Sacroiliac Joint Injury

What is Sacroiliac Joint Injury?

The sacroiliac joint (SI), which is the junction where your spine and pelvis meet, is often a source of lower back pain. You’ll find this joint between the flat parts of your hip and tailbone. An injury to this area can cause significant discomfort in your lower back and buttocks. The SI joint has to handle a lot of different types of stress, including from twists, turns, and weight-bearing activities. It’s also crucial for walking, because it’s the only joint connecting your upper and lower body. Fluid fills the relatively stiff joint where tough, fibrous tissue binds the bones of your tailbone and hip.

Diagnosing SI joint problems can be tricky. One issue medical providers face is distinguishing between pain in the lower part of the spine (lumbago) and pain from SI joint. Special tests can help make clear distinctions. It’s worth noting that up to 30% of all lower back pain cases can be traced back to issues with the SI joint. Pregnant women may experience joint looseness due to hormone changes, putting the SI joint at risk of injury. People between 40 and 50 years old may also have a fusing SI joint, which can affect the joint’s flexibility. This lack of movement and pregnancy can lead to excessive movement or too little movement, contributing to SI joint pain. The wear-and-tear arthritis known as osteoarthritis is a common trigger for this sort of discomfort.

There are several factors contributing to SI joint injuries, including common causes of lower back pain and various origins of SI joint issues. Diagnosing the problem can be challenging, especially when chronic pain sets in after three months of persistent discomfort. Ruling out a spinal issue can be tricky considering the amount of back pain that isn’t related to the SI joint. It’s often difficult to determine if SI joint issues are the main cause of a patient’s back pain, except in cases of trauma and pregnancy.

Increased mobility of the joint can cause pain, but notably, decreased mobility marks inflammatory sacroiliac injury commonly seen in ankylosing spondylitis. In some cases, the issue might lie in the discs between your lower spine bones, and the pain can feel like it’s coming from the SI joint. Pain can be referred to areas such as the back of your thigh, knee, or foot, with the back of the thigh being the most common site. In addition, the lack of clear guidelines in diagnosing and treating SI joint pain can complicate the process. An MRI scan is a useful tool to evaluate the SI joint, and an anesthetic injection guided by X-ray can reliably identify SI joint pain in many cases.

Besides being a common area of treatment for chronic lower back pain, the SI joint can also be managed through various treatment options. These include physical therapy, in-home exercises, over-the-counter pain relievers like NSAIDs or acetaminophen. If conservative management doesn’t work, corticosteroid injections and heat-producing treatment methods can be considered. In severe cases resistant to treatment, surgery to fuse the SI joint might be necessary. Patient education is vital, which includes teaching good posture, proper lifting method, flexibility, and work out routine. Losing weight can also help ease SI joint pain.

What Causes Sacroiliac Joint Injury?

Injuries to the sacroiliac joint, which is where your spine connects to your pelvis, can happen for several reasons. 88% of these injuries either come from repeated small injuries or a single severe one. Athletes often experience injuries to this joint. Also, 20% of these injuries relate to pregnancy, while 4% are unexplained.

One example of a sacroiliac joint injury is trauma in the area known as the pelvic ring. This can occur in three different ways: front-to-back compression, side compression, or up-and-down shear-type injuries. Injuries to the sacroiliac joint can also involve incomplete or complete dislocation of the joint, or a fracture coupled with dislocation.

There are also three types of fractures linked to sacroiliac joint injuries. The first type is a less severe fracture at the front of the S2 foramen (the small hole in your pelvic bones where nerves and blood vessels pass through), causing a large, stable crescent-shaped fragment. Here, less than one-third of the sacroiliac joint is affected, and this type of fracture involves the least amount of ligament injury. The second type of fracture also occurs at the front of the S1 and S2 foramen, and it causes a smaller crescent-shaped fragment. This fracture involves one-third to two-thirds of the sacroiliac joint. The third type of fracture involves the upper and rear portions of the sacroiliac joint up to the S1 nerve root and has the highest degree of ligament disruption. This fracture is typically smaller than types one or two. A posterior fracture-dislocation of the sacroiliac joint involves varying disruption of the sacroiliac ligament complex.

The L5 nerve root, which runs across the sacral ala (the wing-like part of your sacrum) a short distance from the sacroiliac joint, can be implicated if the joint gets hurt, possibly causing radicular pain (pain that radiates along the nerve). In response to an injury of these nerves, you might feel this type of pain in your sacroiliac joint. Generalized gluteal pain (pain throughout your buttock region) can often be due to an injury of the sacroiliac joint or the local nerves surrounding the joint, which can also lead to radiculopathy (nerve pain that extends from the nerve root). If the S1 nerve root is harmed during a sacroiliac joint injury, it can also cause radiculopathy.

