Sacroiliac Dysfunction

Aka: Sacroiliac Dysfunction, Sacroiliac Joint Dysfunction, SI Joint Dysfunction, Sacroiliitis, Sacroiliac instability, Sacroiliac Ligament Sprain

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II. Epidemiology

  1. Prevalence: 25% of Low Back Pain in adults
  2. More common in women

III. Risk Factors

  1. Women
    1. Increased sacroiliac joint mobility and secondary strain
    2. Pregnancy and Postpartum State also increase the risk of SI Joint Dysfunction
  2. Rheumatologic Conditions
    1. Osteoarthritis
    2. Spondyloarthropathy (e.g. Ankylosing Spondylitis)
    3. Posttraumatic Arthritis
  3. Preexisting structural abnormalities
    1. Pubic Symphysis abnormalities (e.g. laxity)
    2. Leg Length Discrepancy or pelvic asymmetry
      1. Distinguish from Functional Leg Length Discrepancy due to SI Joint Dysfunction
    3. Hypomobility of the SI Joint
    4. Hypermobility of the SI Joint
  4. Trauma
    1. Sudden drop of leg on unlevel ground
    2. Heavy lifting
    3. Fall onto buttocks
    4. Motor Vehicle Accident
    5. Torsional forces at Pelvis (e.g. football, gymnastics, golfing)

IV. Pathophysiology

  1. Bony Pelvis is tightly bonded at 3 joints (2 SI joints and Symphysis Pubis)
    1. Sacroiliac joint functions as a shock absorber for axial loads on the Lumbar Spine
    2. Lumbar Spine transmits axial load forces to the lower extremities via the sacroiliac joint when bending
  2. Anterior and posterior ligaments supporting the SI joint tend to allow minimal laxity normally
  3. Injury or inflammation of the joint formed between the Sacrum and the ilium

V. Exam

  1. See Hip Exam
  2. See Patrick's Test (Figure of Four Test)
  3. See Low Back Exam
  4. Observe
    1. Iliac crests at unequal heights
    2. Pelvic tilt on standing (asymmetric hip height)
  5. Function
    1. Weak gluteus medius
    2. Tightness of iliopsoas Muscle, piriformis Muscle, hamstring Muscles
    3. Functional Leg Length Discrepancy
  6. Provocative: General
    1. Tenderness on palpation of SI joint (esp. inferomedial aspect of posterior superior iliac spine)
    2. See Patrick's Test (Figure of Four Test)
    3. One Legged Hyperextension
  7. Provocative: Cluster of Laslett SI Joint Provocative Maneuvers
    1. General
      1. Laslett maneuvers are considered positive if 4 of 5 maneuvers produce pain at the affected SI Joint
      2. Video
        1. https://www.youtube.com/watch?v=8biQsdgdyzA
    2. Gaenslen Test
      1. See Gaenslen Test
    3. Thigh Thrust Test
      1. Patient supine with Sacrum fixed against table, and hip and knee flexed to 90 on the affected side
      2. Examiner places one hand on the SI joint and other hand over the top of the knee
      3. Examiner applies pressure down onto the knee into the affected hip, towards the table
    4. Distraction Test (Gapping Test)
      1. Patient lies supine on table, with examiner with hands over bilateral, lateral aspect of Pelvis
      2. Apply posterior force into each anterior superior iliac spine against the table
    5. Compression Test
      1. Patient lies on their side, and examiner places hands over the lateral hip and Pelvis
      2. Examiner applies compression force to the iliac crest and into the table
    6. Sacral Thrust Test
      1. Patient lies prone, on their Stomach, on the exam table
      2. Apply downward pressure over the Sacrum

VI. Symptoms

  1. Low Back Pain localized to the SI joint (lateral to midline)
  2. Pain may be referred into the leg
  3. Provocative activities
    1. Climbing or descending stairs
    2. Jogging uphill
    3. Jumping (pain on landing)
    4. Prolonged sitting or standing
    5. Weight applied to the affected side or lying on the affected side

