Sacroiliac Dysfunction

There are a plethora of reasons why one would have lower back pain. More often this is related to having a weak core and tight hips. Sometimes, at least a quarter of the time, the cause for lower back pain is because of sacroiliac joint dysfunction (Newman & Soto, 2022). The SI joint is a shock absorber and it transfers vertical loads from the lumbar spine to the lower extremities during bending movements. The pain may come directly from the SI joint or it may come from surrounding structures which will affect the joint's load transfer function and produce a painful stimulus.

Dysfunction in the SI joint may also result from osteoarthritis or inflammatory conditions such as ankylosing spondylitis, posttraumatic arthritis, and other spondyloarthropathies (Newman & Soto, 2022). Mechanical faults can also occur in the pubic symphysis or dysfunction can result in pelvic asymmetry or joint instability. Nonoptimal load transfer is also seen in those with stiff joints, or hypomobility, and in those with insufficient pelvic girdle stability or hypermobility.

Sacroiliac pain can be painful on one side or both, but not midline. Women more often suffer from this type of low back pain, because this joint is more mobile in women compared to that of men, resulting in larger stress, load, and pelvic ligament strain (Newman & Soto, 2022).

These can be a challenge to identify and diagnose, but a positive response to at least three of the provocation tests performed by a primary care provider, and local anesthetic SI joint blocks can be useful in confirming diagnosis. Other conditions can mimic SI dysfunction, such as femoral acetabular impingement, fractures from trauma or osteoporosis, infection, ischiofemoral impingement, lumbar disc herniation, lumbar facet syndrome piriformis syndrome, pudendal nerve irritation, spondyloarthropathies, or even a tumor.

Clinicians are very skilled at ascertaining history to help discern diagnosis. They also have a number of tools for identifying the source of pain, whether from the spine, pelvic girdle, or hips. Red flags are a history of trauma, unexplained weight loss, fever, bowel and bladder changes, cancer, and night pain.

Most often though, individuals with SI dysfunction can point to their pain. Pain is often triggered when going up and down stairs as well, or when jogging uphill. It can be triggered when landing after jumping, lying on the affected side, or after a long ride in the car. Standing for long periods or when standing, shifting weight to the affected side or turning over in bed.

This pain can often initiate with heavy lifting, a fall onto the bum or even a motor vehicle accident. Sometimes this is more insidious in onset. Recreational activities with repeated weight bearing and shear or torsional forces experienced during sports such as football, gymnastics, and golfing can also initiate SI dysfunction.

The clinician will evaluate someone with these complaints by watching their gait. Do they have a shortened stride length or pain with walking? They will evaluate their range of motion, strength, flexibility, and palpate the area to discern anomalies. They will also utilize tests that can identify pathology. Neurologic testing is also important when considering diagnosis. Reflexes, sensations, strength testing, and straight leg raises will be evaluated.

Interestingly, what we will find upon evaluation is differences in the height of the iliac crest or asymmetry in the hips when standing on one leg (Newman & Soto, 2022). When walking, there may be a painful catch or increasing pain ipsilaterally when in the stance of the walk, or decreased hip extension resulting in shortened contralateral stride length. There may be weakness in the gluteus medius or tightness in the iliopsoas, piriformis, or hamstring. The clinician will also utilize provocation tests and if three of five are positive, this leans into clinical diagnosis. However, when these tests are used in isolation, they do have poor sensitivity and specificity, but together, they are quite conclusive. Training and experience are important in utilization of these tests.

Magnetic resonance imaging, computed tomography, and bone scans do not reliably determine the source of pain with SI joint dysfunction (Newman & Soto, 2022). They may help ruling out other diagnoses with symptoms that mimic SI joint dysfunction. Laboratory tests to rule out other conditions include rheumatoid factor and human leukocyte antigen B27, which may be elevated or positive in inflammatory arthropathies.

Treatment for Sacroiliac Joint Dysfunction

If SI joint dysfunction is suspected or confirmed by the physical examination, initial treatment would be offering nonsteroidal anti-inflammatory medications, and a referral to physical therapy. Manipulative therapy combined with an exercise program can also strengthen the pelvic girdle and lengthen tight muscles (Newman & Soto, 2022). This was critical for myself, with my own SI dysfunction. It was yoga that really helped me identify the cause, which was multifactorial, between having a weak core after six pregnancies and tight hips from sitting as a clinician for long hours over many years.

