Sacroiliac joint

dysfunction
Sakunrat Sarikit, MD.
REFERENCES
SCOPE
01 04
Introduction History

02 05
Anatomy Physical examination and
special test

03 06
Diseases of Sacroiliac joint Treatment
SI joint dysfunction

 Abnormal motion in the

sacroiliac joint
 Too much motion or too
little motion
 SI joint dysfunction
 10% and 25% of low back pain

 Female-to-male ratio 3:1 to 4:1

 20% to 80% during pregnancy

 Source of low back or posterior pelvic

pain

 Associated with SI joint dysfunction

- chronic low back pain

- female gender
- low BMI
ANATOMY
ANATOMY
Nutation
(Sacral locking)
 Forward motion sacrum into the pelvis
 Backward rotation of the ilium on the
sacrum
 Sacrum : slide down and posteriorly
 Ilium move closer together
 Ischial tuberosities move farther apart
 “pelvic tilt” position
Counternutation
(Sacral unlocking)
 Backward motion of the sacrum out of
the pelvis
 Anterior rotation of the ilium on the
sacrum
 Sacrum : slide anteriorly and superiorly
 Iliac bones move farther apart
 Ischial tuberosities approximate
 “lordotic” or “anterior pelvic tilt” position
LIGAMENT FUNCTION
Sacrospinous Resists forward tilting (Nutation) of
Sacrotuberous the sacrum on pelvis

Interosseous Resists anterior and inferior movement

on the sacrum

Posterior (dorsal) sacroiliac Resists backward tilting

(Counternutation)
of the sacrum on pelvis
 Forward Flexion
One thumb is on PSIS
other thumb is parallel on the sacrum

A : feel forward movement (Nutation) of the

sacrum (occurs early movement )
deep posterior structures become tight

B : feel backward movement (Counternutation)

(occurs around 60° of hip flexion)

PSIS move superior

ASIS move flare out
 Backward bending
 Palpates both PSIS
 Sacral nutation : posterior rotate
 PSISs move inferiorly
 anterior oblique lateral

deep longitudinal posterior oblique

Outer group
inner muscle group anterior-posterior superficial group
Stability at the SI joint
Determined by three factors

 Motor control
 Form closure: close packed position
intrinsic factors joint shape, friction of the joint surfaces, and integrity of the
ligaments
 Force closure: loose packed position
extrinsic factors muscles and neurological control (forces applied to the joint)
Neutral pelvis
 Get into the “neutral pelvis” position?
 Hold the “neutral pelvis” statically
while moving distal joints dynamically?
 Hold the “neutral pelvis” when moving it dynamically?

“restricting the movement,

weakness, not correctly
functioning”
SI joint dysfunction

 Abnormal motion in the

sacroiliac joint
 Too much motion or too
little motion
Aging of the SI Joint
changes throughout life that affect the biomechanics of the joint

childhood adult older

Surface irregularity Adhesion

Smooth
Thickening cartilage Ankylosis
more mobile
Restrict movement markedly restricted
PATHOLOGIC CHANGES
AFFECTING SI JOINT

 Capsular or synovial disruption  Abnormal joint mechanics

 Capsular and ligamentous  Microfractures or macrofractures
tension  Soft tissue injury
 Hypomobility or hypermobility  Inflammation
 Extraneous compression or
shearing forces
RISK FACTORS

 Leg length discrepancy

 Gait abnormalities
 Prolong vigorous exercise
 Scolosis
 Spinal fusion of the sacrum
 Pregnancy
DIFFERENTIAL DIAGNOSIS
 Discogenic low back pain  Multiple myeloma
 Lumbar radicular pain  Gout
 Lumbar facet syndrome  Pseudogout
 Spondylolisthesis  Seronegative
 Spinal stenosis spondyloarthropathy
 Bertolotti syndrome  Septic joint
 Hip osteoarthritis  Pelvic abscess
 Piriformis syndrome  SAPHO (synovitis, acne,
pustulosis, hyperostosis, osteitis)
 Sacral fractures syndrome
 Metastatic disease  Osteochondritis dissecans
 Osteitis condensans ilii
HISTORY
 Location : usually not midline
at or lateral to PSIS
Lower back
Gluteal

