Evidence-based diagnosis and treatment of the painful sacroiliac joint

Abstract

Sacroiliac joint (SIJ) pain refers to the pain arising from the SIJ joint structures. SIJ dysfunction generally refers to aberrant position or movement of SIJ structures that may or may not result in pain. This paper aims to clarify the difference between these clinical concepts and present current available evidence regarding diagnosis and treatment of SIJ disorders. Tests for SIJ dysfunction generally have poor inter-examiner reliability. A reference standard for SIJ dysfunction is not readily available, so validity of the tests for this disorder is unknown. Tests that stress the SIJ in order to provoke familiar pain have acceptable inter-examiner reliability and have clinically useful validity against an acceptable reference standard. It is unknown if provocation tests can reliably identify extra-articular SIJ sources of pain. Three or more positive pain provocation SIJ tests have sensitivity and specificity of 91% and 78%, respectively. Specificity of three or more positive tests increases to 87% in patients whose symptoms cannot be made to move towards the spinal midline, i.e., centralize. In chronic back pain populations, patients who have three or more positive provocation SIJ tests and whose symptoms cannot be made to centralize have a probability of having SIJ pain of 77%, and in pregnant populations with back pain, a probability of 89%. This combination of test findings could be used in research to evaluate the efficacy of specific treatments for SIJ pain. Treatments most likely to be effective are specific lumbopelvic stabilization training and injections of corticosteroid into the intra-articular space.

Keywords: Corticosteroid Injection; Diagnostic Accuracy; Intra-Articular Injection; Lumbopelvic Stabilization Training; Pregnancy-Related Pelvic Girdle Pain; Sacroiliac Joint Dysfunction; Sacroiliac Joint Pain.

Figures

Figure 1

The distraction test (testing right and left SIJ simultaneously).

Figure 2

The thigh thrust test (testing the right SIJ).

Figure 3

Gaenslen's test (testing the right SIJ in posterior rotation and the left SIJ in anterior rotation).

Figure 4

The compression test (testing right and left SIJ).

Figure 5

The sacral thrust test (testing right and left SIJ simultaneously).

Figure 6

The drop test (testing the left SIJ).

Figure 7

Fagan's nomogram from data derived from Laslett et al, N=43.

Figure 8

Fagan's nomogram from data derived from Laslett et al, N=34.