Sacroiliac joint (SIJ) pain originates from the joint proper or the surrounding soft tissue structures. Exact prevalence of SIJ pain among athletes remains unknown and is likely underreported because SIJ pain referral patterns are often similar to spinal disease (28,40), and 39% of patients with SIJ dysfunction have concomitant spinal pathology (40). Additionally, 10% to 30% of all low back pain (3,11,15,16,18,22,30,34,35,40), and 20% to 80% of pelvic pain in pregnancy (40) can originate from the SIJ. According to the National Health Measurement Study, the effect of recalcitrant SIJ disease on patients' daily life is comparable to that experienced by patients considering surgery for end-stage knee and hip osteoarthritis (30).
There is a paucity of literature regarding SIJ pathology in athletes. However, sports requiring repetitive or asymmetric loading (kicking, swinging, throwing, and single leg stance) place athletes at increased risk. Any athlete can develop SIJ dysfunction, but sports with the highest prevalence include football, basketball, powerlifting, gymnastics, golfing, cross country skiing, and rowing (4,12,26,29,40). Step aerobics and use of elliptical and stair stepper machines also predispose athletes to SIJ pathology (29). Other risk factors include systemic inflammatory conditions (15), pregnancy, leg length discrepancy, hypermobility (30), scoliosis, direct trauma (4,23,40), degenerative joint disease (40), and biomechanical abnormalities (3). Degenerative changes at the SIJ are common after spinal fusion surgery, occurring in 40% to 75% of patients (30).
The SIJ has intricate anatomy with numerous supporting structures and variable innervation. As a result, SIJ pain is often multifactorial (28,30) and has been described as SIJ syndrome or SI complex pain (19,28). The SIJ is a diarthrodial joint that is synovial anteriorly and fibrous posteriorly (12,15,17,30,39). Thinner cartilage lends vulnerability of the ventral portion to degenerative changes that start as early as the third decade of life (3,39). This thin cartilage allows leakage of joint fluid with subsequent irritation of local soft tissue and nerves (33).
The SIJ is primarily supported by anterior and posterior interosseous ligaments (3,6,17,39,40) with accessory iliolumbar, sacrotuberous, and sacrospinous ligaments, enhancing stability (17,39,40). The SIJ has minimal mobility, allowing for only about 2 degrees of motion in each plane (3,12,39). The joint functions to provide load transfer between the spine and lower extremities (12,30,39).
The most common mechanism of injury for acute SIJ pain is sudden rotation and axial strain (15), but most athletes experience gradual progression of symptoms after repetitive microtrauma. There is no pathognomic symptomology indicative of SIJ pathology (3). However, athletes often present complaining of achy low back pain that makes it difficult to find a comfortable position (26). Pain worsens with running, climbing stairs, or standing from seated position (12,29,33,40). Pain that is insidious in onset, worse at night, associated with morning stiffness and improved by exercise is suspicions for rheumatologic etiology (33).
SIJ pathology causes no radicular symptoms (4); however, if mobility or alignment of the joint is altered, abnormal stress loads surrounding structures resulting in pain in the low back, buttock, groin, posterolateral thigh, or abdomen (3–6,10,12,15,29,30,33,37). Symptoms involving structures above the L5 spinal level suggest etiologies other than the SIJ (3,12,17,40).
Diagnosis can be challenging due to the complexity of the SIJ and variable pain referral pattern in athletes. Tenderness to palpation over the sacral sulcus is highly sensitive but not specific (3–6,40). Special tests such as Fortin finger, thigh thrust, compression, Gaenslen, and Patrick have inconsistent sensitivity, specificity, and interexaminer reliability when used individually. See Table 1 for description of these special tests. When at least three tests are positive, sensitivity and specificity improves to 85% to 94% and 80%, respectively (3,6,12,15,28,30,36,37,40). Leg length measurement and dynamic examination (i.e., Trendelenberg test, gait assessment) can help identify the etiology (3,12,29).
Although rare, sacroiliitis merits consideration in athletes with acute SIJ pain and fever. Causes include infection, reactive arthritis, gout, hematologic malignancies, hyperparathyroidism, Behcet disease, familial Mediterranean fever and medication side effects of isotretinoin (33). If acute sacroiliitis is considered, blood cultures, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are recommended. If possible, joint aspiration evaluation through culture, gram stain, cell counts, microscopy, and histology also are recommended (33).
