The sacroiliac (SI) joint is the largest joint in the body and is the cause of up to 25% of all low back pain1 and more than 40% of low back pain in those with prior lumbar fusion.2 Other causes of SI joint pain include obesity, degenerative or inflammatory arthritis, scoliosis, leg length discrepancy, trauma, or pregnancy. The SI joint itself is designed to move less than 5 mm in any direction.3 Anything that leads to excessive joint movement, caused either by abnormal torque forces through the joint or ligamentous laxity, if severe or long-lasting enough, can result in injury to the joint and pain – especially in the absence of a strong supporting core musculature.

SI joint pain is typically felt below the beltline, in the buttocks, and can extend into the posterolateral thigh and less commonly below the knee.4 It is worse with sitting (versus standing), lying on the painful side, rolling over in bed, and climbing stairs. SI joint pain highly impacts quality of life scores, so how can we recover from this?

How to Diagnose

To effectively treat, it is imperative to properly diagnose. The case for SI joint pain is first built on a comprehensive history and physical exam. X-ray or advanced imaging might also be necessary, especially to rule out other conditions. SI joint pain can be challenging to diagnose, even despite report of typical symptoms and reproducible pain on exam. Therefore, if SI joint pain is suspected, the gold standard for diagnosis is an intra-articular SI joint injection5 with local anesthetic only (i.e., lidocaine). If this injection results in at least 50-70% relief of the typical pain during the anesthetic duration of action (a few hours, depending), then the diagnosis of SI joint pain can be made. An injection that resulted in less than 50% relief of the typical pain should prompt further work-up of other causes of low back pain.

How to Treat

Once diagnosed, a course of conservative treatment should be trialed over 6-12 weeks. This might include relative rest, alternating applied heat/ice, the use of oral and/or topical anti-inflammatories, and/or application of a transcutaneous electrical nerve stimulation (TENS) unit or SI joint belt. A physical therapy program also comes highly recommended, with a focus on strengthening the gluteus maximus, biceps femoris, and erector spinae.6 MLS laser therapy might be used as an adjunctive treatment during this phase. If after 4 weeks this approach is not hitting the mark, then a therapeutic intra-articular SI joint injection may be of some benefit. This would include the injection of local anesthetic and steroid into the SI joint. Ideally, this would result in at least 3 months of 50-70% relief and may facilitate ongoing conservative therapies. Therapeutic intra-articular steroid injections may be repeated up to 4 times per year, as appropriate. Should a therapeutic intra-articular SI joint injection result in less than 3 months of relief, then more advanced interventions can be considered.

Minimally Invasive SI Joint Fusion

While open SI joint fusion has been performed since the 1920s, it wasn’t until 2010 did minimally invasive SI joint fusion take over the market.7 Now, through use of the SIrosTM 3D Printed Lateral Sacroiliac Joint Fusion system by Genesys Spine, each SI joint can be fused with 3 small screw-like implants through a 1-inch incision done in outpatient day surgery with little-to-no down time. Recall, SI joint pain is often caused by joint hypermobility, so it stands to reason that long-term relief might be found in securing the joint together. Sure enough, a 2020 meta-analysis8 of 19 different studies found across multiple implant manufacturers the average pain score was reduced from 8.03 to 3.22 (on a scale of 1 to 10) at 1 year follow-up. A 2018 retrospective study9 of 137 patients found that those who underwent minimally invasive SI joint fusion experienced on average a 6 point reduction of pain (on a scale of 1 to 10), reduced reliance on pain medications, and improved functional scores that were all maintained over a 6 year follow-up period.

Peripheral Nerve Stimulation for SI Joint Pain

Another option is peripheral nerve stimulation, or PNS. While this has been around since 196710, much technological advancement has been made just in recent years. A type of neuromodulation, this bit of implanted wire aims to stimulate the nerve(s) suspected of transmitting pain signals and prevent those signals from reaching the brain. For the SI joint, the target nerve is the middle cluneal nerve. While there are many studies that highlight the successes of neuromodulation as a whole, including spinal cord stimulation and PNS for a variety of other applications, literature on PNS for SI joint pain specifically is limited to case reports and observational studies.11-12 However, one small 2017 study13 found that in those who underwent PNS for SI joint pain, the average pain score was reduced from 8.8 to 1.6 (on a scale of 1 to 10) at 1 year and remained down at 2.0 (on a scale of 1 to 10) at 3 years.

