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RFS – Clinical Pearls

Diagnosing and Managing Sacroiliac Joint Pain

Gusfa, Donald BS; Bashir, Daniyal A. MD; Saffarian, Mathew R. DO

Author Information
American Journal of Physical Medicine & Rehabilitation: April 2021 - Volume 100 - Issue 4 - p e40-e42
doi: 10.1097/PHM.0000000000001540
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Abstract

Sacroiliac joint (SIJ) pain corresponds to dysfunction in the setting of anatomical disruption with resultant joint hypermobility or hypomobility, as well as concomitant or resultant arthritic inflammation. Typical presentations include sharp pain inferolateral to the SIJ that worsens with transitioning positions or rotational pelvic motion. This is commonly secondary to multiple factors including excessive axial loading and joint stress, degenerative changes, traumatic events, pregnancy, and inflammatory arthropathies.1

Once non-SIJ causes of pain (Table 1) are ruled out with imaging and physical examination maneuvers, additional stress tests should be performed to determine the structural origin of the pain. It was found that testing positive on three or more sacral provocation tests (distraction, thigh thrust, sacral compression, Gaenslen’s right, Gaenslen’s left, and sacral thrust) yielded a 94% sensitivity and 78% specificity to SIJ pathology diagnosed using an image-guided diagnostic injection (Table 2). Furthermore, all patients diagnosed via injection had at least one positive stress test.2 However, a more recent study by Schneider et al.3 argues their diagnostic validity. Common tests such as seated flexion and FABER should also be assessed. Beyond the physical examination, SIJ imaging can show varying levels of diagnostic accuracy in evaluating SIJ pathophysiology and seem to be more adept at excluding other causes of the pain.1

TABLE 1 - Common causes of SIJ mimics
Differential Common Findings
Lumbar facet arthropathy Axial, nonradicular spinal pain. Diagnostic confirmatory medial branch blocks can be performed to properly diagnose. Traditionally aggravated facet loading via extension and rotation.
Lumbosacral radiculopathy Varies according to the level of the nerve roots involved. Most commonly L5 and S1. Typically sudden onset LBP radiating down the lateral aspect of the leg into the foot during lifting activities, coughing/sneezing, bending/twisting activities. Often (+) Straight Leg Raise (SLR) test, reproducing pain. Once SLR positive, can do additional maneuvers like Bowstring Test, Ely’s Test, Sitting Root test. MRI is frequently abnormal with lumbar disc herniation. EMG can be positive with axon loss.
Piriformis syndrome Lateral buttock, posterior hip, and proximal posterior thigh, as well as the SI region. Possibly exacerbated by walking up stairs. FAIR test—Pain with hip flexion, adduction, and internal rotation (FAIR).
Ankylosing spondylitis More common in males, RF(−), HLA-B27 positive. Symptoms: back pain and significant stiffness, most notably in the morning and night. Bamboo spine seen on imaging.
Psoriatic arthritis Psoriatic skin lesions, nail pitting, HLA-B27 (+), dactylitis, and pencil in cup deformity of the distal interphalangeal joint seen on radiography.
Enteric arthropathy HLA-B27 (+), asymmetric joint involvement, synovitis affecting the peripheral joints. In conjunction with IBD presentation.
Spinal stenosis Most commonly due to degenerative changes. Patient’s present with axial spinal pain +/− lower limb and buttocks pain. Neurogenic claudication with positive shopping cart sign. Exacerbated by prolonged standing or walking with spine extended, and relieved with lumbar flexion.
Somatic dysfunction Restricted range of motion in the SIJ causing a torsion, flexion, extension motion pattern.
Spondylolisthesis Males more commonly affected than females, but progression is more frequently seen in females. Presentation is typically back pain +/− radiation to the buttocks or LEs. Lumbar extension, prolonged standing and walking all increase symptomology. Dynamic flexion-extension x-rays, and MRI are the imaging of choice.
Information is adapted from Cuccurullo et al.5
EMG, electromyography; IBD, inflammatory bowel disease; LBP, lower back pain; LEs, lower extremities.

