The Diagnosis, Evaluation and Treatment of Sacroiliac Joint Dysfunction
As an orthopaedic surgeon, I treat a very wide range of musculoskeletal conditions on a daily basis. Some patients improve by taking an anti-inflammatory medication, others need physical therapy to retrain muscles to interact with and support their bones, while other patients will eventually need surgery. Patients are often curious about their diagnosis and are interested to learn more particularly when it comes to back pain. Some perceive back pain to be an enigma in our society; in fact, a large number of orthopaedic surgeons choose not to treat back pain. As a fellowship-trained spine specialist, a large portion of my practice focuses on treating conditions of the spine, so I am always interested to see if I may be able to help someone feel better.
One common ailment associated with lower back pain is called Sacroiliac (SI) Joint Dysfunction.
Before I delve into this condition, let’s have a brief anatomy lesson.
The SI Joint is part of the pelvis. The pelvis is comprised of many bones, muscles, and tissue. The major bones are the ilium (the largest bone of the pelvis that looks like two kidney shaped bones on either side), and the sacrum (the triangular shaped bone at the base of the spine). The SI joint is where the ilium and sacrum meet on both sides and are joined by strong ligaments. It doesn’t have much motion, and is prone to dysfunction simply by design: The SI joint acts as a shock absorber, and transmits forces of the upper body to the pelvis and legs. As many other joints in the body do, the SI joint can become inflamed, causing great pain or discomfort leading to SI Joint Dysfunction.
SI Joint Dysfunction is the condition given to the pain and discomfort in that region, most likely due to tight muscles. It isn’t entirely clear what the cause of the pain is, but common thought is that if you alter your normal joint use and motion, you may experience discomfort. A sudden increase in movement (such as jumping head first into a new exercise program) or too much movement is typically felt in the hip or lower back area. If the joint is underused or has too little movement, the joint can become stiff and cause pain on one side of the lower back or buttocks and radiate down the leg, like sciatica.
SI Joint Dysfunction symptoms mimic other conditions, so accurately diagnosing it can be a challenge. Symptoms are similar to those caused by disc herniation, facet syndrome, or radiculopathy. If we suspect a patient is suffering from this condition, we will conduct a physical exam to determine if the SI joint is the cause of the pain. If specific movement tests cause pain and there are no other possible causes (such as disc herniation), the SI joint is likely the cause. Multiple tests that reproduce the pain specifically at the SI joint improves the likelihood that the patient has SI Joint Dysfunction.
Another diagnostic tool is the sacroiliac joint injection. We use live X-Ray guidance (fluoroscopy) and insert a needle into the SI joint. We inject a numbing solution and if that relieves the pain, we can infer that the SI joint is the cause of pain. We will also inject an anti-inflammatory steroid that will also help relieve the pain.
So now that you have been diagnosed with SI Joint Dysfunction, what is next? As with everything else, we start with conservative treatment first.
- Ice, heat and rest – Begin with cold packs to reduce the inflammation in the area. Ice will help with the more acute, sharp pains associated with a new injury. Ice can be continued for two days to two weeks. Apply ice 15-20 minutes per day, 3 or 4 times per day. During this time, you will want to take a rest from any activities that aggravate your pain. Once you notice that the intense pain has subsided, you may use the application of heat (heating pad or warm bath), and gradually return to your normal activity level.
- Anti-inflammatory medications –You can choose from naproxen, ibuprofen or I may recommend a prescription anti-inflammatory for you. These will help reduce the swelling associated with the pain. Take these on a regular schedule, as directed on the bottle, for several weeks and if you do not improve, you should move on to other treatment options. Combined with ice, heat and rest, anti-inflammatories will work for a good percentage of people. These medications can cause gastro-intestinal issues and discomfort in some people, so if you are one of those, we can prescribe a topical gel or solution for you. We have not seen great success with these topical options for SI joint issues because the joint is so deep in the body, behind layers of muscle and tissue. However, we can try those if you are intolerant of the oral medications.
- Manual manipulation – This can be helpful if the patient feels like the joint is “stuck.” You will want to see a highly qualified osteopathic physician or chiropractor to assist you with this. The doctor will choose the movements appropriate for you and your situation.
- SI Joint Injections – As previously mentioned in this article, this can be used as a diagnostic tool and also a therapeutic tool. The immediate relief may help get a patient ready to begin physical therapy.
- Physical therapy and exercise – We are huge advocates of physical therapy at OSC because it works! Controlled movements will help increase the strength in the muscles surrounding the SI joint and will improve the range of motion. We have a physical therapy suite at our location, or we can gladly refer you somewhere else if you prefer to be closer to work or home.
- Sacroiliac Joint Fusion – For very severe cases that do not improve with the previously mentioned options, surgery may be appropriate for you. This procedure entails one of both sacroiliac joints being fused with the goal of achieving normal motion. In rare situations new techniques in minimally invasive percutaneous SI joint fusion can be performed. This procedure has been growing in effectiveness over the last five years as surgeons have become more familiar with this technique. This is only considered after a failure of the previously mentioned conservative care options.
In my practice, typically patients improve with conservative care, which is always the best case scenario. SI Joint Dysfunction can make it challenging for you to do your normal daily activities, such as standing, walking, and sitting. In my experience, most patients see a full recovery from this condition and return to their normal activity level fairly quickly. If you are in pain and would like to feel better, please give us a call and schedule an appointment at 757.596.1900.
Mark W. McFarland, DO is a Fellowship-trained spine specialist and orthopaedic surgeon. His practice is focused primarily on the care and treatment of injuries and disorders of the spine. Dr. McFarland practices at Orthopaedic & Spine Center in Newport News, VA. For more information on Dr. McFarland or OSC, go to www.osc-ortho.com or contact us at 757-596-1900 for a consultation.