 Character : deep, dull, undefined pain

 Radiated : Complex innervation of the SIJ
patterns can mimic
thigh, groin, leg, lower abdomen
may describe as sciatica
HISTORY
 Study of 50 patients with diagnostic fluoroscopically guided SIJ
injection
The most common symptoms were buttock pain (94%)
lower lumbar pain (72%)
lower extremity pain (50%)
 Activities said to aggravate
prolonged standing, asymmetric weight bearing bending,
lifting, stair climbing, running, large strides
Relief with weight bearing or lying on unaffected side

 Refractory to traditional interventions

HISTORY

 Trauma (mechanism of injury)

fall on the buttocks
an overzealous kick (either missing the object or hitting the ground)
lift and twist maneuver

 Pregnancy
 Psychosocial issues
PHYSICAL EXAMINATION
 Assessment of musculoskeletal and neurologic test
(low back, hips, and pelvis)
exclude other common diagnoses

 Gait
 ROM, Leg length
 Muscle atrophy : gluteal, lower extremities
 Palpation of the bony structure, subcutaneous tissues, muscles, and
ligaments
 Neurologic exam
 PELVIC ASYMMETRY
 ASIS , iliac crest, PSIS, gluteal folds, ischial tuberosities
 ASIS and PSIS are higher than other side
upslip of the ilium on sacrum,
short leg on opposite side or muscle spasm

 ASIS is higher and PSIS is lower on one side

Pathological nutation

 ASIS is lower and PSIS is higher on one side

Pathological counternutation
 PELVIC ASYMMETRY

 PALPATION : SACRAL SULCUS AND SACROILIAC JOINT

PSIS as a starting point

 Sacral sulcus :
-slightly below PSIS on sacrum adjacent to ilium
-compared the depth

 Sacroiliac joints :
-slightly medially and distal to the PSIS
-knee flexed to 90° and hip is passively
medial rotated
 ACTIVE MOVEMENT
● SI joints do not have muscles directly control
● Stress SI joints by contraction of muscles other joints
SPECIAL TEST FOR SI JOINT

Provocation test Non-provocation test

 FABER test  Fortin finger test

 Gaenslan’s test  Seated flexion test
 Sacral thrust  Gillet test (Stork test)
 Compression
 Distraction
 Thigh thrust
FORTIN FINGER TEST

 Sitting or standing
 Use one finger to localize pain
 Positive : twice identifies the painful
region (within 1 cm of inferomedial to
the PSIS)
SEATED FLEXION TEST
 Sitting position
 Places thumbs under each PSIS
 Patient bends forward
 Observe each PSIS and their
movement

 Positive : one PSIS moves more

superior
(Side with greater movement is affected
side) Sensitivity : 9 % Specificity : 93 %
GILLET TEST
 Standing position
 palpates PSIS
 flex the hip on the affected side
 Normally functioning pelvis
pelvis : rotate posteriorly
causing the PSIS : drop or move inferiorly

 Positive : PSIS on the ipsilateral side of knee

flexion does not move inferiorly

Sensitivity : 8 % Specificity : 93 %
PROVOCATION TEST

 FABER test 3 OR MORE POSITIVE

 Gaenslan’s test PROVOCATION TESTS
 Compression
 Distraction Sensitivity 82-85%
 Thigh thrust Specificity 57-79%
FABER TEST (PATRICK TEST)
 Supine position
 Hip is flexed
 Ankle placed above the opposite patella
Flexion, ABduction, External Rotation
 Downward pressure to the flexed knee
and the opposite ASIS

 Positive : reproduce pain

Sensitivity : 71 % Specificity : 100 %
GAENSLEN’S TEST
 Position : Supine with buttock over side
of table
 leg is dropped off the table
(thigh and hip are in hyperextension)
 Contralateral knee is then maximally
flexed
 Positive : pain ipsilateral SI joint
False-positive:
L2-L4 nerve root lesion, spondylolisthesis, spinal
stenosis, sacral fractures, spinal fractures

