Sacroiliac Joint Pain

Epidemiology:

Sacroiliac joint pain comes underneath the umbrella term of low back pain. It is estimated that 80% of people will experience low back pain at least once during their life (Hoy et al. 2014). Research shows that between 14% to 22% of all low back cases are SIJ related pain (Sayed 2021).

Pathophysiology:

The Sacroiliac Joint (SIJ) is the largest axial joint in the body that connects the lumbar spine to the pelvis. It is a large, irregularly shaped joint that is surrounded by the sacroiliac ligaments. It’s primary function is to act as a shock absorber for the spine and provide stability to this region. It works to transmit and reduce loads to the lower extremities, whilst also providing resistance against shear forces. Pain can occur at this region if the ligaments responsible for stabilising the joint are compromised. If the SIJ isn’t as ‘stable’ as usual, pain and inflammation can arise.

Associated risk factors:

There are multiple risk factors that are linked with SIJ pain. Some of these include lumbar fusion surgery, prolonged vigorous exercise, pregnancy, infection, leg length discrepancy, arthritis or hip pathology (Falowski et al. 2020). Accidents such as a fall or MVA are also associated risk factors for developing SIJ pain.

Clinical features:

Subjective Assessment:
Ensure to take a thorough subjective assessment and rule out any potential red flags in your screen.

In terms of pain patterns, they can differ majorly between individuals. Pain is often sharp however can also present as an ache. It usually occurs during movement and can be felt in the pelvis, groin, gluteal or hip region. Pain tends to be unilateral and can refer down towards the ischial tuberosity or anterior hip. Muscle spasm in the gluteal region is a common response to SIJ irritation.

In relation to aggravating movements, actions that involve rotation through the pelvis tend to be painful. Running, lateral movements and hopping are often irritable due to the force occurring at the SIJ. Clients may report feeling pain following extended periods of sitting, walking downstairs, or walking uphill.

Discussing exercise routine and any associated changes in load, frequency or style of training is important. It is common to see an SIJ irritation because of increased repetitive loading through the pelvic region.

Objective Assessment:
It is important to also complete any relevant low back tests that you deem appropriate following the subjective assessment.
In terms of specific SIJ tests, there is a SIJ test battery that involves 5 tests. The tests include sacral compression, sacral distraction, thigh thrust, sacral thrust and Gaenslen test. SIJ pain is deemed to be positive if 3 or more of the provocation tests are positive. These tests have a high sensitivity and specificity (SN 94%, SP 78%) when assessed as a cluster.
Imaging can be completed to exclude any red flags such as infections, fractures or malignancies, as well as detect any abnormalities within the joint (Simopoulos et al. 2015).

Treatment:

In the acute phase of the injury, activity modification is key. It is important to avoid excessive twisting or rotation through the pelvis, single leg exercises, heavy shearing loads, running, excessive stairs and uphill walking. Anti-inflammatories, heat and soft tissue massage can also be effective strategies to reduce inflammation and pain.

From here, strengthening the surrounding structures of the SIJ is crucial. Creating a functional program targeting the core, gluteal muscles, hamstrings, and back extensors is important. To begin with, the exercises should be focused on building strength and stability through the core and hips, with limited shear and rotational forces occurring at the SIJ.

Plank

Dosage: 30 secs x 3
Technique cues: Make sure your shoulders are above your elbows, hips are square and back isn’t arched.

Banded glute bridge

Dosage: 10 reps x 3
Technique cues: Avoid coming all the way up into full extension and keep your hips still throughout.

Side lying clam

Dosage: 15 reps x 3 (each side)
Technique cues: Only lift your top leg to hip height and avoid twisting through the torso.

Where to progress from here:
Once foundational strength has been built and the irritation has settled, split stance exercises such as Bulgarian’s can be introduced. It is important to start with small ranges of flexion and progress from here pending how the client responds. Make sure to consistently check in with your client to see how they are tolerating re-introducing these movement patterns, especially 24 hours post the session.

In summary:

Like any musculoskeletal injury, it is important to individualise the treatment program so that it is relevant, tolerable, and enjoyable. Education needs to be a major focus from day 1 and it is important to remember that flare ups may occur along the way.

If you currently experiencing SIJ pain, BOOK IN HERE to see one of our experienced physiotherapists. We will create an individualised treatment plan to get you back to running, jumping, and rotating!

References:
Falowski, S., Sayed, D., Pope, J., Patterson, D., Fishman, M., Gupta, M. and Mehta, P., 2020. A review and algorithm in the diagnosis and treatment of sacroiliac joint pain. Journal of pain research, pp.3337-3348.
Hoy, D., March, L., Brooks, P., Blyth, F., Woolf, A., Bain, C., Williams, G., Smith, E., Vos, T., Barendregt, J. and Murray, C., 2014. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Annals of the rheumatic diseases, 73(6), pp.968-974.
Sayed, D., 2021. Sacroiliac Joint Pain: A Comprehensive Guide to Interventional and Surgical Procedures. Oxford University Press.
Simopoulos TT, Manchikanti L, Gupta S, Aydin SM, Kim CH, Solanki D, et al. Systematic review of the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2015;18(5): E713–56.