SI Joint Pain
Sacroiliac joints are the joints where the lowermost portion of the spine, called the sacrum, connects with the pelvis. In our body, there are two sacroiliac joints, one on either side. The sacrum is a triangle-shaped bone present beneath the lumbar spine and above the tail bone. The joint can become dysfunctional, irritated, inflamed, or injured like other joints of the body resulting in pain.
The function of the Sacroiliac joint is to absorb shock, reduce stress on the spine and pelvis, and transfer the body weight to the lower body from the upper body. To understand more about the Sacroiliac joint, we need to first understand the anatomy of the joint.
Anatomy of the Sacroiliac joint
The sacroiliac joint is a synovial joint between the sacrum and the ilium. Both sacroiliac joints, along with pubic symphysis and sacrococcygeal joint, make the pelvic girdle. The main function of the joint is to transfer the bodyweight to the hip bones. The weight of the axial skeleton is divided between two femurs when an individual is standing and on ischial bones when he is sitting.
As the joint plays an important role in weight transfer, the sacroiliac joint has many strong ligaments for stabilization. The important ligaments of the joint are anterior and posterior sacroiliac ligaments, sacrotuberous ligament, and sacrospinous ligament.
The joint is surrounded by powerful muscles, but they don’t have a direct influence on joint motion (Norris C.M.,2008)
Sacroiliac joint pain is not easy to diagnose as other conditions can also present the same symptoms. SI joint pain is mostly felt in the lower back and buttocks, but it can also refer to the leg and thigh. SI joint pain can aggravate during prolonged sitting, stair climbing, and standing on one leg.
The symptom of sacroiliac joint pain is sharp or dull pain felt in the lower back or in the back of the hip region. Occasionally one can feel pain in the groin, thigh, or leg. There are few movements or positions that can put stress on the joints, which can worsen the pain, like standing up from sitting, climbing the stairs, turning on the bed.
The symptoms mainly depend on the cause of the pain. For example, in ankylosing spondylitis, an individual experiences stiffness in the back which is worse in the morning and improves with the activity. Other symptoms of the condition are pain in the hip and shoulder, blurry vision, and eye pain.
The common cause of SI joint pain is repetitive use, like running. Other possible causes are:
a. Injury and trauma to the ligaments around SI joints
b. Any past surgery of the spine
c. Temporary pain may be in pregnancy
d. Leg length discrepancy that affects the walking styles
e. Obese people are more affected with sacroiliac joint pain.
f. SI joint pain is commoner in people leading a sedentary life style.
g. Occasionally when posterior sacral ramus which innervates the SI joint is compressed or inflamed then also it causes pain in sacroiliac joint.
h. Pregnant women are more prone to developing Sacroiliac joint pain. Hormones releasing in pregnancy causes sacroiliac ligaments to relax making the joint hypermobile and resulting in pain.
The sacroiliac joint is a synovial joint, so conditions affecting the whole body can also cause inflammation of sacroiliac joint. For example – Ankylosing spondylitis is inflammatory arthritis affecting the SI joint and other joints in the spine. Gout is another arthritis that causes a uric acid build-up in joints, including the SI joint.
The sacroiliac joint is not easy to locate during physical examination. However, even the tenderness in the SI joint doesn’t confirm the diagnosis as there are other conditions like disc prolapse, spinal stenosis, bursitis of the hip, or osteoarthritis where you can get referred pain to the Sacroiliac joint.
Pain provocation tests are usually done by physiotherapists where SIJ structures are stressed by compression, distraction, thigh thrust, Gaenslen’s, and sacral thrust (Laslett M.,2008).
Imaging tests like X-Ray, CT scan, MRI may be helpful, but they can also show ‘normal’ even when there is a problem in SI joint. Some experts think that image-guided anesthesia to the joint may be very helpful in diagnosing SI joint dysfunction. If there is more than 75% relief in the pain, the test is positive (Kennedy DJ et al., 2015). In such a case, a corticosteroid injection can be given into the SI joint to get long-lasting relief.
Physical therapy can provide great relief in SI joint pain. In addition, your doctor may want to prescribe NSAIDs to ease inflammation and pain. The physical therapist will examine the SI joint along with the spine, hips, pelvis, and leg muscles. After asking a few questions, he will devise a treatment plan according to the severity of your condition.
