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'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;{{Matthias Van den Bossche}}  
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== Definition/Description  ==
== Introduction ==
[[File:Sacroiliac joint.png|thumb|Sacroiliac joint]]Sacroiliitis, is an inflammation of one or both sacroiliac (SI) joints, and a common cause of buttocks or [[Low Back Pain|lower back pain]]. Inflammation of the [[Sacroiliac Joint|sacroiliac joint]] may occur secondary to [[osteoarthritis]], pregnancy, [[Overview of Spondyloarthropathies|spondyloarthropathies]], and trauma.<ref name=":0" /><ref>Radiopedia Sacroiliitis Available:https://radiopaedia.org/articles/sacroiliitis (accessed 4.6.2022)</ref>
== Etiology ==
Various conditions result in the inflammation of the SI joint, leading to significant pain.
*[[Osteoarthritis]] can cause degeneration of the joint resulting in pathologic articulation and motion leading to this condition.
* Spondyloarthropathies can cause significant inflammation of the joint itself eg [[Ankylosing Spondylitis (Axial Spondyloarthritis)|Ankylosing spondylitis]], [[Reactive Arthritis|Reactive arthritis,]] [[Psoriatic Arthritis|psoriatic arthritis]], arthritis of chronic inflammatory bowel disease
*[[Low Back Pain and Pregnancy|Pregnancy]] is another cause of the inflammation due to the hormone relaxin leading to the relaxation, stretching, and possible widening of the SI joint(s). The increased weight of pregnancy also causes extra mechanical stress on the joint, leading to further wear and tear.
* Trauma can cause direct or indirect stress and damage to the SI joint.
* Pyogenic sacroiliitis is the most frequently reported cause of acute sacroiliitis.
* Pain can originate from the synovial joint but can also originate from the posterior sacral ligaments<ref name=":0">Buchanan BK, Varacallo M. [https://www.ncbi.nlm.nih.gov/books/NBK448141/ Sacroiliitis]. InStatPearls [Internet] 2019 Feb 15. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK448141/ (last accessed 13.6.2020)</ref>


[[Image:Sacroiliac joint.png|right|300px]]  
== Epidemiology ==
[[File:Active-sacroiliitis.png|thumb|Bone scan: Active-sacroiliitis]]Reports on the prevalence of sacroiliac pain vary widely.
* Some studies report the prevalence as 10% to 25% of those with lower back pain.
* In those with a confirmed diagnosis, the presentation of pain was ipsilateral buttock (94% cases) and midline lower lumbar area (74%).
* Up to 50% of cases have radiation to the lower extremity: 6% to the upper lumbar area, 4% percent to the groin, and 2% percent to the lower abdomen<ref name=":0" />
* 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.<ref name="Clinical Rheumatology">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)</ref><ref name="Medyczna">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)</ref>&nbsp;
* The hospital prevalence of sacroiliac diseases is 0,55%, the female sex predominates( 82,35%) and the mean age of 25,58 years. Gyneco-obstetric events are the predominant risk factors (47,05%). The etiologie found are bacterial arthritis (82,3%) mainly pyogenic (70,58%), osteoarthritis(11,7%) and ankylosing spondylitis (5,9%) .


Sacroiliitis is an inflammation of one or both [[Sacroiliac joint|sacroiliac joints]], which can lead to inflammatory low back pain, although some patients remain asymptomatic. Sacroiliitis is linked to [[Spondyloarthropathies|spondyloarthropathies]] (a group of diseases) and it can be defined as a sacroiliac joint dysfunction, which seems to be in a state of altered mechanics. Sacroiliitis is a hallmark of ankylosing spondylitis and may also be seen in the course of other rheumatic and non-rheumatic disorders, such as psoriatic arthropathy, familial Mediterranean fever, Bechet's disease, hyperparathyroidism and others.&nbsp;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.<ref name="Clinical Rheumatology">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)</ref><ref name="Physical Therapy">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)</ref>&nbsp;<ref>38. Solmaz D, Akar S, Soysal O, Akkoc Y, Can G, Gerdan V, Birlik M, Onen F, Akkoc N (2014) Performance of different criteria sets for inflammatory back pain in patients with axial spondyloarthritis with and without radiographic sacroiliitis. Clin Rheumatol 33(10):1475–9 (Level 1A)</ref>'''(level 1A and 2 B)'''
== Clinical Presentation ==
[[File:SI pain.jpg|thumb|Pregnancy can cause sacroiliitis]]
Symptoms of sacroiliitis can vary. People with sacroiliitis commonly present with ipsilateral or bilateral buttock and/or midline lower lumbar area pain. Up to 50% may have pain radiating to the lower extremity.  


== Clinically Relevant Anatomy  ==
Sacroiliitis pain can be aggravated by:


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.<sup><ref>Stefan Endres and Esther Ludwig (2013) Outcome of distraction interference arthrodesis of the sacroiliac joint for sacroiliac arthritis. Indian J Orthop. 2013 Sep-Oct; 47(5): 437–442 (level 1A)</ref></sup>&nbsp;'''(level 1A)'''<br>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.
* Prolonged standing
* Bearing more weight on one leg than the other
* Stair climbing
* Running
* Taking large strides<ref name=":1">Mayo Clinic Sacroiliitis Available:https://www.mayoclinic.org/diseases-conditions/sacroiliitis/symptoms-causes/syc-20350747 (accessed 4.6.2022)</ref>


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.<br>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.<sup></sup><ref>Thomas T. Simopoulos, MD1, Laxmaiah Manchikanti, MD2, Vijay Singh, MD3, Sanjeeva Gupta, MD4, Haroon Hameed, MD5, Sudhir Diwan, MD6, and Steven P. Cohen, MD7A (2012) Systematic Evaluation of Prevalence and Diagnostic Accuracy of Sacroiliac Joint Interventions. Pain Physician 2012; 15:E305-E344 (level 1A)</ref>'''(level 1A)&nbsp;'''It has been variously described that the sacroiliac joint receives its innervation from the ventral rami of L4 and L5, the superior gluteal nerve, and the dorsal rami of L5, S1 and S2 or that it is almost exclusively derived from the sacral dorsal rami. (Level 1A)&nbsp;<ref>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 (level 1A)</ref>'''<br>'''<br><br>
== Diagnosis ==
A medical history will be taken, including previous inflammatory disorders. Other tests include:


== Epidemiology /Etiology  ==
# Physical exam, movement tests - Spine is examined for proper alignment and rotation, and various physical movement tests are performed (see physio section below).  
 