VII. Signs

  1. Focal tenderness over the SI Joint
  2. One Legged Hyperextension Test
  3. Figure of Four Test (Patrick's Sign, FABER Test)
  4. Functional Leg Length Discrepancy

VIII. Differential Diagnosis

  1. Lumbar Disc Disease with radiculopathy
  2. Lumbar facet syndrome
    1. Seen in older patients, especially on hyperextension
  3. Musculoskeletal Low Back Pain
  4. Femoral Acetabular Impingement
    1. Hip Joint locking or clicking
  5. Ischiofemoral Impingement
    1. Snapping Hip with Hip Pain
  6. Piriformis Syndrome
    1. Pain at buttocks radiating into posterior leg, especially on sitting
  7. Pudendal nerve irritation
    1. Pain in perineum or Scrotum, especially with sitting
  8. Fractures (e.g. Pelvic Bone)
    1. Consider in Osteoporosis or Trauma
  9. Bony neoplasm
  10. Septic Sacroiliitis (emergency)
    1. Presents with fever, limp and SI joint region pain
    2. Most common in children 0.5 to 4 years old and in adolescents
  11. Spondyloarthropathy causing Sacroiliitis
    1. Ankylosing Spondylitis
    2. Reactive Arthritis (e.g. Reiter's Syndrome)
    3. Inflammatory Bowel Disease with secondary Arthropathy
    4. Psoriatic Arthritis

IX. Imaging

  1. Normal in most cases (unless underlying Spondyloarthropathy)

X. Management

  1. NSAIDs
  2. Physical therapy with mobilization techniques
    1. Perform manipulation in 2 sessions over 2 weeks
    2. Most effective for longterm relief if combined with Stretching Program below
    3. Javadov (2021) Pain Physician 24(3): 223-33 [PubMed]
  3. Pelvic girdle Stretching and strengthening program (see video below under resources)
    1. Iliopsoas muscle Stretching
    2. Piriformis muscle Stretching
    3. Thoracolumbar fascia Stretching
      1. Indicated if tightness on forward flexion
      2. Treated with foam roller and deep tissue mobilization
    4. Evaluate and treat with Core Muscle Exercises for abdominal Muscle or Pelvic Floor Muscle Weakness)
    5. Evaluate and treat Ipsilateral gluteal Muscle Weakness
    6. Evauate and treat contralateral latissimus Muscle Weakness
  4. Other measures in specific cases
    1. Consider differential diagnosis (including Spondyloarthropathy)
    2. Pelvic belts
      1. Consider for SI Joint stabilization in peripartum patients
      2. Mens (2006) Clin Biomech 21(2): 122-7 [PubMed]
  5. Pain Management and Surgical Management Interventions in Refractory Cases
    1. SI Joint Corticosteroid Injection
      1. Indicated in refractory cases or Sacroiliitis
      2. Simopoulos (2015) Pain Physician 18(5): E713-E756 [PubMed]
    2. Cooled Radiofrequency Ablation (Radiofrequency Neurotomy)
      1. Ablation at L4 and L5 Medial Branch, and lateral sacral branches
      2. Chen (2019) Medicine 98(26): e16230 [PubMed]
      3. Cohen (2008) Anesthesiology 109(2): 279-88 [PubMed]
    3. SI Joint Fusion (Sacroiliac Arthrodesis)
      1. Consider if refractory to all other measures
      2. Buchowski (2005) Spine J 5(5): 520-8 [PubMed]

XI. Resources

  1. Sacroiliac Joint Dysfunction Self Treatment (Bob and Brad)
    1. https://www.youtube.com/watch?v=iUVY4CpI7vI

XII. References

  1. Madden (2010) Netter's Sports Medicine, Elsevier, Philadelphia, 402-3
  2. Newman (2022) Am Fam Physician 105(3): 239-45 [PubMed]

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