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Sacroiliac (SI) joint pain represents a significant cause of lower back pain that originates from the joint where the sacrum connects with the ilium of the pelvis. The SI joints are large, weight-bearing joints that connect the sacrum to iliac bones, featuring limited mobility of 2-4 degrees of movement. These joints are stabilized by strong ligaments and function to transfer forces between the upper body and lower extremities.
Several factors can contribute to SI joint pain, including pregnancy and postpartum changes, trauma or falls, degenerative joint disease, inflammatory arthritis, leg length discrepancy, abnormal gait mechanics, sports-related injuries, and post-lumbar fusion syndrome.
Patients typically present with unilateral low back pain that may radiate to the buttocks and posterior thigh. The pain commonly worsens with prolonged sitting or standing, and patients often experience difficulty with stairs or single-leg activities. Morning stiffness and pain with position changes are also characteristic symptoms.
Physical examination includes several specific tests such as FABER test, Gaenslen’s test, thigh thrust test, compression test, distraction test, Patrick’s test, and evaluation of tenderness over the SI joint. Diagnostic testing may involve X-rays to rule out other pathology, CT scan for detailed bone imaging, MRI to evaluate soft tissues, and diagnostic injection for confirmation.
The differential diagnosis includes lumbar radiculopathy, hip pathology, piriformis syndrome, facet joint pain, muscle strain, and trochanteric bursitis.
Treatment approaches begin with conservative management, including activity modification, physical therapy, core strengthening, manual therapy, belt/brace support, NSAIDs, and ice/heat therapy. Interventional procedures may include corticosteroid injections, prolotherapy, radiofrequency ablation, and SI joint fusion in refractory cases.
Physical therapy focuses on core stabilization, pelvic alignment exercises, gait training, postural education, manual therapy techniques, and hip/gluteal strengthening.
The prognosis varies depending on the underlying cause. Many patients improve with conservative care, though some require ongoing management, and surgical intervention may be necessary in resistant cases.
Prevention strategies include proper lifting mechanics, core strengthening, regular exercise, maintaining healthy weight, good posture, and ergonomic modifications.
Clinicians should be alert to red flags such as fever, unexplained weight loss, neurological deficits, bowel/bladder dysfunction, history of cancer, severe trauma, and progressive symptoms.
Follow-up care involves regular assessment of symptoms, monitoring treatment response, activity modification as needed, progressive return to activities, and prevention education.
The sacroiliac joints are located at the junction of the sacrum and iliac bones, forming the posterior aspect of the pelvic ring. These joints: – Provide stability for the pelvis
– Transfer load between the spine and lower extremities
– Allow for minimal movement (2-4 degrees of rotation and translation)
The SI joints are surrounded by strong ligaments and muscles, which contribute to their stability and function.
Etiology: SI joint pain can result from various factors, including:
1. Trauma:
– Falls
– Motor vehicle accidents
– Sports injuries
2. Biomechanical factors:
– Leg length discrepancy
– Gait abnormalities
– Scoliosis
3. Pregnancy and postpartum: – Hormonal changes causing ligament laxity
– Altered biomechanics due to weight gain and postural changes
4. Degenerative conditions:
– Osteoarthritis
– Ankylosing spondylitis
– Rheumatoid arthritis
5. Iatrogenic causes:
– Lumbar fusion surgery
– Iliac crest bone graft harvesting
– Prevalence estimates vary widely, ranging from 10-30% of patients with chronic low back pain
– More common in women, particularly during pregnancy and postpartum periods
– Incidence increases with age due to degenerative changes
Patients with SI joint pain typically present with:
1. Pain location:
– Lower back – Buttocks
– Posterior thigh (rarely below the knee)
– Groin (less common)
2. Pain characteristics:
– Dull, aching pain
– Sharp, stabbing pain with certain movements
– Unilateral or bilateral
3. Aggravating factors:
– Prolonged sitting or standing
– Transitional movements (e.g., sit-to-stand)
– Climbing stairs
– Walking on uneven surfaces
4. Associated symptoms:
– Stiffness
– Reduced range of motion
– Sensation of instability in the pelvic region
Accurate diagnosis of SI joint pain can be challenging due to its similarity to other lower back conditions. A comprehensive approach includes:
1. History taking:
– Detailed pain description
– Onset and duration
– Aggravating and relieving factors
– Previous treatments
2. Physical examination:
– Inspection for asymmetry or postural abnormalities
– Palpation for tenderness over the SI joint
– Range of motion assessment
– Special tests:
a. FABER (Patrick) test
b. Gaenslen’s test
c. Thigh thrust test
d. Distraction test e. Compression test
3. Imaging studies:
– Plain radiographs: Limited utility, may show degenerative changes or asymmetry
– CT scan: Better visualization of bony structures
– MRI: Useful for identifying soft tissue pathology and inflammation
4. Diagnostic injections:
– Considered the gold standard for diagnosis
– Intra-articular injection of local anesthetic under fluoroscopic or CT guidance
– Positive response: >50% pain relief
– Lumbar radiculopathy
– Facet joint pain
– Hip pathology
– Piriformis syndrome
– Myofascial pain syndrome
Treatment of SI joint pain is typically multimodal and depends on the underlying cause and severity of symptoms.
1. Conservative management: a. Physical therapy:
– Core strengthening exercises
– Pelvic stabilization techniques
– Manual therapy
– Postural correction
b. Activity modification:
– Avoiding aggravating activities
– Ergonomic adjustments
c. Bracing:
– SI joint belts or pelvic support devices
d. Medications:
– NSAIDs
– Muscle relaxants
– Topical analgesics
2. Interventional procedures: a. Intra-articular injections:
– Corticosteroids
– Hyaluronic acid
b. Prolotherapy:
– Injection of irritant solution to promote ligament strengthening
c. Radiofrequency ablation:
– Neurotomy of lateral branches innervating the SI joint
3. Surgical intervention:
– Reserved for refractory cases
– SI joint fusion:
a. Open approach
b. Minimally invasive techniques
The prognosis for SI joint pain varies depending on the underlying cause and treatment approach:
– Many patients respond well to conservative management
– Chronic cases may require ongoing multimodal treatment
– Surgical intervention can provide long-term relief in carefully selected patients
Strategies to reduce the risk of SI joint pain include:
– Maintaining a healthy weight
– Regular exercise focusing on core and pelvic stability
– Proper body mechanics during lifting and daily activities
– Addressing leg length discrepancies or gait abnormalities
Sacroiliac joint pain is a complex condition that requires a thorough understanding of its anatomy, etiology, and clinical presentation for accurate diagnosis and effective management. A multidisciplinary approach, incorporating conservative measures, interventional procedures, and, in select cases, surgical intervention, can lead to improved outcomes for patients suffering from this challenging condition. Continued research and advancements in diagnostic and treatment modalities will further enhance our ability to manage SI joint pain effectively.
©2025 Dr Frank McCormick All Rights Reserved.
©2025 Dr Frank McCormick All Rights Reserved.