Imaging rarely provides beneficial information for the diagnosis of SIJ dysfunction (12,15,22,28–30). However, imaging is recommended if there is concern for infection, inflammatory athropathy, fracture, anatomic anomalies, or neoplasm (15). See Table 2 for common findings in SIJ pathology. Degenerative changes are common and progressive with age but do not correlate well with symptoms (22). One study found that degenerative changes affect up to 65% of asymptomatic adults (30). It is crucial that imaging be correlated with history and physical examination to avoid misdiagnosis.
Anterior-posterior radiographs of the pelvis assess for fracture, tumor, and structural changes from chronic inflammation or degenerative disease, but also serve as a baseline for future comparison (4,20,40). The shape and obliquity of the SIJ creates bony overlap making radiographs difficult to interpret (20). Prone images, such as the Ferguson view, have been described but infrequently add useful information to the diagnosis (40). Computed tomography (CT) can be considered to further evaluate bony abnormalities or to look for evidence of active infection (32,33,40). CT is preferred if magnetic resonance imaging (MRI) is contraindicated (20), but MRI is the choice imaging modality to evaluate for inflammation, infection, stress fracture, structural lesions, and anatomic variations in the SIJ. Gadolinium enhancement is needed to visualize abscesses and determine the extent of soft tissue involvement of infectious and inflammatory processes on MRI (33). Single-photon emission CT and bone scintigraphy can be used for assessment of SIJ pathology but are not routinely utilized (40).
Systemic etiology must be considered in SIJ pain in young athletes, especially since spondyloarthritis (SpA) presents at a median age of 23 years. MRI criteria have been developed by the Assessment of Spondyloarthritis International Society (ASAS) for the diagnosis of sacroiliitis in spondyloarthritis (32). Early use of MRI can identify inflammatory changes that precede structural damage by up to 5 to 7 years (2,8,32) leading to more timely treatment of diseases such as ankylosing spondylitis (32). The ASAS MRI working group found insufficient evidence to change the current MRI criteria for SpA diagnosis because only 30% to 50% of patients with SpA have active sacroiliitis on MRI (21). Significant consideration has recently been given to adding the presence of structural lesions to MRI diagnosis of SpA but lack of international consensus on how erosion should be defined or quantified on MRI limits the proposal (2,21). Traditionally, short tau inversion-recovery sequences have been used to evaluate for SIJ subchondral bone marrow edema on MRI, but a recent study found spectral attenuated inversion recovery (SPAIR) T2 sequences to be comparable. Further research is needed before SPAIR T2 can be considered an acceptable alternative (8).
Periarticular bone marrow edema has been observed on imaging as a sequela of mechanical low back pain (20). Artifacts, such as inhomogeneous fat suppression and periarticular blood vessels, also can have similar appearance as bone marrow edema on MRI (20). Therefore, isolated “inflammatory changes” should be carefully correlated with the history and physical examination in the athlete with SIJ pain (21).
Physical examination and imaging alone cannot distinguish between SIJ pain and symptoms from associated soft tissue structures (36,37). Hence, intra-articular injections can provide important diagnostic information. Many sources raise concern that the ventral aspect of the joint capsule is thin and allows fluid to leak into the surrounding tissues (3,36,39). Despite this, intra-articular injections have a 90% diagnostic confidence (3,36) and are the most definitive diagnostic modality when more than 75% symptomatic relief is achieved following injection (30). If 50% to 74% improvement is noted, the pain is likely multifactorial or the injectate was not localized to the synovial joint. If less than 50% symptom relief results, other etiologies of pain should be considered (30).
The success rate of landmark based injections is only 12% to 22% (9,12,16,17,34), hence SIJ intra-articular injections should be image guided. Reported accuracy of intra-articular injections guidance are 40% to 90% (5,16,34) with ultrasound, 97% to 98% (16,17) with fluoroscopy, and 100% with CT guidance (9). Therefore, if the intra-articular injection is being used, fluoroscopy or CT is the preferred modality.
Diagnostic nerve blocks can differentiate the etiology of pain in or around the SIJ and have been shown to improve the efficacy of radiofrequency neurotomy (RFN) (14) which can be used for treatment of SIJ pain. However, given the multiple innervations and anatomic variance of the SIJ, single-location nerve blocks of a fixed depth are inadequate (19). A comprehensive fluoroscopy-guided protocol exists and has been validated, but requires 17 injections and is not routinely used (11). Improved understanding of the anatomy has allowed the development of ultrasound-guided nerve blocks. A recent comparison of fluoroscopy and ultrasound-guided nerve blocks demonstrated shorter procedure times, fewer injections and vascular breaches in the ultrasound group, with similar efficacy across both groups (11). Another benefit of ultrasound-guided techniques is the avoidance of ionizing radiation. Ultrasound and fluoroscopy are readily available to many athletes in the training room or associated medical facilities which increase utility of these modalities.
