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

Treatment Options for Sacroiliac (SI) Joint Pain

For patients with sacroiliac joint pain, a stepwise approach starting with conservative management and progressing to interventional procedures is recommended, with cooled radiofrequency ablation showing the strongest evidence for refractory cases.

Diagnostic Criteria

• SI joint pain should be diagnosed when patients demonstrate at least 3 of 5 positive provocative physical examination tests, which provides a sensitivity of 94% and specificity of 78% 1
• Pain is typically localized to the sacrum, buttock, and posterior thigh region 2, 1
• Diagnostic SI joint injections with at least 70-80% pain relief confirm the SI joint as the primary pain generator 2, 1

First-Line Treatment Options

• NSAIDs are conditionally recommended as adjunct therapy for SI joint pain 3
• Physical therapy is strongly recommended over no treatment, with supervised exercise (active interventions) conditionally recommended over passive interventions 3
• Land-based physical therapy is conditionally recommended over aquatic therapy interventions 3

Second-Line Treatment Options

• Intra-articular SI joint injections with corticosteroids have moderate level evidence for short-term effectiveness 3
• For isolated active sacroiliitis despite NSAIDs, locally administered parenteral glucocorticoids are conditionally recommended 3
• Peri-articular (extra-articular) SI joint injections may also be therapeutic, with some research suggesting potentially greater response rates compared to intra-articular injections 3

Third-Line Treatment Options

• Radiofrequency ablation (RFA) of the L5 dorsal ramus and S1-3 (or S4) lateral branches is supported by numerous studies 4
• Cooled radiofrequency ablation has the strongest evidence among RFA techniques 4
• After failed SI joint intra-articular steroid injection, cooled RF or standard RF can be considered (weak recommendation) 3

Fourth-Line Treatment Options

• SI joint fusion may be considered for patients who fail conservative and interventional treatments 5, 6
• Minimally invasive SI joint fusion has shown effectiveness in reducing pain and improving function in patients with chronic SI joint pain 5, 7
• Patients must demonstrate at least 70% pain relief from diagnostic SI joint injections to be considered appropriate candidates for SI joint fusion 2, 5

Special Considerations

• For patients with inflammatory sacroiliitis (such as in spondyloarthropathies), TNF inhibitors are strongly recommended over no treatment with TNFi when NSAIDs fail 3
• Secukinumab or ixekizumab are strongly recommended for active ankylosing spondylitis with sacroiliitis that fails NSAID therapy 3
• Novel treatments being investigated include prolotherapy with dextrose water, platelet-rich plasma, and subcutaneous spinal cord stimulation 3, 8

Treatment Algorithm

1. Begin with NSAIDs and physical therapy (supervised exercise) for 4-6 weeks 3, 4
2. If inadequate response, proceed to intra-articular or peri-articular SI joint corticosteroid injection 3, 1
3. For patients with >50% relief lasting at least 2 months, repeat injections may be appropriate when symptoms recur 1
4. For patients with inadequate response to injections, radiofrequency ablation (preferably cooled RFA) should be considered 3, 4
5. For persistent pain despite RF procedures, minimally invasive SI joint fusion may be considered in patients with confirmed SI joint pain (>70% relief with diagnostic blocks) 2, 5

Common Pitfalls

• Proceeding with SI joint interventions without confirming the SI joint as the primary pain generator can lead to treatment failure 2
• Using fewer than 3 positive provocative tests reduces the specificity for diagnosing SI joint pain 3, 1
• Failing to consider inflammatory causes of sacroiliitis that may require specific disease-modifying treatments 3
• Performing SI joint fusion without adequate diagnostic confirmation exposes patients to surgical risks without high likelihood of benefit 2