Sacroiliac joint dysfunction

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Sacroiliac joint dysfunction
Other namesSacroiliac joint disorder, sacroiliac joint disease, sacroiliac joint syndrome, sacroiliac syndrome, sacroilliac dysfunction and instability
Sacroiliac Joint.png
The sacroiliac joint, posterior view

The term sacroiliac joint dysfunction refers to abnormal motion in the sacroiliac joint, either too much motion or too little motion, that causes pain in this region.

Contents

Signs and symptoms

Common symptoms include lower back pain, buttocks pain, sciatic leg pain, groin pain, hip pain (for explanation of leg, groin, and hip pain (see referred pain), urinary frequency, and "transient numbness, prickling, or tingling". [1] [2] [3] [4] [5] [6] [7] Pain can range from dull aching to sharp and stabbing and increases with physical activity. [1] [8] [2] Symptoms also worsen with prolonged or sustained positions (i.e., sitting, standing, lying). [8] [9] [2] Bending forward, stair climbing, hill climbing, and rising from a seated position can also provoke pain. Pain can increase during menstruation in women. [8] [9] [2] People with severe and disabling sacroiliac joint dysfunction can develop insomnia and depression. [10] Sacral rotation can be transmitted distally down the kinematic chain and, if left untreated over a long period of time, may lead to severe Achilles tendinitis. [11]

Causes

Hypermobility

Sacroiliac joint dysfunction is an outcome of either extra-articular dysfunction or from intraarticular dysfunction.

SI joint dysfunction is sometimes referred to as "sacroiliac joint instability" or "sacroiliac joint insufficiency" due to the support the once strong and taut ligaments can no longer sustain. [8] [9] [2] [12] When the joint is hypermobile or loose, it is classified as an extra-articular dysfunction because abnormal joint movement and alignment is a consequence of weakened, injured, or sprained ligaments, while the joint itself is structurally normal and healthy. The sacroiliac joint itself often will not show degenerative changes, such as arthritis, until many years of the dysfunction being allowed to continue. [8] Injury to the ligaments that hold the sacroiliac joints in proper support is thought to be caused by a torsion or high impact injury (such as an automobile accident) or a hard fall, resulting in the hypermobility. [8] As many as 58% of people diagnosed with sacroiliac joint pain had some inciting traumatic injury based on clinical examination findings. [7] The joint that was once stabilized by strong ligaments, now overly stretched, sprained, or torn, will move beyond its normal range. This is thought to result in the ilium and sacral surfaces "locking" in an incongruent or asymmetrical fashion (one innominate bone is tilted anteriorly; the other innominate bone is tilted posteriorly) causing pain that can be debilitating. [8]

Hormone imbalances, particularly those associated with pregnancy and the hormone relaxin, can also cause a ligamentous laxity resulting in the weakening of the sacroiliac structure. [13] During pregnancy, relaxin serves as nature's way of allowing the female pelvis to achieve distention of the birthing canal. [13] Pelvic joint pain in post pregnancy women is thought to be derived from the inability of the stretched out ligaments to return to normal tautness. [13] Women who have delivered large babies or who have had extended labors also are prone to developing chronic sacroiliac joint pain and instability.[ citation needed ]

In some people, the sacroiliac joints reverse the normal concave-convex 'locking' relationship, which can lead to rotational misalignment. [8] [9] [2] The variation in joint configuration results in some sacroiliac joints being inherently weaker or more prone to misalignment. [9]

Certain biomechanical or muscle length imbalances may ultimately predispose a person to sacroiliac dysfunction and pain. Likely, this is a result of altered gait patterns and repetitive stress to the SI joint and related structures. [1] These conditions exist in persons with leg-length inequality, scoliosis, a history of polio, poor-quality footwear, and hip osteoarthritis. [1]

There is also a notable incidence of lumbar spinal fusion patients that present with sacroiliac pain and hypermobility, potentially due to the adjacent lumbar joints being fixed and unable to move. Clinical studies have found up to 75% of post-lumbar fusion patients develop SI joint degeneration within five years of surgery. [14]

