Sacroiliitis
Original Editors - Charlotte Fastenaekels
Top Contributors - Annelies Noppe, Lucinda hampton, Kim Jackson, Stéphanie Dartevelle, Charlotte Fastenaekels, Matthias Bossche, Admin, Laura Ritchie, Sally Ngo, WikiSysop, 127.0.0.1, Rachael Lowe, Kai A. Sigel, Claire Knott, Wanda van Niekerk, Nicole Hills and Shreya Pavaskar
Search Strategy[edit | edit source]
The vast majority of information regarding my Physiopedia subject has come from PubMed. However, this wasn’t the only search method I’ve used. Web of Science and the public library were too a reliable source of information. My preference however goes out to PubMed, since you can work with different sets of search parameters which can help you to really target your search. For example, I’ve checked on parameters such as ‘reviews’ and ‘rct’s’ in the function ‘Limits’. This allowed me to select articles that were fully accessible. I’ve also made use of ‘Mesh’-terms. The subject I’ve chosen, namely ‘sacroiliitis’, is one in which you are not flooded by with the amount information (articles, books). So I had to point out some key terms in which I could build around my search. These key words were: sacroiliac joint, sacroiliac pain, sacroiliac joint dysfunctions, etc… The use of these terms allowed me to select eight articles which helped me to gain and lift out interesting, relevant and more so useful information about my subject.
Definition/Description[edit | edit source]
Sacroiliitis is an inflammation of one or both sacroiliac joints, which can lead to inflammatory low back pain however some patients remain asymptomatic. Sacroiliitis is linked to spondyloartropathies (a group of diseases) and it can be defined as a sacroiliac joint dysfunction, which seems to be in a state of altered mechanics. Pain caused by sacroiliitis can be related to either too much or not enough motion in the SI joint. That makes it less a pathological diagnosis and more a patho-mechanical diagnosis.[1][2] (level 1A and 2 B)
Clinically Relevant Anatomy[edit | edit source]
The sacroiliac joint (SIJ) forms the lowest segment of the spinal axis and distributes the forces coming from the upper body. Movements occurring in the sacroiliac joint play an important role in distributing forces and is influenced by the movement of the lumbosacral spine.13 (level 1A)
The sacroiliac joint has been implicated as the primary source of pain in 10% to 27% of patients with mechanical low back pain below L5, utilizing controlled, comparative local anesthetic blocks.
The sacroiliac joint is a true diarthrodial joint, the articular surfaces are separated by a joint space containing synovial fluid and enveloped by a fibrous capsule. It has unique characteristics not typically found in other diarthrodial joints. The sacroiliac joint consists of fibrocartilage in addition to hyaline cartilage and is characterized by discontinuity of the posterior capsule, with ridges and depressions that minimize movement and enhance stability. The sacroiliac joint has been described as a synovial joint only in the anterior portion in contrast to the posterior portion. The posterior connection is a syndesmosis, consisting of the ligament sacroiliaca, the gluteus medius and minimus, and the piriformis muscles.
The sacraoiliac joint is well provided with nociceptor and proprioceptors. The innervation pattern is the subject of considerable discussions. The sacral plexus innervates the anterior portion whereas the spinal nerves innervate the posterior portion. It has been proposed that the predominant innervation is by L4 to S1 nerve roots with some contribution from the superior gluteal nerve.14 (level 1A)
Epidemiology /Etiology[edit | edit source]
Spondyloartropathies: Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, arthritis of chronic inflammatory bowel disease and undifferentiated spondyloarthropathy. Symmetrical sacroiliitis is found in more than 90% of ankylosing spondylitis and 2/3 in reactive arthritis and psoriatic arthritis. It is less severe and more likely to be unilateral and asymmetrical in reactive arthritis, psoriatic arthritis, arthritis of chronic inflammatory bowel disease and undifferentiated spondyloarthropathy. Also traumatic injuries, infections and inflammatory conditions like rheumatoid arthritis, degenerative joint diseases, metabolic conditions like gout and even pregnancy, sacroiliitis can cause sacroiliitis.[1][3] (level 1A and 1C)
Characteristics/Clinical Presentation[edit | edit source]
Pain can be felt in the buttocks, lower lumbar and postero-lateral thigh region. It may also extend down to one or both legs; predominantly unilateral pain inferior to the PSIS and groin pain is experienced (might not be a sensitive indicator). In some cases there are aggravating or improving factors but with no diagnostic value. Sometimes decreased or increased range of motion is observed, but this too may not be a useful predictor.[1][3] (level 1A and 1C)
Differential Diagnosis[edit | edit source]
Seronegative spondyloarthopathies with sacroiliitis vs osteitis condensans ilii16 (level 1B)
The differential diagnosis of sacroiliitis on plain film17
- Ankylosing spondylitis
