfunction and pain. Likely, this is a result of altered gait patterns and repetitive stress to the SIJ and related structures. These conditions exist in persons with leg-length inequality, scoliosis, a history of polio, poor-quality footwear, and hip osteoarthritis. DIFFERENTIALSSection 4 of 11
Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy Hip Fracture Hip Overuse Syndrome Iliotibial Band Syndrome Lumbosacral Discogenic Pain Syndrome Lumbosacral Facet Syndrome Lumbosacral Radiculopathy Piriformis Syndrome Sacroiliac Joint Infection Seronegative Spondyloarthropathy Superior Cluneal Nerve (Iliac crest) Syndrome Trochanteric Bursitis Other Problems to Be ConsideredCrohn disease WORKUPSection 5 of 11
Lab StudiesIn a patient with sacroiliitis, inflammatory origins (eg, ankylosing spondylitis [AS], psoriatic arthritis) must be considered. The following laboratory studies are appropriate when an inflammatory disorder is suspected in a young patient:
In patients in whom the pain has become chronic, clinicians need to consider whether the patients may have secondary reactive depression. Testing for hypothyroidism, cortisol abnormalities, or other metabolic or endocrine imbalances may be appropriate as part of the workup for a patient with depression. Prostate-specific antigen (PSA) testing, serum protein electrophoresis/urine protein electrophoresis, and other laboratory tests used to investigate for malignancy are appropriate for older patients who have not improved with initial care and may have symptoms warranting further investigation. Imaging Studies
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TREATMENTSection 6 of 11
Acute Phase (1-10 d):Subacute phase (if acute phase does not resolve; 10-180 d) Chronic phase (>6 mo of pain)Rehabilitation ProgramPhysical TherapyPhysical therapy focuses on pain control in the acute phase. Modalities such as ultrasonography with or without phonophoresis, deep and superficial heat, and superficial cold treatments can reduce pain. Neural therapies such as deep tissue massage, myofascial release, and muscle energy stretching techniques can also help. Pelvic myofascial stretching in the neutral spine position can be used for immediate, short-term relief of discomfort. By identifying activities that aggravate the condition, the physician or therapist can have the patient avoid these activities. Osteopathic/chiropractic treatmentAlthough in the acute-phase muscle spasms may prevent frank manipulation, less aggressive techniques such as muscle energy stretching can be very helpful. Medical complicationsPatients may experience difficulty or even worsening symptoms with physical therapy treatments in certain cases. In these patients, reevaluate the diagnosis and consider other diagnostic possibilities (eg, infection, inflammatory disease, malignancy, neural [lumbosacral root] injury). Patients with acute inflammatory disorders or infections should not usually be administered heat treatments. Patients who cannot perform physical therapy may also have a functional component to their disorder or an underlying psychologic disorder, which needs to be addressed. Medical interventionsOften, oral medications can be quite effective in the acute phase. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used judiciously in this phase, often with good results. In the first 24-72 hours, a muscle relaxant can be quite effective if a myofascial component to the pain is present. Ice can be considered in the first 48-72 hours; then, the typical switch to heat or contrast treatments is warranted. Oral medication management may change if the pain persists into the subacute and especially the chronic phase. Chronic lower back pain from any source often leads to the development of a cognitive/behavioral component. In such cases, the use of antidepressants, anticonvulsants, and antiarrhythmic topical and oral medications has been reported to benefit certain selected patients. Because the potential benefits of any of these medications is uncertain, their use must be balanced against their potential adverse effects. Surgical interventionSurgical intervention is rarely used for nontraumatic SIJ pain.4, 17 Surgery is considered only in patients with chronic pain that has lasted for years, has not been effectively treated by other means, and has led to an extremely poor quality of life. The procedure is a fusion across the joint; however, although the surgery has been reported to result in benefit in selected cases or small case series, no randomized controlled study has shown reliable pain reduction with SIJ fusion. ConsultationsConsultation with a rheumatologist is necessary when the possibility of an underlying inflammatory disorder exists. Consultation with a musculoskeletal specialist is often helpful. The musculoskeletal specialist should provide each patient with a functional assessment, can direct nonoperative treatment, and can communicate with the entire treatment team (eg, physical therapists, trainers). Often, a physiatrist (specialist in the field of physical medicine and rehabilitation) can provide a unique, functional-based history and examination that can lead to an accurate diagnosis and a holistic treatment program. Other Treatment (injection, manipulation, etc.):In the immediate acute phase, treatment consists of pain reduction through pain medications, rest, and avoidance of the inciting activity. Anti-inflammatory treatment with NSAID medications and externally applied ice is often helpful. Recommend the patient return to usual activities as soon as possible, usually within 24-48 hours. Sometimes a local trigger point injection into the muscle can relieve symptoms. If the pain does not resolve well in the first 2-3 weeks, an intra-articular injection under fluoroscopic guidance should be considered. SIJ injection is frequently performed with a mixture of anesthetic and steroid, as described by Fortin in 1994 and others.8, 18, 19, 20, 21 When the actual source of the patient’s discomfort is unclear, postinjection pain reduction offers significant diagnostic information. Fluoroscopic guidance is important because, although a local blind injection into the area of maximal pain can be temporarily effective, the needle rarely enters the joint. CT scanning or MRI can also be used to guide injections into the SIJ, with excellent reliability. Günaydin and colleagues reported that 20 of 31 patients with spondylarthropathy reported subjective improvement after the first SIJ injection of MRI-guided corticosteroid, and 9 of 15 patients reported subjective improvement after the second injection.20 The improvement lasted for a mean of 8.7 for the first group and 16.1 months for the second group. Luukkainen and colleagues reported that periarticular injection of methylprednisolone may be effective in the treatment of pain in the region of the SIJ in nonspondyloarthropathy patients from a study of 24 