Hypomobility

Pathological hypomobility (too little movement) of the sacroiliac joint is an intra-articular disorder in which the joint locks due to wearing down with age or degenerative joint disease.[ citation needed ]

Hypomobility of this kind can also occur with an inflammatory disease such as ankylosing spondylitis, [15] [ unreliable medical source? ] rheumatoid arthritis, or an infection.[ citation needed ]

Pathophysiology

The sacroiliac joint is a true diarthrodial joint that joins the sacrum to the pelvis. [1] [8] [16] [17] The sacrum connects on the right and left sides to the ilia (pelvic bones) to form the sacroiliac joints. The pelvic girdle is made up of two innominate bones (the iliac bones) and the sacrum. The innominate bones join in the front of the pelvis to form the pubic symphysis, and at back of the sacrum to form the sacroiliac (SI) joints. Each innominate bone (ilium) joins the femur (thigh bone) to form the hip joint; thus the sacroiliac joint moves with walking and movement of the torso. [9]

In this joint, hyaline cartilage on the sacral side moves against fibrocartilage on the iliac side. The sacroiliac joint contains numerous ridges and depressions that function in stability. Studies have documented that motion does occur at the joint; therefore, slightly subluxed and even locked positions can occur. [8] [16] [2] [18] [3] [19] [12] [ excessive citations ]

Muscles and ligaments surround and attach to the SI joint in the front and back, primarily on the ilial or sacral surfaces. These can all be a source of pain and inflammation if the SI joint is dysfunctional. [9] [2] The sacroiliac joint is highly dependent on its strong ligamentous structure for support and stability. [9] The most commonly disrupted and/or torn ligaments are the iliolumbar ligament and the posterior sacroiliac ligament. [9] The ligamentous structures offer resistance to shear and loading. The deep anterior, posterior, and interosseous ligaments resist the load of the sacrum relative to the ilium. [1] More superficial ligaments (e.g., the sacrotuberous ligament) react to dynamic motions (such as straight-leg raising during physical motion). [1] The long dorsal sacroiliac ligament can become stretched in periods of increased lumbar lordosis (e.g., during pregnancy). [20]

Affected muscle groups

Many large and small muscles have relationships with the ligaments of the sacroiliac joint including the piriformis (see "piriformis syndrome", a condition often related with sacroiliac joint dysfunction), rectus femoris, gluteus maximus and minimus, erector spinae, latissimus dorsi, thoracolumbar fascia, and iliacus. [1] Any of these muscles can be involved or spasm with a painful and dysfunctional sacroiliac joint. [1] [8] [2] [3] [19] [12] The SI joint is a pain-sensitive structure richly innervated by a combination of unmyelinated free nerve endings and the posterior primary rami of spinal segments L2-S3. The wide possibility of innervation may explain why pain originating from the joint can manifest in so many various ways, with different and unique referral patterns (see "referred pain") for individual patients. [1] [18] Patients with sacroiliac joint dysfunction can also develop tightness and dysfunction in the hamstring, quadriceps, iliotibial tract (see "iliotibial band syndrome") and hip flexors, including the psoas muscle. Individuals with severe and long-standing sacroiliac joint dysfunction can develop muscle deconditioning and atrophy throughout the body due to limitation of activities and exercise that bring about pain in the low back. [1]

Diagnosis

Perhaps the biggest reason for misdiagnosis or lack of diagnosis of sacroiliac joint dysfunction is based on the inability of common radiological imaging to discern the disorder. Diagnostic testing, such as X-ray, CT scan, or MRI, do not usually reveal abnormalities; therefore, they cannot reliably be used for diagnosis of sacroiliac joint dysfunction. [9] [2] There is a new imaging test SPECT/CT which can sometimes detect sacroiliac joint dysfunction. There is also a lack of evidence that sacroiliac joint mobility maneuvers (Gillet, Standing flexion test, and Seated Flexion test) detect motion abnormalities. [21] [22] Given the inherent technical limitations of the visible and palpable signs from these sacroiliac joint mobility maneuvers another broad category of clinical signs have been described called provocative maneuvers. These maneuvers are designed to reproduce or increase pain emanating within the sacroiliac joint.[ citation needed ]

