Pain in the sacroiliac joint.

Sacroiliac joint pain often occurs when lifting heavy objects in an awkward position, or when there is tension in the joint, supporting ligaments, and soft tissues. The sacroiliac joint is also susceptible to the development of arthritis from various diseases that damage the articular cartilage. Osteoarthritis is a common form of arthritis that results in sacroiliac joint pain: rheumatoid and post-traumatic arthritis are also common causes of pain. Less common causes include ankylosing spondylitis, infections, and Lyme disease. Collagen diseases are more likely to be polyarthropathies than monoarthropathies limited to the sacroiliac joint, although sacroiliac joint pain from ankylosing spondylitis responds extremely well to the intra-articular injections described below. Occasionally, patients present with iatrogenic sacroiliac joint dysfunction caused by traumatic removal of a bone graft.

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Symptoms of Sacroiliac Joint Pain

Most patients with sacroiliac joint pain complain of pain around the joint and in the upper leg, radiating to the buttock and down the back of the leg; the pain never extends below the knee. Motion increases the pain, while rest and warmth provide relief. The pain is constant and may interfere with sleep. The affected sacroiliac joint is tender to palpation. Patients often spare the affected leg and bend toward the unaffected side. There is often lumbar axial muscle spasm, which limits lumbar motion in the extended position and improves the necessary relaxation of the biceps femoris in the sitting position. Patients with sacroiliac joint pain have a positive pelvic rocking test. For this test, the examiner places his hands on the iliac crests and thumbs on the anterior superior iliac spines and then forcibly brings the pelvic wings together toward the midline. A positive test is characterized by the appearance of pain in the sacroiliac joint area.

Clinical Features of Sacroiliac Joint Pain

Sacroiliac joint lesions can be differentiated from other lumbar spine injuries by asking the patient to bend forward while sitting. Patients with sacroiliac pain do this with relative ease due to the relaxation of the biceps femoris in this position. In contrast, patients with low back pain experience an increase in symptoms when bending forward while sitting.

The described injection is quite effective in treating sacroiliac joint pain. Coexisting bursitis and tendinitis may increase sacroiliac joint pain, which requires additional treatment with more local injections of local anesthetics and methylprednisolone.

The sacroiliac joint injection is performed in the supine position, the skin over the joint is treated with an antiseptic solution. A sterile syringe with 4 ml of 0.25% preservative-free bupivacaine and 40 mg of methylprednisolone is connected to the needle in a sterile manner. The posterior superior iliac spine is found. At this point, the needle is carefully advanced through the skin and subcutaneous tissues at an angle of 45 degrees in the direction of the affected joint. If the bone is hit, the needle is withdrawn into the subcutaneous tissues and directed again higher and slightly laterally. After penetration of the joint, the contents of the syringe are carefully injected. There should be slight resistance to the injection. If significant resistance is observed, the needle has probably hit a ligament and it should be advanced slightly into the joint area until the injection comes without significant resistance. The needle is then removed, a sterile bandage and cold are applied to the injection site.

Physical therapy, including heat treatments and light exercise, should be started a few days after the injection. Avoid excessive physical activity, as it will worsen symptoms.

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Survey

Plain radiography is indicated in all patients with sacroiliac joint pain. Since the sacrum is susceptible to traumatic fractures and the development of both primary and secondary tumors, MRI of the distal lumbar spine and sacrum is indicated if the cause of pain is unclear. In such patients, radionuclide bone scans (scintigraphy) may be performed to rule out tumors and incomplete fractures that may be missed with conventional radiography. Based on clinical manifestations, additional tests may include complete blood count, ESR, HLA B-27 antigen, antinuclear antibodies, and blood biochemistry.

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Differential diagnosis

Pain originating from the sacroiliac joint can be mistaken for myogenic pain, lumbar bursitis, inflammatory arthritis, and lesions of the lumbar spinal cord, roots, plexus, and nerves.

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Treatment of Sacroiliac Joint Pain

Initial treatment of sacroiliac joint pain and dysfunction includes a combination of NSAIDs (eg, diclofenac or lornoxicam) and physical therapy. Local application of heat and cold may also be helpful. In patients who do not respond to these treatments, injection of local anesthetics and steroids is indicated as a next step.

Complications and diagnostic errors

The injection technique is safe with a good knowledge of anatomy. For example, if the needle is inserted laterally, it may damage the sciatic nerve. The main complication of intra-articular injection is infection, which is extremely rare if the rules of asepsis and universal precautions are strictly observed. The occurrence of ecchymosis and hematoma formation can be reduced by pressing the injection site immediately after it is performed. About 25% of patients complain of a transient increase in pain after intra-articular injection, they should be warned about this.

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