# Blood tests - looking for signs of inflammation.
[[Spondyloarthropathies|Spondyloartropathies]]: [[Ankylosing Spondylitis|Ankylosing spondylitis]], [[Reactive Arthritis|reactive arthritis]], [[Psoriatic 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.<ref name="Clinical Rheumatology" /><ref name="Medyczna">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)</ref>&nbsp;'''(level 1A and 1C)'''
# Imaging tests - X-rays, CT scans, and/or MRI scans may be ordered.
 
# Steroid injection - An injection of steroids into the sacroiliac joint is both a diagnostic test (if it relieves pain) and a treatment<ref name=":1" />
 
The hospital prevalence of sacroiliac diseases is 0,55%, the female sex predominates( 82,35%) and the mean age of 25,58 years. Gyneco-obstetric events are the predominant risk factors (47,05%). The etiologie found are bacterial arthritis (82,3%) mainly pyogenic (70,58%), osteoarthritis(11,7%) and ankylosing spondylitis (5,9%) . (Level 2B)
 
== Characteristics/Clinical Presentation  ==
 
Patients report low back pain (below L5), pain in the buttocks and/or pelvis and postero-lateral on the thigh, which may extend down to one or both legs. The pain mostly occurs unilateral, inferior to the PSIS and above the knee with possible numbness, tingling and weakness. Pain may also radiate to the hip and groin region. Patients may report intolerance with lying or sitting and increasing pain while climbing stairs or hills. They experience poor sleep habits and unilateral giving way or buckling. Pain also occurs with position changes or transitional motions (i.e., sit to stand, supine to sit).&nbsp;<ref>Szadek et al. - Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. The Journal of Pain. 2009: 10:354-‐368.fckLRfckLR== Differential Diagnosis  ==fckLRfckLRSeronegative spondyloarthopathies with sacroiliitis vs osteitis condensans ilii&amp;lt;sup&amp;gt;&amp;lt;ref&amp;gt;Olivieri I., Gemignani G., Camerini E., Semeria R., Christou C., Giustarini S., Pasero G. Differential diagnosis between osteitis condensans ilii and sacroiliitis. J. Rheumatol. 1990; 17(11): 1504-12. (level 1B)</ref>
 
 
 
'''<u></u>'''<u>'''Differential Diagnosis:'''</u>
 
The diagnosis of acute sacroiliitis is often challenging because of both the relative rarity of this presentation and diverse character of acute sacroiliac pain, frequently mimicking other, more prevalent disorders <br>New-onset intense pain is a major clinical manifestation of acute sacroiliitis, pointing to the diagnosis. However, the character of acute SIJ pain may be variable in different individuals without a specific diagnostic pattern. Thus, the diagnosis of acute sacroiliitis is frequently overlooked at presentation. While the classic distribution of SIJ pain involves the ipsilateral buttock and paramidline lower lumbar area (in 94 and 72 %, respectively), its radiation to the groin (14 %), lower abdomen (2 %), upper lumbar area (6 %), and/or lower extremity (up to 50 %)—including thigh and trochanteric pain, lower leg pain, and even foot pain—may lead to confusion, suggesting alternative diagnoses, such as intervertebral disk disruption, hip joint disease, or even an abdominal event. <ref>40. Slipman CW, Whyte WS 2nd, Chow DW, Chou L, Lenrow D, Ellen M (2001) Sacroiliac joint syndrome. Pain Physician 4(2):143–52 (Level 1B)</ref>&nbsp;<ref>Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y (2006) Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain. Joint Bone Spine 73(1):17–23 (Level 1B)</ref>&nbsp;(Level 1B)<br><br>The differential diagnosis of sacroiliitis on plain film<sup><ref>Shahid Hussain, Sherif A. A. Latif, Adrian D. Hall., Rapid Review of Radiology, Manson Publishing, 2010. (BOOK)</ref></sup><br>- [[Ankylosing Spondylitis|Ankylosing spondylitis]]<br>- [[Irritable Bowel Syndrome|Inflammatory bowel disease]]<br>- Hyperparathyroidism – tends to cause sacroiliac joint widening due to bone reabsorption<br>- [[Rheumatoid Arthritis|Rheumatoid arthritis]]<br>- [[Gout|Gout]]<br>- [[Psoriatic Arthritis|Psoriatic arthropathy]]<br>- [[Reiter's Syndrome|Reiter’s syndrome]]<br>- Osteoarthritis (OA)<br>- Infection – [[Tuberculosis|TB ]]
 
There is even another way to differentiate sacroiliitis<sup><ref>James M. Provenzale, Rendon C. Nelson, Radiology Case Review : Imaging, Differential Diagnosis and Discussion, Lippincott Williams &amp; Wilkins, 1998. (BOOK)</ref></sup><br>- Unilateral septic sacroiliitis<br>- Unilateral seronegative sacroiliitis<br>- Ewing’s sarcoma and lymphoma
 
Low grade radiographic sacroiliitis is a prognostic factor for ankylosing spondylitis in patients with undifferentiated spondyloarthritides (SpA).<sup><ref>G. Huerta-Sil et al., Low grade radiographic sacroiliitis as prognostic factor in patients with undifferentiated spondyloarthritis fulfilling diagnostic criteria for ankylosing spondylitis troughout follow up, Ann Rheum, 2006, 642-646 (level 2A)</ref></sup> '''(level 2A) '''<br><br>
 
== Diagnostic Procedures  ==
 
The diagnosis of sacroiliitis in clinical practice is based mainly on imaging techniques. It can be difficult to diagnose sacroiliitis in the early and acute stages because conventional radiographs may be normal, although other techniques, to be discussed, might detect sacroiliac inflammation. The radiographic images of the sacroiliac joint changes in advanced disease, sclerosis and may cause erosions. However, this might no longer be visible on the radiograph because of ankylosis. <br>Inflammatory back pain (IBP) can be a result of sacroiliitis. Because IBP is not a highly specific indicator of sacroiliitis, there is a need for valuable imaging techniques.
 
