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SI Joint: Diagnosis and Management
Fred Flandry, M.D., F.A.C.S., F.A.A.O.S., F.A.C.S.M.The Hughston Clinic
Columbus GA
Disclosures
I have no financial arrangement or affiliation with any corporate organization or with any product manufacturer of any medical device related to this topic.
I have endeavored to keep this presentation free of commercial bias and any product depicted or discussed is done so solely for illustrative purpose and should not be construed as a product endorsement.
Some of the images used in this presentation have been provided by and are used with the permission of SI Bone, a medical device manufacturer, and are considered proprietary
SI Joint: Diagnosis and Management
What is the SI Joint?
What causes SI Joint pain?
How common is SI joint dysfunction?
How is SI Joint dysfunction diagnosed?
How is SI Joint dysfunction treated?
Conservative
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What is the SI Joint?
Anatomy
Sacroiliac Joint
Articular Surface
Anatomy
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Anatomy
"Arch voussoirs" by Jhbdel ‐ inkscape. Licensed under CC BY‐SA 3.0 via Commons ‐ https://commons.wikimedia.org/wiki/File:Arch_voussoirs.svg#/media/File:Arch_voussoirs.svg
Anatomy
Anterior Ligaments Posterior Ligaments
Form Closure/Structural Integrity:
The shape of the sacrum and the integrity of the supporting ligaments
contribute to SI joint stability (11‐13)
Integrated Model of SIJ Function (11‐16)
Force Closure/Joint Compression: The external dynamic forces created by contraction of the stabilizing muscles and their fascial and ligamentous attachments (11‐13)
Motor Control: Nervous System Coordination / Co‐activation of deep stabilizing muscles
(onset, duration, timing) (14‐16)
11. Lee DG, Vleeming. 199812 Vleeming A, Stoeckart R, Volkers ACW, Snijders CJ. Spine. 1990a: 15(2): 130 13. Vleeming A, Stoeckart R, Volkers ACW, Snijders CJ. Spine. 1990b: 15(2): 13314. Snijders CJ, Vleeming A, Stoeckart R. 199315. Hodges P W, Richardson C A 199616. Richardson C A, Snijders C J, Hides J A, Damen L, Pas M S, Storm J 2002
Components
Local Core Muscles: Transversus, Rectus Abdominus, Multifidus, Pelvic Floor Muscles
Core Muscles should contract before load reaches the low
back and pelvis so as to prepare the system for impending load.
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Biomechanics
Nutation: Sacral base movement
anteroinferior (9)
Counternutation: Sacral base movement
poster superior (9)
Translation: Linear motion; motion in
any one direction
Nutation
Counternutation
9. Frost, Wheeler, Fortin: The Sacroiliac Joint: Anatomy, Physiology and Clinical Significance. Pain Physician 2006
SI Joint Motion
Multi‐planar motion Simultaneously rotate and
translate through 3 axes of motion
Motions (<4° in any plane)• Nutation/Counternutation
- Primary motion- Males: 1 ‐ 2°
- Females: 2 ‐ 4°
Sacral Translation • (A‐P motion) up to 1.6mm
Sturesson B et al :Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine 1989 Feb;14(2):162‐5.
What causes SI Joint pain?
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Potential Causes of SIJ Pain
Inflammation
Arthrosis
Instability
Trauma: Chronic sprain
• First: establish that it is the SI Joint,
• Then : determine if it is primary or secondary
Potential Causes of SIJ Pain: Traumatic
MVA: Foot on Brake
Slip and Fall
Lifting and Twisting
Traction Injuries
Potential Causes of SIJ Pain: Gradual Onset
Laxity of the SIJ / Multiple Pregnancies
Repetitive Forces on SIJ and Supporting Structures
Biomechanical Abnormalities
Leg Length Inequality
Pelvic Obliquity/Scoliosis
Iliac crest bone graft
Arthritis: Ankylosing Spondylitis
Post Infection Degeneration
Adjacent Segment Degeneration
After Lumbar Spinal Fusion
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SIJ & Adjacent Segment Degeneration
Ha et al: Degeneration of the Sacroiliac Joint After Instrumented Lumbar or Lumbosacral Fusion. Spine 2008; 33 11:1192‐1198Ivanov et al: Lumbar Fusion Leads to Increases in Angular Motion and Joint Stress Across the Sacroiliac Joint. Spine. 2009; 34: E162‐169.
75% of post lumbar fusion patients showed SIJ degenerative changes on CT scan five (5) years after lumbar fusion.
75% of post lumbar fusion patients showed SIJ degenerative changes on CT scan five (5) years after lumbar fusion.