A clinician (i.e., a spine surgeon, orthopedic surgeon, sports medicine doctor, athletic trainer, medical massage therapist, physical therapist, physiatrist, osteopath or chiropractor) can develop a probable diagnosis of sacroiliac joint dysfunction by using a hands on approach through palpating the painful areas and performing the following provocative maneuvers below:[ citation needed ]

Cautious interpretation is warranted because there are no biomechanical studies showing that the Thigh Thrust test isolates forces in the SIJ when performed at 90 degrees and due to intra-individual variation in body type, hip flexibility, general flexibility of the trunk and pelvis. [23] In all the tests, pain along the typical area raises suspicion for sacroiliac joint dysfunction. However no single test is very reliable in the diagnosis of sacroiliac joint dysfunction. It is important to remember true neurogenic weakness, numbness, or loss of reflex should alert the clinician to consider nerve root pathology. [24]

The current "gold standard" for diagnosis of sacroiliac joint dysfunction emanating within the joint is sacroiliac joint injection confirmed under fluoroscopy or CT-guidance using a local anesthetic solution. The diagnosis is confirmed when the patient reports a significant change in relief from pain and the diagnostic injection is performed on two separate visits. Published studies have used at least a 75 percent change in relief of pain before a response is considered positive and the sacroiliac joint deemed the source of pain. [25] [26] [27] However, several other injection studies have compared intra-articular with extra-articular injection, and indicate that the ligament injection behind the joint is oftentimes superior to injection in the joint and seems to be a very underutilized diagnostic tool. [24] [28]

Misdiagnosis

In the early 1900s, dysfunction of the sacroiliac joint was a common diagnosis associated with low back and sciatic nerve pain. [18] However, research by Danforth and Wilson in 1925 concluded that the sacroiliac joint could not cause sciatic nerve pain because the joint does not have a canal in which the nerves can be entrapped against the joint. [29] The biomechanical relationship between the sacroiliac joint, the piriformis muscle (see "piriformis syndrome"), and the sciatic nerve had not yet been discovered. [18]

In 1934, the work of Mixter and Barr shifted all emphasis in research and treatment from the sacroiliac to the herniated intervertebral disc, namely lumbar discs. [30] Medical focus on herniated discs was further forwarded by the invention of the MRI in 1977. [31] Over-diagnosis and attention on herniated discs has led to the SI joint becoming an underappreciated pain generator in an estimated 15% to 25% of patients with axial low back pain. [1] [8] [3] [5] [6] [7]

The ligaments in the sacroiliac are among the strongest in the body and are not suspected by many clinicians to be susceptible to spraining or tearing. Skepticism of the existence of sacroiliac joint dysfunction within the medical community is furthered by the debate on how little or much the sacroiliac joint moves. A discrepancy as large as 2–17 degrees has been reported in clinical findings. [32] [33] [34]

Treatment

Treatment is often dependent on the duration and severity of the pain and dysfunction. In the acute phase (first 1–2 weeks) for a mild sprain of the sacroiliac, it is typical for the patient to be prescribed rest, ice/heat, spinal manipulation, [35] and physical therapy; anti-inflammatory medicine can also be helpful. [1] [4]

If the pain does not resolve in the first 1–2 weeks, then the patient may benefit from a steroid and anesthetic mixture fluoroscopically injected into the joint (this also serves in confirming diagnosis), as well as manipulative or manual therapy. [1] [8] [9] [2] [3] [12] For the most severe and chronic forms of sacroiliac dysfunction, treatment should proceed with the support of a sacroiliac belt, injection therapy, and finally, surgery. [1] [8] [9] [2] [18] The anti-inflammatory effect of injection therapy is not permanent, and the injections do not offer an opportunity to stabilize an incompetent joint. [36] Surgery is often considered a last resort, but for some patients, it is the only method of effectively stabilizing the loose joint. A fixation of the joint (screws or similar hardware only, without the use of bone grafting) is more common than a spinal fusion, as it is much less invasive, surgically straightforward, and results in a quicker recovery time for the patient. [8] [9] [18] [37] Some experts in the field believe that it is important to make sure the sacroiliac joint is in an anatomically correct position prior to fixation or fusion, but published research contradicts this belief. [8] [9] [2] [18] [38] [39]