Techniques currently used to diagnose sacroiliitis:<br>- Radiography<br>- Scintigraphy<br>- Conventional tomography<br>- Computed tomography<br>- Magnetic resonance imaging
 
Scintigraphy lacks specificity. Computed tomography (CT) is a very good method to demonstrate already established bony changes and magnetic resonance imaging (MRI) has the ability to localize edema and differentiate degrees of inflammation. The MRI gives a good visualization of the complex anatomy of the sacroiliac joint. This testing can prove a possible spread to muscles as it occurs in septic sacroiliitis, an important differential diagnosis.<sup><ref>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 (level 1A)</ref></sup> '''(level 1A)'''
 
Devauchelle-Pensec et al compared computed tomography scanning and radiographs for the diagnosis of sacroiliitis. The conclusion of this study was that definite sacroiliitis was underestimated by radiography, as compared to CT scanning.<sup><ref>20. Valérie Devauchelle-Pensec et al (2012) Computed tomography scanning facilitates the diagnosis of sacroiliitis in patients with suspected spondylarthritis: results of a prospective multicenter French cohort study. Arthritis Rheum. 2012 May;64(5):1412-9. doi: 10.1002/art.33466 (Level 2B)</ref></sup> '''(level 2B) '''<br> <br>Blum et al determined the specificity and sensitivity for the diagnosis of active sacroiliitis, for each imaging method (plain radiography, scintigraphy, and contrast enhanced MRI). They used a reference standard, based on the clinical symptoms of inflammatory low back pain with or without laboratory signs, and clinical and radiographic findings. They performed a follow up during 1.5-2.5 years to confirm diagnosis. According to the results, MRI was most sensitive for the detection and confirmation of active sacroiliitis (95%) and superior to quantitative SI scintigraphy (48%) or conventional radiography (19%). MRI also had a higher specificity (100%) than scintigraphy (97%) or plain radiography (47%) for the assessment of inflammatory signs. There were persistent pathological signal intensities in the subchondral bone area despite clinically successful anti-inflammatory drug therapy, at repeat MRI testing after 2-30 months.<ref>Blum U, Buitrago-Tellez C, Mundinger A, Krause T, Laubenberger J, Vaith P, Peter HH, Langer M (1996) Magnetic resonance imaging (MRI) for detection of active sacroiliitis--a prospective study comparing conventional radiography, scintigraphy, and contrast enhanced MRI. The Journal of Rheumatology [1996, 23(12):2107-2115]  (Level 2B)</ref><sup></sup> '''(level 2B)&nbsp;)''' It’s also possible to differentiate the diagnosis between infection and spondyloarthritis using the MRI features of bone lesions, soft-tissue lesions and joint space enhancement in unilateral sacroiliitis. Among various findings, periarticular muscle edema was the single most important predictor of infectious sacroiliitis. <ref>Y. Kang et al. Unilateral sacroiliitis: Differential Diagnosis Between infectious Sacroiliitis and spondyloarthritis Based on MRI findings. AJR AM J ROENTGENOL 2015 (level 2B)</ref>(Level 2B)<br>Sacroiliitis of seronegative spondyloarthropathy may sometimes show on pelvis plain films findings indistinguishable from those of osteitis condensans ilii. Computed tomography (CT) can differentiate earlier than plain radiography. There are criteria proposed by the European Spondlylarthropathy Study Group (EESG) that you can use to differentiate the two conditions. There is proof that the criteria are useful. It is right to differentiate clinically between the two diseases.<br><br>


== Outcome Measures  ==
== Outcome Measures  ==
 
* [[Oswestry Disability Index|Oswestry Disability Index]] (ODI) is most effective for persistent, severe disability
Outcome measures such as the [[Oswestry Disability Index|Oswestry Disability Index]] (ODI) is most effective for persistent, severe disability, while the Roland-Morris is more appropriate for mild to moderate disability.<sup><ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) (Level 1A)</ref> </sup>'''(level 1A)'''
* [[Roland‐Morris Disability Questionnaire|Roland-Morris]] is more appropriate for mild to moderate disability.<sup><ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) </ref>  
 
* Short-form [[McGill Pain Questionnaire|McGill Pain]] Questionnaire
<span>&nbsp;</span><br>The [[Short-form McGill Pain Questionnaire|Short-form McGill Pain Questionnaire]] (link) and The Assessment of Pain and Occupational Performance may also be appropriate. <br>
* The Assessment of Pain and Occupational Performance may also be appropriate.


== Examination  ==
== Examination  ==
[[File:FABERs test.jpg|right|frameless]]
Examine pelvis for proper alignment and rotation, inspection can reveal pelvic asymmetry. Measurement of the limbs can rule out a leg-length discrepancy. Inspect the spine for any abnormal curvatures or rotational abnormalities.


Some individual pain provocation tests show sufficient inter-rater reliability. The following tests seem to have sufficient diagnostic accuracy:[[FABER Test|(Patrick-) FABER = Flexion, ABduction, External Rotation test]] , [[Posterior pelvic pain provocation test|thigh thrust test]]*, [[Gaenslen Test|Gaenslen test]], Mennell’s test**, [[Sacral Thrust Test|sacral thrust test]]***, c[[Sacroiliac Compression Test|ompression test]]**** and [[Distraction Test|distraction test]]. <ref name="Physical Therapy" /><ref name="Medyczna" />&nbsp;<ref name="Ozgocmen et al.">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)</ref>&nbsp;<ref name="Stuber et al.">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)</ref>
Special provocative tests can be very helpful in reproducing the patient’s pain:
 
<br>Combinations 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 respectively, if 2 or 4 tests are positive. A positive test means it provokes pain. <ref name="Ozgocmen et al." />&nbsp;<ref name="Kokmeyer et al.">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)</ref>&nbsp;<ref name="Stuber et al." />
 
<br>
 
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. <ref name="Physical Therapy" />&nbsp;<ref name="Medyczna" /><br>MRI and CT are also uses in the early stage to diagnose sacroiliitis. <ref name="Ozgocmen et al." />
 
