Pain Associated With Sacroiliac Joint Region: A Malady of Common Proportions
An astute DO utilizing enhanced palpatory skill and direct testing can accurately diagnose sacroiliitis and apply multiple treatment options
By Robert A. Kominiarek, DO, FACOFP
Inflammation of the sacroiliac (SI) joint, called sacroiliitis, is a common disorder seen by primary care physicians.1 Sacroiliitis can be the primary pain generator in up to 20 percent of patients with low back pain.2 Sacroiliac pain comes from the joint in the lower part of the back made up of the articulation between the sacrum and the iliac portion of the coxal bones. The sacroiliac joint’s main function is to provide shock absorption for the spine by a gliding type motion and to support great weight. Ligaments around the joint hold these bones together.3
Several different activities can cause sacroiliac pain, such as twisting, bending, heavy lifting, a fall or direct injury to the area. Other causes include somatic imbalance of the muscles around the hip or pelvis, one leg being longer than the other, poor posture, as well as laxity of the sacroiliac joint ligaments.4 Conditions that can predispose patients to sacroiliitis are pregnancy, infections of the skin, osteomyelitis, urinary tract infections, endocarditis, drug addictions, inflammatory bowel disease, and the spondyloarthropathies.5
Anatomy
The sacroiliac joints are classified as synovial and cartilaginous joints with only a quarter of the superior aspect covered with synovium and the majority of the inferior aspect completely cartilaginous. The iliolumbar ligament, which has three distinct attachments, is designed to help prevent translation/rotation of the L5 vertebra.
The sacrotuberous ligament is a large heavy ligament that attaches over a wide area to the posterior inferior spine of the ilium, to the fourth and fifth transverse tubercles of the sacrum, and to the inferior part of the lateral margin of the sacrum and the coccyx.
The sacrospinous ligament, which runs from the ischial spine to the anterior inferior aspect of the sacrum along with the posterior sacroiliac ligament, helps create the borders of the greater sciatic foramen. The sacrospinous ligament and the sacrotuberous ligament help to create the borders of the lesser sciatic foramen. The anterior sacroiliac ligament connecting the anterior aspect of the sacrum with the iliac fossa is in close proximity to the lumbosacral trunk and the obturator nerve and is structurally the weakest ligament of the sacrum.3
The nerve supply to the sacrum consists of unmyelinated nerve endings that are located in the capsule and ligaments that provide pain and thermal sensation. The capsule also contains encapsulated and unencapsulated nerve endings that provide positional and vibratory sensation.6 The posterior structures are innervated by lateral branches of the posterior rami, primarily L5-S2 and the anterior structures are innervated by the lateral branches of the posterior rami, primarily L4-S1.3
Biomechanics
The motion of the sacrum is complex and not based on a single axis. There are seven sacral axes: the vertical axis, right oblique axis, respiratory axis, sacroiliac axis, iliosacral axis, left oblique axis, and the anteroposterior axis. Problems with the motion of the sacrum can originate from either above the sacrum, below the sacrum or a combination of the two.7
History
Patients will complain of back pain with early morning stiffness that generally improves with mild exercise, but worsens with inactivity or prolonged periods of rest.4 It is not uncommon for the back pain to be diffuse, include pelvic pain, buttock pain, or pain in the thigh. Many times, there will be swelling over the affected side or diffusely over the entire sacrum.2
Patients may give a history of recent or remote trauma, pregnancy, rapid weight loss or gain or an anatomic discrepancy such as a shorter leg. Patients often present with complaints of pain in the sacroiliac area of the low back, difficulty bending or twisting, pain after sitting for a long time, stiffness, feeling like their low back is out of alignment and some relief with movement. Some patients report direct trauma to the involved side such as a fall or missing a step while descending.6
Evaluation
Sacroiliitis can be diagnosed by T.A.R. T.: tissue texture change, asymmetry of position, restriction of motion, and tenderness.7 Tenderness to palpation will occur at the sacroiliac joint, the posterior superior iliac spine or in the sacral sulcus.1 (Figure 1). The patient will commonly have an antalgic gait which, can be identified before doing the physical exam simply by observing the patient’s gait as they walk to the exam room.