Usually, the first stage of treatment is to decrease the inflammation using ice packs and NSAIDs. After that, using mobilization, exercises, and manipulation, mobility is improved. If a patient complains of instability, he is recommended to use a sacroiliac belt that temporarily supports the pelvis. In addition, progressive stabilization training is given to increase stability and motor control. The patient is also given postural advice to prevent reinjury in the future. The exercises suggested to the patient with Sacroiliac joint pain are:
1. Stabilization Exercises of the core – Exercise is a key component in treatment protocol of sacroiliac joint pain. In patients with Sacroiliac Joint pain, specific isometric co-contraction of lumbar multifidi and musculus transversus abdominis, which are core stabilizers, are suggested. During weight-bearing exercise, it is important to maintain neutral lordosis and controlled respiration (P.B.O’Sullivan et al.,2000). The physiotherapist must palpate the muscle to ensure the effective contraction of muscle.
Your therapist might start the stabilization exercises and later integrate them to light dynamic functional tasks and heavy-load dynamic functional tasks.
For stabilization exercises, your therapist might want you to come in quadruped position and then you will be asked to tuck in the chin while hollowing the abdomen and tilting the pelvis posteriorly. Lift one arm slowly while maintaining your spine in neutral position. Now your therapist will ask you to return to the starting position and continue with the other side. To make it more challenging, you can be asked to preform single leg extension in quadruped. With alternating the arm and leg extension the exercise becomes even more challenging.
To improve the coordination, single leg bridging with alternating the lower extremities on unstable base of support can be done. This improves balance and coordination while also challenging the stabilization function of the core muscles.
The co-contraction of musculus transversus abdominis and multifidi is important in all these exercises. The lumbar multifidi muscle is palpated in the medial side of the lumbar facet joint of both the side.
2. Manipulation – Both lumbar and Sacroiliac joint manipulations are helpful in Sacroiliac joint pain. Pain and functional disability can be significantly improved by using manual therapy techniques. Manual Spinal Thrust manipulation can be effective in Sacroiliac joint syndrome (Kamali et al., 2013).
SIJ manipulation and lumbar manipulation both decreases the pain and functional disabilities in patients with SIJ pain. Manual spinal thrust manipulation can also bring relief in SIJ pain.
3. Stabilization – The use of a pelvic belt in Sacroiliac joint pain is common. The tension of the pelvic belt is similar to the muscle activity of the transversus abdominis. 30-40% of the max. voluntary force of muscle transverse abdominis is good to attain stability of the pelvis. There is no increase in stability by increasing the tension of the belt to 100 N from 50 N. The effective positioning of the belt is just below the ASIS; if placed too low there may be decrease in the laxity.
If the Sacroiliac joint pain is due to hypermobile SI joint, then your therapist may recommend Sacroiliac Binder, which needs to be worn for 24 hours up to 12 weeks. In addition, proper physical exercises and manual therapy should be incorporated. Once the patient regains control of lumbopelvic musculature, the belt can be removed.
If you are experiencing Sacroiliac joint pain, then visit Progressive care where your condition will be treated by expert physiotherapist so that you can regain a pain-free life.
a. NORRIS CM. Back Stability: Integrating science and therapy. Human Kinetics, p. 24; 44; 2008
b. Laslett M. (2008). Evidence-based diagnosis and treatment of the painful Sacroiliac joint. The Journal of manual & manipulative therapy, 16(3), 142–152.
c. Kennedy DJ, Engel A, Kreiner DS, Nampiaparampil D, Duszynski B, Macvicar J. Fluoroscopically Guided Diagnostic and Therapeutic Intra-Articular Sacroiliac Joint Injections: A Systematic Review. Pain Med. 2015;16(8):1500-18. doi:10.1111/pme.12833
d. P.B. O’Sullivan et al., Masterclass. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management, Manual therapy, 2000. (Level of evidence 2A)
e. Kamali et al., The effect of two manipulative therapy techniques and their outcome in patients with sacroiliac joint syndrome, Journal of bodywork and Movement Therapies, 2013 (Level of evidence 1B)