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Sacroiliac Joint Pain Syndrome in Active Patients

A Look Behind the Pain

Yung C. Chen, MD; Michael Fredericson, MD; Matthew Smuck, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 11 - NOVEMBER 2002

In Brief: The bones, ligaments, muscles, and nerves of the sacroiliac joint (SIJ) may be damaged by direct trauma or by smaller, repetitive stresses. Injury to many complex adjacent structures can refer pain to the SIJ, and SIJ pathology can refer pain elsewhere. Because of the varied and overlapping presentation of symptoms, a precise diagnosis of SIJ pain syndrome is often challenging. Physicians who recognize the condition early and offer prompt treatment (eg, physical therapy, corrective exercises with mobilization, and, if necessary, corticosteroid injection) will make a definite contribution to improving their patients' athletic performance.

Various athletic activities, including walking, running, jumping, leaping, and squatting, can produce unwanted motion or stress in the sacroiliac joint (SIJ) and surrounding tissues. Soft-tissue failure, overload injures, and direct trauma provide mechanisms for the evolution of SIJ pain syndrome.

Clinical symptoms or dysfunction may directly relate to intra-articular SIJ sources, extra-articular sources, or soft tissues around the SIJ, including muscles, tendons, ligaments, and neurovascular structures. Each has a specific function, mechanism of injury, and healing response to a given injury. SIJ pain syndrome may also be a distant manifestation of a musculoskeletal injury in other parts of the kinetic chain that are stressed during sports activities.

Anatomy

Bones. The pelvic ring includes two innominate bones and the sacrum. The innominate bones are the most proximal portion of the lower-extremity skeleton. They articulate at the pubic symphysis and with the spine at the sacroiliac joints. The sacrum joins the lumbar spine at one pseudojoint, the L5-S1 disk, and two synovial joints, the L5-S1 facets. The SIJ is also a true synovial joint,1 with many irregularities in the joint surface. Based on cadaver studies,2 the most common sacral segments involved in a disease process are S-1, S-2, and a portion of S-3.

The SIJ is C-shaped, with the convexity toward the pubis and concavity toward the posterior superior iliac spine. Gravity would force the wedged-shaped sacrum inferiorly and posteriorly between the pelvic bones if not for the strong ligamentous support provided by the thin anterior ligament (considered a thickening of the joint capsule) and the strong posterior and interosseous ligaments that permit only a small degree of motion in the joint. These three ligaments receive further support from the iliolumbar, sacrotuberous, and sacrospinous ligaments.2 Athletic activity that exerts either a single strong force or repetitive lower-intensity forces across these ligaments can injure the ligaments or the SIJ.

Muscles. The SIJ is surrounded by many powerful muscles of the spine, lower limbs, pelvis, and hips. However, none of these muscles act directly on the joint, with an origin from the pelvis and insertion to the sacrum. The long head of the biceps femoris, the gluteus maximus, and the piriformis muscles often have attachments to the sacrotuberous ligament that supports the SIJ.

Nerves. The SIJ is richly innervated by nociceptors that sense and transmit pain.3,4 Unmyelinated free nerve endings terminate in the joint capsule and overlying ligaments.5,6 In addition, the joint capsule contains nerve fibers that transmit pressure and proprioception.5 Innervation of the SIJ is from the posterior primary rami of L-4 through S-3 posteriorly, and the anterior primary rami from L-2 through S-2 anteriorly.2,5 Various studies6,7 have also demonstrated the close physical relationships between the sacroiliac joint capsule and adjacent neural structures, including the lumbosacral nerves and sympathetic nerves. Given the wide range of innervation of the SIJ and its adjacent neural structures, SIJ capsular stimulation may refer various pain patterns to the buttock, groin, thigh, calf, or foot.4,8,9

Biomechanic Interplay

During walking, running, or jumping, the SIJ transmits gravity forces from the vertebral column to the pelvis and transmits ground reaction forces from the lower limbs to the spine.10 Complex relationships between coordinated movement patterns and forces in the SIJ are observed in various athletic activities11 that integrate movements of the two sacroiliac joints, the symphysis pubis, the spine, and the hip joints. A detailed explanation of the various movements is beyond the scope of this article.

Movement of the SIJ is so small that controversy surrounds the topic. The primary movements are rotation and translation, and together they are called "nutation." The joint does not move around a single, clearly identified axis.12,13 The axes of motion for the SIJ are not straightforward and largely depend on the surface topography of the joints.14 The best in vivo studies of SIJ motion were done radiographically by implanting metal markers under local anesthesia.12,13 The greatest degree of motion was observed from straight standing into hyperextension. Average rotation was 2°, with a maximum of 4°. Average translation was 0.5 mm, with a maximum of 1.6 mm.