- Inflammatory bowel disease
- Hyperparathyroidism – tends to cause sacroiliac joint widening due to bone reabsorption
- Rheumatoid
- Gout
- Psoriatic arthropathy
- Reiter’s syndrome
- Osteoarthritis (OA)
- Infection – TB
There is even another way to differentiate sacroiliitis18
- Unilateral septic sacroiliitis
- Unilateral seronegative sacroiliitis
- Ewing’s sarcoma and lymphoma
Low grade radiographic sacroiliitis is a prognostic factor for ankylosing spondylitis in patients with undifferentiated spondyloarthritides (SpA).19 (level 2A)
Diagnostic Procedures[edit | edit source]
add text here related to medical diagnostic procedures
Outcome Measures[edit | edit source]
add links to outcome measures here (also see Outcome Measures Database)
Examination[edit | edit source]
Some individual pain provocation tests show sufficient inter-rater reliability. The following tests seem to have sufficient diagnostic accuracy:(Patrick-) FABER = Flexion, ABduction, External Rotation test , thigh thrust test*, Gaenslen test, Mennell’s test**, sacral thrust test***, compression test**** and distraction test. [2][3] [4] [5]
A combination of these tests give a better accuracy to differentiate sacroiliitis from low back pain. We can use a combination of 3 tests (ex. Gaenslen, Mennell, and thigh thrust tests) or 5 tests (ex. Gaenslen, Patrick-Faber, Mennell, thigh thrust, and sacral thrust tests), which give favorable results if respectively 2 or 4 tests are positive. A positive test means it provokes pain. [4] [6] [5]
A complete physical examination with an excellent accuracy to diagnose sacroiliac joint related pain should involve a cluster of sacroiliac joint tests and a McKenzie evaluation. [2] [3]
MRI and CT are also uses in the early stage to diagnose sacroiliitis. [4]
Thigh thrust test*:
subject: Supine, contralateral leg extended
examiner: Stands next to the subject
technique: The examiner flexes the affected leg (contralateral), approximately hip at 90°, knees remain relaxed and graded force pressure is applied through the long axis of the femur (=posterior shearing stress), one hand underneath the sacrum, the other one around the knee to give pressure
Mennell’s test**:
Subject: Side-lying position, affected side is down, back towards the edge of the table. Affected (table contacting) side hip flexed to the abdomen, knee is flexed
Examiner: Stands behind the patient
Technique: Examiner puts one hand over the ipsilateral gluteal region and iliac crest, other hand grasps the semi flexed ipsilateral knee and lightly forces the leg to extension
Sacral thrust test***:
Subject: Prone, legs relaxed, semi abducted
Examiner: Stands behind the subject, close to the feet at the lower edge of the table
Technique: Puts hands over the sacrum applies anterior pressure to the sacrum
Compression test****:
Subject: Compression Side-lying position, affected side is up, close to the side of the table and back towards the edge of the table. Hips
flexed approximately 45°, knees are flexed approximately 90° degrees
Examiner: Stands behind the subject
Technique: Examiner’s Folded hands over the anterior edge of the iliac crest and applies downward pressure [4]
The sacroiliac joint can be examined by Special tests.
Medical Management
[edit | edit source]
add text here
Physical Therapy Management
[edit | edit source]
Cryotherapy is useful in the acute phase. Once the pain is under control the patient can start with specific stabilizing exercises, which will help reduce the pain. Specific pelvic stabilizing exercises, postural education and training muscles of the trunk, but also the lower extremities, can be useful in patients with sacroiliac joint dysfunctions. The transversus abdominis, lumbar multifidi muscles and pelvic floor are the muscles that will need training. Teaching your patient to activate and control these muscles together with relaxed breathing is an efficient exercise. We can do this exercise in many different positions (sitting, standing, four-point kneeling, supine and prone) and when the patient has local segmental control he can train these muscles by stabilizing the low back and pelvis during activities of daily living, work or even sports. [7]Training of the muscle transversus abdominis independently of other abdominal muscles is effective to provide more stiffness in the sacroiliac joints and prevent laxity, which can cause low back pain. [8]In an early stage we can use a pelvic belt or girdle during exercise and activities of daily living. It stabilizes and reduces the pain in the sacroiliac joint.[7] If the patient has a leg length discrepancy or an altered gait mechanism, the most reliable treatment would be correcting the underlying defect.[9][10][11][12]
Key Research[edit | edit source]
add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
Resources
[edit | edit source]
add appropriate resources here
Clinical Bottom Line[edit | edit source]
add text here
Recent Related Research (from Pubmed)[edit | edit source]
see tutorial on Adding PubMed Feed
Extension:RSS -- Error: Not a valid URL: Feed goes here!!|charset=UTF-8|short|max=10
References[edit | edit source]
see adding references tutorial.