Lumbar fusion leads to increases in angular motion and increases in joint stress at the sacroiliac joint.
Lumbar fusion leads to increases in angular motion and increases in joint stress at the sacroiliac joint.
The corollary also exists for degenerative hip disease or more distal disease, deformity, or dysfunction of the lower extremity.
The corollary also exists for degenerative hip disease or more distal disease, deformity, or dysfunction of the lower extremity.
How common is SI Joint
Dysfunction?
Prevalence of SI Joint Pain
As a Component of LBP
22.6%
14.5%
21.0%
18.5%
0%
5%
10%
15%
20%
25%
Bernard1987
(n=1293)
Sembrano/Polly 2009(n=200)
Schwarzer1995(n=43)
Maigne1996(n=54)
In symptomatic patients after Lumbar Fusion
35‐43% Patients with LBP after lumbar fusion.
43% DePalma 20115
40% Liliang 20116
35% Maigne 20054
I s the S I Jo int t ru ly a prob lem?
1 2 3 4
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Diagnosis &
Diagnostic Challenges
“Doctor, I have hip and leg pain…”
Clinical History
A Typical patient history
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History and Complaints
HISTORY
When did the pain start? Diagnosis is usually delayed
Prior trauma A fall on the buttock
Car accident (T‐bone, rear‐end, head‐on)
Lift/Twist
Other
Prior lumbar fusion Prior iliac bone graft harvest
Pregnancy
COMPLAINTS
Lower back pain
Lower extremity pain (numbness, tingling, weakness)
Pelvis / buttock pain
Hip / groin pain
Unilateral leg instability (buckling, giving way)
Disturbed sleep patterns
Disturbed sitting patterns (unable to sit for long periods, on one side)
Pain going from sitting to standing
Exacerbating Activities
Unilateral Weight Bearing ‐ Putting on Socks/Shoes
‐ Ascending/Descending Stairs
‐ Getting in and out of Car
‐ Prolonged Walking
‐ 85% of Gait is Single leg Stance (22)
Sexual Intercourse
Pain with Transitional Motions‐ Supine to painful side ‐ Sit to stand‐ Rolling over in bed‐ Getting in /out of bed
Pain while Stationary‐ Sitting on affected side‐ Prolonged standing/sitting
Pain with Transitional Motions‐ Supine to painful side ‐ Sit to stand‐ Rolling over in bed‐ Getting in /out of bed
Pain while Stationary‐ Sitting on affected side‐ Prolonged standing/sitting
Janda, V. On the concept of postural muscles and posture in man. Aust J Physiotherapy 1983;29:83‐90
Relieving Activities
Bearing weight on unaffected side
Lying on unaffected side
Manual or belt stabilization
Bearing weight on unaffected side
Lying on unaffected side
Manual or belt stabilization
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History
Pain Diagram
• Pain in buttock and posterior thigh
• Usually not midline
• Usually below L5
• At or lateral to PSIS
• Occasionally groin
• Secondary pain in lateral thigh, groin, and/or lateral calf
Pain Diagram
• Pain in buttock and posterior thigh
• Usually not midline
• Usually below L5
• At or lateral to PSIS
• Occasionally groin
• Secondary pain in lateral thigh, groin, and/or lateral calf
Overlapping Pain Diagrams
18 18
Differential Diagnosis: Shooting at the Right Target
Multiple possible pain generators
HipLumbar Spine SI Joint
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Differential Diagnosis: Rule out Lumbar Spine
Premise: Pain is coming from lumbar spine until proven otherwise
Compressed nerve
Stenosis: central, lateral recess, foraminal
Herniated nucleus pulposus
Disc damage, annulus tear
Lumbar instability (Spondylolisthesis)
Facet
Differential Diagnosis: Rule out the Hip
Premise: Pain may be coming from the hip!