During pregnancy, joints in the pelvis—including the sacroiliac joint—often become loose due to the hormone relaxin. As the pelvis widens during this time, the sacroiliac joint becomes more flexible. As a result, expectant mothers can experience pain from this joint as the hips rotate and put pressure on it. This pain can be either on one side or on both during pregnancy. This type of pain during pregnancy is a part of pelvic girdle pain. Women who experience pelvic girdle pain during pregnancy often have higher rates of disability compared to those suffering from mechanical back pain. Risk factors for sacroiliac joint dysfunction during pregnancy include forceps delivery, intense contractions, a large baby, giving birth more than once, rapid labor, and a swift second stage of labor.

Your body’s natural differences can also lead to an injury of the sacroiliac joint. For instance, an increase in the curvature in the lower back, or a forward tilt of the pelvis, can cause this joint to malfunction. Patients with less muscle development can develop imbalances in their posture, such as having one leg shorter than the other.

Moreover, osteoarthritis (a type of joint disease that results from a breakdown of joint cartilage and underlying bone) plays a role in creating sacroiliac joint pain. As with all osteoarthritic joints, you might see the space between the joint narrowing, bony spurs forming, and the sacroiliac joint becoming more rigid on an x-ray.

Furthermore, inflammatory arthritis (a group of conditions where the body’s immune system attacks its own tissues) can cause injury to the sacroiliac joint. The most common of these is ankylosing spondylitis. Over time, this can cause the joint to erode, leading to disabling pain. A sign of inflammation in the sacroiliac joint is subchondral edema (swelling under the hard outer part of the bone) visible on imaging. Over time, as the joint decays, the space widens and becomes rigid. Eventually, the joint fuses as the decay spreads across the entire joint. The seriousness of deterioration ranges from zero (being normal) to four (full fusion of the joint). Higher rates of progression of injury to the sacroiliac joint seem to relate to active inflammation of the joint visible with a rise in CRP (a substance the liver makes in response to inflammation) or on an MRI, a history of smoking, being male, and testing positive for HLA-27 (a gene linked to ankylosing spondylitis).

Risk Factors and Frequency for Sacroiliac Joint Injury

The sacroiliac (SI) joint plays a role in a significant portion of chronic low back pain. This joint is problematic in about 13% of those suffering from chronic low back pain, and it can be the source of 15 to 30% of all low back pain.

When it comes to injuries around the pelvis, the SI joint is also frequently involved. Approximately 80% of injuries to the pelvis rim are due to lateral compression of the SI joint, and 12% of pelvic ring injuries are because of Crescent fracture-dislocations of the SI joint.

Abnormal movement of the SI joint is not rare. This condition is found in 20% of college students and can be present in 8 to 16% of people who do not show any symptoms.

After surgical fusion of the SI joint, over 80% of patients report significant improvement in pain.
However, only 25% of those who do not undergo surgery report such improvement.
On the downside, 3% of those who have the fusion surgery need another surgery later.
Before surgery, doctors generally look for at least a 75% improvement following an SI joint diagnostic injection.

Signs and Symptoms of Sacroiliac Joint Injury

Sacroiliac (SI) joint pain can often mimic the symptoms of general back pain. However, it does have some unique characteristics. Usually, the pain is localized to the buttock region and may be accompanied by feelings of numbness, tingling, weakness, pelvic pain, leg instability, and groin pain. Activities such as climbing stairs, sitting cross-legged, sitting or standing for extended periods may make the symptoms worse. In some instances, the pain may be severe, resembling a stabbing feeling. Common complaints also include the aggravation of pain during sleep and in some women, during menstruation.

Sometimes, those with an SI joint injury may also experience radiation of pain, which is reported in around 50% of cases. This can result in pain spreading to the posterior thigh, knee, foot, gluteus muscles and even the groin region which might even cause a misdiagnosis of hip pain. Some may mistake it for sciatica due to pain or tingling in the lower leg, extending to the foot.

A physical examination includes a detailed check of the musculoskeletal and neurologic aspects of the lumbar spine, and both lower extremities. It’s worth noting that a complete neurological and musculoskeletal check-up of the lower extremity should typically return normal results, with normal muscle strength, sensation, and reflexes. However, there may be noticeable pelvic asymmetry. Tests assessing lower limb motion and palpation of the pelvic floor muscles are important in diagnosing SI joint dysfunction.

