by Holly Jahshan
Note: All references cited are included at the beginning of each section, as opposed to traditional AMA formatting, to take advantage of the interactive footnote capabilites of Wikidot.com.
Sacroiliac joint dysfunction is a controversial term used to explain pain resulting from biomechanical abnormalities of the sacroiliac joint when no evident sacroiliac joint injury is present. According to a 2003 study by Laslett et al, "The sacroiliac joint (SIJ) may produce pain in the back, buttock, groin and lower extremity similar to patterns from other lumbosacral sources." SIJ dysfunction is often difficult to diagnose, but it may be the cause for up to 30% of all chronic low-back pain.
The sacroiliac joints are synovial joints located between the irregularly shaped, articular surfaces of the sacrum and the ilium. The left and right sacroiliac joints function to transmit ground reaction forces from the lower extremities to the vertebral column. As a necessity of function, each SIJ is designed for stability, which is provided by the unique interlocking fit of the articular facets and three primary ligaments: the anterior sacroiliac ligament, the interosseous sacroiliac ligament, and the posterior sacroiliac ligament. Although there are no muscles that directly influence movement of the SIJ, certain muscles such as gluteus maximus, piriformis, and biceps femoris indirectly influence SIJ mobility due to functional ligamentous connections.
During pregnancy, women experience an increase in the hormone relaxin, which contributes to increased ligamentous laxity to facilitate parturition.
As stated by Cohen in a 2005 study, “The innervation of the SI joint remains a subject of much debate. The lateral branches of L4-S3 dorsal rami are cited by some experts as composing the major innervation to the posterior SI joint. Other investigators claim that L3 and S4 contribute to the posterior nerve supply. The innervation of the anterior joint is similarly ambiguous… More recent literature suggests the anterior joint is innervated by L2-S2, L4-S2, and the L5-S2 ventral rami. Some authors have even suggested that the anterior SI joint is devoid of nervous tissue.”
With age, the sacroiliac joints become fibrous. These fibrous changes to the articular surfaces of the sacrum and the ilium begin during adolescence and speed up by the fourth decade of life. By the sixth decade, capsular mobility of the SIJ is restricted. These degenerative changes are a naturally occuring part of life, and may eventually cause complete ossification of the SIJ.
Sacroiliac joint dysfunction commonly affects women more than men, with an incidence of between 15% and 38% in the general population. During pregnancy, the prevalence of posterior pelvic pain, which is pain located distally and laterally to the lumbosacral junction, is approximately 20%. Because the symptoms of sacroiliac joint dysfunction may mimic many other pathologies, differential diagnosis including provocation and diagnostic testing is key to successful treatment.
IV. Clinical Presentation:
V. Potential Etiologies:10
In their 2003 review, Hansen and Helm outlined many of the potential causes of sacroiliac joint dysfunction, which are represented in the table below.
|Ankylosing spondylitis||Inflammatory bowel disease||Lymphoma||Pituitary disease|
|Herniated nucleus pulposus||Pyogenic sacroiliitis||Ovarian Cancer||Fibromyalgia|
|Muscle strain||Sickle cell anemia||Intraspinal neoplasms||Osteoporosis|
|Genetic disorders||Matastases||Abdominal aneurysm|
|Reiter's syndrome||Carcinoma of colon|
|Eosinophilic granuloma||Carcinoma of prostate|
|Psoriatic spondylitis||Multiple myeloma|
|Diffuse idiopathic skeletal hyperostosis|
The gold standard for diagnosis of intra-articular sacroiliac joint pain is the anaesthetic block. Performed under fluoroscopic guidance, this test is administered by injecting contrast enhanced anaesthetic into the painful area of the sacroiliac joint. Common anaesthetics used in sacroiliac joint blocks are Lidocaine Hydrochloride and Bupivacaine Hydrochloride. Diagnosis is confirmed when the patient experiences relief from pain. This diagnostic test can double as a treatment method when corticosteroid is injected into the painful sacroiliac joint in addition to the local anaesthetic.
VIII. Conservative Treatment:15
Treatment of sacroiliac joint dysfunction in the acute stage might involve the use of cryotherapy, anti-inflammatory medication, and rest, which will aid in decreasing inflammation and pain in the affected area. Although the eventual goal is to restore normal mechanics, pelvic stabilizers such as SIJ belts, water-resistant tape, and three-point pelvic stabilization orthoses can provide the patient with increased proprioceptive awareness and confidence. To decrease long-term reliance on orthotics, conservative treatment may also include pelvic stabilization exercises that increase dynamic postural control and muscle strengthening of the two joint muscles around the SIJ. Plyometric exercises can be introduced in the final rehabilitation stages of SIJ dysfunction, but only after the patient has demonstrated pelvic control during non-impact dynamic movements.