There are several evaluation options.
The Faber test can be utilized by flexing the knee and hip and abducting and externally rotating the lower extremity while applying downward pressure on the flexed knee and the contralateral anterosuperior iliac spine which will illicit pain in the affected sacroiliac joint or hip.1 (Figure 2).
Have the patient lying supine with a flexed knee pushed towards the opposite shoulder, which will illicit pain in the affected SI joint.1 (Figure 3).
Compress the pelvis with the patient lying supine and apply direct force to the anterosuperior iliac spines which forces them laterally apart to also illicit pain in the SI joint.1 (Figure 4).
Performing the straight leg test can be useful for identifying any restriction of motion.
Radiographic evaluation with plain films of the sacroiliac joints may demonstrate erosions, bridging, joint space narrowing or sclerosis (these finding are not necessary to confirm sacroiliitis. Up to 25 percent of asymptomatic adults can have these radiographic abnormalities.)6
An MRI is useful in demonstrating inflammatory changes or tumors.
A bone scan is useful in demonstrating infection, tumor infiltration and inflammation.5
Differential Diagnosis
Consideration should be given to the following disease processes before a formal diagnosis is given:
Patients with a history of drug abuse need to have an underlying infection ruled out. If there is a history of trauma or strenuous athletic activity then either fracture or stress fracture should be a consideration. If the patient is elderly then osteoporosis may be the underlying cause.
Primary synovial villoadenomas of the SI joint can arise, although they are rare. Iatrogenic instability from previous pelvic surgery, bone graft or biopsy, plasma cell disorder, multiple myeloma, and referred pain from pelvic disease can all mimic sacroiliac pain.9 The examiner should also give consideration to Chapman’s posterior reflex points, as tenderness over the sacroiliac joints bilaterally could indicate possible disease in the fallopian tubes, uterus, vagina, prostate or seminal vesicles.8
Treatment
Appropriate treatment to be rendered will depend on the acuteness or chronicity of the sacroiliitis. Initially, in acute sacroiliitis, the treatment for the first two to three days should be ice packs for 15 to 30 minutes every six to eight hours.10 Later, moist heat should be applied to help loosen stiff muscles associated with the low back and the sacroiliac joint.
Osteopathic manipulative treatment can be utilized to help mobilize the sacrum at any point during the treatment sequence. A variety of modalities may be employed including HVLA, Muscle Energy, Strain-Counterstrain, Myofascial Release, Indirect Balancing or Craniosacral treatment.7
The examiner should keep in mind that there may be a dysfunction either above or below the sacrum or a combination thereof, which may be contributing to the sacroiliitis. Other treatment modalities that may be employed are anti-inflammatory medications such as non-steroidal anti-inflammatory drugs, steroids, bromelain, and non-narcotic medications such as tramadol. Although not usually indicated as a first-line intervention, narcotic medications may be used for those patients with chronic recalcitrant sacroiliitis.
Physical therapy needs to be prescribed that uses exercises geared toward rehabilitating the sacroiliac joint, and strengthening the core muscle groups. A patient education handout is available to download at http://www.acofp.org/publications/ archives/0607/0607_1.pdf
The three-page handout, provided by the Ohio State University Medical Center, describes both verbally and with illustrations, exercises your patients can do to stretch and strengthen the SI joint.
Inserts for shoes can be beneficial if there is a leg length discrepancy, and a sacroiliac belt will help support the joint. Pain management using dietary modifications, and weight management can help prevent sacroiliitis. The use of a sacroiliac joint injection should be the last treatment option, only used when all other treatment modalities have failed. After a particular treatment modality has been employed, the patient should be reassessed.
