Sacroiliac Joint Syndrome

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Definition/description       

Sacroiliac joint syndrome occurs when the sacroiliac ligaments are damaged or torn by age causing too much play in the joints.  This causes an inflammation of the joint making it possible to disrupt. Degenerative changes need to be considered as well. It occurs more frequently in older people, but there is too little research done to substantiate this conclusion.
Sacroiliac Joint Syndrome is a condition that is difficult to diagnose and is often overlooked by physicians and physiotherapists.

Clinically Relevant Anatomy      

The sacroiliac joints are located on each side of the spine between the two pelvic bones, which attach to the sacrum.
Multiple structures are involved in the support and movement of the sacroiliac joints.  The ligaments which contribute to this synovial joint are the anterior and posterior sacroiliac ligament, interosseus ligament, sacrotuberous ligament, sacrospinous ligament and iliolumbar ligament. The joints are surrounded by some of the most powerful muscles of the body, but none of these have direct influence on joint motion.
The main function within the pelvic girdle is to provide shock absorption for the spine and to transmit forces between the upper body and the lower limbs. 

Epidemiology/Etiology       

It is often hard to determine exactly what caused the wear and tear to the joints. One of the most common causes of problems at the Sacroiliac joint is a trauma. The force from these kind of injuries can strain the ligaments around the joint. Tearing of these ligaments leads to too much motion in the joint and over time it will lead to degenerative arthritis.
Pain can also be caused by an abnormality of the sacrum bone, which can be seen on X-rays.
Pregnant women have a greater chance to develop sacroiliac joint syndrome. Female hormones are released during pregnancy, relaxing the sacroiliac ligaments. This stretching in ligaments results in changes to the sacroiliac joints, making them hypermobile.

Clinical presentation       

Symptoms of sacroiliac joint syndrome are often difficult to distinguish from other types of low back pain. This is why making a diagnosis of sacroiliac joint syndrome is very difficult. The most common symptoms include:
- Low back pain
- Buttock pain
- Thigh pain
- Difficulty sitting in one place for too long due to pain
- Local tenderness of the posterior aspect of the sacroiliac joint (near the PSIS) 
- Pain occurs when the joint is mechanically stressed
- Forward bending causes also pain
- Absence of neurological deficit
- Absence of nerve root tension signs
- Aberrant sacroiliac movement pattern

 Differential diagnosis       

Sacroiliac joint syndrome is a controversial diagnosis, therefore pain and injury to the sacroiliac joint is commonly overlooked.  This condition is often listed under the general term dysfunction, a term that serves as a collective term for different conditions.
The differential diagnosis should include radicular pain, piriformis syndrome, ankylosing spondylitis, lumbosacral facet syndrome, spondyloarthropathy, trochanteric bursitis, hip fracture, hip overuse syndrome …
Important to notice: the sacroiliac joint syndrome is not a synonym of sacroiilitis!

Diagnostic procedures       

Physiotherapists use a variety of orthopedic provocation tests. The diagnosis can be conclusive if at least one of these tests is positive.
Besides the known provocation tests: Gaenslen Test, Sacral Thrust Test, Thigh Thrust test, Compression test and Distraction Test, there are also the Yeoman's test, Faber test (Patrick Sign), Gillet test, Laguerre test and the Sacroiliac Stress Test; described below.

Yeoman's test: The patient is prone with the knee flexed 90°. The examiner raises the flexed leg off the examining table, hyperextending the hip. This test places stress on the posterior structures and anterior sacroiliac ligaments. Pain suggests a positive test.

Gillet test:  The examiner’s thumbs are placed under the posterior superior iliac spine and S2. The patient is asked to stand on one leg while moving the opposite leg towards the chest. If the joint side that is flexed moves up, this is considered a positive test.

Laguerre test: The patient lies supine and the examiner flexes, abducts and rotates the patients affected joint. The pelvis must be stabilized and pain signifies a positive test. This test differentiates hip pain from sacroiliac pain.

Sacroiliac Stress Test: The patient lies supine. The examiner exerts anterior pressure on the iliac wings with both hands. By crossing his or her hands, the examiner adds a lateral force to the compression. Pain is a sign of strained anterior sacroiliac ligaments.

 

CT and MRI are often used to confirm the diagnosis.

 

 

 

Physical Therapy Management      

In the first stage of the treatment the aim is to reduce the inflammation with icepacks and anti-inflammatory medication. A second important goal is to improve mobility using mobilizations, manipulation or exercise therapy. If there are complaints of instability, it can be useful to make use of a sacroiliac belt to temporarily support the pelvis, together with progressive stabilization training to increase motor control and stability. If the sacroiliac joint is severely inflamed, a sacroiliac belt can also be used. Finally, postural and ergonomic advice will help the patient to decrease the risk of reinjury.

 
Key Research          

• Kamali, F., Shokri, E., The effect of two manipulative therapy techniques and their outcome in patients with sacroiliac joint syndrome. Journal of Bodywork & Movement Therapies, 2011.

Sacroiliac joint and lumbar manipulation was more effective for improving functional disability than Sacroiliac joint manipulation alone in patients with Sacroiliac Joint Syndrome. Spinal high-velocity low-amplitude manipulation may be a beneficial addition to treatment for patients with SIJ syndrome.

• SLIPMAN W.C. Sacroiliac Joint Syndrome. Pain Physician. Vol. 4, N° 2, p 143-152, 2001. ISSN 1533-3159

History and physical examination can enter Sacroiliac Joint Syndrome into the differential diagnosis, but cannot make a definitive diagnosis of Sacroiliac Joint Syndrome. Treatment options for Sacroiliac Joint Syndrome include physical therapy, orthotics and manipulation.

It is important to notice that there is only a small amount of research available about the Sacroiliac Joint Syndrome. Further research will be a great contribution.

Clinical Bottom Line        

A Sacroiliac Joint Syndrome is a condition that is often overlooked by physiotherapists. It is often listed under the general term “dysfunction”, but this syndrome has to be differentiated from other sacroiliac joint disorders. To get a clear view of the Sacroiliac Joint Syndrome, further research has to be done in the future.