consecutive patients.22 Even if the injections do relieve the patient's pain, the relief from the injections alone is very often short-lived. Therefore, using the injections only as part of an interdisciplinary rehabilitation program is important. The pain relief offers a window of opportunity to increase the rehabilitation. The point in the course of recovery when a second or even third injection should be attempted is unclear. Most clinicians wait 2-4 weeks before proceeding with a repeat injection. Manipulation has been reported in multiple studies as effective treatment for acute lower back pain. However, studies specifically on SIJ syndrome are less abundant. The SIJ is accessible to manipulation treatments and these may be extremely effective. As with other passive modalities, these treatments should be coupled with an extensive active rehabilitative program. Manipulation following intra-articular injection has been reported anecdotally to be beneficial in selected cases. In chronic conditions, some practitioners believe that SIJ pain is due to hypermobility of the joint, which occurs because of laxity in the ligamentous complex. Prolotherapy is a series of saline and glucose injections applied to the SIJ ligaments to cause an inflammatory reaction, which results in scarring and tightening of the ligaments and a reduction in pain. However, no satisfactory outcome investigations have been performed on prolotherapy for this condition. A relatively more recent procedure, radiofrequency denervation, has been advocated for the treatment of especially recalcitrant sacroiliac dysfunction.23, 24 The procedure was thought to be ineffective for SIJ pain because the innervation to the joint is so diffuse. However, in a study by Gevargez and colleagues, the authors reported that 3 months after the procedure, 13 patients (34.2%) were completely free of pain. Twelve patients (31.6%) reported substantial pain reduction, 7 patients (18.4%) had slight pain reduction, and 3 patients (7.9%) had no pain reduction. No longer-term follow-up data are available; further study regarding this procedure is needed. Recovery PhaseRehabilitation ProgramPhysical TherapyThe recovery phase cannot proceed without an active, aggressive rehabilitation program. Often, SIJ injury leaves patients with significant deconditioning and muscle imbalances. These functional muscular deficits were sometimes present before the injury and may have predisposed the patient to injury. Some muscles are known to be functioning in a tight or shortened position, such as the hip flexors, hamstrings, tensor fascia lata, obturator internus, and rectus femoris. Other muscles are weak or inhibited, such as the gluteal and abdominal muscles. Begin physical therapy by correcting any mechanical or leg-length asymmetries (eg, orthotic/shoe lift), stretching overly tight lumbopelvic muscles, and strengthening weak and inhibited muscles. All of this should begin in the neutral spine position or a pelvic position, which minimizes acute discomfort. The patient is asked to take on more challenging tasks while progressing through the program. Stabilization exercises are performed with the patient in a more dynamic, functional position and often include balance and proprioceptive activities. Strengthening of the core muscles surrounding the spine can be achieved in various ways. In the past several years, Pilates training has become very popular for this purpose. Finally, the patient should graduate to sport- or work-specific training designed to return the patient to his or her previous level of functioning. Braces and belts In patients who develop chronic injuries, an SIJ belt can provide compression and feedback to the gluteal muscles. Patients with ligamentous hypermobility can especially benefit from this apparatus because the belt can reduce SIJ rotation. The belt differs from a generalized lumbar orthosis because it is much thinner and thus secures across the anterior superior iliac spines. Orthotics can decrease leg-length inequalities; these items include custom-fitted orthotics, internal shoe lifts, and external shoe lifts. Medical Issues/ComplicationsSIJ dysfunction usually improves significantly, relatively quickly. Reexamine patients whose pain persists, despite treatment, for longer than 4 weeks and consider other diagnostic possibilities. Other TreatmentPerform injection under fluoroscopic guidance (see Image 1). SIJ injection is frequently performed with a mixture of anesthetic and steroid, as described by Fortin in 1994 and others.8 Postinjection pain reduction offers significant diagnostic information when the actual source of the patient’s discomfort is unclear. Although a local blind injection into the area of maximal pain can be temporarily effective, the needle rarely enters the joint. CT scanning or MRI can also be used to guide injections into the SIJ, with excellent reliability.18, 19, 20, 21 Unfortunately, injections usually offer only temporary relief. Therefore, couple injections with physical therapy and exercise to achieve more durable pain relief. The point in the course of treatment when a second or even third injection should be attempted is unclear. Most clinicians wait at least 2-4 weeks before proceeding with a repeat injection. In a subset of patients who had temporary relief, Vallejo and coauthors performed pulsed radiofrequency denervation (PRFD) of lateral branches from L3-S2 and found good or excellent results in 16 of 22 subjects for 6-32 weeks.23 In chronic conditions, some practitioners believe that SIJ pain is due to hypermobility of the joint, which occurs because of laxity in the ligamentous complex. Prolotherapy is a series of saline and glucose injections applied to the SIJ ligaments to cause an inflammatory reaction, which results in scarring and tightening of the ligaments and a reduction in pain. However, no satisfactory outcome investigations have been performed on prolotherapy for this condition. Maintenance PhaseRehabilitation ProgramPhysical TherapyAfter the patient's pain resolves and he or she has regained sufficient strength, therapy should be transitioned from the therapy office to the gym or home gym. The therapist should teach the patient a home gym or gym program, and the patient should perform stabilization and general training at least 3 times per week to prevent recurrence. MEDICATIONSection 7 of 11
As in most conditions involving acute and even chronic musculoskeletal pain, many oral medications can provide initial pain relief. NSAIDs are a mainstay and can be combined with acetaminophen for added effect. When the injury is acute and associated with secondary muscle spasm, muscle relaxants, light narcotics (eg, hydrocodone), or benzodiazepines are reasonable options. However, these medications should be administered cautiously and only for the initial acute phase of pain because dependence and tolerance can quickly occur.