Sports physicians should be aware of the importance of the SIJ in athletic performance. The SIJ does not move in isolation; it is one link in a kinetic chain. Distant structural or mechanical alterations, such as leg-length discrepancy, muscle imbalance, trunk and hip hyperflexibility or hypoflexibility, or improper sport-specific mechanics, can increase stress on the SIJ and adjacent structures. Joint and soft-tissue stresses can lead to subclinical mechanical adaptations that may impair future performance and increase the risk of injury to the SIJ and other supporting structures in the kinetic chain. Small aberrations in movement may damage the joint or its supporting tissues. The SIJ can also be injured directly via a fall or a direct blow over the joint.

Clinical Presentation

History. Because the SIJ is part of a kinetic chain, athletes may report a history of ankle, foot, knee, hip, or spine injuries before the SIJ pain syndrome manifests. A patient's pain drawing, in conjunction with a careful clinical history, may help in the initial screen for SIJ pain syndrome. Although not pathognomonic for the syndrome, pain in the region of the sacral sulcus is nearly always present.3,4 Fortin et al4 showed that medial buttock pain (SIJ pain that is generally inferior and medial to the posterior superior iliac spine) is the most classic presentation. However, athletes may report buttock and lower lumbar pain15-28 with or without referred pain to the greater trochanter17,22,28; groin22,29; lower abdomen20,22,29; anterior, lateral, or posterior thigh16,17,21,24,28,30,31; or calf.16,24,28,31 The distinguishing feature for SIJ pain is lack of pain above the L-5 level.9 This variable pattern of pain and pain referral may be caused by multilevel innervation, irritation of adjacent neural elements and soft tissues, or varying locations of injury within the SIJ.32

Physical exam. Any physical exam for evaluation of SIJ syndrome should first screen for more obvious sources of low-back or hip pathology that can refer pain to the SIJ region, including posterior facet syndrome, disk disease, lateral recess spinal stenosis, and degenerative joint disease of the hip. Full lumbar spine and hip range of motion are expected with primary SIJ pain syndrome in athletes, although unilateral external rotation deficits of the hip have been associated with SIJ dysfunction.32,33 The hamstring may also be tight. The neurologic exam is usually normal, with negative nerve-root tension signs.

The hip abductors are the main coronal plane stabilizers of the pelvis, and any weakness leads to increased pelvic drop during the stance phase of gait and increased shear forces across the pelvis. Gluteus medius (the main hip abductor) weakness is often combined with overactivity and tightness in the piriformis muscle.34 The piriformis and the hamstring muscles have attachments to the sacrotuberous ligament, and any tightness can adversely affect forces in the SIJ. Tightness in the quadratus lumborum may also be present. When the gluteus medius is weak, the quadratus lumborum may compensate with excessive hip hiking, and it can become a source of pain caused by overactivity and resultant trigger points that refer into the SIJ region.

Pain provocation tests. No single test is sufficiently sensitive to accurately identify SIJ symptoms.9,24-33,35-39 Most physical examination procedures used for diagnosing sacroiliac dysfunction attempt to define abnormal motion or position of the SIJ. These tests induce shearing or rotational forces through the SIJ, with the force applied to either the sacrum or the innominate bone in an attempt to stress inflamed structures, thus provoking pain.

All of these tests will stress a combination of adjacent structures, including the lower lumbar spine, the hip joint, and the femoral or sciatic nerves. Although many practitioners use these tests, scientific studies have found numerous problems with reliability, sensitivity, and specificity. Of these, the thigh thrust and Gaenslen's sign have the greatest reliability.40,41 Studies41,42 have shown that the predictive value of these tests is maximized when a combination of tests are used. The tests are positive if back or buttock pain is elicited. The most common provocation tests are:

  • Posterior pelvic pain provocation test (thigh thrust). With the patient supine, the hip is flexed to 90° and the knee is bent (figure 1). The examiner applies posterior shearing stress to the SIJ through the femur. Excessive adduction of the hip is avoided, as combined flexion and adduction is normally painful.
  • Gaenslen's sign. With the patient supine, the hip is maximally flexed on one side, and the opposite hip is extended (figure 2). This maneuver stresses both SIJs simultaneously by counterrotation at the extreme range of motion. This test also stresses the hip joints and stretches the femoral nerve on the side of hip extension, so care should be taken to ensure normal hip findings and the absence of neurologic conditions affecting the femoral nerve.
  • Patrick's test. This test stresses the hip and SIJ by flexion, abduction, and external rotation of the hip. A positive test reproduces back or buttock pain, whereas groin pain is more indicative of hip joint pathology.
  • Sacroiliac shear test. With the patient prone, the palm of the examiner's hand is placed over the posterior iliac wing, and an inferiorly directed thrust produces a shearing force across the SIJ.
  • Compression test. With the patient in a side-lying position, downward pressure is applied to the uppermost iliac crest, directed toward the opposite iliac crest. It is intended to stretch the posterior sacroiliac ligaments and compress the anterior SIJ.
  • Distraction test (gapping). With the patient supine, a posterior and lateral force is applied to both anterior superior iliac spines to stretch the anterior sacroiliac ligaments and synovium.