If sacroilitis or other spondyloarthropathies are suspected, referral to an orthopedist, interventional radiologist, or pain management for intra-articular corticosteroid injection may be appropriate. Physical therapy exercise programs have demonstrated intermediate and long-term benefits (Newman & Soto, 2022). Primary care physicians can share stretches for the iliopsoas and piriformis, and the physical therapist may also address core muscles in the abdominals, pelvic floor, ipsilateral gluteal muscles, and contralateral latissimus muscles. Certainly yoga instructors can assist in gaining this core strength and support for the pelvis.

The fascia can also be tight in the thoracic cavity and is often present in those with SI joint dysfunction (Newman & Soto, 2022). Tightness of the thoracolumbar fascia can be assessed by having the person forward flex the lumbar spine. If flexion is limited by the sensation of diffuse tightness along the lower back and sacrum, the individual can be taught self-mobilization techniques or referred to physical therapy or a massage therapist. Treatment options to address tight thoracolumbar fascia include foam rolling and deep tissue mobilization.

When SI joint manipulation is utilized independently, these benefits seem to be short-term, but when combined with exercise programs, this achieves longer-term results compared even to exercise programs alone (Newman & Soto, 2022). Just two sessions of manipulative therapy to the SI joint over a two-week period has shown to result in improved outcomes, compared to six weeks of stretching and lumbar and pelvic floor strengthening program. Pelvic girdle stretching and strengthening exercises have also shown more effective in reducing pain and improving function compared with SI joint manipulation and lumbar-focused exercises. There is also evidence to support pelvic belts in stabilizing SI joint motion and reducing ligament strain for peripartum women with SI joint dysfunction.

Yoga and the Sacroiliac Joint

Yoga can be beneficial practice for SI joint pain, but it's crucial to approach it with awareness and modifications to avoid aggravating the condition. Certain poses, like deep twists and single-leg forward bends, should be avoided or modified. Focusing on strengthening the core and stretching the hips and surrounding muscles can help relieve pain and improve stability.

A strong core, including abdominal and back muscles, provides crucial support for the SI joint, helping to stabilize it and reduce strain. Yoga can also help stretch and lengthen muscles in the hips, lower back, and legs, improving flexibility and reducing stiffness around the SI joint. Gentle stretching and twisting can help release tension in the muscles surrounding the SI joint, reducing pain and discomfort. Stress and anxiety are also reduced with yoga which can then reduce pain further.

Child's pose gently stretches the lower back and hips. Cat-cow pose helps mobilize the spine and improves flexibility. The reclined pigeon pose stretches the hips and groin, which can be beneficial for reducing SI joint pain. Supine twists can release tension in the lower back and hips, but should be done with caution and awareness. The standing forward fold can also be modified by keeping the knees slightly bent to protect the SI joint.

Avoid poses that involve intense twisting of the spine, as they can put excessive strain on the SI joint. Single-leg forward bends may create an imbalance in the pelvis and should be modified or avoided. Avoid activities that involve jumping or quick, jarring movements. Full sit-ups and other exercises with extreme torso twisting can aggravate the SI joint. Listen to your body. Pay attention to your body's signals and stop if you feel any pain. Avoid pushing yourself beyond your current limits. Know too that that it takes time to get results from yoga; be patient and consistent in your practice.

More Interventional and Surgical Treatment

Corticosteroid injections or radiofrequency ablation may provide short- and long-term relief in refractory SI joint dysfunction (Newman & Soto, 2022). This is especially true for inflammatory scenarios. Ablation involves the application of radiofrequency energy to cause a thermal lesion to the nerve that interrupts the pain signal. Cooled radiofrequency ablation at the L4 and L5 has shown to be beneficial to those who have a positive response to a diagnostic SI joint block. Referral to a pain physician may be necessary if these less invasive measures are not successful. Surgical fusion of the SI joint may also be necessary.

References

Newman, D. P. & Soto, A. T. (2022). Sacroiliac joint dysfunction: diagnosis and treatment. American Family Physician, 105(3), 239-245.