<br>
 
[[Posterior pelvic pain provocation test (aka Thigh Thrust aka Posterior Shear)|Thigh thrust test*]]: <br>Subject: Supine, contralateral leg extended<br>Examiner: Stands next to the subject<br>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
 
<br>Mennell’s test**:<br>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<br>Examiner: Stands behind the patient<br>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
 
<br>[[Sacral Thrust Test|Sacral thrust test***]]:<br>Subject: Prone, legs relaxed, semi abducted<br>Examiner: Stands behind the subject, close to the feet at the lower edge of the table<br>Technique: Puts hands over the sacrum applies anterior pressure to the sacrum
 
<br>[[Sacroiliac Compression Test|Compression test****]]:<br>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<br>flexed approximately 45°, knees are flexed approximately 90° degrees<br>Examiner: Stands behind the subject <br>Technique: Examiner’s Folded hands over the anterior edge of the iliac crest and applies downward pressure <ref name="Ozgocmen et al." /><br>
 
 
 
[[Sacroiliac Distraction Test|Distraction test:]] <br>The SIJ (Sacroiliac joint) Distraction (Colloquially know as Gapping) test is used to add evidence, positive or negative, to the hypotheses of an SIJ sprain or dysfunction when used in the Laslett SIJ Cluster testing. This test stresses the anterior sacroiliac ligaments &nbsp;This test has also been described as the Transverse Anterior Stress Test or the Sacroiliac Joint Stress Test.
 
1. The patient lies supine and the examiner applies a vertically orientated, posteriorly directed force to both the anterior superior ilac spines (ASIS) (Cook and Hegedus 2013, Laslett et al 2008, Laslett et al 2005, Laslett et al 2003).
 
Note: Cook and Hegedus (2013) suggest applying a sustained force for 30 seconds before applying a repeated vigorous force in an attempt to reproduced the patient’s symptoms. However, Laslett (2008) does not suggest any timings or changes in force.<br>Because of the lack of standardisation in the technique it is quite feasible different therapists will practise this test different ways, giving rise to variability in response and lowering the inter-tester reliability (Laslett et al 2005, Levin et al 2005). No evidence to suggest either method is preferable (Levin et al 2005), therefore, more evidence needed.
 
2. The presumed effect is a DISTRACTION of the anterior aspect of the sacroiliac joint. (Laslett et al 2005, Laslett et al 2003)
 
3. A test is positive if it reproduces the patient's symptoms. This indicates SIJ dysfunction or a sprain of the anterior sacroiliac ligaments (Cook and Hegedus 2013, Cook et al 2007, Laslett 2008, Laslett et al 2005, Laslett et al 2003)
 
However, this test should be used in concordance within a SIJ testing cluster to ensure maximum reliability and validity when confirming hypotheses (Albert et al 2000, Kokmeyer et al 2002, Laslett 2008, Laslett et al 2005,Laslett et al 2003, Ozgocmen et al 2008, Robinson et al 2007).&nbsp;<ref>Laslett M, April CN, McDonald B, Young SB. Diagnosing Painful SI joints: A validation study of Mckenzie and SI provocation tests. Aust J Physiotherapy. 2003; 49:89-97.</ref><ref>Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of SI joint pain: validity of individual provocation test and composites of tests. Manual Therapy 2005; 10:207-218.</ref><ref>Cook C and Hegedus E., 2013. Orthopedic Physical Examination Tests: An Evidence Based Approach. 2nd ed. New Jersey: Pearson Education</ref>
 
 
 
The sacroiliac joint can be examined by [[Sacroiliac joint|Special tests]].


== Medical Management <br>  ==
# “Fortin finger sign”- reproduction of pain after applying a deep palpation with the four-hand fingers posteriorly at the patient's SI joint(s).
# [[FABER Test|FABER]] test- reproduction of pain after flexing the hip while also abducting and externally rotating the hip.
# [[Sacroiliac Distraction Test|Sacroiliac distraction test]]- reproduction of pain after applying pressure to the anterior superior iliac spine.
# [[Sacroiliac Compression Test|SacroIliac compression test]]- reproduction of pain after applying pressure downward on the superior aspect of the iliac crest.
# [[Gaenslen Test|Gaenslen]] test- reproduction of pain after having the patient flex the hip on the unaffected side and then dangle the affected leg off the examining table. Pressure is then directed downward on the leg to extend further the hip, which causes stress on the SI joint.
# Thigh thrust test- reproduction of pain after flexing the hip and applying a posterior shearing force to the SI joint.
# [[Sacral Thrust Test|Sacral thrust test]]- reproduction of pain with the patient prone and then applying an anterior pressure through the sacrum.


Reducing inflammation in the SI-joint and increasing the flexibility of the lumbosacral spine and SI areas are the main goals of treatment.&nbsp;NSAIDs (non-steroidal anti-inflammatory drugs) and anti-rheumatic drugs are the primary treatment for spondyloarthropathy. Global pain decreased significantly following treatment with naproxen (NSAID). Sulfasalazine is believed to reduce the erythrocyte sedimentation rate and morning stiffness. <ref>Cui et al. - Evaluation of treatments for sacroiliitis in spondyloarthropathy using the Spondyloarthritis Research Consortium Canada scoring system</ref>&nbsp;Research revealed that a continuous treatment with NSAID’s reduces radiographic progression in symptomatic patients with AS. <ref>Astrid Wanders et al., Nonsteroidal Antiinflammatory Drugs Reduce Radiographioc Progression in Patients With Ankylosing Spondylitis, Arthritis &amp; Rheumatism, Vol. 52, 2005, 1756;1765 (level 2A)</ref>&nbsp;(level 2A)
The likelihood of SI joint mediated pain increases as the number of positive-provocative tests increase<ref name=":0" />.


The patient must be referred to a physiotherapist. Suggest 3 to 4 days bed rest for severe acute cases. For persistent cases (2 to 4 weeks) with severe pain, a sacroiliac joint injection may be recommended to confirm the sacroiliac joint as the source of the pain and to introduce the anti-inflammatory medication directly into the joint. Advise 3 to 4 days of bed rest after the injection. Next it is recommended to continue with the restrictions and begin with flexion strengthening exercises after the pain and inflammation have been controlled. These exercises include side-bends, knee chest pulls and pelvic rocks.<sup><ref>N.A. Dunn et al., Quantitative sacroiliac scintiscanning : a sensitive and objective method for assessing efficacy of nonsteroidal, anti-inflammatory drugs in patients with sacroiliitis, Annals of the Rheumatic Diseases, 1984, 157-159 (level 1B)</ref></sup> '''(level 1B) '''<br>
== Management ==
Treatment depends on your signs and symptoms, as well as the cause of your sacroiliitis.