Imaging Considerations

Certain studies are more useful than others for diagnosing SIJ pain syndrome.

X-ray and computed tomography (CT). Conventional radiologic tests are rarely diagnostic in SIJ pain syndrome. Interpretations of degenerative changes of the SIJ on x-ray have proven clinically insignificant because they are commonly observed in asymptomatic individuals.28

CT is a very good method to demonstrate previously established bony changes but also offers little diagnostic value.42 Single-photon emission CT offers high sensitivity but low specificity in seronegative spondyloarthropathies and are, therefore, useful tests in suspected cases.42-47

Nuclear medicine. Despite its good specificity, bone scanning is not recommended in the diagnostic algorithm for evaluation of possible SIJ pain syndrome because of its very low sensitivity.48

Magnetic resonance imaging (MRI). Good visualization of the complicated soft-tissue anatomy of the SIJ and the ability to see septic, inflammatory, or stress-related changes in the bones make MRI advantageous.42,47-51 Stress-related bone changes are very important in the differential diagnosis of SIJ pain because they are well documented, especially in female athletes.52 MRI can detect both stress reaction and stress fractures. However, for typical SIJ pain syndrome, MRI specificity is low, offering little diagnostic value for determining if the SIJ is the true pain generator.

Diagnostic injection. The gold standard for the diagnosis of SIJ pain syndrome is diagnostic injection under fluoroscopic guidance.4,31,35,40 It is an invasive procedure and should not be used as a first-line diagnosis or treatment. Controlled-block technique is preferred in which the diagnosis is confirmed by reproducing symptoms with provocative analgesic injection and relieving symptoms with an anesthetic block.4,8,9,36,53-56 This is the most reliable method to establish the diagnosis of intra-articular SIJ pain and allows immediate interpretation of SIJ arthrography (figure 3). Intra-articular sacroiliac injections, however, do not assess all periarticular or extra-articular structures, such as muscles, ligaments, or tendons, which may also be sources of pain.9

Differential Diagnosis

A myriad of possible conditions make diagnosis challenging, especially because pain may be referred from other sites.

Sacral stress fractures should be considered in any athlete, especially distance runners, who report pain in the sacral region.47,50-52,57 Our series with the Stanford University track team has now identified 17 cases (2 recurrences) in 5 years. Ten of these occurred in women, all of whom were either amenorrheic or oligomenorrheic and had suboptimal bone density.

Spondyloarthropathies often begin with symptoms of sacroiliitis. Ankylosing spondylitis typically produces symmetric findings, as does the spondyloarthropathy associated with inflammatory bowel disease, such as Crohn's disease or ulcerative colitis. Sacroiliitis with psoriatic arthritis and Reiter's syndrome is more often asymmetric and usually involves other signs of the disease, such as conjunctivitis, uveitis, cystourethritis, peripheral arthritis, and enthesopathies. Radiographic findings seen in enthesopathies include whiskering of the ilium and ischium and plantar heel spurs.

Osteitis condensans ilii typically occurs in young, multiparous women. It is presumably linked to increased laxity and stress to the joint during pregnancy and parturition. It is distinguished radiographically from sacroiliitis by bilaterally increased radiodensity on the iliac, as opposed to the sacral side, of the SIJ.19

Myofascial pain caused by trigger points in the piriformis, gluteus maximus, or quadratus lumborum muscles can refer pain into the SIJ. Local soft-tissue injections with an anesthetic agent can be used for diagnostic purposes. The needle should be inserted into the point of maximal tenderness, most commonly in the belly of the muscle. Other than local tenderness, no direct evidence of pathology typically exists in trigger point areas.

Other conditions that can cause primary pain in the SIJ are less likely in a young athletic population. These include degenerative joint disease of the SIJ, infection by hematogenous spread from typically cutaneous sources, tumors, and metabolic conditions such as gout, pseudogout, and hyperparathyroidism. Finally, trauma with contusion or fracture of the sacrum or pelvic ring can also produce SIJ pain.

Treatment Options

Because the SIJ and its surrounding structures have various responses to injury, a wide array of treatments may prove beneficial.