Pain pressure threshold with algometry and assessment of innominate movement using an electromagnetic palpation digitization technique have differentiated patients with and without SIJ pain (1,37). These concepts are outside the scope of this article because devices used in these measurements are not widely available in the training room/clinic at present.
The differential diagnosis for SIJ pain in athletes is broad and should include musculoskeletal, visceral, and systemic etiologies. Providers should have high suspicion for rheumatologic disease in cases of low back pain with atypical presentations or poor response to management (25). Depending on clinical clues, lumbar disc disease, facet disease, osteitis condensans, sacral herniated nucleus pulposus, muscle spasm or strain, osteoarthritis, spondyloarthropathy, stress fracture, osteomyelitis, neoplasia, gout, pseudogout, other inflammatory arthridities (psoriatic, reactive, rheumatoid), inflammatory bowel disease, and endometriosis should be considered (3,20,24,25,28,38,40).
Athletes are managed similarly to the general population, but require sport specific rehabilitation and gradual return to activity. Treatment goals include managing symptoms and treating the underlying dysfunction (3,4,29). Conservative management with activity modification, topical and oral medication, physical therapy (PT), manual manipulation are first-line treatments (22,28,30). Bracing is second line. There is minimal evidence supporting complementary medicine, such as acupuncture, massage, or yoga in SIJ pain, but these can be considered as adjunctive therapy (30).
There is limited discussion in the literature regarding the use of medications in SIJ pain. Polsunas et al. (28) describe a stepwise approach starting with topical medications (i.e., lidocaine and diclofenac) and acetaminophen. Nonsteroidal anti-inflammatories have a role in the setting of acute pain for management of athletes with evidence of sacroiliitis (4,13) but should not be used chronically due to their significant side effects. If pain is not controlled with first-line medications, tramadol can be considered. Caution is advised if considering opioids (28).
PT with a home exercise program is the mainstay for all athletes who have musculoskeletal SIJ pain. Studies suggest that 95% of the patients have improved function after PT, although a validated exercise protocol has yet to be established (40). Several sources have recommended a phased rehabilitation program (12,29). In general, core and pelvic stabilization, correction of muscle imbalances and retraining of posture and proprioception are targeted (3,4,12,28,29,40).
If injury is acute, the initial phase includes 1 to 3 days of ice, anti-inflammatory medications as needed, and relative rest. Once pain is adequately controlled, muscular imbalances are addressed. Attention should be given to external hip rotators, such as the piriformis. Tightness in these muscles is thought to contribute to recurrence of symptoms. Agonist-antagonist relationships should be carefully considered. For example, if the iliopsoas is tight and the hamstrings and gluteus maximus are weak, an anterior pelvic tilt will result. This will prevent adequate rehabilitation of the iliopsoas due to shortening. If this dysfunction is unilateral, there will be a functional leg length discrepancy thus worsening symptoms due to asymmetric loading of the SIJ (29).
Athletes with SIJ pain frequently have tightness in the hip adductors, piriformis, obturator internis, rectus femoris, tensor fascia lata, quadratus lumborum, and latissimus dorsi. Weakness is commonly noted in the hamstrings, gluteus medius, gluteus maximus, and lower abdominals. Appropriate strength and flexibility of the hamstrings and gluteus maximus are vital because they play an integral role in SIJ function due to their attachment to the sacrotuberous ligament (29).
Rehabilitation begins with closed kinetic chain strength training with progression to multiplanar strengthening exercises once core and lumbopelvic stabilization has been achieved (29). Gait analysis may be useful in running intensive athletes. Sports-specific training and performance errors should be corrected before returning to activity (3,4).
Orthotic devices may be useful in addressing biomechanical issues. Shoe orthoses may be necessary if there is significant pes planus or pes cavus that alters gait mechanics. Heel lifts are recommended for use if anatomic leg length discrepancy is discovered (3,12,29,40). SI bracing is most effective when SIJ dysfunction is due to hypermobility. SI braces provide proprioceptive feedback and stability (29) which can reduce rotational movement up to 30% (39). Use should only be considered in the initial phases of rehabilitation for the general population (3,10) but can be useful throughout pregnancy (40). The underlying issue causing the hypermobility, whether joint laxity or muscular imbalances, should ultimately be addressed (29).