Therapeutic solutions include intra-atricular injections with short-term pain relief and surgical fusion, which appears ineffective. Radiofrequency of the joint capsule or lateral branches has been previously reported with variable successes. The majority of patients with chronic SI joint pain experienced a clinically relevant degree of pain relief and improved function following cooled radiofrequency of sacral lateral branches and dorsal ramus of L5 at 3-4 months follow-up. <ref>Kapura et al. - Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis: the first case-series.</ref>  
* Medications. Depending on the cause of your pain, the following may be recommended:
** Pain relievers. If over-the-counter pain medications don't provide enough relief stronger versions of these drugs may be ordered.
** Muscle relaxants. Medications such as cyclobenzaprine (Amrix, Fexmid) might help reduce the muscle spasms often associated with sacroiliitis.
** TNF inhibitors. Tumor necrosis factor (TNF) inhibitors [eg etanercept (Enbrel), adalimumab (Humira) and infliximab (Remicade)] often help relieve sacroiliitis that's associated with ankylosing spondylitis<ref name=":1" />.


<br>  
* Real-time image-guided intra-articular anesthetic/[[Therapeutic Corticosteroid Injection|steroid injections]] can be performed for diagnostic and therapeutic effect. If the condition persists (6 to 8 weeks) with no improvement of at least 50 percent, repeat corticosteroid injections. Subsequently begin strengthening exercises including sit-ups and weighted side bends. Start with general conditioning of the back and increase slowly to low-impact walking or swimming. Take up normal activities with proper care of the back.<ref>Kapura et al. - Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis: the first case-series.</ref>


If the condition persists (6 to 8 weeks) with no improvement of at least 50 percent, repeat corticosteroid injections. Subsequently begin strengthening exercises including sit-ups and weighted side bends. Start with general conditioning of the back and increase slowly to low-impact walking or swimming. Take up normal activities with proper care of the back.  
* If the previous treatments do not provide adequate relief, then some providers will consider radiofrequency ablation<ref name=":0" />.


<br><br>  
* Joint fusion. Although surgery is rarely used to treat sacroiliitis, fusing the two bones together with metal hardware can sometimes relieve sacroiliitis pain.<ref name=":1" />


== Physical Therapy Management <br>  ==
== Physical Therapy Management   ==
Physical therapy can be very helpful if the pain is due to hypermobility. Therapy can help to stabilize and strengthen lumbopelvic musculature. If the pain is due to immobility, then physical therapy can help increase mobilization of the SI joint. Depending on the diagnosis the following techniques may be used.


Reducing inflammation in the SI-joint and increasing the flexibility of the lumbosacral spine and SI areas are the main goals of treatment. Give advice on proper lifting techniques involving the knees. The patient should also avoid movements such as tilting, twisting and extremes of bending. Maintaining correct posture is necessary, therefore a lumbar support for the office chair and vehicle is advised.<sup><ref name="p2">Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) (Level 1A)</ref></sup> '''(level 1A)'''<br>
In the early treatment stages heat, cold or alternating cold with heat are effective in reducing pain.<sup><ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) </ref>&nbsp;'''&nbsp;'''


<br>  
SI Belt: In the early stage a pelvic belt or girdle during exercise and activities of daily living can be used. These SI belts provide compression and reduce SI mobility in hypermobile patients. The belt should be positioned posteriorly across the sacral base and anteriorly below the superior anterior iliac spines. This belt may also be used when this condition becomes chronic (10-12 weeks).<sup><ref>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</ref> <ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) </ref><ref>Cusi MF; Paradigm for assessment and treatment of SIJ mechanical dysfuntion.; J Bodyw Mov Ther.; 2010;14(2):152-161. </ref>


In the early treatment stages heat, cold or alternating cold with heat are effective in reducing pain.<sup><ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) (Level 1A)</ref>&nbsp;</sup>'''(level 1A)&nbsp;'''Cryotherapy can be used to control the inflammation and pain. This form of treatment can be applied by ice massage or the application of ice packs. Cryotherapy should be applied for no more than 20 minutes, with at least one hour between applications. Ice massages will usually require a shorter treatment time. Thermotherapy can also be used by applying hot packs for a maximum of 20 minutes. This form of therapy is used to control pain, increase circulation and to increase soft tissue extensibility. With the aim of reducing pain, conventional TENS (Transcutaneous electrical nerve stimulation) can also be applied.<sup><ref>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 (level 1B)</ref> <ref>Prather H.; Sacroiliac joint pain: practical management; Clin J Sport Med.; 2003;13(4):252-255. (level 1A)</ref></sup><ref>Cusi MF; Paradigm for assessment and treatment of SIJ mechanical dysfuntion.; J Bodyw Mov Ther.; 2010;14(2):152-161. (level 1A)</ref>'''(level 1B-1A- 1A)'''<br>  
Flexibility Exercises: Once the acute symptoms are under control, the patient can start with flexibility exercises and specific stabilizing exercises. To maintain SI and lower back flexibility, stretching exercises are principal. These exercises include side-bends, knee chest pulls, and pelvic-rocks with the aim of stretching the paraspinal muscles, the gluteus muscles and the SI joint. After hyperacute symptoms have resolved these kinds of exercises should be started. Each stretch is performed in sets of 20. These exercises should never surpass the patient’s level of mild discomfort.<sup><ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) </ref>


<br>  
Stabilisation exercises: Specific [[Core Stability|pelvic stabilising]] exercises, postural education and training muscles of the trunk and lower extremities, can be useful in patients with sacroiliac joint dysfunctions. See [[Core Strengthening|core strengthening]]<br>After rehabilitation, low-impact aerobic exercises such as light jogging and water aerobics are designated to prevent recurrence.<sup><ref>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 </ref> <ref>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 </ref><ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) </ref><ref>C.A. Richardson; Muscle control-pain control. What would you prescribe?; Manual therapy;1995;2-10 </ref><ref>J.J.M. Pel; Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces; Annals of biomedical engineering; 2008; 36(3): 415–424.</ref>  