Cryotherapy is used during the acute phase (48-72 hours) of a SIJ injury to control inflammation and pain. Cryotherapy can also be used to prevent delayed-onset muscle soreness after SIJ mobilizations or stability exercises. Cryotherapy for the SIJ area can be delivered through ice massage, the application of cold packs, or the application of ice packs. Cold packs and ice packs should be wrapped in towels to protect the patient's skin from tissue damage. Wet towels can be used with cold packs to facilitate the cooling process, but dry towels work best with ice packs since they have a lower temperature than cold packs. It is important to cool the cold packs for at least two hours before the first use and for at least 30 minutes between uses. Cryotherapy treatment time should be limited to no more than 20 minutes with at least one hour between applications, although ice massage applications will typcially require a shorter treatment time because the patient will experience analgesia more quickly. The following are contraindications/precautions to cryotherapy use:
- Cold hypersensitivity
- Cold intolerance
- Paroxysmal cold hemoglobinuria
- Raynaud's disease or phenomenon
- Over regenerating peripheral nerves
- Over an area with circulatory compromise or peripheral vascular disease
- Over a superficial main branch of a nerve (PRECAUTION)
- Over an open wound (PRECAUTION)
- Hypertension (PRECAUTION)
- Poor sensation or poor mentation (PRECAUTION)
- Very young or very old patients (PRECAUTION)
Thermotherapy is used in patients with SIJ dysfunction to control pain, increase soft tissue extensibility, increase circulation, and accelerate healing. Thermotherapy for the SIJ area is best delivered through a superficial heating method such as a bentonite-filled moist hot packs. Moist hot packs should be wrapped in six to eight layers of towels or in a specially designed hot pack cover, which can substitute for two to three layers of towels. Ensuring that the patient only feels a sensation of mild warmth upon application of the moist hot pack is vital to protecting the patient's skin from tissue damage. It is important to heat the moist hot packs for at least two hours before the first use and for at least 30 minutes between uses. Thermotherapy treatment time should be limited to no more than 20 minutes. The following are contraindications/precautions to thermotherapy use:
- Recent or potential hemorrhage
- Impaired sensation
- Impaired mentation
- Malignant tumor
- Acute injury or inflammation (PRECAUTION)
- Pregnancy (PRECAUTION)
- Impaired circulation (PRECAUTION)
- Poor thermal regulation (PRECAUTION)
- Edema (PRECAUTION)
- Cardiac insufficiency (PRECAUTION)
- Metal in the area (PRECAUTION)
- Over an open wound (PRECAUTION)
- Over areas where topical counterirritants have recently been applied (PRECAUTION)
- Demyelinated nerves (PRECAUTION)
Transcutaneous electrical nerve stimulation (TENS) is used in patients with SIJ dysfunction to reduce pain. Coventional, or high-rate TENS, reduces pain by taking advantage of the gate control theory of pain.
Low-rate, or acupuncture-like TENS, reduces pain by stimulating the production and release of endorphins. Burst mode TENS reduces pain similarly to low-rate TENS except that the electrical stimulation is delivered in bursts, which may make the treatment easier for some patients to tolerate. TENS is delivered through strategically placed electrodes. Cameron 2009 states, "If two channels, and thus four electrodes are used, the electrodes can be placed to surround the area of pain. The two channels can be placed so that they intersect, allowing the current to cross at the area of pain or they may be placed parallel, either horizontally or vertically. The two channels must intersect if an interferential current is desired. If one channel and thus two electrodes are used, placement around the painful area is most common."
|Setting||Pulse Frequency||Pulse Duration||Amplitude||Treatment Time|
|Conventional (high-rate)||100-150 pps||50-80 µs||To produce tingling||Up to 24 hours, as needed|
|Acupuncture (low-rate)||2-10 pps||200-300 µs||To visible contraction||20-30 minutes|
|Burst mode||Generally preset at 10 bursts||Generally preset with a max of 100-300 µs||To visible contraction||20-30 minutes|
The following are contraindications/precautions to electrical current use:
- Cardiac pacemaker or unstable arrhythmias
- Placement of electrodes over carotid sinus
- Areas where venous or arterial thrombosis or thrombophlebitis is present
- Pregnancy - over or around the abdomen or low back
- Cardiac disease (PRECAUTION)
- Patients with impaired mentation or in areas with impaired sensation (PRECAUTION)
- Malignant tumors (PRECAUTION)
- Areas of skin irritation or open wounds (PRECAUTION)
Sacroiliac joint belts are used in patients with SIJ dysfunction to provide compression and reduce SIJ movement in hypermobile or weak patients. According to Cusi 2010 the SIJ belt is best utlized in the early stages of rehabilitation. Although the belt may be worn when the patient is performing sedentary activities, it is best used during walking and standing activities when more stabilization is required. Proper positioning of the SIJ belt is posteriorly across the sacral base and anteriorly below the anterior superior iliac spines.
X. Surgery & Post-op Treatment:19
There are two main surgical procedures associated with sacroiliac joint dysfunction. The first procedure is a SIJ denervation, which works well for patients who respond favorably to the anaesthetic nerve block. In this procedure, a radiofrequency probe is used to cut the sensory nerves to the SIJ. Damage to surrounding structures is minimal because fluoroscopic or CT guidance of the probe is utilized.
The second surgical procedure associated with sacroiliac joint dysfunction is SIJ fusion, which is often used in patients with dislocation or fracture dislocation of the joint. One safe and reliable method for SIJ fusion is percutaneous iliosacral fixation with screws or bars. Like the SIJ denervation, the SIJ fusion is performed under fluoroscopic or CT guidance.