Define Sacroiliac Joint Dysfunction

Four Essential Tests to Define Sacroiliac Joint Dysfunction

The sacroiliac joint (SIJ) is the load-bearing, shock-absorbing union between the spine and pelvis. It is a mechanical link that connects the chain of locomotion to the rest of the body. This irregular, synovial and fibrocartilagenous joint is surrounded by a strong ligamentous-reinforced capsule and is minimally mobile, allowing only about 4 degrees of rotation and up to 1.6 mm of translation ^1,2. 

Approximately 13% of low back pain is attributable to SIJ 3. Sacroiliac joint dysfunction (SIJD) can be divided into two general categories: mechanical and arthritic. “Mechanical” SIJD results from any process that alters normal joint mechanics (i.e. hyper- or hypomobility). Common culprits include leg length inequalities, gait abnormalities, lower extremity joint pain, pes planus, improper shoes, scoliosis, prior lumbar fusion, lumbopelvic myofascial dysfunction, repetitive strenuous activity and trauma, especially a fall onto the buttocks. Although patients may not always recognize or report a traumatic onset, studies show that over half of mechanical SIJD results from an inciting injury ⁴. Pregnancy creates a firestorm of sacroiliac joint insult with weight gain, gait changes and postural stressors occurring contemporaneously with hormone-induced ligamentous laxity.

Causes

“Arthritic” SIJD results from either osteoarthritis or from an inflammatory arthropathy including; ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, and Reiter’s/reactive arthritis, which produce sacroiliitis and resulting pain. Morning pain that resolves with exercise is characteristic of arthritic SIJD. 

The clinical presentation of Sacroiliac Joint Dysfunction is quite variable and shares several common characteristics with other lumbar and hip problems. When asked to point specifically to the site of pain, the SIJD patient will often place their index finger over the PSIS (Fortin finger test). Pain may or may not refer to the lower back, buttock, thigh, or rarely into the lower leg via chemical radiculopathy of the neighboring L5 or S1 nerve roots 5. Sacroiliac joint pain may refer to different regions, depending upon which section of the joint is irritated. 15 Irritation to the upper 1/3 of the joint generates pain in the region of the PSIS. Irritation to the midsection causes referral to the mid-gluteal region, while the lowest section refers to the lower gluteal region. Interestingly, 44% of SI joint patients report referral to the groin. ¹⁵

Symptoms

Symptoms may be exacerbated by bearing weight on the affected side and relieved by shifting weight to the unaffected leg. Pain may be provoked by arising from a seated position, long car rides, transferring in and out of a vehicle, rolling from side to side in bed or by flexing forward while standing. Pain is often worse while standing or walking and relieved by lying down. 

Testing

No single orthopedic maneuver is diagnostic for SIJD, but collectively, any two of the following four tests can have a very high predictive value: SI distraction, thigh thrust (aka P4), SI compression and sacral thrust 6. For each provocation maneuver, a “positive” test is a reproduction of symptoms that are generally unilateral and located near the PSIS.

• The SI Distraction Test is performed on a supine patient as the clinician uses straightened arms to apply a simultaneous posterior directed force to a patient’s ASIS’s to “spread” the anterior SI joint. (Watch at https://goo.gl/C73UZ1)
• The Thigh Thrust Test (AKA Posterior Pelvic Pain Provocation) is performed on a supine patient with the patient’s hip and knee flexed to 90 degrees, thigh only slightly adducted. The clinician places one hand beneath the patient’s sacrum and the other contacts the knee as a downward force is applied along the shaft of the femur to create “shearing” of the SI joint. (Watch at: https://goo.gl/dfBW77)
• The SI Compression Test is performed on a side lying patient in the fetal position. The clinician applies a downward compressive force to the uppermost iliac crest. (Watch at: https://goo.gl/ggQSpf)
• The Sacral Thrust Test is traditionally performed with the patient prone while the examiner applies an anterior pressure through the sacrum to generate a shearing force through the SI joints. (Watch at: https://goo.gl/9oI2kA)

Other potentially useful tests include; Gaenslen’s test, Gillet test, Drop test (unload affected leg, then abruptly drop locked leg to the floor), FABER, standing flexion and motion demand spring test. 

Sacroiliac Joint Dysfunction provocation tests are commonly positive in discogenic patients. Many clinicians employ the philosophy that pain in the sacroiliac region is of lumbar origin until proven otherwise. Discogenic pain may mimic SIJD symptoms but the two rarely co-exist 7. McKenzie assessment protocols that cause SIJ complaints to centralize point to a discogenic origin. Nerve tension signs are generally absent in SIJD. Neuro evaluation should be unremarkable.