Sensitivity : 50-53 % Specificity : 71-77 %

LATERAL PELVIC COMPRESSION TEST
 Lateral decubitus position
 Apply pressure on the Iliac crest
 Positive : pain localized at sacroiliac joint
Sensitivity : 69 % Specificity : 69 %
DISTRACTION TEST
 supine position
 pressure downward and laterally
to the bilateral ASIS

 Positive : reproduces pain

Sensitivity :11-21 % Specificity : 90-100%
THIGH THRUST TEST
 Supine position
 Hip and knee are flexed to 90°
 Applying axial pressure along femur
directed into posteriorly
 Positive : reproduce pain
 INVESTIGATION

 X-rays, CT, MRI, and bone scan do not provide used for the diagnosis
 Intraarticular Injection : Gold standard for diagnosis of intraarticular SIJ pain
 70-80% (>75%) relief of pain is diagnostic
 PLAIN RADIOGRAPH

 Plain radiography can reveal osteologic causes

 Ex. Fracture, SIJ erosions, infection and inflammatory or degenerative arthritis.
 Plain film view (SI joint ): including Ferguson views and AP views
 PLAIN RADIOGRAPH

 Bone scan and CT : bone changes fracture, infection, tumor,

SIJ erosions, and arthritis
 MRI : soft tissue disease, marrow changes in sacroiliitis,
erosions
 Ultrasound : posterior ligamentous structures

 SIJD can often be seen in the presence of normal imaging

 Fluoroscopically guided
diagnostic intra-articular injection of anesthetics

 Gold standard for diagnosis of intraarticular SI joint pain

 70-80% (>75%) relief of pain is diagnostic
 Fluoroscopically guided
diagnostic intra-articular injection of anesthetics

 Fluoroscopic guidance
with the use of contrast media is recommended

 A 1.5 to 2.0 mL mixture of 40 mg of

methylprednisolone acetate and
local anesthetic is injected

Complication
 Pain
 Local bleeding
 Side effect of steroid
 Complete Diagnosis of pain of SI joint
International Association Society for the Study of Pan (IASP)

3 diagnostic criteria

 Pain in SI joint region

 Pain reproduced by clinical tests selectively stressing the joint
 Pain completely relieved by selective delivery of local anesthetic
TREATMENT
Conservative Intervention

 Education  SI joint injection

 Medication  Radiofrequency neurotomy
 Modality
 Exercise Surgery
 Orthosis  SI joint fusion
EDUCATION
 Relative rest

 Avoidance of provocative activities

 Postural education
MEDICATION
 Acetaminophen

 NSAIDs

 Muscle relaxants

 Opiates(short term use)

 Topical analgesics (Lidocaine in patch form)

MODALITY
- Heat
 Subacute muscle strain or ligament sprain
 Hot pack (keep skin temp 40 c / 20 min / q 24 hr)
- Cold
 Chronic pain
 Alleviation of pain or muscle spasm
 Apply ice pack (0 – 10 c/ 20 min/ q 1-2 hr )
MODALITY
- TENS
- LASER
EXERCISE
Goal

 Improving strength

 Improving range of motion

 Improving cardiovascular endurance

 Prevent deconditioning
EXERCISE
 Lumbar core muscle strength
 Hip girdle flexibility
 Correction of gait abnormalities
MANIPULATIVE THERAPY
 Pain and muscle spasms
 Not change joint alignment significantly
 Approximately only 2 degrees of rotation
and 0.77 mm of translation manipulation

 Some evidence : combination of

high-velocity, low-amplitude manipulation
improved pain and functional
disability 1 month
SACROILIAC JOINT BELTS
INTRA ARTICULAR INJECTION
Indications
Inflammation of SI joints secondary to
 Trauma
 Rheumatoid arthritis
 Degenerative joint disease
 Mechanical changes in posture or gait

- Analgesic drugs: lidocaine, Bupivacaine

- Steroid: Triamcinolone acetonide
- Dextrose
RADIOFREQUENCY NEUROANATOMY
 Using energy in the radiofrequency
range cause necrosis of specific
nerves

Complications
 Pain
 Bleeding
 Infection
 Paralysis
SURGERY
Indication

 Sacroiliac joint disruption

 Degenerative sacroiliitis
THANK YOU