Sacroiliac Joint Dysfunction: Diagnosis and Treatment

 

Am Fam Physician. 2022 Mar ;105(3):239-245.

  Patient information: See related handout on sacroiliac joint dysfunction and back pain, written by the authors of this article.

Author disclosure: No relevant financial relationships.

Sacroiliac (SI) joint dysfunction is a common cause of low back pain and accurate diagnosis can be challenging. A complete history and physical examination are critical in differentiating other diagnoses that may have similar signs and symptoms. Positive responses to at least three physical provocation tests suggest SI joint dysfunction, and local anesthetic SI joint blocks can also be useful for confirming the SI joint as the source of pain. Conservative treatment consists of a multimodal program combining patient education, pelvic girdle stabilization with focused stretching, and manipulative therapy. These programs can be performed by physical therapists or clinicians trained in manipulative therapy. Pelvic belts may be beneficial in affected postpartum patients. Patients with symptoms that do not improve with conservative management may benefit from interventional treatment options including intra-articular corticosteroid injections, cooled radiofrequency ablation, or SI joint fusion.

The prevalence of sacroiliac (SI) joint dysfunction is approximately 25% in adult patients with chronic low back pain.1 Pain can be unilateral or bilateral but usually not midline.2 Women are more likely to present with SI joint dysfunction than men.3 The SI joint in women is more mobile compared with the SI joint in men, resulting in larger stress, load, and pelvic ligament strain.4 SI joint dysfunction is common in pregnant and postpartum patients.5

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Use the clinical decision rule of at least three out of five positive provocation tests (Gaenslen, thigh thrust, distraction, compression, and sacral thrust) to assist in diagnosing SI joint dysfunction.6,17

B

Consistent results from prospective and blinded validity trials

Confirmation of SI joint pain can be made by an image-guided anesthetic block to the SI joint.1,20

B

Systematic reviews to identify diagnostic accuracy of SI joint injections

Nonsteroidal anti-inflammatory drugs may be beneficial as part of a multimodal treatment approach.25,26

C

Expert opinion and accepted practice standards

Physical therapy exercise programs, SI joint manipulation, or a combination of both should be considered as first-line treatment options.11,14,15,2124,2729

B

Consistent results from randomized controlled trials and practice recommendations from in-depth reviews


SI = sacroiliac.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Use the clinical decision rule of at least three out of five positive provocation tests (Gaenslen, thigh thrust, distraction, compression, and sacral thrust) to assist in diagnosing SI joint dysfunction.6,17

B

Consistent results from prospective and blinded validity trials

Confirmation of SI joint pain can be made by an image-guided anesthetic block to the SI joint.1,20

B

Systematic reviews to identify diagnostic accuracy of SI joint injections

Nonsteroidal anti-inflammatory drugs may be beneficial as part of a multimodal treatment approach.25,26

C

Expert opinion and accepted practice standards

Physical therapy exercise programs, SI joint manipulation, or a combination of both should be considered as first-line treatment options.11,14,15,2124,2729

B

Consistent results from randomized controlled trials and practice recommendations from in-depth reviews


SI = sacroiliac.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Etiology and Differential Diagnosis

The SI joint serves as a shock absorber and transfers vertical loads from the lumbar spine to the lower extremities during bending movements. The etiology of SI joint dysfunction is not well understood. The SI joint may be the primary source of pain, or dysfunction at the joint or surrounding structures may affect the joint’s load transfer function and produce a painful stimulus.6

SI joint dysfunction can be associated with osteoarthritis or inflammatory conditions such as ankylosing spondylitis, posttraumatic arthritis, and other spondyloarthropathies.7 Similarly, mechanical faults at the pubic symphysis or SI joint can result in pelvic asymmetry or joint instability.

The Authors

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DAVID P. NEWMAN, PT, DPT, MAdEd, MBA, is a physical therapist at the Interdisciplinary Pain Management Center at the Tripler Army Medical Center, Honolulu, Hawaii....

ADAM T. SOTO, MD, is the director of readiness and a staff anesthesiologist and interventional pain physician at the Interdisciplinary Pain Management Center at the Tripler Army Medical Center and an assistant professor in the Departments of Anesthesiology and Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.

Address correspondence to David P. Newman, PT, DPT, MAdEd, MBA, Tripler Army Medical Center, 1 Jarrett White Rd., Honolulu, HI 96859 (email: dnewmanpt@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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