What is Sacroiliac Joint Pain?
Pain coming from the sacroiliac joint, or the connection between the lower spine and the pelvis, could be a reason for lower back pain. Actually, about 25% of lower back pain might be traced back to the sacroiliac joint. This type of discomfort can result from injury, pregnancy, repetitive stress, sports, or even after a surgery on the spine. Through this piece, we aim to give a brief introduction on sacroiliac joint pain and how it can be treated.
What Causes Sacroiliac Joint Pain?
Sacroiliac joint pain, or pain in the joint connecting your spine and hip, can be due to a variety of causes. These causes can be broadly grouped into two categories: traumatic, or caused by a physical injury, and atraumatic, not directly caused by a physical injury.
Traumatic causes of this type of pain could include fractures in the pelvis, injuries from falling on your buttock, indirect injuries from a car crash, or strain from heavy lifting or twisting movements.
On the other hand, atraumatic causes could include conditions like spondyloarthropathy (an umbrella term for diseases causing inflammatory joint pain), enthesopathy (a disorder affecting the point where the ligaments and tendons connect to the bone), osteoarthritis (a type of arthritis that’s caused by a breakdown of joint cartilage), infections, or effects from previous surgery in the lumbar spine (the lower back). Certain conditions or states can also trigger sacroiliac joint pain, such as pregnancy, having one leg longer than the other, and scoliosis (a sideways curve in your spine).
Playing sports that involve repetitive twisting forces, such as figure skating, golf, and bowling, can also cause pain in the sacroiliac joint. Pregnancy can lead to this type of pain due to weight gain, changes in the spinal curvature, hormonal changes in the third trimester, and the physical stresses of childbirth. Car crashes, especially rear-end collisions, can indirectly strain the joint and cause pain, particularly if one leg is pushing on a pedal during the impact. Previous spinal surgery can also cause sacroiliac joint pain, which can often be overlooked. In fact, studies have shown increased stress on the sacroiliac joint after fusion surgery, a procedure to join two or more bones of the spine together, with one study even noting a doubling in the rate of joint degeneration following such surgery compared to people who did not have the surgery.
Risk Factors and Frequency for Sacroiliac Joint Pain
Low back pain affects 85% of people at some point in their lives, with the sacroiliac joint being the cause in 25% of those cases. Problems with the sacroiliac joint mainly impact adults. That said, two groups particularly prone to these issues are younger adults who’ve had sports injuries or pregnancies, and older adults suffering from wear and tear on the body. It’s important to know that both men and women of all races can experience sacroiliac joint dysfunction.
Signs and Symptoms of Sacroiliac Joint Pain
Sacroiliac joint pain, known as SI joint pain, can happen due to many reasons. It’s important to examine a patient’s medical history and current symptoms to correctly identify these disorders.
Typically, people with SI joint disorders describe feeling a deep pain that reaches from the back of the thigh to the knee. This discomfort can often mimic other types of pain and even be wrongly diagnosed. Common complaints include feeling pain when sitting, lying on the side of the affected joint, or walking up stairs. SI joint pain usually occurs after a specific event and doesn’t tend to come on gradually. Such triggering events might be a car accident, a fall, continuous stress, or pregnancy.
Those with SI joint dysfunction tend to experience pain below and to the inside of the Back of Hip Bone (PSIS). However, this pain can appear in various patterns, including down the back or side of the thigh, beyond the knee, and even in the foot.
During a physical examination, other potential causes of pain in the lower back, pelvic region, or hip should also be considered. Your doctor will check the flexibility and sensitivity of these areas, along with a neurological examination that includes sensory testing, muscle strength, reflexes, and the Babinski sign for both legs. Leg length should also be measured since different lengths might lead to SI joint dysfunction.
There are many different exams that can identify SI joint dysfunction, but none is particularly sensitive or accurate alone. Here is a list of the most common ones:
- Patrick’s or FABER’s test: While lying flat on your back, your doctor will move your hip and knee in certain ways. Pain in the SI joint suggests dysfunction, while pain in the hip or groin indicates a problem with the hip.