Platelet-rich plasma (PRP) injections have shown positive results as a treatment for Sacroiliac Joint Dysfunction, with randomized trials and case reports showing them to be more effective over periods of 3 months than steroid injections. Studies have also shown PRP injections into the sacroiliac joint are able to provide complete relief of symptoms, lasting as long as four years. [40] [41] [42] [43]

Dextrose prolotherapy injections performed either intraarticularly or into the dorsal sacroiliac ligaments is sometimes performed as an alternative treatment option. This is a controversial therapy but it does have research evidence to support its use. Kim et al. in 2010 published a randomized controlled trial evaluating the effect of intraarticular prolotherapy injections versus intraarticular steroid injections in proven sacroiliac joint pain. The two interventions were equal in the short term at 3 months, but the prolotherapy group had superior pain relief at the 15 month mark at the end of follow up. This type of trial is considered high level evidence in medical circles. [44] Hoffman et al. in 2018 published a prospective cohort study with positive results in the treatment of those with sacroiliac joint dysfunction. [45]

See also

Related Research Articles

<span class="mw-page-title-main">Sacrum</span> Bone of the spine

The sacrum, in human anatomy, is a large, triangular bone at the base of the spine that forms by the fusing of the sacral vertebrae (S1–S5) between ages 18 and 30.

<span class="mw-page-title-main">Ankylosing spondylitis</span> Type of arthritis of the spine

Ankylosing spondylitis (AS) is a type of arthritis from the disease spectrum of axial spondyloarthritis. It is characterized by long-term inflammation of the joints of the spine, typically where the spine joins the pelvis. With AS, eye and bowel problems—as well as back pain—may occur. Joint mobility in the affected areas sometimes worsens over time. Ankylosing spondylitis is believed to involve a combination of genetic and environmental factors. More than 90% of people affected in the UK have a specific human leukocyte antigen known as the HLA-B27 antigen. The underlying mechanism is believed to be autoimmune or autoinflammatory. Diagnosis is based on symptoms with support from medical imaging and blood tests. AS is a type of seronegative spondyloarthropathy, meaning that tests show no presence of rheumatoid factor (RF) antibodies.

<span class="mw-page-title-main">Lumbar spinal stenosis</span> Narrowing of the lower spinal canal

Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case it is known as cervical spinal stenosis or thoracic spinal stenosis. Lumbar spinal stenosis can cause pain in the low back or buttocks, abnormal sensations, and the absence of sensation (numbness) in the legs, thighs, feet, or buttocks, or loss of bladder and bowel control.

<span class="mw-page-title-main">Sacroiliac joint</span> Joint of the pelvis and spine

The sacroiliac joint or SI joint (SIJ) is the joint between the sacrum and the ilium bones of the pelvis, which are connected by strong ligaments. In humans, the sacrum supports the spine and is supported in turn by an ilium on each side. The joint is strong, supporting the entire weight of the upper body. It is a synovial plane joint with irregular elevations and depressions that produce interlocking of the two bones. The human body has two sacroiliac joints, one on the left and one on the right, that often match each other but are highly variable from person to person.

<span class="mw-page-title-main">Lordosis</span> Abnormal inward curvature of the lower spine

Lordosis is historically defined as an abnormal inward curvature of the lumbar spine. However, the terms lordosis and lordotic are also used to refer to the normal inward curvature of the lumbar and cervical regions of the human spine. Similarly, kyphosis historically refers to abnormal convex curvature of the spine. The normal outward (convex) curvature in the thoracic and sacral regions is also termed kyphosis or kyphotic. The term comes from Greek lordos 'bent backward'.

