What is the best treatment for acute sacroiliac (sacroiliac joint) pain?

Treatment for Acute Sacroiliac Joint Pain

For acute sacroiliac joint pain, NSAIDs should be used as first-line therapy, followed by locally administered parenteral glucocorticoid injections if NSAIDs fail, and progressing to TNF inhibitors for refractory cases. 1

Initial Treatment Approach

First-Line Therapy

• NSAIDs (naproxen, ibuprofen, diclofenac, or COX-2 inhibitors) are strongly recommended as initial therapy 1
  • Assess response after 2-4 weeks
  • Continue if effective; proceed to next step if inadequate response

Second-Line Therapy

• Image-guided sacroiliac joint injections with glucocorticoids for patients who fail to respond to NSAIDs 1, 2
  • Should be fluoroscopically guided for accuracy
  • Considered both diagnostic and therapeutic
  • Repeat injection may be appropriate if ≥75% relief from diagnostic injection or ≥50% relief for at least 2 months after first injection 1

Adjunctive Conservative Measures

• Physical therapy focusing on pelvic girdle stabilization exercises 1
• Sacroiliac belt for temporary support 2, 3
• Activity modification to reduce mechanical stress 2

Management of Refractory Pain

Third-Line Therapy

• TNF inhibitors (etanercept, adalimumab, infliximab, golimumab) are strongly recommended when NSAIDs and injections fail, particularly for inflammatory sacroiliitis 1

Fourth-Line Options

• Radiofrequency ablation (preferably cooled radiofrequency) for patients with:

  • Positive response to SI joint injection (>75% relief)
  • Failure of conservative management 1, 4
  • Target the SI joint, not the cluneal nerves 1

• IL-17 inhibitors (secukinumab, ixekizumab) for patients who fail TNF inhibitors 1

• Short-course oral glucocorticoids (<3 months) for cases with:

  • High disease activity
  • Limited mobility
  • Significant symptoms 1

Last Resort Options

• Sulfasalazine for patients who:

  • Have contraindications to TNF inhibitors
  • Have failed more than one TNF inhibitor
  • Have concomitant peripheral arthritis 1

• JAK inhibitors when biologics are contraindicated or unavailable 1

• Surgical intervention (SI joint fusion) only when:

  • Patient had positive response to SI injection with >75% relief
  • All nonsurgical treatments have failed
  • Patient has continued or recurrent SIJ pain 1, 2
  • Percutaneous SI arthrodesis is preferred over open arthrodesis due to improved safety profile 2

Important Clinical Considerations

Diagnostic Confirmation

• 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, 4
• SI joint pain accounts for up to 25% of cases of lower back pain 5

Treatment Pitfalls to Avoid

• Do not use methotrexate monotherapy for sacroiliitis (strongly recommended against) 1
• Do not use chemical denervation (e.g., alcohol, phenol) in routine care 6
• Do not perform conventional radiofrequency ablation of the dorsal root ganglion for lumbar radicular pain 6
• Do not rely solely on imaging findings as they may not always correlate with pain location 1

Monitoring Recommendations

• Use standardized measures like ASDAS to monitor disease activity 1
• Regular assessment of treatment response including patient-reported outcomes, clinical findings, and laboratory tests (including CRP) 1

By following this stepwise approach, most patients with acute sacroiliac joint pain can achieve significant pain relief and improved function.