Special tests are administered in cases of suspected SI joint injuries. One example is the Gaenslen test that targets the sacroiliac joint. The patient is positioned supine (on their back), with one hip flexed to their chest. The provider applies pressure to the flexed hip on the painful side while pushing the knee of the other leg downward. If the patient’s pain is reproduced, it’s considered a positive Gaenslen test. Other tests include the supine hip posterior thrust test and Trendelenburg testing to identify any contribution of gluteus medius weakness to the SI joint pain. A positive FABER test is when pain is felt over the opposite sacroiliac joint. These tests have high sensitivity and specificity, meaning they are reliable for identifying SI joint dysfunction.

Testing for Sacroiliac Joint Injury

If you’re experiencing discomfort in your sacroiliac (SI) joint, which is located in your lower back and connects your spine to your pelvis, the doctor may recommend you to take some tests. One of the first tests they might utilize is an X-ray, which can help them assess the cause of your pain. An X-ray can show them if the space between your sacrum (the bottom of your spine) and ilium (part of your hip bone) has narrowed; an average distance should be 4-5 millimeters. If this space is reduced, it could indicate an injury.

However, X-rays are not always the most reliable and can sometimes appear normal even if there’s a dysfunction in the SI joint. It’s also worth noting that around 20-30% of people with a certain type of arthritis known as seronegative spondyloarthropathy will have abnormal X-rays.

The doctor might also consider ordering an MRI (Magnetic Resonance Imaging), which gives a more in-depth view of your SI joint and is better for identifying injuries, even though it can have a fair proportion of false positives in healthy patients. Certain features, such as bone marrow edema (fluid build-up in the bone marrow), are common in over 20% of people with mechanical back pain.

Various conditions can cause structural joint changes, such as erosion, which can also be detected via an MRI. If the MRI results are unclear, another imaging technique called scintigraphy may be used.

In instances where an MRI is not advisable or accessible, a CT (Computed Tomography) scan can be a good alternative. It is better than an X-ray at identifying SI joint injuries but inferior to an MRI. Even though CT scans aren’t commonly recommended for diagnosing sacroiliitis (inflammation of the SI joints), they can come in handy when an MRI can’t be done for some reason.

There are also more direct tests the doctor might use if they’re unsure about the diagnosis. One such option is a local anesthetic block, in which they will use ultrasound or X-ray guidance to inject anesthetic into your SI joint. They will then compare your pain levels before and after the injection to see if it reduces your discomfort. If you experience a 75% reduction in pain after this procedure, it’s a strong indicator of SI joint pain.

Finally, the doctor might also use blood tests to assess potential inflammatory damage to your SI joint. Tests like a CBC (Complete Blood Count), CRP (C-reactive protein), and ESR (Erythrocyte Sedimentation Rate) could give them essential information if sacroiliitis is spotted in an X-ray of your pelvis.

Treatment Options for Sacroiliac Joint Injury

The treatment for sacroiliac (SI) joint pain can vary a lot depending on the individual situation. For instance, if the pain is related to pregnancy, it will usually go away a few months after giving birth. If the pain is due to a sudden injury, the person might need surgery quickly.

In the case of a recent injury, using ice and taking anti-inflammatory painkillers can often provide some relief. Medications called muscle relaxers might also be used if the pain is thought to be due to muscle spasms. Certain kinds of inflammatory sacroiliac joint pain can be treated with medications called TNF inhibitors.

Weakness in certain core muscles could also contribute to SI joint pain. Exercises to strengthen these muscles, which could be done at home or with a physical therapist, can help alleviate pain over time. Different waist belts have also been found to help support the core and limit movement in the SI joint, thereby reducing pain. However, research is limited on its overall effectiveness.

Some studies suggest that manipulation (physically moving and adjusting the body), stretching, and other physical therapies can effectively treat SI joint pain. However, there is a general agreement that time, combined with exercise and patience, is often the best remedy for most cases of SI joint pain.

In some cases, when conservative treatments (like anti-inflammatory medications and physical therapy) are not effective, injections of medicines like corticosteroids around the joint’s area are suggested. However, the efficiency of these injections is still up for debate. These injections can be done with or without the help of ultrasound guidance, with the latter proving more effective. Also, it’s not recommended to have more than three of these injections per year.