Manual manipulation provides reflexive relaxation and pain inhibition at the segmental level through the firing of afferent mechanoreceptors when stress is applied to the periarticular structures (40). Patient selection is vital and manipulation is ideally suited for those having symptoms less than 17 days, no pain distal to the knee, hypomobility of the lumbar region, Fear-Avoidance Beliefs Questionnaire Work subscale less than 20, and at least one hip with greater than 35 degrees of internal rotation (6). Before manipulation, the athlete should be evaluated to determine if hypermobility is the etiology of the SIJ dysfunction because further mobilization may worsen symptoms (29).
Various forms of manual manipulation are performed by osteopaths, chiropractors, physical therapists, and athletic trainers and terminology describing dysfunction has some overlap but also can be unique depending on specialties (3,4,40). Common findings that affect the SIJ include innominate shears, rotations, and flares as well as sacral torsions and unilateral flexion or extension dysfunctions (3). Initially, soft tissue, counterstrain, myofascial release and muscle energy techniques are helpful and generally well tolerated even if the athlete has significant pain. High-velocity, low-amplitude and low-velocity, high-amplitude techniques also may be used. An exhaustive listing of treatment techniques is beyond the scope of this article. Studies have shown that up to 95% of patients have excellent short-term results after manipulation but long-term benefit and recurrence prevention effects are unproven (40). If repetitive mobilization is required, the underlying muscular imbalances should be addressed (29).
Injection therapy is recommended when diagnosis is in question, the athlete is unable to tolerate rehabilitation due to pain, or pain is unresponsive to conservative management (22,28–30,40). Intra-articular or periarticular injections can be performed and image-guided injections are preferred. No difference has been found in the therapeutic outcomes of improved pain and disability when fluoroscopic guidance was compared with ultrasound guidance for intraarticular injections (16,34) or intra-articular injections were compared with periarticular injections (28,34). A recent fluoroscopic technique has been described that provides three-dimensional views to ensure the needle is in the SIJ and advanced far enough to deliver medication into the anterior third of the joint (17). In this procedure, the needle is initially inserted using a posterior view, and then a lateral view is obtained to confirm needle placement and guide advancement. This technique was found to have 93% accuracy of needle placement and 87% accuracy of contrast spread (17). Limitations of fluoroscopy and CT guidance compared with ultrasound include exposure to radiation and lack of real-time visualization of soft tissues and vasculature during needle advancement (16,34). Limitations of ultrasound guidance are: loss of visualization of the needle behind calcified structures and suboptimal visualization in athletes with a body mass index above 30 (16,34). Potential complications of any injection include intravascular injection, sciatic nerve injury, and periosteal irritation (16). Absolute contraindications to SIJ injections include allergy to the injectate, bleeding disorders, decubitus ulcer, local infection, femoral head avascular necrosis, severe uncontrolled hypertension, unstable angina, or severe coronary artery disease (16,28). Relative contraindications to SIJ injections are anticoagulation therapy and uncontrolled diabetes.
The most common medications used for intraarticular and periarticular injections are corticosteroids combined with local anesthetic (e.g., 0.5% to 1% lidocaine or 0.25% levobupivicaine) for a total volume of 2.5 mL to 4 mL. There is no consensus on dosing preference but dexamethasone 10 mg (16), triamcinolone acetonide 40 mg (18), and methylprednisone 40 mg have been studied (34).
Data are limited for use of sclerosing agents such as dextrose prolotherapy. In one study, when compared with intra-articular corticosteroid injection, intra-articular prolotherapy resulted in similar improvements in pain and disability at 2-week follow-up. However, prolotherapy was found to provide longer duration of improvement, lasting an average of 9 months compared with 3 months with corticosteroids. Both groups produced greater than 50% pain relief. The corticosteroid group required fewer injections (1 to 2 vs 2 to 3 in the prolotherapy group) to achieve >90% pain relief. No serious adverse effects were noted in either group (18).
Another small study assessed the efficacy of prolotherapy injections in the posterior interosseous ligament to improve pain and stability at the SIJ when hypermobility was present. This study proposed that ligamentous instability altering load transfer at the SIJ may not be sufficiently addressed through exercise programs and may benefit from the potential ability of prolotherapy to build collagen fibers. The study reported improved pain and disability in 76% of participants at 3 and 12 months and 32% of the participants at 24 months (7).