TABLE 2 - Diagnostic measures of SIJ pain
Study Type Diagnostic Measure Description Sensitivity Specificity Source
Provocation Distraction Posterior force applied to the left and right ASIS while the patient lies supine. 60% 81% Laslett et al.2
35% 83% Schneider et al.3
Compression Downward force is placed on the iliac crest while the patient lies on their side. 69% 69% Laslett et al.2
35% 78% Schneider et al.3
Thigh thrust Posterior force is placed on the patient’s femur while the examiner’s hand is on the under the sacrum. The patient lies supine with their hip flexed to 90 degrees. 88% 69% Laslett et al.2
29% 72% Schneider et al.3
Gaenslen’s Examiner hyperextends the symptomatic hip and flexes the asymptomatic hip while the patient lies supine and with their symptomatic sided leg off the table. 53%, 50% 71%, 77% Laslett et al.2
(left, right) (left, right)
29% 44% Schneider et al.3
Sacral thrust Anterior force is applied to the sacrum while the patient lies prone. 63% 75% Laslett et al.2
77% 28% Schneider et al.3
FABERE FABERE (Patrick’s test) reproduction of pain with flexion, abduction, external rotation of the hip joint, and extension of the leg via downward force by the examiner. In a degenerative hip, there will be ipsilateral pain. In a patient with a dysfunctional SIJ, pain will occur in the contralateral hip. 77% 28% Schneider et al.3
Imaging Radionuclide bone scanning Examiner hyperextends the symptomatic hip and flexes the asymptomatic hip while the patient lies supine and with their symptomatic sided leg off the table. 46% 89.5% Cohen1
13% 100% Cohen1
Radiographic stereophotogrammetry Using radiographic imaging to assess SIJ motion in various loading positions. Poor correlation Poor correlation Cohen1
CT imaging Use of multiple radiographic images to assess structural damage within the SIJ. 57.5% 69% Cohen1
Poor correlation Poor correlation Cohen1
All compared with SIJ injection as criterion standard diagnosis. Information adapted from Cohen,1 Laslett et al.,2 and Schneider et al.3
ASIS, anterior superior iliac spine; CT, computed tomography..

Once SIJ pathology is suspected, it is important to use a patient-centered approach to build a treatment plan that will best accommodate the needs of a specific patient. Aside from pain medication such as nonsteroidal anti-inflammatory drugs and muscle relaxants for concomitant muscle spasm, noninvasive treatments such as therapeutic exercise, manual medicine, SIJ belts, and orthotics should be considered as options for a patient’s pain control. If noninvasive options fail to reach a patient’s pain control goals, then procedures such as fluoroscopic, ultrasound, or computed tomography–guided SIJ injections and radiofrequency denervation should be considered,4 with SIJ fusion being a last resort option.

BOARD QUESTIONS

  • 1. A 47-yr old man with a body mass index of 38.2, and a past medical history of hypertension, diabetes mellitus type 2, and osteoarthritis presents with unilateral, right-sided lower back and medial buttocks pain that is most noticeable with changing between sitting and standing positions. The pain began 2 mos before presentation after he was involved in a motor vehicle accident as a restrained driver. He experiences limited relief with nonsteroidal anti-inflammatory drugs and heat massage. When he enters your office, he exhibits slight forward flexion toward the left side of his body on ambulation. Radiographic imaging from the time of injury shows no evidence of sacral or pelvic fracture. Upon examination, there is a negative straight leg raise test, but positive thigh thrust, sacral distraction, and sacral compression tests and presence of a focal point of pain 1 cm inferomedial to the posterior superior iliac spine. What test would confirm your suspicions of an SI joint dysfunction?
    1. Computed tomography
    2. Diagnostic injection
    3. Magnetic resonance imaging
    4. Pelvis/lumbar spine radiograph
  • 1. Answer: B. Having an inciting incident 1–3 months prior, his patient is likely in the subacute stage of SIJ pathology. Though SIJ pathology is currently a diagnosis of exclusion, when suspected an image-guided diagnostic injection is the most useful tool to confirm a pain originating from the SIJ.
  • 2. A 34-yr old woman comes to your office with a 1-yr history of lower back pain that worsens throughout the day. She is an office manager with a height of 5′3″ and a weight of 198 lb (body mass index = 35). The pain was described as 7/10 in severity with a stabbing quality. She has been taking over the counter ibuprofen to some effect but wants to discuss further treatment options. Upon examination, she is tender over her left posterior superior iliac spine, positive left thigh, and left sacral thrust tests and has a negative straight leg raise test. What initial treatment do you recommend to best help control her symptoms?
    1. Therapeutic exercise and SIJ belt
    2. Radiofrequency denervation
    3. 100 mg daily of oral extended-release tramadol
    4. Microsurgical discectomy
  • 2. Answer: A. The patient’s current symptoms and physical examination are indicative of probable chronic SIJ pain. The initial management of which is recommended to be controlling of the pain with NSAIDs and icing followed by noninvasive treatments such as Therapeutic Exercise, manual medicine, orthosis (belting), and orthotics. If noninvasive treatments show little to no pain reduction, then invasive procedures such as steroid injection and radiofrequency denervation should be considered. Opioids are not initially recommended for pain management due to their extensive side effect profile. This patient’s straight leg raise test was negative, implying the treatment of a herniated disc with Microsurgical discectomy is not indicated.

REFERENCES

1. Cohen SP: Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005;101:1440–53
2. Laslett M, Aprill CN, McDonald B, et al.: Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 2005;10:207–18
3. Schneider BJ, Ehsanian R, Rosati R, et al.: Validity of physical exam maneuvers in the diagnosis of sacroiliac joint pathology. Pain Med 2020;21:255–60
4. Prather H, Bonnette M, Hunt D: Nonoperative treatment options for patients with sacroiliac joint pain. Int J Spine Surg 2020;14(suppl 1):35–40
5. Cuccurullo S, Lee J, Bagay L: Physical Medicine and Rehabilitation Board review, 4th ed. New York, NY, Demos Medical, 2020
    Keywords:

    Sacroiliac Pain; Diagnosis; Physical Examination; Treatment

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