Possible Hip Conditions: Labral tear Chondral pathology Ligamentum teres injury AVN, Occult fracture, DJD Pre‐arthritic hip conditions (FAI)
Work Up: MRI Sensitive for hip pathology Differential Diagnostic injections
• Lumbar spine pathology• Maigne’s Syndrome• Gluteus maximus / minimus syndrome• Quadratus lumborum syndrome• Pyriformis syndrome• Hamstring origin syndrome• Tensor fascia lata syndrome• Ankylosing spondylitis• Other arthropathies• Hip pathology• Tumor
Differential Diagnosis: Rule out other Mimes
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ObjectivePhysical Exam
Findings
Fortin Finger Test
Point to pain while standing • Able to localize with one finger
• Within 1 cm of PSIS (inferomedial)
• Consistent over at least 2 trials
Ask patient to point to location of primary pain• Below L5: Consider SIJ
• Above L5: Consider lumbar spine etiologies
Neurologic Basis of the Arthrokinetic reflex: Hilton’s Law (1863)
The same trunk of nerves whose branches supply the groups of muscles moving a joint also:
– Furnishes a distribution of nerves to the skin over the insertion of the same muscles
– Furnishes a distribution of nerves to the interior of the joint
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Arthrokinetic Reflex
• Overlying muscles affect the underlying joint
• Joint affects overlying muscles
• Normal sacroiliac joint kinematics exists when the arthrokinetic reflex is balanced
• Imbalanced arthrokinetic reflex opens the gate to nociceptive input and sacroiliac joint dysfunction
Testing Normal SIJ Function: Hip Rotation Test (Bernard)
Sacroiliac Provocation Tests
The following provocative tests, when performed in combination are proven to have a high degree of sensitivity and specificity:
1. Direct tenderness
2. Arthrokinetic reflex
3. Distraction
4. Thigh Thrust
5. Compression *
6. Patrick‐FABER
7. Gaenslen’s Maneuver
Laslett: Evidence Based Diagnosis and treatment of the painful Sacroiliac Joint . Journal of Manual & Manipulative Therapy, 2008,Szadek et al: Diagnostic Criteria for Sacroiliac Pain, a Systemic Review. J Pain. 2009;Apr:10(4):354-68.
* Most sensitive
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Sacroiliac Provocation Test Tips
Start with light pressure and gradually increase, keeping hands cupped to minimize local contact pressure (30 second max).
Keep arms straight and lean forward with your upper body to create gentle steady force.
Stabilize patient on the table to prevent muscle guarding.
Stabilize contralateral ASIS during Thigh Thrust and FABER tests.
If pain is provoked with test, ask patient to identify pain location to confirm it is their typical pain.
Distraction
Thigh Thrust
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Compression
Patrick ‐ FABER
Gaenslen’s
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Sacroiliac Provocation TestsThe following five provocative tests, when performed in combination are proven to have a high degree of sensitivity and specificity:
1. Distraction* (Highest PPV**)
2. Thigh Thrust*
3. Compression *
4. Patrick‐FABER
5. Gaenslen’s Maneuver
Laslett (23) Szadek (24)
Sensitivity 91% 85%
Specificity 78% 76%
23. Laslett: Evidence Based Diagnosis and treatment of the painful Sacroiliac Joint . Journal of Manual & Manipulative Therapy, 2008,24. Szadek et al: Diagnostic Criteria for Sacroiliac Pain, a Systemic Review. J Pain. 2009;Apr:10(4):354-68.
*Most sensitive of tests.
**PPV (positive predictive value)
Reliability and Specificity
• Specificity increases when symptoms don’t centralize or peripheralize with repeated trunk flexion/ extension (23,25)
• In some cases a patient may not tolerate having five (5) tests performed. Therefore, it’s recommended that the three (3) most sensitive, specific and reliable tests be performed first.
How to Interpret Your Results: (23,25)
1 Positive Test – Suspicion
2 Positive Tests ‐ Fair Confidence
3+ Positive Tests – High Confidence
23. Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man & Manip. Ther. 2008;16:142-152.25. Laslett et al , Diagnosis of sacroiliac joint pain: validity of individual and composite provocation tests. Man Ther. 2005; Aug;10(3):207-8.
Differential Diagnosis:Physical Exam: Hip, Lumbar, SIJ
Lumbar SPINE Exam:
Range of Motion: Forward flexion, extension, lateral flexion, rotation, combination
Neuro Exam
– Motor, Sensory, Deep Tendon Reflexes (DTRs)
– Dural tension tests
SI JOINT EXAM:
Palpation
– PSIS
– Iliac crest
– Dorsal Ligament
– Sacral Sulcus
Provocative Tests
ASLR
HIP and Pelvis Exam:
Range of Motion: Flexion, extension, internal / external rotation
Scour Test: (loaded circumduction)
Gait evaluation
Palpation: Piriformis, trochanteric area
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What’s the Gold Standard for Diagnosis?
Diagnostic Injection• Confirm with contrast and
imaging
• Low volume, local anesthetic
• 50‐75% pain reduction
Therapeutic Injection• Local anesthetic +
corticosteroid
• May provide intermediate or long term relief
• Results of therapeutic injections can be unpredictable
Injection Under Fluoroscopy
Justification for SIJ Injection
Negative lumbar and hip exam
Positive History
Positive Fortin Finger test and physical exam
Positive pain provocation tests
Injection Assessment
Patient pain diary
Significant positive clinical response 50‐75% VAS reduction indicates positive diagnosis of SI joint as pain generator
Obtain copy of arthrogram to ensure accuracy
Equivocal or no relief < 50% VAS reduction indicates a non‐significant clinical response
May have SIJ pain, but consider other pain sources
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NO
YES
Significant Positive Clinical Response?
