Sacroilitis

The sacroiliac joint (SIJ) is the load-bearing, shock-absorbing union between the spine and pelvis. It is a mechanical link that connects the chain of locomotion to the rest of the body. This irregular, synovial and fibrocartilagenous joint is surrounded by a strong ligamentous-reinforced capsule and is minimally mobile, allowing only about 4 degrees of rotation and up to 1.6 mm of translation.

Sacroiliac joint dysfunction (SIJD) can be divided into two general categories: mechanical and arthritic. “Mechanical” SIJD results from any process that alters normal joint mechanics (i.e. hyper or hypomobility). Common culprits include: leg length inequalities, gait abnormalities, lower extremity joint pain, pes planus, improper shoes, scoliosis, prior lumbar fusion, lumbopelvic myofascial dysfunction, repetitive strenuous activity and trauma- especially a fall onto the buttocks. Although patients may not always recognize or report a traumatic onset, studies show that over half of mechanical SIJD results from an inciting injury. Pregnancy creates a firestorm of sacroiliac joint insult with weight gain, gait changes and postural stressors occurring contemporaneously with hormone-induced ligamentous laxity.

“Arthritic” SIJD results from either osteoarthritis or from an inflammatory arthropathy including; ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, and Reiter’s/reactive arthritis which produce sacroiliitis and resulting pain. Morning pain that resolves with exercise is characteristic of arthritic SIJD.

The clinical presentation of SIJD is quite variable and shares several common characteristics with other lumbar and hip problems. When asked to point specifically to the site of pain, the SIJD patient will often place their index finger over the PSIS (Fortin finger test). Pain may or may not refer to the lower back, buttock, thigh or rarely into the lower leg via chemical radiculopathy of the neighboring L5 or S1 nerve roots. Sacroiliac joint pain may refer to different regions, depending upon which section of the joint is irritated. Irritation to the upper 1/3 of the joint generates pain in the region of the PSIS. Irritation to the mid section causes referral to the mid-gluteal region, while the lowest section refers to the lower gluteal region. Interestingly, 44% of SI joint patients report referral to the groin.

Symptoms may be exacerbated by bearing weight on the affected side and relieved by shifting weight to the unaffected leg. Pain may be provoked by arising from a seated position, long car rides, transferring in and out of a vehicle, rolling from side to side in bed or by flexing forward while standing. Pain is often worse while standing or walking and relieved by lying down.

The differential diagnosis for mechanical SIJD includes: inflammatory arthropathy, lumbosacral referral- especially discogenic pain, hip DJD or pathology, myofascial pain- especially piriformis syndrome, sacral insufficiency fracture (elderly), neoplasm, infection and vicerosomatic referral.

Traditional conservative management of SIJD lacks significant scientific support.
Sacroiliac joint manipulation can restore motion to hypomobile joints and has shown benefit (10,12,14). Ultrasound, ice and e-stim may help control pain and inflammation. Cross friction massage or IASTM may be utilized to initiate healing of the tendons and ligaments surrounding the SIJ.   Myofascial release and stretching may be appropriate for the gluteus, hamstrings, piriformis, TFL, quadratus lumborum lumbar erectors, and contralateral lattissimus dorsi. The goal of strengthening is lumbopelvic stability. Specific targets include the transverse abdominus, abdominal obliques, lumbar erectors, gluteus, hip abductors and hip adductors to strengthen the core and pelvic floor.

Patients should be counseled on posture and ergonomic awareness, and advised to avoid activities that provoke symptoms including prolonged standing on the affected leg, prolonged sitting, and forced hip abduction during intercourse. Arch supports, orthotics or a heel lift to correct structural deficits may be indicated. A sacroiliac support belt may provide benefit, although excessive tightness may aggravate the trochanteric bursa.

If you think you are experiencing SIJ dysfunction or Sacroilitis, give us a call today (434)293-3800 and we will be happy to help.

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