Research Review By Dr. Jeff Muir©

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Date Posted:

May 2020

Study Title:

Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area

Authors:

Palsson TS, Gibson W, Darlow B, Bunzli S, Lehman G et al.

Author's Affiliations:

Department of Health Science and Technology, SMI, Aalborg University, Aalborg, Denmark; School of Physiotherapy, The University of Notre Dame, Fremantle, Australia; Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand; Department of Surgery, University of Melbourne, Melbourne, Australia; Greg Lehman Physiotherapy, Toronto, Ontario, Canada; Thrive Physiotherapy, Guernsey, Channel Islands; Thrive Physiotherapy; and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia; Pain Research Group, Pain Center South, Odense University Hospital, Odense, Denmark and Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Neuroscience Research Australia, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia and New College Village, University of New South Wales; School of Physiotherapy, The University of Notre Dame; and School of Physiotherapy and Exercise Science, Curtin University, Australia.

Publication Information:

Physical Therapy 2019; 99: 1511–1519.

Background Information:

Low back pain (LBP) remains a leading cause of disability worldwide (1), with a substantial proportion (up to 35%) thought to be linked to the sacroiliac joint (SIJ) (2-5). SIJ pain is traditionally categorized broadly as pregnancy-related, SIJ-specific pathologies and SIJ-related pain of other origin (6, 7). Clinicians generally attempt to draw a diagnostic distinction between LBP with or without SIJ involvement, with the SIJ, when involved, either acting as the source of the nociception or as a dysfunctional biomechanical junction, which itself either becomes painful or causes pain to be referred to another location (8).

Differentiating SIJ pain versus SIJ movement dysfunction is an important factor in diagnosis. There are challenges, at least partly due to the ability of provocative tests to identify the SIJ as a source of pain but the corresponding inability of these tests to indicate the reason behind the joint sensitivity. SIJ movement dysfunction is often labelled as the driver of symptoms; however, the ability to reach diagnostic conclusions based on palpation of movement dysfunction has long been questioned (8, 9). Despite these concerns, these concepts and associated provocative tests continue to be taught to clinicians.

These authors sought to review our current clinical knowledge and offer recommendations for practice based on the existing evidence.

Summary:

Implying SIJ Involvement

Local Tissue Sensitivity at the SIJ:
SIJ dysfunction is generally assessed using pain provocation tests which identify the SIJ as the source of local (tissue or joint) sensitivity. Although such tests are clinically useful with good diagnostic validity, they do not provide insight as to the reasons why the structures themselves are sensitive. The SIJ is a potential source of nociception due to trauma or other aberrant loading, although the presence of signs of SIJ involvement and symptoms do not necessarily define a causal relationship. In other words, SIJ pain or sensitivity does not necessarily indicate the presence of an SIJ movement disorder. This is how many clinicians explain this to patients, however!

Explaining SIJ Pain as a Consequence of SIJ Movement Dysfunction: Is This Plausible?
The SIJ is an inherently stable joint, with only very small movement possible during normal activity, which is generally limited to a few degrees of rotation about a transverse axis (10, 11). Despite this, provocation tests purport to detect movement dysfunction, which is often attributed to instability. This assumes the clinician has the ability to detect movements of the SIJ through multiple layers of tissue (12), movements which are generally imperceptibly small (13). Indeed, radiostereometric analysis has determined that movements of the SIJ during testing (ex. standing hip flexion as in a Gillet test) are very small, with rotation of only 0.2 degrees and translations of only 0.3 mm detected (13). Given this small movement, it is likely that movement dysfunction detected via provocation tests are related to soft-tissue motion (12) or pain-associated muscle activation (14). Compounding this is the difficulty in reliably identifying anatomical landmarks and assessing their symmetry and motion during testing, which evidence indicates is not reliably accurate (15). As such, the weight of existing evidence suggests that the use of tests and models of movement dysfunction in the SIJ remains unsupported.

Evidence that Nociceptive Activity from the SIJ Contributes to Pain:
Recent studies using radiofrequency denervation to address SIJ pain have noted that while this intervention decreases pain, it does not entirely eliminate SIJ pain, indicating that pain from the SIJ itself likely represents a portion of a complex, multidimensional pain experience (16). As such, attributing SIJ pain solely to the dysfunction in the joint itself is likely an inaccurate and incorrect assumption.

Implications for Clinical Practice

Accepting that movement dysfunction is difficult to identify and likely does not fully explain SIJ-related pain, there are several implications for clinical practice:
  • Changes in motor planning are known to begin immediately following the onset of low back pain (17) and could be influenced by cognitive factors, such as the fear of movement while in pain (18), which could contribute to the pain presentation.
  • Characterization of pathoanatomical models as structural weakness, abnormality or instability can lead to movement-related fear and a perception that the condition is irreversible, both of which will contribute to an individual’s pain presentation.
  • Clinicians should avoid communicating messages of fragility to the patient (regardless of the body region involved!), as this will reinforce the perceived irreversibility of the condition and potentially impact the patient’s ability to cope with their pain and ultimately recover from it.
  • Clinicians should attempt to help the patient reconceptualize their pain experience (ex. describe the spine as a strong structure and that their SIJ pain is due to increased sensitivity of the tissues and not overt instability in the joint).
  • Treatment options should align with diagnostic descriptions (ex. manual therapy to increase movement in the SIJ combined with home exercises designed to increase joint stability are contradictory). Exercise, for example, could be rationalized not as a means to improve stability but as a way to address the sensitivity issue by explaining that sensitive tissues respond well to physical load and movement (19, 20).