- Gaenslen’s test: While lying flat on your back, your doctor will move your opposite hip and knee towards your chest while allowing your other leg to hang off the table. Pain in the SI joint on the dangling leg suggests dysfunction.
- Distraction test: As you lie flat on your back, your doctor will apply force against the front of your hip bones. Pain in the SI joint indicates dysfunction.
- Thigh thrust: While you lie on your back, your doctor will position one of your legs vertically and apply pressure downwards. If you feel pain in the SI joint, it suggests dysfunction.
- Lateral compression: When lying on your side, your doctor will apply pressure downward with their hand against your upper hip bone. Pain in the SI joint suggests dysfunction.
- Sacral thrust: While you lie on your stomach, your doctor will apply downward force over the center of your lower back. Pain here in the SI joint region suggests dysfunction.
Testing positive in three or more of these tests can help confirm a diagnosis of SI joint dysfunction.
Testing for Sacroiliac Joint Pain
Imaging tests can help to rule out other potential causes of pain. Basic X-ray images can identify problems in the hip and changes in what we call your sacroiliac joint, which connects your spine to your hips.
In a condition called ankylosing spondylitis, the sacroiliac joint can show changes such as:
1. Subchondral bony erosion, which means there’s wear and tear under the surface of the joint.
2. Subchondral sclerosis, which means there’s hardening under the surface of the joint.
3. Fusion of the sacroiliac joint, which means two bones are growing together.
CT scans can provide more detailed images of these bone structures. Though, a test called radionuclide imaging isn’t useful to identify issues with the sacroiliac joint. MRI scans are 90% effective in finding a type of arthritis known as spondyloarthritis but aren’t effective for non-inflammatory conditions.
The most certain way to identify problems with the sacroiliac joint is through an image-guided injection. This is a procedure where the doctor uses images to guide an injection into your joint, which can firstly cause some pain as it inflates the joint and then provide relief through a local anesthetic. Several imaging methods can be used to guide these injections. The most effective are those guided by CT scans, followed by those using a technique called Fluoroscopy, and finally those guided by ultrasound technology. During this procedure, the doctor directs the needle towards the lower part of the joint and only uses a small amount (1-2 milliliters) of fluid for the injection.
Treatment Options for Sacroiliac Joint Pain
The first step in dealing with sacroiliac joint syndrome (a type of lower back pain) is doing exercises that help stabilize the spine and stretch it. Using belts to hold the sacroiliac joints in place is just as effective as a home or professional exercise program in managing pain during pregnancy. Pain relievers and nonsteroidal anti-inflammatory drugs (NSAIDs) can help soothe discomfort.
If certain sports or activities make the pain worse, it might be necessary for the patient to adjust or avoid these activities. Therapeutic adjustments, such as those made by osteopaths (doctors who specialize in the musculoskeletal system) and chiropractors, can be helpful. Kinesio taping, where a special tape is applied to your skin can also provide positive results.
There are also more aggressive treatments available, these involve:
- Prolotherapy – a procedure that involves injecting substances like sugar water and platelet-rich plasma (a component of your blood) into the joint.
- Steroid injections. These can be done on the outside of the joint, inside the joint, or a combination of both. It is generally preferred to do both or just the outside injections rather than just inside.
- Radiofrequency denervation. This process involves damaging the nerves that bring the pain to the sacroiliac joint. Some versions of this treatment can cover a larger area, but they only affect the nerves on the backside and not the front.
- Pulsed radiofrequency. Unlike normal radiofrequency, which destroys nerves, this procedure changes the way pain signals travel in the nerves.
If the pain is severe and does not respond to these treatments, surgery may be necessary. However, the results can vary. Past research has shown that many patients were not entirely satisfied with the surgery results, and a significant number of them needed another operation. Newer surgical techniques using triangular implants have shown better results, but we are still waiting to see how well these work in the long term.