Don’t let SI joint pain steal your quality of life!

Give us a call today: (469) 290-7246

 

Dustin Leek, MD

Updated 06/12/2023

 

Resources

  • Raj MA, Ampat G, Varacallo M. Sacroiliac Joint Pain. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470299/
  • DePalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med. 2011 Feb;12(2):224-33. doi: 10.1111/j.1526-4637.2010.01045.x. Epub 2011 Jan 25. PMID: 21266006.
  • Garras DN, Carothers JT, Olson SA. Single-leg-stance (flamingo) radiographs to assess pelvic instability: how much motion is normal? J Bone Joint Surg Am. 2008 Oct;90(10):2114-8. doi: 10.2106/JBJS.G.00277. PMID: 18829908.
  • DePalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med. 2011 Feb;12(2):224-33. doi: 10.1111/j.1526-4637.2010.01045.x. Epub 2011 Jan 25. PMID: 21266006.
  • Poley RE, Borchers JR. Sacroiliac joint dysfunction: evaluation and treatment. Phys Sportsmed. 2008 Dec;36(1):42-9. doi: 10.3810/psm.2008.12.10. PMID: 20048471.
  • Added MAN, de Freitas DG, Kasawara KT, Martin RL, Fukuda TY. STRENGTHENING THE GLUTEUS MAXIMUS IN SUBJECTS WITH SACROILIAC DYSFUNCTION. Int J Sports Phys Ther. 2018 Feb;13(1):114-120. PMID: 29484248; PMCID: PMC5808006.
  • Lorio MP, Polly DW Jr, Ninkovic I, Ledonio CG, Hallas K, Andersson G. Utilization of Minimally Invasive Surgical Approach for Sacroiliac Joint Fusion in Surgeon Population of ISASS and SMISS Membership. Open Orthop J. 2014 Jan 24;8:1-6. doi: 10.2174/1874325001408010001. PMID: 24551025; PMCID: PMC3924210.
  • Martin CT, Haase L, Lender PA, Polly DW. Minimally Invasive Sacroiliac Joint Fusion: The Current Evidence. Int J Spine Surg. 2020 Feb 10;14(Suppl 1):20-29. doi: 10.14444/6072. PMID: 32123654; PMCID: PMC7041666.
  • Vanaclocha V, Herrera JM, Sáiz-Sapena N, Rivera-Paz M, Verdú-López F. Minimally Invasive Sacroiliac Joint Fusion, Radiofrequency Denervation, and Conservative Management for Sacroiliac Joint Pain: 6-Year Comparative Case Series. Neurosurgery. 2018 Jan 1;82(1):48-55. doi: 10.1093/neuros/nyx185. PMID: 28431026.
  • Helm S, Shirsat N, Calodney A, Abd-Elsayed A, Kloth D, Soin A, Shah S, Trescot A. Peripheral Nerve Stimulation for Chronic Pain: A Systematic Review of Effectiveness and Safety. Pain Ther. 2021 Dec;10(2):985-1002. doi: 10.1007/s40122-021-00306-4. Epub 2021 Sep 3. PMID: 34478120; PMCID: PMC8586061.
  • Shah T, Khosla A (November 14, 2022) Successful Use of Subcutaneous Stimulation for Bilateral Sacroiliac Joint Pain. Cureus 14(11): e31495. doi:10.7759/cureus.31495
  • Chakrabortty S, Kumar S, Gupta D, Rudraraju S. Intractable sacroiliac joint pain treated with peripheral nerve field stimulation. J Anaesthesiol Clin Pharmacol. 2016 Jul-Sep;32(3):392-4. doi: 10.4103/0970-9185.173336. PMID: 27625495; PMCID: PMC5009853.
  • Guentchev M, Preuss C, Rink R, Peter L, Sailer MHM, Tuettenberg J. Long-Term Reduction of Sacroiliac Joint Pain With Peripheral Nerve Stimulation. Oper Neurosurg (Hagerstown). 2017 Oct 1;13(5):634-639. doi: 10.1093/ons/opx017. PMID: 28922873.

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