<span class="mw-page-title-main">Spondylolisthesis</span> Displacement of one spinal vertebra compared to another

Spondylolisthesis is when one spinal vertebra slips out of place compared to another. While some medical dictionaries define spondylolisthesis specifically as the forward or anterior displacement of a vertebra over the vertebra inferior to it, it is often defined in medical textbooks as displacement in any direction.

Meralgia paresthetica or meralgia paraesthetica is pain or abnormal sensations in the outer thigh not caused by injury to the thigh, but by injury to a nerve which provides sensation to the lateral thigh.

<span class="mw-page-title-main">Multifidus muscle</span> Muscle in the back

The multifidusmuscle consists of a number of fleshy and tendinous fasciculi, which fill up the groove on either side of the spinous processes of the vertebrae, from the sacrum to the axis. While very thin, the multifidus muscle plays an important role in stabilizing the joints within the spine. The multifidus is one of the transversospinales.

Failed back syndrome or post-laminectomy syndrome is a condition characterized by chronic pain following back surgeries. Many factors can contribute to the onset or development of FBS, including residual or recurrent spinal disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness, spinal muscular deconditioning and even Cutibacterium acnes infection. An individual may be predisposed to the development of FBS due to systemic disorders such as diabetes, autoimmune disease and peripheral blood vessels (vascular) disease.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the intervertebral disc between two spinal vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.

<span class="mw-page-title-main">Symphysis pubis dysfunction</span> Medical condition

Symphysis pubis dysfunction (SPD), commonly known as pubic symphysis dysfunction or lightning crotch, is a condition that causes excessive movement of the pubic symphysis, either anterior or lateral, as well as associated pain, possibly because of a misalignment of the pelvis. Most commonly associated with pregnancy and childbirth, it is diagnosed in approximately 1 in 300 pregnancies, although some estimates of incidence are as high as 1 in 50.

<span class="mw-page-title-main">Superior cluneal nerves</span>

The superior cluneal nerves are pure sensory nerves that innervate the skin of the upper part of the buttocks. They are the terminal ends of the L1-L3 spinal nerve dorsal rami lateral branches. They are one of three different types of cluneal nerves. They travel inferiorly through multiple layers of muscles, then traverse osteofibrous tunnels between the thoracolumbar fascia and iliac crest.

<span class="mw-page-title-main">Pubic symphysis diastasis</span> Medical condition

Pubic symphysis diastasis is the separation of normally joined pubic bones, as in the dislocation of the bones, without a fracture that measures radiologically more than 10 mm. Separation of the symphysis pubis is a rare pathology associated with childbirth and has an incidence of 1 in 300 to 1 in 30,000 births. It is usually noticed after delivery but can be observed up to six months postpartum. Risk factors associated with this injury include cephalopelvic disproportion, rapid second stage of labor, epidural anesthesia, severe abduction of the thighs during delivery, or previous trauma to the pelvis. Common signs and symptoms include symphyseal pain aggravated by weight-bearing and walking, a waddling gait, pubic tenderness, and a palpable interpubic gap. Treatment for pubic symphysis diastasis is largely conservative, with treatment modalities including pelvic bracing, bed rest, analgesia, physical therapy, and in some severe cases, surgery.

Pelvic girdle pain can be described as a pregnancy discomfort for some women and a severe disability for others. PGP can cause pain, instability and limitation of mobility and functioning in any of the three pelvic joints. PGP has a long history of recognition, mentioned by Hippocrates and later described in medical literature by Snelling.

The affection appears to consist of relaxation of the pelvic articulations, becoming apparent suddenly after parturition or gradually during pregnancy and permitting a degree of mobility of the pelvic bones which effectively hinders locomotion and gives rise to the most peculiar and alarming sensations.

