What are the treatment options for Sacroiliac (SI) joint pain?

Treatment Options for Sacroiliac (SI) Joint Pain

NSAIDs are strongly recommended as first-line therapy for SI joint pain, with local corticosteroid injections recommended for patients with inadequate response to NSAIDs. 1

First-Line Treatment

NSAIDs

• NSAIDs are the cornerstone of initial treatment for SI joint pain 2, 1
• Should be used continuously for 2-4 weeks to evaluate response 1
• After achieving symptom control, transition to on-demand use rather than continuous treatment 2
• For patients with increased gastrointestinal risk, consider:
  • Non-selective NSAIDs plus gastroprotective agent
  • Selective COX-2 inhibitors 2
• NSAID failure should be considered after 1 month of continuous use (at least two different NSAIDs for 15 days each) 2

Non-Pharmacological Approaches

• Physical therapy and regular exercise are strongly recommended throughout the disease course 2, 1
• Focus on:
  • Pelvic girdle stabilization exercises
  • Active supervised exercise programs 1
• Patient education about the condition and self-management strategies 2

Second-Line Treatment

Local Corticosteroid Injections

• Conditionally recommended for isolated active sacroiliitis when NSAIDs provide inadequate relief 2, 1
• Intra-articular or periarticular corticosteroid injections have shown effectiveness for sacroiliitis pain in small RCTs (level Ib evidence) 2
• Responses may persist for at least 8 weeks 2
• Imaging guidance (ultrasound or CT) is preferred when available 2
• Should be performed in experienced specialist centers 2

Analgesics

• Analgesics such as paracetamol (acetaminophen) and opioids may be considered when NSAIDs are insufficient, contraindicated, or poorly tolerated 2
• Limited evidence specifically for SI joint pain, but may provide symptomatic relief 2

Third-Line Treatment

Biologic Therapy (for inflammatory sacroiliitis)

• TNF inhibitors are strongly recommended for patients with inadequate response to NSAIDs in cases of inflammatory sacroiliitis 1
• Options include etanercept, adalimumab, and golimumab 1
• IL-17 inhibitors (secukinumab, ixekizumab) are recommended for patients who fail TNF inhibitors 1

Radiofrequency Ablation

• Both continuous and pulsatile radiofrequency ablation have shown good outcomes 3, 4
• Considered when conservative treatments fail 4
• Extensive lesioning strategies (e.g., cooled RFA) have the strongest evidence 4

DMARDs

• Sulfasalazine may be considered in patients with peripheral arthritis accompanying SI joint pain 2
• No evidence supports the use of DMARDs (including sulfasalazine and methotrexate) for isolated axial disease 2

Interventional Procedures for Refractory Cases

• SI joint fusion can be considered for patients with:
  • Positive response to SI injection (>75% relief)
  • Failure of nonsurgical treatment
  • Continued or recurrent SI joint pain 5
• Percutaneous SI arthrodesis may be recommended as first-line surgical treatment due to improved safety profile compared to open arthrodesis 5

Important Considerations and Cautions

• Systemic glucocorticoids: Long-term use is strongly recommended against due to adverse effects 2, 1
• Diagnostic approach: When SI joint pain is suspected but diagnosis is uncertain, fluoroscopically guided diagnostic injections can help confirm the source of pain 4, 5
• Treatment monitoring: Use standardized measures like ASDAS (Ankylosing Spondylitis Disease Activity Score) to monitor response 1
• Adjunctive therapies: SI joint belts may provide additional support and symptom relief 6, 5

Treatment Algorithm

1. Start with NSAIDs for 2-4 weeks
2. If inadequate response, try a second NSAID for 2 weeks
3. Add physical therapy throughout treatment course
4. For persistent pain despite NSAIDs, consider local corticosteroid injection
5. For refractory pain, consider radiofrequency ablation
6. For inflammatory sacroiliitis unresponsive to above measures, consider biologic therapy
7. Surgical options (SI joint fusion) should be considered only after failure of all conservative approaches

Remember that SI joint pain accounts for approximately 15-30% of mechanical low back pain cases 4, 6, making proper diagnosis and targeted treatment essential for improving outcomes related to morbidity, mortality, and quality of life.