Drug Category: Analgesics
For most episodes of SIJ pain, oral outpatient analgesics can achieve adequate pain control.
Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)NSAIDs work by decreasing inflammatory reactions and providing direct pain relief. Numerous choices are available, and they are separated into different families of agents. If an NSAID is ineffective, another agent from a different family can often provide relief. Efficacy and adverse effect profiles differ among agents and families. Cyclooxygenase (COX)–2 inhibitors had been shown to reduce certain adverse effects (eg, gastrointestinal [GI] bleeding) and provide similar efficacy to standard agents. Unfortunately, 2 of the 3 agents (ie, rofecoxib [Vioxx], valdecoxib [Bextra]) were voluntarily removed from the market by their parent companies when an increased potential risk of adverse cardiovascular events was identified in an increased number of patients taking the drugs. Dosing requirements are usually individualized, based on the individual patient and patient response.
Drug Category: Muscle relaxantsMuscle relaxants can provide adjunctive pain relief in the acute setting. These agents usually should not be used in protracted courses.
FOLLOW-UPSection 8 of 11
Return to PlaySimilar to most conditions of mechanically related low back injury, an athlete's return to competition is a complex issue. In most SIJ injury cases, the athlete does not have a condition that can anatomically worsen with competition. However, pain may be exacerbated by the extreme motion and pelvic stress many athletes experience in their sport. Additionally, SIJ pain often leads to myofascial guarding and muscle imbalances, which, if not addressed before return to play, can lead to secondary injury in another part of the body. For example, a baseball pitcher with an SIJ strain may not be able to generate the support base or hip rotation needed to support the shoulder on overhead throws. Added stress to the shoulder can result in strains and even tears to the intrinsic elbow or shoulder muscles and ligaments. ComplicationsComplications arise more from missed alternative causes of back pain than from any mechanical damage to the joint. Systemic conditions (eg, AS, Crohn-related arthritis) can cause future problems. Missed stress fractures to the hip could progress to a complete fracture. Finally, overlooked malignancy is a rare but real possibility. Other complications can occur in athletes not fully rehabilitated. Muscle imbalances may persist and put the athlete at risk for reinjury or future injury to another structure. Finally, with any back injury, an inherent risk exists that the pain may become chronic. Excessive rest can often lead to adaption of a deconditioned state or sick role. These mechanical spine conditions must be identified early and rehabilitated aggressively to reduce this complication. PreventionPrevention of lower back injuries, including those to the SIJ, is multifaceted and relies on patient education concerning the back. Excessive lifting with a rotatory component can injure the SIJ in a manner similar to lumbar disk injuries. Using accessory muscles in forceful activities and training them for these activities can prevent injury. Sport-specific training after rehabilitation and before return to play is most important to prevent future injury. PrognosisSacroiliac injury has an excellent prognosis for full recovery. While most studies suggest 80% of people with a lower back injury significantly improve within 2 weeks, no scientific studies show any stratification into diagnostic groups (ie, SIJ injury vs disk injury vs piriformis injury). EducationPatient education is essential to achieving good outcomes. Patients can be informed that their SIJ pain is considered a benign condition, which, in most cases, improves with time and conservative treatments. Encourage them to resume physical activity as soon as possible to prevent deconditioning. Also encourage them to immediately enlist the help of a physical therapist to assist with therapeutic exercise. Home exercise programs are essential to help prevent reinjury and can be provided by a physician, chiropractor, or physical therapist. MISCELLANEOUSSection 9 of 11
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MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Sacroiliac Joint Injury excerpt Article Last Updated: Apr 28, 2008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
