What is the recommended treatment for sacroiliac (SI) pain?

Treatment of Sacroiliac Joint Pain

NSAIDs should be used as first-line therapy for sacroiliac joint pain, followed by TNF inhibitors for refractory cases, with physical therapy as an important adjunctive treatment throughout the management process. 1

Step-wise Treatment Algorithm

First-line Treatment

• NSAIDs: Strongly recommended as initial therapy for active sacroiliac joint pain 2, 1
  • Options include naproxen, ibuprofen, diclofenac, or COX-2 inhibitors
  • Should be used for 2-4 weeks before assessing response 1
  • Note: While effective for initial management, NSAIDs are recommended as adjunct therapy rather than monotherapy for chronic, persistent cases 1

Second-line Treatment (for inadequate response to NSAIDs)

• TNF inhibitors (TNFi): Strongly recommended when NSAIDs fail to control symptoms 2, 1

  • Options include etanercept, adalimumab, infliximab, golimumab
  • TNFi have shown significant efficacy in reducing pain and improving function in sacroiliitis 2
  • Particularly important for patients with inflammatory sacroiliitis

• Bridging therapy options during initiation of TNFi:

  1. Short-course oral glucocorticoids: Conditionally recommended for < 3 months 2

     • Most useful in cases of high disease activity, limited mobility, or significant symptoms
     • Note: Systemic glucocorticoids lack strong evidence for long-term management of axial disease 1

  2. Intra-articular glucocorticoid injections: Conditionally recommended as adjunct therapy 2, 1

     • Fluoroscopically or CT-guided injections can be both diagnostic and therapeutic 3
     • Can provide pain relief for over 3 months in some patients 4

Alternative Second-line Options (when TNFi contraindicated)

• Sulfasalazine: Conditionally recommended for patients who:

  • Have contraindications to TNFi
  • Have failed more than one TNFi
  • Have concomitant peripheral arthritis 2, 1

• Strongly recommended against:

  • Methotrexate monotherapy for sacroiliitis 2
  • Note: Methotrexate may be useful as adjunct therapy for concomitant peripheral polyarthritis 2

Third-line Treatment (for TNFi failures)

• IL-17 inhibitors: Strongly recommended for patients who fail TNF inhibitors 1

  • Options include secukinumab and ixekizumab

• JAK inhibitors: Strongly recommended when biologics are contraindicated or unavailable 1

• Radiofrequency ablation (RFA): Consider for patients who fail medication management 4

  • Cooled RFA has shown strong evidence for efficacy 1, 4
  • Targets L5 dorsal ramus and S1-3 (or 4) lateral branches

Fourth-line Treatment (last resort)

• Sacroiliac joint fusion: Reserved for patients with: 1, 3
  • Positive response to SI injection with >75% relief
  • Failure of all nonsurgical treatments
  • Continued or recurrent SIJ pain
  • Percutaneous SI arthrodesis preferred over open arthrodesis due to improved safety profile

Adjunctive Treatments (throughout management)

• Physical therapy: Conditionally recommended throughout treatment 2, 1

  • Focus on pelvic girdle stabilization exercises
  • Active supervised exercise programs
  • Can help identify and reduce mechanical factors contributing to microtrauma 2

• SI belt: May provide symptomatic relief in some patients 3

• Patient education: Recommended regarding condition and self-management strategies 1

Diagnostic Considerations

• Positive responses to at least three physical provocation tests suggest SI joint dysfunction 1
• Diagnostic SI joint blocks with local anesthetic can confirm the SI joint as the pain source 1
• MRI findings may not always correlate with the location of pain 1

Monitoring

• Assess treatment response after 2-4 weeks of NSAID therapy 1
• Use standardized measures like ASDAS to monitor disease activity 1
• If a significant change in disease course occurs, consider causes other than inflammation 1

Important Caveats

• SI joint pain is responsible for approximately 15-25% of reported back pain 5
• Patients with SIJ pain report some of the lowest quality of life scores of any chronic disease 5
• Diagnostic value of SI joint infiltration remains controversial due to potential for false-positive and false-negative results 4
• Reported complication rates for SI joint treatments are generally low 4