Diagnostic Algorithm for SI Joint PainHistory
Physical Exam
Provocative Tests
Diagnostic Injections
Treatment OptionsMedication(s), PT, SIJ Injections, RF Denervation, MIS SI Joint Fusion
Other possible pain generator;Continue workup
Conservative treatment of
SI Joint Dysfunction?
Conservative Treatment Options
Sembrano: Diagnosis and Treatment of SI Joint Pain. Current Orthopedic Practice 2011Cohen*: Sacroiliac joint pain; a comprehensive review of anatomy, diagnosis and treatment. Anesth Analg, 2005.
Symptom Management • Medications (Non Steroidal anti‐inflammatory, non‐narcotic analgesics, Topical)
• External SI joint stabilization (belting?)
• Therapeutic SI Injections (<4 per year)
Physical Therapy (Patient Specific)
• Motor control & core strength
• Restore normal functional movement patterns / proper gait
• Soft tissue mobilization
• Restore muscle length and balance
• Manual therapy (muscle energy techniques/ SI joint mobilization etc.)
• Modification of ADLs (Patient education on posture, body mechanics, positioning)
• Targeted exercise program
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The Cycle of SI Joint Dysfunction
Thomas Boers, R.P.T., Fellow American Academy of Orthopedic Manual Therapists
Hamilton Medical Center, Dalton GA
Sacroiliac Joint Function NormalPain Free CycleNormal Muscle Function
Predisposing factors:TraumaDegenerative diseasePregnancyPoor Conditioning
Sacroiliac Joint Function NormalPain Free CycleNormal Muscle Function
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Predisposing factors:TraumaDegenerative diseasePregnancyPoor Conditioning
Sacroiliac Joint DysfunctionPainful CycleMuscle Dysfunction
Arthrokinetic Reflex Imbalance
Predisposing factors:TraumaDegenerative diseasePregnancyPoor Conditioning
Sacroiliac Joint DysfunctionPainful CycleMuscle Dysfunction
Arthrokinetic Reflex Imbalance
Mobilization of Muscle or Joint
Anti Inflammatory agents
Predisposing factors:TraumaDegenerative diseasePregnancyPoor Conditioning
Exercise
Sacroiliac Joint DysfunctionPainful CycleMuscle Dysfunction
Arthrokinetic Reflex Imbalance
Mobilization of Muscle or Joint
Anti Inflammatory agents
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Predisposing factors:TraumaDegenerative diseasePregnancyPoor Conditioning
Exercise
Sacroiliac Joint DysfunctionPainful CycleMuscle Dysfunction
Arthrokinetic Reflex Imbalance
Manipulation of Muscle or Joint
Mobilization of Muscle or Joint
Anti Inflammatory agents
Predisposing factors:TraumaDegenerative diseasePregnancyPoor Conditioning
Exercise
Sacroiliac Joint DysfunctionPainful CycleMuscle Dysfunction
Arthrokinetic Reflex Imbalance
Manipulation of Muscle or Joint
Joint InjectionMobilization of Muscle or Joint
Anti Inflammatory agents
Predisposing factors:TraumaDegenerative diseasePregnancyPoor Conditioning
Arthrokinetic Reflex Balanced
Exercise
Sacroiliac Joint DysfunctionPainful CycleMuscle Dysfunction
Arthrokinetic Reflex Imbalance
Manipulation of Muscle or Joint
Joint InjectionMobilization of Muscle or Joint
Anti Inflammatory agents
Sacroiliac Joint Function NormalPain Free CycleNormal Muscle Function
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Predisposing factors:TraumaDegenerative diseasePregnancyPoor Conditioning
Arthrokinetic Reflex Balanced
Exercise
Sacroiliac Joint DysfunctionPainful CycleMuscle Dysfunction
Arthrokinetic Reflex Imbalance
Manipulation of Muscle or Joint
Joint InjectionMobilization of Muscle or Joint
Anti Inflammatory agents
Sacroiliac Joint Function NormalPain Free CycleNormal Muscle Function
Why exhaust conservative measures?
SI Joint Arthrodesis
SI Joint: Diagnosis and Management
Fred Flandry, M.D., F.A.C.S., F.A.A.O.S., F.A.C.S.M.The Hughston Clinic
Columbus GA