Dietary Management
Healthy eating habits are critical to an individual’s overall well-being. Obesity is linked to many disease states such as hypertension, hyperlipidemia, diabetes, heart disease and back pain. Sacroiliitis can be precipitated by excessive weight gain or even too rapid a weight loss.
Individuals suffering from sacroiliitis should make dietary adjustments to reduce joint inflammation. This diet should incorporate significant reduction of animal fats and protein intake, and eliminate the consumption of hydrogenated oils and aspartame. In the human body, aspartame is converted to methanol and formaldehyde. These byproducts accumulate and are excreted slowly from the body. Hydrogenated oils directly interfere with cell membrane synthesis and repair.
Elimination of the these products will help to reduce inflammation in the joint and allow the prostaglandin synthesis pathway to function appropriately. This is essential to controlling pain mediated pathways. Healthy eating habits are difficult lifestyle changes for many patients; however, reduction of sacroiliac pain can be achieved by dietary elimination of unhealthy foods.11
Sacroiliac Joint Injections
Employ sacroiliac joint injections when all other treatment modalities have failed to resolve inflammation. Accessing the joint can be done either with or without fluoroscopic guidance depending on the physician’s skill level. The patient should be placed prone on the fluoroscopy table and the landmarks over the affected SI joint identified. Use sterile technique so as not to introduce any contaminants into the joint.
Adequate anesthesia can be obtained either with a vapocoolant spray or shot blocker. Generally, a 25-gauge, 1½-inch needle is sufficient, however for larger patients a 31/2-inch spinal may be required. A 1 ml of steroid solution and 2 ml of 1 percent lidocaine without epinephrine are injected after inserting the needle at a 30-degree angle laterally to the sagittal plane, and 15 degrees inferiorly to the transverse plane. There should be no resistance to the injection. Ice packs should be applied after the injection.
Possible complications from sacroiliac injections are:
• Post injection flare
• Steroid arthropathy
• Facial flushing
• Skin atrophy
• Infectious arthritis
• Transient paresis of the injected side
• Hypersensitivity reaction and acceleration of joint attrition
The most common complication is post injection flare. Treat with ice packs and anti-inflammatory drugs – resolution should take no longer than two to three days.12
Conclusion
Sacroiliitis is a common presentation of back pain in the primary care setting. It has numerous precipitators such as trauma, weight loss/gain, pregnancy and delivery, structural abnormalities, infection, rheumatologic disease and metastasis. The astute clinician with knowledge of appropriate palpatory skills and testing can formulate an accurate diagnosis. Multiple treatment options exist to resolve this often painful and debilitating condition.
Providing effective patient education on how to manage this common malady is essential to overall treatment success, addressing factors such as weight, exercise, and dietary habits. Treatment should be initiated as soon as possible to optimize success at recovery. Teaching the patient preventative measures will enable them to live with little or no pain at all.
Dr. Kominiarek is a 1995 graduate of Nova Southeastern University College of Osteopathic Medicine, Ft. Lauderdale, Florida. He first received his certification in family medicine in 1998, and is currently in private family practice as owner and Director of Preble County Family Practice and After Hours Care in Eaton, Ohio, and is Co-Medical Director of Preble County Medical Center.
References:
Additional Bibliography:
Huber, R., Herdrich, A., Rostock, M., & Vogel, T. (2001, August 8). Clinical remission of an HLA B27-positive Sacroiliitis on Vegan diet. Retrieved March 2, 2006 from http://www.ncbi.nlm.nlh.gov
VanderCruyssen, B., Peeters, H., Laukens, D., Coucke, P., Mielants, H., DeVos, M., & DeKeyser, F. (2004, February 24). Radiological sacroiliitis is linked with CARD15 gene polymorphisms in patients with Crohn’s disease. Abstract retrieved March 2, 2006 from http://arthritis-research.com
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