Скачать или смотреть The Sacroiliac Joint Pain Mystery: A Common but Overlooked Cause of low Back Pain

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The sacroiliac joint is often overlooked, yet it is a significant cause of lower back pain—accounting for approximately 22% of cases. Among patients who have undergone spinal fusion, SI joint pain is present in up to 40% of cases.
What is the sacroiliac joint?
This is the spine.
This is the sacrum, the triangular bone at the base of the spine.
The pelvis connects to the spine through the sacroiliac joints.

Why is this connection important?
Because the sacroiliac joint transfers force and load from the spine to the legs.

The sacroiliac joint allows minimal movement—intentionally so.
Its motion is limited to less than 4 degrees of rotation and about 1.6 mm of translation.
So the pain is not due to excessive movement.

Some believe the cause is neuroplasticity—a condition where the nervous system becomes overly sensitive to even small movements. The ligaments around the sacroiliac joint are rich in nerve fibers.
Neuroplasticity refers to rewiring of the nervous system in response to injury. It leads to maladaptive reorganization and persistent pain—but it can improve with treatment.

In many cases, the exact cause of pain is difficult to determine.

To function properly, the sacroiliac joint is stabilized by strong ligaments that prevent shear forces and supported by muscles that help during movement.

What causes SI joint pain?
The causes are varied, and pain from multiple nearby sources often overlaps.

The sacroiliac joint, lumbar spine, and hip may all produce similar patterns of pain.
A patient may have pain from one or more of these regions at the same time.
That’s why diagnosis of SI joint dysfunction is challenging and often requires diagnostic injection, with at least 75% pain relief to confirm.

Most SI joint pain is idiopathic, with multiple contributing risk factors.

Standard X-rays, MRIs, and CTs may appear normal.
In fact, up to 25% of people over age 50 have abnormal SI joints on imaging—even if they have no symptoms.

So what are the main risk factors?
The most important is prior lumbar fusion—especially fusions involving more than three levels. This is similar to adjacent segment disease. When the spine is fused, the SI joint may compensate with more motion and become painful.

Other risk factors include:

Pregnancy

Trauma to the pelvis — with 80% of patients reporting a specific twisting injury

Bone graft harvesting from the iliac crest, which may violate the SI joint

Always take a detailed history:
Ask about trauma, infections, inflammatory diseases like ankylosing spondylitis, Reiter’s syndrome, or psoriasis.
Also assess for spinal fusion, scoliosis, and leg length discrepancy.

How does the pain present?
SI joint pain is usually off the midline, and below the L5 level.
To locate this, note the iliac crest line, which corresponds to L4.
The pain is usually just below L5, near the posterior superior iliac spine (PSIS).
Only about 4% of SI joint pain is located above L5.

So how do you identify it?
Ask the patient: “Where does it hurt?”
They will often point directly at or just below the PSIS.
This is known as the Fortin Finger Test — a strong clinical clue for SI joint pain.

The pain may radiate into the buttock or upper thigh.
Patients often report pain while:

Sitting with weight on the affected side

Climbing stairs or stepping up

Turning in bed or trying to sleep

Bearing weight or loading the joint
Relieving pressure on the joint often improves symptoms.
The symptoms may mimic herniated disc or nerve root compression.
Because many nerves run around the SI joint, patients may report sciatica-like symptoms, including pain radiating down the thigh, and occasionally past the knee.
Groin pain is also possible, so hip pathology (such as arthritis, bursitis, or impingement) must be ruled out.
Is the SI joint the primary pain generator?
If the patient points to a spot just below and medial to the PSIS, SI joint dysfunction is likely. This is the Fortin Finger Test.
You then proceed with provocative testing to confirm.

At least three positive tests are needed. Warn the patient — these will provoke pain.
Tests include:
FABER test
Compression test
Sacral thrust test
Gaenslen test
Distraction test
Thigh thrust test
The two most reliable are the compression test and thigh thrust test.
No single test is 100% accurate.
Perform the following
Straight leg raise and full neurological exam to rule out disc herniation
Hip exam to rule out hip joint disease
SLR is usually negative in SI joint dysfunction.

Treatment:
Start with non-operative management:
Anti-inflammatory medications
Physical therapy
Pelvic support belt
Try conservative treatment for at least 4 weeks before considering injection.
In patients with suspected SI joint pain, the exact location of the pain must be confirmed.
This is done by diagnostic injection, which also may provide relief.
Surgical fusion is the last resort.

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