What is the recommended treatment for sacroiliac joint pain?

From the Guidelines

The recommended treatment for sacroiliac joint pain typically begins with conservative approaches, including rest, ice/heat therapy, and over-the-counter pain medications such as NSAIDs (ibuprofen 400-800mg three times daily or naproxen 500mg twice daily) for 1-2 weeks, as supported by the 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis 1.

Initial Treatment Approaches

• Rest and ice/heat therapy to reduce inflammation and pain
• Over-the-counter pain medications such as NSAIDs (e.g., ibuprofen or naproxen) for 1-2 weeks
• Physical therapy focusing on core strengthening, pelvic stabilization exercises, and stretching for 6-8 weeks, with sessions 2-3 times weekly

Additional Treatment Options

• A sacroiliac belt may provide symptomatic relief by stabilizing the joint during daily activities
• For persistent pain, corticosteroid injections directly into the sacroiliac joint can provide temporary relief lasting 1-3 months, as conditionally recommended by the Pan American League of Associations for Rheumatology 1
• In severe cases unresponsive to conservative measures, radiofrequency ablation or minimally invasive sacroiliac joint fusion might be considered

Biologic Agents and Other Therapies

• Tumor necrosis factor inhibitors (TNFi) are strongly recommended for adults with active nonradiographic axial spondyloarthritis despite treatment with NSAIDs, as per the 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations 1
• Other biologic agents, such as secukinumab or ixekizumab, may be considered for patients with contraindications to TNFi or who have failed TNFi therapy, as conditionally recommended by the Pan American League of Associations for Rheumatology 1

Key Considerations

• The treatment approach should be individualized based on the patient's specific needs and circumstances
• A multidisciplinary team, including rheumatologists, physical therapists, and other healthcare professionals, may be involved in the management of sacroiliac joint pain
• Regular monitoring and follow-up are essential to assess the effectiveness of treatment and adjust the treatment plan as needed, as recommended by the 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis 1

From the Research

Sacroiliac Joint Pain Treatment Pharmacology

• The treatment of sacroiliac joint pain can be divided into conservative and surgical options 2, 3, 4, 5, 6.
• Conservative measures include medications, physical therapy, radiofrequency denervation, and direct SI joint injections, which may have limited durability in therapeutic benefit 2.
• Nonsurgical modalities such as activity modification, use of a sacroiliac belt, NSAIDs, and physical therapy are recommended as the initial phase of treatment 3.
• Prolotherapy and radiofrequency ablation may offer a potential benefit as therapeutic modalities, although limited data support their use as a primary treatment modality 3.
• Corticosteroids, platelet-rich plasma, and stem cells have only midterm lasting effects, at most for nine months, and can be used for intra-articular injections 4.
• Radiofrequency ablation is another methodology for pain relief, with both continuous and pulsatile radiofrequency ablation associated with good outcomes 4.

Surgical Options

• Surgical treatment is indicated for patients with a positive response to an SI injection with >75% relief, failure of nonsurgical treatment, and continued or recurrent SIJ pain 3.
• Percutaneous SI arthrodesis may be recommended as a first-line surgical treatment due to its improved safety profile compared with open arthrodesis 3.
• SIJ fusion can be performed using different techniques, although a clear recommendation on the most appropriate modality for the management of SIJ pain is still debated 4.
• Surgical treatment is cost-effective in appropriately selected patients, with high-quality clinical trials demonstrating statistically and clinically significant improvement compared with nonsurgical management 5.

Diagnosis and Treatment Approach

• The diagnosis of sacroiliac joint pain can be challenging, and a patient-centered approach that focuses on pain control and restoration of function is recommended 6.
• Provocation tests such as FABRE, distraction, thigh thrust, sacral compression, Gaenslen's, and sacral thrust can be a useful diagnostic tool for the diagnosis of sacroiliac joint pain, although their validity has been challenged 6.
• Image-guided injections of local anesthetic are currently the most accurate way to assess sacroiliac joint pain, with pain reduction after the injection indicating the pain originating from the sacroiliac joint 6.