- ↑ 1.0 1.1 1.2 J. Braun, J. Sieper and M. Bollow, Review Article Imaging of Sacroiliitis, Section of Rheumatology, Department of Nephrology and Endocrinology, UK Benjamin Franklin, Free University, Berlin; Department of Radiology, UK Charite´ , Humboldt University, Berlin, Germany,©2000 Clinical Rheumatology (A1)
- ↑ 2.0 2.1 2.2 M. Monticone, A. Barbarino, C. Testi, S. Arzano, A. Moschi, S. Negrini, Evaluation of the Presence of Sacroiliac Joint Region DysfunctionfckLRUsing a Combination of Tests: A Multicenter Intertester Reliability Study, Physical Therapy . Volume 82 . Number 8 . August 2002 (B)
- ↑ 3.0 3.1 3.2 3.3 Peter Huijbregts, PT, MSc, MHSc, DPT, OCS, MTC, FAAOMPT, FCAMT fckLRSacroiliac joint dysfunction: Evidence-based diagnosis,fckLRAssistant Online Professor, University of St. Augustine for Health Sciences, St. Augustine, FL, USA, Consultant, Shelbourne Physiotherapy Clinic, Victoria, BC, Canada,Rehabilitacja Medyczna (Vol. 8, No. 1, 2004)(C)
- ↑ 4.0 4.1 4.2 4.3 Salih Ozgocmen, Zulkif Bozgeyik, Mehtap Kalcik, Arafe Yildirim. The value of sacroiliac pain provocation tests in early active sacroiliitis. Clinical Rheumatology 2008; 27:1275–1282 (B)
- ↑ 5.0 5.1 Kent Jason Stuber, BSc, DC. Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. J Can Chiropr Assoc 2007; 51(1) (A1)
- ↑ Dirk J. Kokmeyer, Peter van der Wurff, Geert Aufdemkampe, and Theresa C. M. Fickenscherd. The Reliability of Multitest Regimens With Sacroiliac Pain Provocation Tests. Journal of Manipulative and Physiological Therapeutics 2002; Vol.25, No.1 (B)
- ↑ 7.0 7.1 Daniel L Riddle, Janet K Freburger, Symptomatic efficacy of stabilizing treatment versus laser therapy for sub-acute low back pain with positive tests for sacroiliac dysfunction: a randomized clinical controlled trial with 1 year follow-up, North American Orthopaedic Rehabilitation Research Network*, EUR MED PHYS 2004 (B)
- ↑ Carolyn A. Richardson, Chris J. Snijders, Julie A. Hides, Le´onie Damen, Martijn S. Pas, and Joop Storm. The Relation Between the Transversus Abdominis Muscles, Sacroiliac Joint Mechanics, and Low Back Pain. SPINE 2002; Vol. 27, No.4, p 399–405 (B)
- ↑ J. J. M. PEL, C. W. SPOOR, A. L. POOL-GOUDZWAARD, G. A. HOEK VAN DIJKE, and C. J. SNIJDERS, Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces, Department of Biomedical Physics and Technology, Erasmus MC, PO Box 2040, Rotterdam 3000 CA, The Netherlands, Annals of Biomedical Engineering, Vol. 36, No. 3, March 2008 (© 2008) pp. 415–424 (C)
- ↑ Steven P. Cohen, REVIEW ARTICLE Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment, MD, Pain Management Divisions, Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD and Walter Reed Army Medical Center, Washington, DC, ©2005 by the International Anesthesia Research Society (A1)
- ↑ Cusi, M.F., Paradigm for assessment and treatment of SIJ mechanical dysfunction, Journal of Bodywork & Movement Therapies (2010), doi:10.1016/j.jbmt.2009.12.004fckLR©2009 Elsevier Ltd. All rights reserved. (C)
- ↑ Stacy L. Forst, PA-C, Michael T. Wheeler, DO, Joseph D. Fortin, DO, and Joel A. Vilensky, PhD, A Focused Review The Sacroiliac Joint: fckLRAnatomy, Physiology and Clinical Significance, Pain Physician. 2006;9:61-68, ISSN 1533-3159 (A1)