<span class="mw-page-title-main">Neurogenic claudication</span> Discomfort in the legs during walking due to nerve impingement

Neurogenic claudication (NC), also known as pseudoclaudication, is the most common symptom of lumbar spinal stenosis (LSS) and describes intermittent leg pain from impingement of the nerves emanating from the spinal cord. Neurogenic means that the problem originates within the nervous system. Claudication, from Latin claudicare 'to limp', refers to painful cramping or weakness in the legs. NC should therefore be distinguished from vascular claudication, which stems from a circulatory problem rather than a neural one.

<span class="mw-page-title-main">Diffuse idiopathic skeletal hyperostosis</span> Medical condition

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterized by abnormal calcification/bone formation (hyperostosis) of the soft tissues surrounding the joints of the spine, and also of the peripheral or appendicular skeleton. In the spine, there is bone formation along the anterior longitudinal ligament and sometimes the posterior longitudinal ligament, which may lead to partial or complete fusion of adjacent vertebrae. The facet and sacroiliac joints tend to be uninvolved. The thoracic spine is the most common level involved. In the peripheral skeleton, DISH manifests as a calcific enthesopathy, with pathologic bone formation at sites where ligaments and tendons attach to bone.

<span class="mw-page-title-main">Pelvis</span> Lower torso of the human body

The pelvis is the lower part of an anatomical trunk, between the abdomen and the thighs, together with its embedded skeleton.

The sacroiliac joint is a paired joint in the pelvis that lies between the sacrum and an ilium. Due to its location in the lower back, a dysfunctional sacroiliac joint may cause lower back and/or leg pain. The resulting leg pain can be severe, resembling sciatica or a slipped disc. While nonsurgical treatments are effective for some, others have found that surgery for the dysfunctional sacroiliac joint is the only method to relieve pain.

<span class="mw-page-title-main">Ultrasound-guided hip joint injection</span>

Ultrasound-guided hip joint injection is a joint injection in the hip, assisted by medical ultrasound. Hip and groin pain often presents a diagnostic and therapeutic challenge. The differential diagnosis is extensive, comprising intra-articular and extra-articular pathology and referred pain from lumbar spine, knee and elsewhere in the pelvis. Various ultrasound-guided techniques have been described in the hip and groin region for diagnostic and therapeutic purposes. Ultrasound has many advantages over other imaging modalities, including portability, lack of ionizing radiation and real-time visualization of soft tissues and neurovascular structures. Many studies have demonstrated the safety, accuracy and efficacy of ultrasound-guided techniques, although there is lack of standardization regarding the injectates used and long-term benefit remains uncertain.

<span class="mw-page-title-main">Deep gluteal syndrome</span> Medical condition

Deep gluteal syndrome describes the non-discogenic extrapelvic entrapment of the sciatic nerve in the deep gluteal space. In simpler terms this is sciatica due to nerve irritation in the buttocks rather than the spine or pelvis. It is an extension of non-discogenic sciatic nerve entrapment beyond the traditional model of piriformis syndrome. Where sciatic nerve irritation in the buttocks was once thought of as only piriformis muscle, it is now recognized that there are many other causes. Symptoms are pain or dysthesias in the buttocks, hip, and posterior thigh with or without radiating leg pain. Patients often report pain when sitting. The two most common causes are piriformis syndrome and fibrovascular bands, but many other causes exist. Diagnosis is usually done through physical examination, magnetic resonance imaging, magnetic resonance neurography, and diagnostic nerve blocks. Surgical treatment is an endoscopic sciatic nerve decompression where tissue around the sciatic nerve is removed to relieve pressure.

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  42. ↑ Wallace, Patrick; Bezjian Wallace, Laurie; Tamura, Sarah; Prochnio, Kirk; Morgan, Kyle; Hemler, Douglas (August 2020). "Effectiveness of Ultrasound-Guided Platelet-Rich Plasma Injections in Relieving Sacroiliac Joint Dysfunction". American Journal of Physical Medicine & Rehabilitation. 99 (8): 689–693. doi:10.1097/PHM.0000000000001389. ISSN   1537-7385. PMID   31972616. S2CID   210880853.
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