What else can Sacroiliac Joint Pain be?
When experiencing pain in the hip or lower back region, several different medical conditions might be the cause. These could include:
- Ankylosing spondylitis (a type of arthritis affecting the spine)
- Insufficiency fracture of the sacrum (a break in the bone at the base of the spine due to bone weakness)
- Hip fracture
- Hip tendonitis (inflammation of the tendons in the hip)
- Iliotibial band syndrome (pain on the outer side of the knee caused by excessive rubbing of the band of fibers that run down the outside of the thigh)
- Lumbosacral discogenic pain syndrome (back pain originating from damaged discs in the spine)
- Lumbosacral radiculopathy (a disorder affecting the nerve roots in the lower spine)
- Piriformis syndrome (a condition causing sciatica-like pain along the sciatic nerve)
- Sacroiliac joint infection (an infection in the joint connecting the spine and the pelvis)
- Iliac crest syndrome (pain in the uppermost region of the hip)
- Trochanteric bursitis (inflammation of the fluid-filled sac at the outside point of the hip)
A proper diagnosis made by a healthcare professional is necessary for effective treatment and relief.
What to expect with Sacroiliac Joint Pain
Getting the right diagnosis is incredibly important. If you’ve experienced a recent injury, stress to the lower back, or had prior lower back surgery, these are crucial details to share with your doctor. Your doctor will use three or more physical tests to figure out if the sacroiliac joint is causing your pain. The sacroiliac joint is located in your lower back and links your hip bones to your spine.
Physical therapy is typically the first step in treatment. This will involve a series of stretching and stabilizing exercises. If one of your legs is slightly longer than the other, adjustments to your footwear can help. For pregnant women experiencing discomfort in the sacroiliac joint, pelvic stabilization belts can provide relief.
If these non-interventional methods don’t work, the next step might involve an image-guided injection of a local anesthetic, potentially paired with a steroid. This process can either target the joint directly (intraarticular), the area around the joint (extra-articular), or both. These injections should alleviate the pain, and those physical tests the doctor performed should come back negative afterwards.
If pain continues, a technique called radiofrequency denervation might be attempted, which uses electrical current produced by a radio wave to reduce nerve pain. The majority of patients find enough pain relief with these methods. However, in the most stubborn cases, a minimally invasive surgery called trans sacroiliac joint fusion surgery could be an option.
Possible Complications When Diagnosed with Sacroiliac Joint Pain
Injections have a couple of risks, including the possibility of causing infection in the joint and leading to bleeding. A strict cleanliness protocol and the use of thin needles for epidurals can minimize the risk of bleeding. When using image guidance, it’s important to accurately target the lower part of the joint.
Side Effects:
- Infection in the joint
- Bleeding
Another procedure, known as radiofrequency denervation, could potentially result in numbness. If the electrodes are not placed correctly, they might harm the nerves in the lower back, resulting in a loss of control over bladder and bowel functions, increased pain, or weakness in the limbs.
Further Side Effects:
- Numbness
- Loss of control over bladder and bowel function
- Increased pain
- Limb weakness
Surgery might also lead to increased pain and damage to the nervous system. Lastly, during percutaneous fusion procedures, two-plane radiography is vital.
Further Risks:
- Increased pain after surgery
- Neurological damage
Preventing Sacroiliac Joint Pain
Pain in the sacroiliac joint, which is located in the lower back and buttocks area, is usually managed well and has a positive outlook, much like other low back pain issues. It’s important that patients don’t stay bedridden and continue to move around. Exercises that focus on stabilizing and stretching the affected area can be helpful.
If the lower back pain is related to pregnancy, it often resolves on its own within a year after giving birth. If the pain continues, professional medical advice from a specialist is recommended.
However, if you experience symptoms like loss of nerve function, problems with bowel or bladder control, severe pain even when not moving, or pain that interrupts your sleep, it’s critical to seek immediate medical attention for proper evaluation.
