Introduction
- Two Types:
Mechanical and arthritic |
- Mechanical: Alteration of normal joint mechanics (hyper/hypomobility, leg length inequalities, gait abnormalities, lower extremity joint pain, pes planus, improper shoes, scoliosis, prior lx fusion, lp myofascial dsyfunction, repetitve strenuous activity and trauma, pregnancy) |
- Arthritic: OA/ inflammatory arthropathy (AS, psoriatic arthritis, enteropathic arthritis, reiters arthritis) |
Presentation
- Patients place their index finger over PSIS (Fortin finger test) |
- Pain in lower back, groin buttock/thigh, sometimes in lower leg (chemical radiculopathy of the nearby L5-S1 NR) |
- Referral depends on which part of SI joint is irritated (Upper 1/3 = region of PSIS)
Mid-section = pain in mid gluts
Lowest = lower gluteal region |
- Exacerbated by weight bearing and arising from a seated position, long car rides, in and out of a vehicle, rolling from side to side in bed, flexing forward whilst standing |
- Relieved by lying down or shifting weight off the affected side |
- 2 of the 4 tests have a high predictive value: SI distraction, thigh thrust, SI compression and sacral thrust (+ve test = reproduction of symptoms unilaterally and located near PSIS) |
- Pain on Gaenslen's, FABER |
- Stiffness/apprehension in SI joint MP |
- Check for TrPs, tightness, weakness in muscles |
- Check for biomechanics of LS and LL |
- SI stress tests can be +ve in discogenic patients
- Pain in SI joint is lumbar until proven otherwise
- NTT and neurological exam are unremarkable in SIJD
CPR
High sensitivity and specificity when patient scores >4 on: |
- One finger test - 3 points |
- Groin pain - 2 points |
- Pain when sitting on a chair - 1 point |
- SI shear test - 1 point |
- Tenderness of PSIS - 1 point |
- Tenderness of sacrotuberous ligament - 1 point |
DDx
- Inflammatory Arthropathy |
- Middle cluneal nerve entrapment |
- LS referral (discogenic) |
- Hip DJD/pathology |
- Myofascial pain (piriformis syndrome, gluts) |
- Sacral insufficiency f# |
- Neoplasm |
- Infection |
- Viceosomatic referral |
Imaging
- X-ray showing bilateral sacroilitis (AS)
- SIJD usually diagnosed clinically
- Rule out other pathology
- MRI and CT more sensitive
- Erosions, sclerosis, joint space narrowing
- Changes does not correlate with symptoms
Management
- Ice, NSAIDs |
- Ultrasound |
- EMT of SI joint |
- CFM of tendons and ligaments (especially long dorsal sacroiliac ligament |
- Myofascial release of gluts, hamstrings, piriformis, TFL, QL, lumbar erectors, contralateral lats |
- Strengthening lumbopelvic stability - transverse abdominus, abdominal obliques, lumbar erectors, gluteus, hip abductors and adductors |
- Education on posture and ergonomic awareness |
- Avoid prolonged standing, sitting and forced hip abduction |
- Arch supports/orthotics/ SI belt |
- Surgery for failure to respond to conservative care with continued/ recurrent SIJ pain and +ve response to SI injection with >75% relief |
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