What are the treatment options for sacroiliac (SI) joint pain or dysfunction?

Treatment Options for Sacroiliac Joint Pain or Dysfunction

The treatment of sacroiliac (SI) joint pain should follow a stepwise approach, beginning with NSAIDs and physical therapy as first-line treatments, progressing to interventional procedures like injections or radiofrequency ablation for refractory cases, and considering SI joint fusion only after failure of conservative measures. 1, 2

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• X-rays of sacroiliac joints and spine are the first-line imaging studies (rated 9/9 for appropriateness) 3
• If radiographs are negative or equivocal:
  • MRI of sacroiliac joints without contrast (rated 8/9) is recommended
  • CT of sacroiliac joints without contrast (rated 7/9) is an alternative, especially for patients unable to undergo MRI 3
• Diagnostic SI joint blocks with local anesthetic can confirm the SI joint as the pain source 1
• Positive response to at least three physical provocation tests suggests SI joint dysfunction 1

Treatment Algorithm

First-Line Treatment

1. NSAIDs

   • Strongly recommended as first-line drug treatment for pain and stiffness 3
   • For patients with increased gastrointestinal risk, use either:
     • Non-selective NSAIDs plus gastroprotective agent
     • Selective COX-2 inhibitor 3

2. Non-pharmacological Approaches

   • Regular exercise and physical therapy (individual or group) 3
   • Patient education 3
   • Pelvic girdle stabilization with focused stretching 1
   • Manipulative therapy performed by physical therapists or trained clinicians 1
   • Pelvic belts (especially beneficial for postpartum patients) 1, 4

Second-Line Treatment

For patients with persistent symptoms despite first-line treatment:

1. Intra-articular Injections

   • Corticosteroid injections under fluoroscopic guidance 1, 5
   • Bridging therapy with limited course of oral glucocorticoids (<3 months) during initiation or escalation of therapy 3
   • Most useful in settings of high disease activity, limited mobility, or significant symptoms 3

2. For Inflammatory Sacroiliitis (Spondyloarthropathy)

   • If NSAIDs fail, TNF inhibitors (etanercept, adalimumab, infliximab, golimumab) are strongly recommended 3
   • Sulfasalazine may be considered for patients who have contraindications to or have failed TNF inhibitors 3
   • Methotrexate monotherapy is strongly recommended against 3

Third-Line Treatment

For patients who fail conservative management and injections:

1. Radiofrequency Ablation

   • Cooled radiofrequency ablation of sacral nerve branches 1, 2

2. Surgical Intervention

   • SI joint fusion should be considered only after failure of all conservative measures 1, 5
   • Percutaneous SI arthrodesis is recommended as first-line surgical treatment due to improved safety profile compared to open arthrodesis 5
   • Open arthrodesis should be reserved for revision surgery, nonunion, or aberrant anatomy 5

Special Considerations

• Inflammatory vs. Mechanical Pain: Treatment approach differs based on whether the pain is inflammatory (spondyloarthropathy) or mechanical in nature
• Pregnancy-Related SI Joint Pain: Pelvic belts are particularly beneficial 1, 4
• Athletes: May require sport-specific rehabilitation protocols 4
• Trauma-Related SI Joint Pain: May respond differently to treatment than atraumatic causes 2

Pitfalls and Caveats

1. SI joint pain is often misdiagnosed or overlooked, accounting for approximately 15-25% of reported back pain 2
2. No single physical examination test is pathognomonic for SI joint pain; multiple positive tests increase diagnostic confidence 6
3. Failure to address contributing factors (gait abnormalities, leg length discrepancies) may result in treatment failure
4. For inflammatory sacroiliitis, failure to escalate to TNF inhibitors when NSAIDs are ineffective can lead to disease progression 3
5. Continuous rather than intermittent NSAID treatment may retard radiographic disease progression in inflammatory cases 3

By following this structured approach to SI joint pain management, clinicians can optimize outcomes and improve quality of life for patients suffering from this common but challenging condition.