Motion palpation may reveal SIJ restriction relative to the unaffected side. Related muscles should be assessed for trigger points, hypertonicity or weakness. Biomechanical evaluation should be performed for the lumbar spine, and lower extremity, especially the foot.

Diagnosis

SIJD is often established by clinical diagnosis and imaging, or lab may not be necessary unless an alternate etiology is suspected ⁸. Sacroiliitis may sometimes be identified by a plain film, but CT or MRI are more sensitive tests. Sacroiliitis presents radiographically as erosions, sclerosis, joint space narrowing, and eventually ankylosis 9. Advanced imaging may also help identify lumbar disc involvement. In patients with sacroiliitis, or when inflammatory arthropathy is suspected, the following lab evaluation is indicated: CBC, ESR, CRP, and HLA-B27.

The differential diagnosis for mechanical SIJD includes inflammatory arthropathy; lumbosacral referral, especially discogenic pain; hip DJD or pathology; myofascial pain, especially piriformis syndrome; sacral insufficiency fracture (elderly); neoplasm; infection; and vicerosomatic referral.

Treatment

Traditional conservative management of Sacroiliac Joint Dysfunction lacks significant scientific support.
Sacroiliac joint manipulation can restore motion to hypermobile joints and has shown benefit 10,12,14. Ultrasound, ice, and e-stim may help control pain and inflammation. 

Cross friction massage or IASTM may be utilized to initiate healing of the tendons and ligaments surrounding the SIJ. Sacroiliac joint dysfunction is associated with irritation of the Long Dorsal Sacroiliac Ligament. ¹³ Clinicians may employ myofascial release techniques or IASTM of this structure. Myofascial release and stretching may be appropriate for the gluteus, hamstrings, piriformis, TFL, quadratus lumborum lumbar erectors, and contralateral lattissimus dorsi. The goal of strengthening is lumbopelvic stability. Specific targets include the transverse abdominus, abdominal obliques, lumbar erectors, gluteus, hip abductors and hip adductors ¹¹. 

Conclusion

Patients should be counseled on posture and ergonomic awareness and advised to avoid activities that provoke symptoms, including prolonged standing on the affected leg, prolonged sitting, and forced hip abduction during intercourse. Arch supports, orthotics or a heel lift to correct structural deficits may be indicated. A sacroiliac support belt may provide benefit, although excessive tightness may aggravate the trochanteric bursa. NSAIDs may be helpful. Glucosamine and chondroitin may provide benefits for osteoarthritis sufferers. Recalcitrant cases may require consultation for SIJ injections ¹⁴ or radiofrequency neurotomy. Surgery is rarely warranted. 

References: 

1. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: A roentgnen stereophotogrammetric analysis. Spine. 1989;14:162–165.
2. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine. 2000;25:214–217.
3. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21: 1889–1892.
4. Bernard TN Jr, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop Relat Res. Apr 1987;217:266-80.
5. Fortin JD, Washington WJ, Falco FJE. Three pathways between the sacroiliac joint and neural structures. AJNR. 1999;20:1429–1434.
6. Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint J Man Manip Ther. 2008; 16(3): 142–152
7. Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B. Agreement between diagnoses reached by clinical examination and available reference standards: A prospective study of 216 patients with lumbopelvic pain. BMC Musculoskelet Disord. 2005;6:28.
8. Poley RE, Borchers JR. Sacroiliac joint dysfunction: evaluation and treatment. Phys Sportsmed. 2008 Dec;36(1):42-9.
9. Michael J. Tuite Sacroiliac Joint Imaging. Semin Musculoskelet Radiol 2008; 12(1): 072-082
10. Foley BS, Buschbacher RM. Sacroiliac joint pain: Anatomy, biomechanics, diagnosis, and treatment. Am J Phys Med Rehabil. 2006;85:997–1006.
11. Stuge B, Laerum E, Kirkesola G, Vollestad N: The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a randomized controlled trial. Spine 2004, 29:351-359.
12. L. H. Visser, N. P. Woudenberg, J. de Bont, F. van Eijs, K. Verwer, H. Jenniskens, and B. L. Den Oudsten Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial European Spine JournalOctober 2013, Volume 22, Issue 10, pp 2310-2317
13. Vleeming A et al. The function of the long dorsal sacroiliac ligament: its implication for understanding low back pain. Spine 1996 Mar 1;21(5):556-62.
14. L. H. Visser, N. P. Woudenberg, J. de Bont, F. van Eijs, K. Verwer, H. Jenniskens, and B. L. Den Oudsten Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial European Spine JournalOctober 2013, Volume 22, Issue 10, pp 2310-2317
15. Kurosawa D, Murakami E, Aizawa T. Referred pain location depends on the affected section of the sacroiliac joint. Eur Spine J. 2015 Mar;24(3):521-7.