Sacroiliac Joint Pain


What are the sacroiliac (SI) joints?

The sacroiliac (SI) joints are formed by the connection of the sacrum and the right and left iliac bones. The sacrum is the triangular-shaped bone in the lower portion of the spine, below the lumbar spine. While most of the bones (vertebrae) of the spine are mobile, the sacrum is made up of five vertebrae that are fused together and do not move. The iliac bones are the two large bones that make up the pelvis. As a result, the SI joints connect the spine to the pelvis.

The sacrum and the iliac bones are held together by a collection of strong ligaments. There is relatively little motion at the SI joints. There are normally less than 4 degrees of rotation and 2 mm of translation at these joints.

Most of the motion in the area of the pelvis occurs either at the hips or the lumbar spine. These joints do need to support the entire weight of the upper body when we are erect, which places a large amount of stress across them. This can lead to wearing of the cartilage of the SI joints.


What is sacroiliac joint dysfunction?

There are many different terms for sacroiliac joint problems, including SI joint dysfunction, SI joint syndrome, SI joint strain, and SI joint inflammation. Each of these terms refers to a condition that causes pain in the SI joints from a variety of causes.


What are the causes of sacroiliac joint dysfunction?

SI joints have a cartilage layer covering the bone. The cartilage allows for some movement and acts as a shock absorber between the bones. When this cartilage is damaged or worn away, the bones begin to rub on each other, and  arthritis occurs. This is the most common cause of SI joint dysfunction. Degenerative arthritis occurs commonly in the SI joints, just like other weight-bearing joints of the body.


Another common cause of SI joint dysfunction is pregnancy. During pregnancy, hormones are released in the woman's body that allows ligaments to relax. This prepares the body for childbirth. Relaxation of the ligaments holding the SI joints together allows for increased motion in the joints and can lead to increased stresses and abnormal wear. The additional weight and walking pattern (altered gait) associated with pregnancy also places additional stress on the SI joints.

Any condition that alters the normal walking pattern places increased stress on the SI joints. This could include a leg length discrepancy (one leg longer than the other), or pain in the hip, knee, ankle, or foot. Patients with severe pain in the lower extremity often develop problems with either the lower back (lumbar spine) or SI joints. In most cases if the underlying problem is treated, the associated lumbar spine or SI joint dysfunction will also improve.

There are many disorders that affect the joints of the body that can also cause inflammation in the SI joints. These include gout, rheumatoid arthritis, psoriasis, and ankylosing spondylitis. These are all various forms of arthritis that can affect all joints. Ankylosing spondylitis is an inflammatory arthritis that always affects the SI joints. It can lead to stiffness and severe pain in the SI joints. As the disease process continues, the SI joints fuse together and have no further motion. Once this occurs, there is no further pain associated with the SI joints.


What are sacroiliac joint dysfunction symptoms?

The most common symptom of SI joint dysfunction is pain. Patients often experience pain in the lower back or the back of the hips. Pain may also be present in the groin and thighs. In many cases, it can be difficult to determine the exact source of the pain. Your physician can perform specific tests to help isolate the source of the pain. The pain is typically worse with standing and walking and improved when lying down. Inflammation and arthritis in the SI joint can also cause stiffness and a burning sensation in the pelvis.


How is sacroiliac joint dysfunction diagnosed?

The first step in diagnosis is typically a thorough history and physical examination by a physician. The physician will ask questions to determine if there are any underlying disorders that could be causing the patient's pain. This can also help differentiate pain coming from the SI joints, lumbar spine, or hips. There are various tests a physician can perform during the physical examination that can help isolated the source of the pain. By placing your hips and legs in certain positions and applying pressure, the SI joints can be moved or compressed to identify them as a source of pain. Other portions of the examination are to exclude certain possibilities that could mimic sacroiliac disease.