In very severe, chronic cases, treatments like disrupting nerve signals (radiofrequency denervation or rhizotomy), using specially designed spinal cord stimulators, or even surgical fusing of the joint may be considered. While these options may provide significant pain relief, their effectiveness can diminish over time, and they should only be considered after more conservative treatments have failed.

Sacroiliac (SI) joint injuries can happen due to a variety of reasons. These can include:

Being pregnant
Traumatic events like hip fractures
Having too much or too little flexibility (hypermobility or hypomobility)
Having legs of different lengths
Being overweight
Surgeries like lumbar fusion (a procedure to join two or more spine bones together)

When diagnosing SI joint injuries, doctors consider several possible conditions that could cause similar symptoms including:

Synovitis, capsulitis, and enthesitis (different types of joint inflammation)
Infections
Piriformis syndrome (a type of nerve issue)
Osteitis condensans ilii (a type of bone condition)
Certain cancers, like multiple myeloma
Conditions related to the structure of the spine, like scoliosis or having short legs
Tearing of the ligaments at the back of the sacrum (the bone at the base of your spine)

Wear and tear on the SI joint from aging can also be a source of pain, in the form of osteoarthritis. This typically causes the space within the joint to become smaller and can result in pain. People experiencing lower back and pelvic pain may also have osteoarthritis in the hip in addition to the SI joint.

Additionally, there are various types of inflammatory conditions that can cause SI joint injuries. These can include reactive arthritis and psoriatic arthritis, which is linked to the skin condition psoriasis. Other conditions such as Bechet disease and hyperparathyroidism, a disorder of the parathyroid glands, can also cause inflammation in the sacroiliac joints. Lastly, conditions like disc herniation, lumbar spinal stenosis, and mechanical back pain are also considered in the diagnosis of SI joint injuries.

What to expect with Sacroiliac Joint Injury

Like mechanical back pain, most Sacroiliac (SI) joint injuries get better with conservative treatment such as pain management and physical therapy. In fact, more than 75% of people with this type of injury respond well to such treatment. It’s also worth noting that non-traumatic SI joint injuries typically heal completely, unlike traumatic ones.

However, it’s important to stay active during recovery. Patients with a sedentary lifestyle tend to have worse outcomes, while those who remain physically active usually maintain excellent quality of life despite their injury.

It’s also interesting to know that stabilization exercises can significantly reduce disability caused by SI joint injury in the long run – by up to 50%!

In some rare cases, symptoms of SI joint injury can persist for a long time – as much as 43 months. For such chronic cases that do not respond to other treatments, about 2% of patients require a surgical procedure known as operative fusion. Also, the SI joint tends to weaken slowly over time in sacroiliitis, a type of inflammation, at a rate of about 1% to 5% per year.

Possible Complications When Diagnosed with Sacroiliac Joint Injury

In more than 30% of chronic cases, the SI joint injury can reoccur. This often results in complications such as difficulty walking, constant pain, disability, and a reduced quality of life. As with many injuries to the muscles and bones, it’s important to treat acute dysfunction quickly to avoid chronic pain. If chronic pain develops, it can cause significant health problems and even increase the risk of death. It can also lead to dependence on opioids. Failure to promptly evaluate and investigate sacroiliitis could lead to severe systemic injuries.

Common Complications:

Reoccurrence of SI joint injury
Difficulty in walking
Chronic pain
Disability
Reduced quality of life
Health risks and potential death
Dependency on opioids
Severe systemic injuries

Preventing Sacroiliac Joint Injury

The first step in figuring out what’s causing your sudden back pain is to check the sacroiliac joint, often referred to as the SI joint. This joint can frequently cause lower back pain, and it’s not the same thing as the lumbar spine or the muscles near the spine, both of which are also common sources of this type of discomfort.

The SI joint is the place where your spine and pelvis connect in the back. It’s located between a bone in your hip (the iliac bone) and the sacrum, which is the part at the bottom of your spine. One common reason for an injury to this joint is trauma, which could be either a series of smaller injuries that build up over time (like what might happen to an athlete) or a single severe injury (like a pelvic fracture from a car accident). It’s also common to injure the SI joint during pregnancy.

Additionally, you could be experiencing pain in your SI joint because of arthritis, which can wear down the joint over time, or because of a type of arthritis that causes inflammation in the joint, known as sacroiliitis. If you have inflammation showing up on an image of your SI joint, it could mean that you have a disease affecting your entire body. Your doctor might use an X-ray or an MRI to get a closer look at your SI joint and see what’s going on.

