Sacroiliac Joint Pain and Dysfunction

By Ervin Bernotus, MD
Sacroiliac (SI) joint dysfunction is understood by clinicians as one of the many causes of lower back pain.

SI joint dysfunction itself may be responsible for the low back pain syndrome and/or may be contributory to low back pain along with pathology from the lumbar spine. It can be acute in occurrence or chronic and recurrent.

The sacroiliac joints are made up of the junctions between the sacrum and the right and left iliac bones. There are two SI joints. The sacroiliac joints can be identified as the two dimples seen on the lower back down by the sacrum. The upper half of the joint is cartilaginous and the lower half is ligamentous.

The movement at the SI joints is minimal because of the strong ligamentous and muscle support. Movement is influenced by the lower extremities below the vertebral column and by the trunk above. In unsymmetrical movements such as bending to the side and twisting the two iliac bones move opposite each other.

The sacroiliac joint is a risk of injury (as is the lumbar spine) when the trunk is flexed forward coupled with side bending and rotation. This results in non-neutral SI and lower lumbar mechanics.

Pain is usually reported as being on one side of the low back. Occasionally, there is pain on both sides. The patient reports posterior low back pain, hip pain, buttock pain, groin pain, lateral thigh pain, knee pain and occasionally leg and calf pain.

This is sometimes called "pseudo-sciatica" because the pain mimics sciatic type pain but is actually from the SI joint. On presentation the patient may have a limp, leg length difference and stabbing aching pain with walking, standing or when getting up from a sitting position.

On clinical examinations there is a tenderness to palpation over the SI join ligaments. There is associated muscle guarding of the muscles of the low back. There is pain with end range of motion of the hip joints as they stress the ÍI joint. Pain from the SI joint is often overlooked and mistaken as coming from the lower lumbar spine.

Diagnostic testing such as x-ray, CT or MRI does not usually demonstrate abnormalities, and therefore cannot be used for diagnosis of SI joint dysfunction. Occasionally in advanced cases of sacroiliac joint dysfunction x-rays or MRI may show degeneration of the joint.

Treatment for Sacroiliac joint dysfunction includes standard physical therapy approaches along with the use of non-steroidal anti-inflammatory medications and muscle relaxants to reduce reactive muscle spasms around the joint region. Manipulative therapy has also benefited SI joint dysfunction.

Chronic SI joint pain also responds to injection therapy with a mixture of corticosteroids and short acting pain medication. Typically the injection is best performed under fluoroscopic guidance to ensure the medication is injected into the joint because the join is deep and lies at a sharp angle. The goal of the injection therapy is to reduce pain, relax the joint, decrease inflammation and improve motion.

Regular exercise, stretching, proper ergonomics and avoiding improper lifting or posture also helps to reduce incidence of sacroiliac joint injury.

Ed. Note: Ervin Bernotus, MD, FAAPM, FAAPM&R is part of the team at Florida Pain and Rehabilitation Institute, Inc. There are four treatment centers in Florida. For more information contact Cristan Cassano, Director of Marketing at 813-454-3470 or at cassano@flapain.com.