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Pain over the sacroiliac joint (SIJ) is an exceedingly common presentation. The Fortin Finger Test tells us that if it hurts to poke on it, the SIJ is a likely culprit. But evidence-based chiropractors recognize that the SIJ is not always the generator of pain that happens to be over its surface.

Various authors have estimated that approximately 14-22% of lumbosacral pain arises primarily from the SIJ (17-19). Now a new study that hit our inboxes on October 31st, suggests the percentage may be significantly lower. (20) Researchers examined 124 patients with pain at the SIJ and performed diagnostic blocks over various potential pain generators. They found:

  • 3% of patients had pain originating primarily from the SIJ
  • 90% originated from the lumbar spine
  • 4% was referred from the hip
  • 3% had an undetermined source of pain

Check out the following video tutorial of a quick and reliable system to differentiate each of these culprits.

ChiroUp has compiled the following evidence-based synopsis of signs and symptoms that help differentiate the most common causes of LBP.

 

Lumbar Facet Pain

  • Ipsilateral symptoms* (1-3)
  • Recurrent low back pain (4)
  • Not usually extending beyond the knee (4)
  • Maximally exacerbated with extension from a fully flexed position (4)
  • Relief with recumbency (5,6)

* Since the medial branch of the dorsal ramus does not cross the midline, facet pain generally presents in an ipsilateral fashion with peak intensity over the affected joint. (1-3)

 

Lumbar  Degeneration

  • Variable and inconsistent- ranging from asymptomatic to severe (7)
  • Local stiffness and limited ROM that gradually worsens
  • Symptoms upon arising in the morning
  • Dissipates with light activity throughout the day
  • Intensifies with strenuous or prolonged activity
  • Temporarily relieved by sitting or lying down

Degenerative  Spondylolisthesis

  • Increased pain with standing or when transitioning to a standing position (8)
  • Symptoms increase throughout the course of the day (8)
  • Radicular complaints, if present, typically involve the L4 or L5 nerve roots and may be unilateral or bilateral (8)
  • Radicular complaints commonly shift from side to side (8)

Stenosis

  • Transient bilateral and symmetrical pain, paresthesia, numbness, fatigue, heaviness and/or weakness in the legs
  • Lower extremity complaints more bothersome than local symptoms
  • Symptoms are bilateral in almost 7 out of 10 patients (9,10)
  • Progressively increasing symptoms from standing or walking and relief while sitting** (11,12)
  • Diminished symptoms when walking with a shopping cart or lawn mower
  • Walking downhill is generally more uncomfortable than walking uphill

**The intervertebral foramina undergoes a 15% decrease surface area in extension and at 12% increase surface area in flexion. (11,12)

 

Sacroiliac Joint

  • Patient will often place their index finger over the PSIS (13)
  • Pain may refer to different regions, depending upon which section of the joint is irritated (14)
    • Irritation to the upper 1/3 of the joint generates pain in the region of the
    • Irritation to the midsection causes referral to the mid-gluteal region
    • The lowest section refers to the lower gluteal region
  • 44% of SI joint patients report referral to the groin (14)
  • Exacerbated by bearing weight on the affected side
  • Relieved by shifting weight to the unaffected leg
  • Provoked by; arising from a seated position, long car rides, transferring in and out of a vehicle, rolling from side to side in bed or by flexing forward while standing
  • Worse while standing or walking and relieved by lying down

Hip

  • Groin, anterior thigh and buttock pain are common
  • The patient will often describe the location of their pain with the “C” sign, demonstrated by placing their index finger over the anterior aspect of the hip, near their ASIS, and their thumb over the posterior trochanteric region (15)

Inflammatory Joint Pain (16)

  • Morning stiffness > 30 minutes
  • Relief of pain with exercise but not rest
  • Awakening because of back pain during the second half of the night
  • Alternating buttock pain

BONUS:

Download this handy ChiroUp Inflammatory Arthropathy Infographic
 

We hope this information enhances your ability to differentiate SIJ dysfunction from its most common imposters. And we welcome your input. Feel free to forward your suggestions anytime. ChiroUp is a shared best-practice resource built to allow providers to access current data then share real-world skills. ChiroUp would not exist without your willingness to contribute. Together, we WILL become the undeniable best choice for patients and payors alike.

 

Not a subscriber yet? Click here to see how easily ChiroUp can fit into your practice today.

 

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References

  1. Cavanaugh JM, Ozaktay AC, Yamashita HT, King AI. Lumbar facet pain: biomechanics, neuroanatomy and neurophysiology. J Biomech. 1996;29 :1117– 1129.
  2. Bogduk N. The innervation of the lumbar spine. Spine. 1983;8 :286– 293.
  3. Jackson H, Winkelmann R, Bickel W. Nerve endings in the human lumbar spinal column and related structures. J Bone Joint Surg Am. 1966;48 :1272– 1281.
  4. Jackson RP, Jacobs RR, Montesano PX. 1988 Volvo award in clinical sciences. Facet joint injection in low-back pain. A prospective statistical study. Spine. Sep 1988;13(9):966-71
  5. Revel M, Poiraudeau S, Auleley GR, et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine. 1998;23:1972–1976.
  6. Revel ME, Listrat VM, Chevalier XJ, et al. Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil. 1992;73:824–828.
  7. Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69–73.
  8. Frymoyer JW. Degenerative spondylolisthesis. In: Andersson GBJ, McNeill TW, editors. Lumbar spinal stenosis. St Louis: Mosby Year Book; 1992. 9. Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ. Lumbar spinal fusion: a cohort study of complications, reoperations, and resource use in the Medicare population. Spine 1993;18:1463-1470
  9. Mazanec, D.J., Podichetty, V.K., Hsia, A. (2002) Lumbar Canal Stenosis: Start with nonsurgical therapy. Cleveland Clinic Journal of Medicine 69(11).
  10. Schönström N, Lindahl S, Willén J, Hansson T. Dynamic changes in the dimensions of the lumbar spinal canal: an experimental study in vitro. Journal of orthopaedic research. 1989;7(1):115–21.
  11. Inufusa A, An HS, Lim TH, Hasegawa T, Haughton VM, Nowicki BH. Anatomic changes of the spinal canal and intervertebral foramen associated with flexion-extension movement. Spine. 1996 Nov 1;21(21):2412–20.
  12. Fortin JD, Washington WJ, Falco FJE. Three pathways between the sacro-iliac joint and neural structures. AJNR. 1999;20:1429–1434.
  13. Kurosawa D, Murakami E, Aizawa T. Referred pain location depends on the affected section of the sacroiliac joint. Eur Spine J. 2015 Mar;24(3):521-7.
  14. Byrd J. Evaluation of the hip: history and physical examination. North American Journal Of Sports Physical Therapy: NAJSPT November 2007;2(4):231-240.
  15. Rudwaleit M. et al. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum. 2006 Feb;54(2):569-78.
  16. Sembrano JN, Polly DW. How often is low back pain not coming from the back? Spine. 2009;34(1):E27–E32
  17. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21: 1889–1892.
  18. Bernard TN, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop. 1987;(217):266–280. 
  19. DePhillipo NN et al. Sacroiliac Pain: Structural Causes of Pain Referring to the SI Joint Region. Clinical Spine Surgery. Publish Ahead of Print():, OCT 2018

 

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman

DC, CCSP, DACO

Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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