In the early stage, we can also use a pelvic belt or girdle during exercise and activities of daily living. These SI belts provide compression and reduce SI mobility in hypermobile patients. The belt should be positioned posteriorly across the sacral base and anteriorly below the superior anterior iliac spines. This belt may also be used when this condition becomes chronic (10-12 weeks).<sup><ref>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 (level 1B)</ref> <ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) (Level 1A)</ref><ref>Cusi MF; Paradigm for assessment and treatment of SIJ mechanical dysfuntion.; J Bodyw Mov Ther.; 2010;14(2):152-161. (level 1A)</ref></sup> '''(level 1B-1A-1A)'''
If the patient has a leg length discrepancy or an altered gait mechanism, the most reliable treatment would be to correct the underlying defect. Sacroiliitis is also a feature of spondyloarthropathies. In this case, this condition should also be treated.<sup><ref>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 </ref><ref>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 </ref><ref>Cusi, M.F., Paradigm for assessment and treatment of SIJ mechanical dysfunction, Journal of Bodywork &amp; Movement Therapies (2010), doi:10.1016/j.jbmt.2009.12.004fckLR©2009 Elsevier Ltd. All rights reserved. </ref><ref>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 </ref><ref>Stuart Porter; Tidy’s physiotherapy; Churchill Livingstone Elsevier; 14th edition; 2008; p513-530 (BOOK)</ref>


<br>  
See also the physiotherapy section in [[Sacroiliac Joint Syndrome]]
== Conclusion  ==
The majority of patients with sacroiliitis have an excellent outcome. However, the recovery may take 2-4weeks. Recurrences are common if patients do not change their lifestyle. Some series report a recurrence rate of over 30%<ref name=":0" />.


Once the acute symptoms are under control, the patient can start with flexibility exercises and specific stabilizing exercises. To maintain SI and lower back flexibility, stretching exercises are principal. These exercises include side-bends, knee chest pulls, and pelvic-rocks with the aim of stretching the paraspinal muscles, the gluteus muscles and the SI joint. After hyperacute symptoms have resolved these kinds of exercises should be started. Each stretch is performed in sets of 20. These exercises should never surpass the patient’s level of mild discomfort.<sup><ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) (Level 1A)</ref></sup>'''(level 1A)'''<br>
Sacroiliitis is best managed by an interprofessional team that consists of a physical therapist, physician rheumatologist, and dietitian. Patient education is the key to good outcomes. All patients should  
 
* Be informed that the condition is benign and will improve with conservative measures.
<br>
* Be encouraged to participate in a regular [[Therapeutic Exercise|exercise]] program, [[Obesity|lose weight]], eat healthily and if applicable quit [[Smoking Cessation and Brief Intervention|smoking]].  
 
* Participate in a [[Adherence to Home Exercise Programs|Home exercise program]] to help prevent deconditioning.  
Specific pelvic stabilizing exercises, postural education and training muscles of the trunk and lower extremities, can be useful in patients with sacroiliac joint dysfunctions. The transversus abdominis, lumbar multifidi muscles and [[Pelvic Floor Anatomy|pelvic floor]] are the muscles that will need most training. Training of transversus abdominis independently of other abdominal muscles is effective to provide more stabilization of the sacroiliac joints and prevent laxity, which can cause low back pain. Therefore it is necessary to teach the patient how to contract the transversus abdominis and multifidus. During this learning process it is necessary to give the patient feedback. Also the specific co-contraction of the transversus abdominus and the multifidus should be included in the revalidation program. The best position to teach the patient to co-contract these muscles is in four point kneeling. When the patient can properly perform this exercise, it is time to increase the intensity by changing the starting position,… <br>Other examples of exercises may include: modified sit-ups, weighted side-bends and gentle extension exercises.<br>Strengthening of the pelvic floor muscles is also important because they oppose lateral movements of the coxal bones, which stabilizes the position of the sacrum. Activation of the transversus abdominis and pelvic floor muscles will reduce the vertical sacroiliac joint shear forces and increase the stability of the sacroiliac joint.<br>After rehabilitation, low-impact aerobic exercises such as light jogging and water aerobics are designated to prevent recurrence.<sup><ref>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 (level 1B)</ref> <ref>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 (level 2B)</ref><ref>Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10) (Level 1A)</ref><ref>C.A. Richardson; Muscle control-pain control. What would you prescribe?; Manual therapy;1995;2-10 (level 1A)</ref><ref>J.J.M. Pel; Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces; Annals of biomedical engineering; 2008; 36(3): 415–424. (level 1A)</ref></sup>'''(level 1B-2B-1A-1A-1A)'''<br>
 
<br>
 
If the patient has a leg length discrepancy or an altered gait mechanism, the most reliable treatment would be to correct the underlying defect. Sacroiliitis is also a feature of spondyloarthropathies. In this case, this condition should also be treated.<sup><ref>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 (level 1C)</ref><ref>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 (level 1A)</ref><ref>Cusi, M.F., Paradigm for assessment and treatment of SIJ mechanical dysfunction, Journal of Bodywork &amp; Movement Therapies (2010), doi:10.1016/j.jbmt.2009.12.004fckLR©2009 Elsevier Ltd. All rights reserved. (level 1C)</ref><ref>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 (level 1A)</ref></sup><ref>Stuart Porter; Tidy’s physiotherapy; Churchill Livingstone Elsevier; 14th edition; 2008; p513-530 (BOOK)</ref>'''(level 1C-1A-1C-1A)'''<br>
 
== Key Research  ==
 
add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
 
== Resources <br>  ==
 
add appropriate resources here <br>
 
== Clinical Bottom Line  ==
 
add text here <br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
 
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]  
<div class="researchbox">
<rss>Feed goes here!!</rss>
</div>
== Presentations  ==
<div class="coursebox">
{| width="100%" border="0" cellspacing="4" cellpadding="4" class="FCK__ShowTableBorders"
|-
| align="center" | <imagemap>
Image:Kegel or not.png |200px|border|left|
rect 0 0 830 452 [http://www.youtube.com/watch?v=w08iCzxnQBU]
desc none
</imagemap>
| [http://www.youtube.com/watch?v=w08iCzxnQBU '''Pelvic Physiotherapy - to Kegel or Not?''']  
This presentation was created by Carolyn Vandyken, a physiotherapist who specializes in the treatment of male and female pelvic dysfunction. She also provides education and mentorship to physiotherapists who are similarly interested in treating these dysfunctions. In the presentation, Carolyn reviews pelvic anatomy, the history of Kegel exercises and what the evidence tells us about when Kegels are and aren't appropriate for our patients.
 