Clinical Application & Conclusions:

The evidence from the literature indicates that the movements of the SIJ itself are imperceptibly small and clinical tests currently used in practice (and still taught in most chiropractic and physiotherapy programs!) are not supported by contemporary evidence. While these traditional tests should not be overlooked, their usefulness is questionable, as the SIJ as the source of pain represents only one potential contributor to the patient’s pain experience. They should be taught and interpreted with this in mind (that is, being only one part of the overall clinical picture).

Given the lack of evidence supporting movement dysfunction as a main source of pathology in the SIJ, the authors caution clinicians from perpetuating this traditional approach, as assessment, management and clinician messaging should reflect the contemporary evidence.

EDITOR’S NOTE: In the last ten years or so, there hasn’t been a lot of great research done on the clinical aspects of the SIJ. What existing evidence does suggest is that a battery of clinical tests is more effective for assessing this region (thigh thrust, Gaenslen’s, compression and dorsal sacral ligament palpation come to mind). Then, how we discuss our findings with patients is also really important – educate them without scaring or overwhelming them (this is a challenge with any clinical condition!). We must balance the ideas of tissue sensitivity and movement issues (whether we feel the area is too stiff or too mobile) – how we do so can really impact the patient and that is one of the challenges of clinical practice. With all of this said, let me be clear – employing SMT/manual therapy to the lumbopelvic region, addressing hip function etc. in combination with exercise and movement is not a bad idea. These authors have appropriately challenged us, as evidence-based clinicians, to reframe how we think about and teach assessment and diagnosis in this area, as well as how we communicate our treatment approach to this region.

Study Methods:

These authors presented a narrative review, discussing the relevant diagnostic, pathophysiological and treatment considerations regarding sacroiliac joint pain. As such, no formal study methods were included.

Study Strengths / Weaknesses:

Strengths:
  • This is a clinically-relevant, yet controversial topic that deserves discussion.
  • This paper contained valuable diagnostic information based on the most current evidence.
Weaknesses:
  • As a narrative review, it did not provide any data nor pooled data analysis.
  • Some supporting citations may be considered out of date. More relevant citations would be helpful in future updates.

Additional References:

  1. Vos T, Abajobir AA, Abate KH, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the global burden of disease study 2016. Lancet 2018; 390: 1211–1259.
  2. Maigne J, Planchon C. Sacroiliac joint pain after lumbar fusion. A study with anesthetic blocks. Eur Spine J 2005;14: 654–658.
  3. Katz V, Schofferman J, Reynolds J. The sacroiliac joint: a potential cause of pain after lumbar fusion to the sacrum. J Spinal Disord Tech 2003; 16: 96–99.
  4. Liliang P-C, Lu K, Liang C-L, Tsai Y-D, Wang K-W, Chen H-J. Sacroiliac joint pain after lumbar and lumbosacral fusion: findings using dual sacroiliac joint blocks. Pain Med 2011; 12: 565–570.
  5. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995; 20: 31–37.
  6. Chou LH, Slipman CW, Bhagia SM, et al. Inciting events initiating injection-proven sacroiliac joint syndrome. Pain Med 2004; 5: 26–32.
  7. Visser LH, Nijssen PGN, Tijssen CC, van Middendorp JJ, Schieving J. Sciatica-like symptoms and the sacroiliac joint: clinical features and differential diagnosis. Eur Spine J 2013; 22: 1657–1664.
  8. Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther 2008; 16: 142–152.
  9. Beales D, O’Sullivan P. A person-centered biopsychosocial approach to assessment and management of pelvic girdle pain. In: Jull G, Moore A, Falla D, Lewis J, McCarthy C, Sterling M, eds. Grieve’s Modern Musculoskeletal Physiotherapy. 4th ed. Elsevier; 2015: 488–495.
  10. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine 1989; 14: 162–165.
  11. Goode A, Hegedus EJ, Sizer P, Brismee J-M, Linberg A, Cook CE. Three-dimensional movements of the sacroiliac joint: a systematic review of the literature and assessment of clinical utility. J Man Manip Ther 2008; 16: 25–38.
  12. McGrath MC. Palpation of the sacroiliac joint: an anatomical and sensory challenge. Int J Osteopath Med 2006; 9: 103–107.
  13. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine 2000; 25: 214–217.
  14. Palsson TS, Hirata RP, Graven-Nielsen T. Experimental pelvic pain impairs the performance during the active straight leg raise test and causes excessive muscle stabilization. Clin J Pain 2015; 31: 642–651.
  15. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159–174.
  16. Bagg MK, McAuley JH, Moseley GL, Wand BM. Recent data from radiofrequency denervation trials further emphasise that treating nociception is not the same as treating pain. Br J Sports Med 2019; 53: 841–842.
  17. Arendt-Nielsen L, Graven-Nielsen T, Svarrer H, Svensson P. The influence of low back pain on muscle activity and coordination during gait: a clinical and experimental study. Pain 1996; 64: 231–240.
  18. Karayannis NV, Smeets RJ, van den Hoorn W, Hodges PW. Fear of movement is related to trunk stiffness in low back pain. PloS One 2013; 8: e67779.
  19. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee: a Cochrane systematic review. Br J Sports Med 2015; 49: 1554–1557.
  20. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev 2014: CD007912. https://doi.org/10.1002/14651858.CD007912.pub2.