Rehabilitation. Thorough rehabilitation requires complete and accurate diagnosis that goes beyond the recognition of clinical symptoms and tissue injury. The SIJ is the main link between the spine, hip, and lower extremities, and treatment needs to address functional biomechanic deficits and subclinical adaptations throughout the kinetic chain. Working directly with a physical therapist who is skilled in this area is recommended. One must determine if any motion restricts the pelvis and which planes of movement are restricted; whether the SIJ is compensating for a lower-extremity deficit in range of motion, strength, or coordination; or whether the inflammation is caused by disturbance in gait.58 Improper or repetitive sport-specific motions can increase stress on the SIJ or adjacent structures; therefore, a detailed history of sports activities is essential.

Strengthening and stabilization. The ligaments of the SIJ and the lumbar spine mesh with the thoracolumbar fascia. These ligaments and fascia are the primary attachments for the main movers and stabilizers of the spine and lower extremities. Thus, coordinated muscle contraction causes compression of the surfaces of the SIJ. The major muscles and fascia involved include the gluteus maximus and medius, latissimus dorsi, hamstrings, abdominals, back extensors, and the thoracolumbar fascia.59

Weakness or inhibition of the hip muscles, especially the hip abductors, should be addressed. Functional exercise programs can create a self-bracing mechanism to stabilize the SIJ against large shear stresses applied to the joints under various loading conditions.60 Appropriate recruitment and sequencing of neuromuscular patterns are considered more important than the development of absolute strength.

Mobilization. Many theories exist regarding the benefits of mobilization.34,61-64 Corrective exercises in conjunction with mobilization may be useful when movement impairments are caused by muscle dysfunction or shear dysfunction. In addition to the presumed improvements in joint mechanics, one study65 associated a consistent reflex response with spinal manipulative treatments. Reflex pathways evoked systematically during spinal manipulative treatment might produce some of the clinically observed benefits, such as pain reduction and decreased muscle hypertonicity.

Pelvic belts. Hypermobility, although rare in an athletic population, is usually seen in patients who have traumatic instability, multiparous women, and people with muscular atrophy from prolonged bed rest or lower motoneuron injuries. Pelvic belts may be used as an adjunct to other treatments to add stability and support.

Heel lifts and orthoses. Abnormal posture or leg-length discrepancy can cause the sacrum to sit askew and contribute to excessive shear force. To help distinguish functional from true leg-length discrepancy, a standing anteroposterior radiograph of the pelvis is indicated. The distance from the top of the femoral head to the bottom of the film is measured and compared side-to-side. Heel lifts and orthoses can help correct true leg-length discrepancy, if the condition is detected on the physical exam.

Injections. Although diagnostic injection is invasive, when it is performed by a skilled clinician, associated risks are extremely low. Some authors recommend diagnostic SIJ injection for athletes who have not responded to comprehensive therapeutic rehabilitation after approximately 3 to 4 weeks.1,53-56, If the athlete responds favorably to the anesthetic block of the joint, corticosteroids can be injected for prolonged pain reduction.

Other treatments. A recent article66 suggests that intra-articular hyaluronic acid injections help relieve pain; however, long-term studies are still warranted. Prolotherapy (a treatment in which a sclerosing solution is injected into ligaments to stimulate hypertrophy and stability) is often recommended for patients who have SIJ hypermobility.66,67 However, it is has not been proven either specific or sensitive for distinguishing pain generators from the SIJ ligaments, and its therapeutic effects remain controversial in the medical literature.

For intractable SIJ pain, neuroaugmentation and surgical fusion have been proposed as treatment options.68,69 Both, however, lack long-term studies and have never been tested in an athletic population. Therefore, we do not recommend either technique for athletes who have SIJ pain.

The Lowdown on Sacral Pain

Diagnosis of the athlete who reports pain in the SIJ region remains a challenge to sports medicine physicians. A detailed history and neuromusculoskeletal exam can help rule out other potential sources of pain. For the primary care physician, we recommend two tests that have proven more reliable when evaluating SIJ dysfunction: provocation testing and injections under fluoroscopy. Pain provocation tests are used to confirm the SIJ as the primary source of pain. The physician working closely with a well-trained physical therapist can then treat muscle imbalances, joint dysfunctions, or other alterations in the kinetic chain that predispose athletes to SIJ injuries. If a conservative course of treatment consisting of physical therapy does not lead to improvement, fluoroscopically guided injection of the SIJ by a skilled physician should be considered for both diagnostic confirmation of the pain source and potential improvement of pain to facilitate rehabilitation.

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Dr Chen is a physiatrist at the Spinal Diagnostic and Treatment Center in Daly City, California. Drs Fredericson and Smuck are physicians in the Department of Functional Restoration at the Stanford University School of Medicine in Stanford, California.

Address correspondence to Yung C. Chen, MD, Spinal Diagnostic and Treatment Center, 901 Campus Dr, Suite 310, Daly City, CA 94015; e-mail to yungchen_99@yahoo.com. Disclosure information: Drs Chen, Fredericson, and Smuck disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.

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