Usually, if you have an injured SI joint, it gets better with some simple treatments, like physical therapy. But if those don’t work, your doctor might suggest more aggressive treatments like injections of medicine to reduce inflammation (corticosteroids), or even surgery.

Frequently asked questions

Sacroiliac Joint Injury is an injury to the junction where the spine and pelvis meet, causing significant discomfort in the lower back and buttocks. It can be caused by various types of stress, including twists, turns, and weight-bearing activities, and can be diagnosed through special tests. Up to 30% of lower back pain cases can be traced back to issues with the SI joint.

Sacroiliac joint injuries are common, affecting approximately 13% of those with chronic low back pain and accounting for 15 to 30% of all low back pain.

Signs and symptoms of Sacroiliac Joint Injury include: - Localized pain in the buttock region - Numbness and tingling sensations - Weakness in the legs - Pelvic pain - Leg instability - Groin pain - Aggravation of pain during activities such as climbing stairs, sitting cross-legged, sitting or standing for extended periods - Severe pain resembling a stabbing feeling - Aggravation of pain during sleep - Aggravation of pain during menstruation in some women - Radiation of pain to the posterior thigh, knee, foot, gluteus muscles, and groin region - Misdiagnosis of hip pain - Pain or tingling in the lower leg, extending to the foot (resembling sciatica) - Noticeable pelvic asymmetry - Normal results in neurological and musculoskeletal check-up of the lower extremity, except for pelvic asymmetry - Tests such as Gaenslen test, supine hip posterior thrust test, Trendelenburg testing, and FABER test can help diagnose SI joint dysfunction with high sensitivity and specificity.

Sacroiliac joint injuries can occur from repeated small injuries or a single severe injury, as well as during pregnancy or for unexplained reasons.

The doctor needs to rule out the following conditions when diagnosing Sacroiliac Joint Injury: - Synovitis, capsulitis, and enthesitis (different types of joint inflammation) - Infections - Piriformis syndrome (a type of nerve issue) - Osteitis condensans ilii (a type of bone condition) - Certain cancers, like multiple myeloma - Conditions related to the structure of the spine, like scoliosis or having short legs - Tearing of the ligaments at the back of the sacrum (the bone at the base of your spine) - Disc herniation - Lumbar spinal stenosis - Mechanical back pain

The types of tests that may be ordered to diagnose a sacroiliac joint injury include: 1. X-ray: This can help assess the cause of pain and determine if there is narrowing of the space between the sacrum and ilium. 2. MRI (Magnetic Resonance Imaging): Provides a more detailed view of the SI joint and is better for identifying injuries, such as bone marrow edema and structural joint changes. 3. CT (Computed Tomography) scan: Can be used as an alternative to an MRI when it is not accessible or advisable. It is better than an X-ray at identifying SI joint injuries. 4. Scintigraphy: Another imaging technique that may be used if MRI results are unclear. 5. Local anesthetic block: A procedure in which anesthetic is injected into the SI joint to assess pain reduction. 6. Blood tests: CBC, CRP, and ESR tests can assess potential inflammatory damage to the SI joint. It is important to note that the specific tests ordered may vary depending on the individual situation and the doctor's clinical judgment.

The treatment for Sacroiliac (SI) joint injury can vary depending on the individual situation. In the case of a recent injury, using ice, taking anti-inflammatory painkillers, and using muscle relaxers can provide relief. Medications called TNF inhibitors can be used for certain types of inflammatory SI joint pain. Strengthening core muscles through exercises and using waist belts to support the core can also help alleviate pain. Manipulation, stretching, and other physical therapies can be effective in treating SI joint pain. Injections of corticosteroids around the joint area may be suggested if conservative treatments are not effective. In severe cases, treatments like radiofrequency denervation, spinal cord stimulators, or surgical fusing of the joint may be considered as a last resort.

The side effects when treating Sacroiliac Joint Injury can include: - Reoccurrence of SI joint injury - Difficulty in walking - Chronic pain - Disability - Reduced quality of life - Health risks and potential death - Dependency on opioids - Severe systemic injuries

- Over 75% of people with Sacroiliac Joint Injury respond well to conservative treatment such as pain management and physical therapy. - Stabilization exercises can significantly reduce disability caused by SI joint injury in the long run, by up to 50%. - In rare cases that do not respond to other treatments, about 2% of patients require a surgical procedure known as operative fusion. - The SI joint tends to weaken slowly over time in sacroiliitis, a type of inflammation, at a rate of about 1% to 5% per year.

You should see an orthopedic doctor or a rheumatologist for a Sacroiliac Joint Injury.