What are the treatment options for sacroiliac (SI) joint pain that worsens with walking?

Treatment of Sacroiliac Joint Pain Worsening with Walking

For sacroiliac joint pain that worsens with walking, begin with NSAIDs and supervised physical therapy for 4-6 weeks, then proceed to intra-articular corticosteroid injections if inadequate response, followed by cooled radiofrequency ablation for persistent pain, and finally consider minimally invasive SI joint fusion for refractory cases. 1

Initial Diagnostic Confirmation

Before initiating treatment, confirm SI joint as the pain generator:

• At least 3 of 5 positive provocative physical examination tests are required (sensitivity 94%, specificity 78%) 1
• Pain typically localizes to the sacrum, buttock, and posterior thigh region 1
• Diagnostic SI joint injection with ≥70-80% pain relief confirms the diagnosis 1
• Consider inflammatory causes (sacroiliitis/spondyloarthropathy) in patients <45 years with pain >3 months duration 2

Common Pitfall: Proceeding with SI joint interventions without confirming the SI joint as the primary pain generator leads to treatment failure 1. Using fewer than 3 positive provocative tests reduces diagnostic specificity 1.

First-Line Treatment (4-6 Weeks)

NSAIDs

• Strongly recommended as first-line therapy for active sacroiliitis 2, 1
• Should be used as adjunct therapy for SI joint pain 1

Physical Therapy

• Supervised exercise (active interventions) strongly recommended over passive interventions 1
• Land-based physical therapy conditionally recommended over aquatic therapy 1
• Particularly important for patients with or at risk for functional limitations 2
• Should include pelvic stabilization exercises for dynamic postural control and muscle balancing of trunk and lower extremities 3

Second-Line Treatment: Corticosteroid Injections

If inadequate response to NSAIDs and physical therapy after 4-6 weeks:

• Intra-articular SI joint corticosteroid injections have moderate-level evidence for short-term effectiveness 1, 4
• Peri-articular (extra-articular) injections may also be therapeutic, with some research suggesting potentially greater response rates 1
• Conditionally recommended for isolated active sacroiliitis despite NSAIDs 1
• Can produce pain relief for >3 months in some patients 5

Bridging Therapy: For high disease activity with limited mobility and significant symptoms, a short course (<3 months) of oral glucocorticoids during treatment initiation may be considered 2

Third-Line Treatment: Radiofrequency Ablation

For patients with inadequate response to injections:

• Cooled radiofrequency ablation has the strongest evidence among RFA techniques 1, 5
• Targets L5 dorsal ramus and S1-3 (or S4) lateral branches 5
• Conventional (80°C) or thermal (67°C) radiofrequency ablation of medial branch nerves should be performed for low back pain when previous diagnostic/therapeutic injections provided temporary relief 2
• Water-cooled radiofrequency ablation may be used for chronic sacroiliac joint pain 2

Fourth-Line Treatment: Surgical Fusion

For persistent pain despite conservative and interventional treatments:

• Minimally invasive SI joint fusion recommended for patients with confirmed SI joint pain (>70% relief with diagnostic blocks) who fail RF procedures 1, 4
• Shows effectiveness in reducing pain and improving function in chronic SI joint pain 1
• Percutaneous SI arthrodesis recommended as first-line surgical treatment due to improved safety profile compared with open arthrodesis 4
• Open arthrodesis reserved for revision surgery, nonunion, and aberrant anatomy 4

Common Pitfall: Performing SI joint fusion without adequate diagnostic confirmation (>75% relief with SI injection) exposes patients to surgical risks without high likelihood of benefit 1, 4

Special Considerations for Inflammatory Sacroiliitis

If inflammatory sacroiliitis/spondyloarthropathy is suspected or confirmed:

Initial Imaging

• X-ray of sacroiliac joints and spine are the appropriate initial imaging studies (rating 9/9) 2
• If radiographs negative or equivocal, MRI sacroiliac joints without IV contrast (rating 8/9) 2

Biologic Therapy

• TNF inhibitors strongly recommended over no treatment when NSAIDs fail 2, 1
• Adding TNFi strongly recommended over continued NSAID monotherapy 2
• Secukinumab or ixekizumab strongly recommended for active ankylosing spondylitis with sacroiliitis that fails NSAID therapy 1
• Sulfasalazine conditionally recommended for patients with contraindications to or failed TNFi 2
• Methotrexate monotherapy strongly recommended against 2

Common Pitfall: Failing to consider inflammatory causes of sacroiliitis that may require specific disease-modifying treatments (TNFi, IL-17 inhibitors) leads to inadequate treatment and disease progression 1.

Alternative/Emerging Therapies

• Subcutaneous spinal cord stimulation has shown success in case reports for bilateral SI joint pain refractory to other treatments 6
• Prolotherapy and conventional radiofrequency ablation may offer potential benefit, though limited data support their use as primary treatment 4