[http://www.youtube.com/watch?v=w08iCzxnQBU View the presentation]
 
|}
</div>
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />  
<references />  


[[Category:Vrije_Universiteit_Brussel_Project]] [[Category:Sacroiliac_Conditions]] [[Category:Lumbar]] [[Category:Pelvis]] [[Category:Presentations]] [[Category:Primary Contact]]
[[Category:Vrije_Universiteit_Brussel_Project]]  
[[Category:Pelvic_Health]]  
[[Category:Lumbar Spine - Conditions]]  
[[Category:Lumbar Spine]]  
[[Category:Pelvis]]  
[[Category:Conditions]]
[[Category:Pelvis - Conditions]]
[[Category:Presentations]]  
[[Category:Primary Contact]]
[[Category:Pelvic Health]]
[[Category:Pelvis]]  
[[Category:Womens_Health]]  
[[Category:Womens_Health]]  
[[Category:Mens_Health]]
[[Category:Mens_Health]]
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]
[[Category:Rheumatology]]

Latest revision as of 07:45, 3 September 2023


Original Editors - Charlotte Fastenaekels

Top Contributors - Annelies Noppe, Lucinda hampton, Kim Jackson, Stéphanie Dartevelle, Matthias Bossche, Charlotte Fastenaekels, Admin, Laura Ritchie, Sally Ngo, WikiSysop, 127.0.0.1, Kai A. Sigel, Claire Knott, Wanda van Niekerk, Nicole Hills, Shreya Pavaskar and Rachael Lowe

Introduction[edit | edit source]

Sacroiliac joint

Sacroiliitis, is an inflammation of one or both sacroiliac (SI) joints, and a common cause of buttocks or lower back pain. Inflammation of the sacroiliac joint may occur secondary to osteoarthritis, pregnancy, spondyloarthropathies, and trauma.[1][2]

Etiology[edit | edit source]

Various conditions result in the inflammation of the SI joint, leading to significant pain.

  • Osteoarthritis can cause degeneration of the joint resulting in pathologic articulation and motion leading to this condition.
  • Spondyloarthropathies can cause significant inflammation of the joint itself eg Ankylosing spondylitis, Reactive arthritis, psoriatic arthritis, arthritis of chronic inflammatory bowel disease
  • Pregnancy is another cause of the inflammation due to the hormone relaxin leading to the relaxation, stretching, and possible widening of the SI joint(s). The increased weight of pregnancy also causes extra mechanical stress on the joint, leading to further wear and tear.
  • Trauma can cause direct or indirect stress and damage to the SI joint.
  • Pyogenic sacroiliitis is the most frequently reported cause of acute sacroiliitis.
  • Pain can originate from the synovial joint but can also originate from the posterior sacral ligaments[1]

Epidemiology[edit | edit source]

Bone scan: Active-sacroiliitis

Reports on the prevalence of sacroiliac pain vary widely.

  • Some studies report the prevalence as 10% to 25% of those with lower back pain.
  • In those with a confirmed diagnosis, the presentation of pain was ipsilateral buttock (94% cases) and midline lower lumbar area (74%).
  • Up to 50% of cases have radiation to the lower extremity: 6% to the upper lumbar area, 4% percent to the groin, and 2% percent to the lower abdomen[1]
  • 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.[3][4] 
  • The hospital prevalence of sacroiliac diseases is 0,55%, the female sex predominates( 82,35%) and the mean age of 25,58 years. Gyneco-obstetric events are the predominant risk factors (47,05%). The etiologie found are bacterial arthritis (82,3%) mainly pyogenic (70,58%), osteoarthritis(11,7%) and ankylosing spondylitis (5,9%) .

Clinical Presentation[edit | edit source]

Pregnancy can cause sacroiliitis

Symptoms of sacroiliitis can vary. People with sacroiliitis commonly present with ipsilateral or bilateral buttock and/or midline lower lumbar area pain. Up to 50% may have pain radiating to the lower extremity.

Sacroiliitis pain can be aggravated by:

  • Prolonged standing
  • Bearing more weight on one leg than the other
  • Stair climbing
  • Running
  • Taking large strides[5]

Diagnosis[edit | edit source]

A medical history will be taken, including previous inflammatory disorders. Other tests include:

  1. Physical exam, movement tests - Spine is examined for proper alignment and rotation, and various physical movement tests are performed (see physio section below).
  2. Blood tests - looking for signs of inflammation.
  3. Imaging tests - X-rays, CT scans, and/or MRI scans may be ordered.
  4. Steroid injection - An injection of steroids into the sacroiliac joint is both a diagnostic test (if it relieves pain) and a treatment[5]

Outcome Measures[edit | edit source]

  • Oswestry Disability Index (ODI) is most effective for persistent, severe disability
  • Roland-Morris is more appropriate for mild to moderate disability.[6]
  • Short-form McGill Pain Questionnaire
  • The Assessment of Pain and Occupational Performance may also be appropriate.

Examination[edit | edit source]

FABERs test.jpg

Examine pelvis for proper alignment and rotation, inspection can reveal pelvic asymmetry. Measurement of the limbs can rule out a leg-length discrepancy. Inspect the spine for any abnormal curvatures or rotational abnormalities.