RFN is another management option for SIJ pain that should be considered if there is a positive response to intra-articular injection or nerve block, but improvement in symptoms after RFN is short lived. This intervention is technically difficult given inaccessibility of some intra-articular nerves and intersubject variation of innervation (9,30). Treated nerves can regrow, and even if initially successful, the procedure sometimes must be repeated. Traditionally, fluoroscopy and CT guidance have been used with comparable safety and success (9), but it has recently been suggested that ultrasound be considered using the transverse sacral tubercle to locate the posterior sacral network for nerve blocks (31). The posterior SIJ soft tissues can be targeted through RFN of the sacral lateral branch if that is believed to be the main source of pain (19).
RFN can be performed via conventional or cooled techniques. Conventional RFN uses temperatures between 80°C and 90°C, limiting the size of the area treated due to heating and potential damage of surrounding tissues. Cooled RFN is performed at about 60°C and circulating water helps remove heat from the probe and adjacent tissues including spinal nerves. This allows for a larger target area and, in theory, should increase success given the variable innervation of the SIJ (27). However, studies have not demonstrated clinical superiority of either treatment (28). Patel et al. found that only about 40% of patients showed clinically significant improvement after cooled RFN at 12 month follow up (27). A small retrospective study using a recently developed probe with a single point of entry and a broad lesion resulted in a 61% mean decrease in pain scores but more data are needed for definitive conclusions (14).
Patients with BMI <30 and increased levels of physical activity tend to have better cooled RFN outcomes. Cooled radiofrequency ablation (RFA) effects are similar across genders, but women report higher post-procedure satisfaction (35).
Surgical Candidate Considerations
Surgical fusion of the SIJ should be considered only for refractory cases that have failed 6 or more months of conservative treatment (30). Level of competition of the afflicted athlete must be considered carefully. Good surgical candidates should have pain localized to the SIJ using three or more positive examination tests and successful but short duration of improvement with intra-articular SIJ injection (10,22,40). Factors, such as malignancy, local infection, and fracture should be ruled out (30). Both open and minimally invasive approaches have improved pain, disability, and quality of life when surgical candidates are selectively chosen (22).
Compared with minimally invasive surgery (MIS) for SIJ fusion, open procedures have larger surgical wounds, longer operating times, lengthier hospital stays, and higher potential complication rates (5.44% in open, 3.49% in MIS). Simultaneous fusion of bilateral SIJ has poor outcome (22). Unilateral fusion using MIS technique should be performed in carefully selected athletes and only after other treatment options have been exhausted (15,30).
Return to Play Considerations
Return to play can be a conundrum and involves proper diagnosis, treatment, and phased rehabilitation. Athletes should observe a short period of relative rest and avoid activities that repetitively load the SIJ, especially if the loading is asymmetric (40). Once the pain is improved without medication, the athlete should be assessed for biomechanical issues correctable with orthotic devices (e.g., heel lift for leg length discrepancy), rehabilitation of muscular imbalances or gait retraining. When the athlete has achieved 75% of their strength and flexibility, they may progress to sports-specific activities (29). Careful attention should be given to identify and correct training and performance errors. It is typically recommended that athletes be rested from competition for 24 hours after SIJ injection has been performed.
If the SIJ pain is due to ankylosing spondylitis, a thorough evaluation should be performed assessing for systemic involvement with consideration for an evaluation for cardiac conduction abnormalities. These athletes also should be made aware that they are at higher risk for spinal fractures to allow for informed decisions regarding sports participation between the athlete and the sports medicine team (13).
SIJ dysfunction is a common cause of low back pain in athletes, especially in sports with repetitive, asymmetric loading. Consideration of the SIJ as a pain generator in this population is important because sports can predispose athletes to SIJ pathology. The anatomy is multifaceted often resulting in symptoms that are vague or mimic other spinal conditions, thus confounding the diagnosis. Careful history and physical examination are key. If diagnosis remains in question, joint injections or nerve blocks may be used. Imaging rarely yields useful information for the diagnosis of SIJ dysfunction but is used to rule out alternate etiologies. First-line treatments include conservative management of pain and phased rehabilitation with progressive sport specific retraining. SIJ injections and RFA may be performed if pain persists despite targeted rehabilitation. Surgical treatment may be considered after all other options have been exhausted. Successful return to play can be achieved in most athletes with accurate and timely diagnosis followed by appropriate pain management and rehabilitation.
The authors declare no conflict of interest and do not have any financial disclosures.
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