The next step in diagnosis is often plain radiographs (X-rays). The patient may have X-rays of the pelvis, hips, or lumbar spine depending on what the physician finds on the history and physical examination. A computed tomography (CAT or CT) scan may also help in the diagnosis. A CT scan gives a more detailed look at the joint and bones. Both X-rays and CT scans can help identify sacroiliitis. This can appear as sclerosis in the joints. More severe wear in the joints can appear as erosion of the bone around the SI joints. These tests can also look for fusion of the SI joints. A (MRI) scan can also be helpful. This provides a better evaluation of the soft tissues, including muscles and ligaments. It can also identify subtle fractures that may not be seen on an X-ray. The MRI can identify inflammation in the SI joint by the presence of excessive fluid in the joint. A bone scan can be obtained to help isolate the source of your pain and can be used to identify bony abnormalities. The bone scan can identify areas of increased activity in the bone. This is a nonspecific test and can be positive in cases of arthritis, infection, fracture or tumors of bone.

Often the most accurate method of diagnosing SI joint dysfunction is by performing an injection that can numb the irritated area, thereby identifying the pain source. An anesthetic material  can be injected along with a steroid  directly into the SI joint. This is usually performed with the aid of an X-ray machine to verify the injection is in the SI joint. The anesthetic and steroid can help relieve the pain from inflammation that is common with SI joint dysfunction. The duration of pain relief is variable, but this is very useful to determine that the SI joint is the source of the pain.


What is the treatment for sacroiliac joint dysfunction?

As stated above, injections into the SI joint can provide both diagnosis and treatment. The duration of pain relief from injection can last from one day to much more long term. The injections can be repeated each month for a total of three each year. Oral anti-inflammatory medications  are often effective in pain relief as well. These can be taken long term if the patient does not have any other medical problems that prevent them from taking these medications. 


Physical therapy can be very helpful. Pain in the SI joint is often related to either too much motion or not enough motion in the joint. A physical therapist can teach various stretching or stabilizing exercises that can help reduce the pain. A sacroiliac belt is a device that wraps around the hips to help stabilize the SI joints, which can also help the SI joint pain. Other options to stabilize the SI joints include manual therapy, and Pilates.

If other treatments fail and pain continues to interfere with normal activities, surgery might be an option. Surgery for SI dysfunction involves a fusion of the SI joints. In this surgery, the cartilage covering the surfaces of the SI joints is removed and the bones are held together with plates and screws until they grow together (fuse). This eliminates all motion at the SI joints and typically relieves the pain. This should be considered only if other less invasive treatments have not been successful.


How can sacroiliac joint dysfunction be prevented?

Unfortunately, SI joint dysfunction is not preventable in some people. For many, it is an unfortunate part of the normal aging process. However, the severity can be reduced through treatment with medication, injections, or physical therapy. Maintaining a healthy body weight and good conditioning can reduce the chances of developing SI joint dysfunction and other forms of arthritis. By reducing the loads on the joints, there is less chance for cartilage damage and subsequent arthritis.


How is the surgery performed?

 

Several methods of fusion have been used including anterior, transgluteal, through the iliac bone, and from posterior (with and without internal fixation). A posterior approach from near the midline has been shown to need a

very small incision but at the same time offering a better anatomic approach and good visualization of the SI joint.

 

The surgery includes:

➔ a very cautious planar approach to the joint that preserves

important functioning anatomy (muscles, fascia, nerves, lumbar

spine)

➔ cautious preparation of the joint (both intra-articularly and

extra-articularly)

➔ carefully selected internal stabilization, and

➔ cautious anatomic repair.

 

Stimulation methods are added when there are co-morbidities or

certain psychosocial risks, as the effect of a failed surgery is especially

severe in such patients. In the new DIANA procedure an implant is inserted via a small incision (3 cm) using special instruments that approximate the ligaments of the pelvic girdle back to their regular state through controlled distraction. This process is called “ligamentotaxis”. Bone and bone replacement material is then added, which aims to ensure a solid, permanent immobilization of the joint after the healing phase is complete.

 

What happens after the surgery?

Patients can walk with crutches and activity is limited to partial

weight bearing on the affected side for six weeks. Patients do not suffer stiffness in the traditional sense or increased stress in the untreated SI joint. Bilateral fusion is unusual and seems to occur in cases of increased stress from fused lumbar discs (especially multilevel) or a congenital anomaly. Post-operative curative treatment and/or rehabilitation is not necessary for patients in a

generally normal state of health.

 

Does the surgery help?

The results of the surgery are encouraging. Experience to date shows that it provides a reliable method of stabilizing the joint and treating the SI pain. Follow-up on more than 200 patients shows significant improvement of life quality and

pain relief with only a few patients who have not experienced an improvement.