Special provocative tests can be very helpful in reproducing the patient’s pain:

  1. “Fortin finger sign”- reproduction of pain after applying a deep palpation with the four-hand fingers posteriorly at the patient's SI joint(s).
  2. FABER test- reproduction of pain after flexing the hip while also abducting and externally rotating the hip.
  3. Sacroiliac distraction test- reproduction of pain after applying pressure to the anterior superior iliac spine.
  4. SacroIliac compression test- reproduction of pain after applying pressure downward on the superior aspect of the iliac crest.
  5. Gaenslen test- reproduction of pain after having the patient flex the hip on the unaffected side and then dangle the affected leg off the examining table. Pressure is then directed downward on the leg to extend further the hip, which causes stress on the SI joint.
  6. Thigh thrust test- reproduction of pain after flexing the hip and applying a posterior shearing force to the SI joint.
  7. Sacral thrust test- reproduction of pain with the patient prone and then applying an anterior pressure through the sacrum.

The likelihood of SI joint mediated pain increases as the number of positive-provocative tests increase[1].

Management[edit | edit source]

Treatment depends on your signs and symptoms, as well as the cause of your sacroiliitis.

  • Medications. Depending on the cause of your pain, the following may be recommended:
    • Pain relievers. If over-the-counter pain medications don't provide enough relief stronger versions of these drugs may be ordered.
    • Muscle relaxants. Medications such as cyclobenzaprine (Amrix, Fexmid) might help reduce the muscle spasms often associated with sacroiliitis.
    • TNF inhibitors. Tumor necrosis factor (TNF) inhibitors [eg etanercept (Enbrel), adalimumab (Humira) and infliximab (Remicade)] often help relieve sacroiliitis that's associated with ankylosing spondylitis[5].
  • Real-time image-guided intra-articular anesthetic/steroid injections can be performed for diagnostic and therapeutic effect. If the condition persists (6 to 8 weeks) with no improvement of at least 50 percent, repeat corticosteroid injections. Subsequently begin strengthening exercises including sit-ups and weighted side bends. Start with general conditioning of the back and increase slowly to low-impact walking or swimming. Take up normal activities with proper care of the back.[7]
  • If the previous treatments do not provide adequate relief, then some providers will consider radiofrequency ablation[1].
  • Joint fusion. Although surgery is rarely used to treat sacroiliitis, fusing the two bones together with metal hardware can sometimes relieve sacroiliitis pain.[5]

Physical Therapy Management[edit | edit source]

Physical therapy can be very helpful if the pain is due to hypermobility. Therapy can help to stabilize and strengthen lumbopelvic musculature. If the pain is due to immobility, then physical therapy can help increase mobilization of the SI joint. Depending on the diagnosis the following techniques may be used.

In the early treatment stages heat, cold or alternating cold with heat are effective in reducing pain.[8]  

SI Belt: In the early stage a pelvic belt or girdle during exercise and activities of daily living can be used. These SI belts provide compression and reduce SI mobility in hypermobile patients. The belt should be positioned posteriorly across the sacral base and anteriorly below the superior anterior iliac spines. This belt may also be used when this condition becomes chronic (10-12 weeks).[9] [10][11]

Flexibility Exercises: Once the acute symptoms are under control, the patient can start with flexibility exercises and specific stabilizing exercises. To maintain SI and lower back flexibility, stretching exercises are principal. These exercises include side-bends, knee chest pulls, and pelvic-rocks with the aim of stretching the paraspinal muscles, the gluteus muscles and the SI joint. After hyperacute symptoms have resolved these kinds of exercises should be started. Each stretch is performed in sets of 20. These exercises should never surpass the patient’s level of mild discomfort.[12]

Stabilisation exercises: Specific pelvic stabilising exercises, postural education and training muscles of the trunk and lower extremities, can be useful in patients with sacroiliac joint dysfunctions. See core strengthening
After rehabilitation, low-impact aerobic exercises such as light jogging and water aerobics are designated to prevent recurrence.[13] [14][15][16][17]

If the patient has a leg length discrepancy or an altered gait mechanism, the most reliable treatment would be to correct the underlying defect. Sacroiliitis is also a feature of spondyloarthropathies. In this case, this condition should also be treated.[18][19][20][21][22]

See also the physiotherapy section in Sacroiliac Joint Syndrome

Conclusion[edit | edit source]

The majority of patients with sacroiliitis have an excellent outcome. However, the recovery may take 2-4weeks. Recurrences are common if patients do not change their lifestyle. Some series report a recurrence rate of over 30%[1].

Sacroiliitis is best managed by an interprofessional team that consists of a physical therapist, physician rheumatologist, and dietitian. Patient education is the key to good outcomes. All patients should

  • Be informed that the condition is benign and will improve with conservative measures.
  • Be encouraged to participate in a regular exercise program, lose weight, eat healthily and if applicable quit smoking.
  • Participate in a Home exercise program to help prevent deconditioning.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Buchanan BK, Varacallo M. Sacroiliitis. InStatPearls [Internet] 2019 Feb 15. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK448141/ (last accessed 13.6.2020)
  2. ↑ Radiopedia Sacroiliitis Available:https://radiopaedia.org/articles/sacroiliitis (accessed 4.6.2022)
  3. ↑ 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)
  4. ↑ 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)
  5. ↑ 5.0 5.1 5.2 5.3 Mayo Clinic Sacroiliitis Available:https://www.mayoclinic.org/diseases-conditions/sacroiliitis/symptoms-causes/syc-20350747 (accessed 4.6.2022)
  6. ↑ Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10)
  7. ↑ Kapura et al. - Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis: the first case-series.
  8. ↑ Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10)
  9. ↑ 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
  10. ↑ Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10)
  11. ↑ Cusi MF; Paradigm for assessment and treatment of SIJ mechanical dysfuntion.; J Bodyw Mov Ther.; 2010;14(2):152-161.
  12. ↑ Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10)
  13. ↑ 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
  14. ↑ 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
  15. ↑ Davies, Claire C.1; Nitz, Arthur J. Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 399-408(10)
  16. ↑ C.A. Richardson; Muscle control-pain control. What would you prescribe?; Manual therapy;1995;2-10
  17. ↑ J.J.M. Pel; Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces; Annals of biomedical engineering; 2008; 36(3): 415–424.
  18. ↑ 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
  19. ↑ 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
  20. ↑ 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.
  21. ↑ 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
  22. ↑ Stuart Porter; Tidy’s physiotherapy; Churchill Livingstone Elsevier; 14th edition; 2008; p513-530 (BOOK)
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