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

Treatment of Sacroiliac Joint Dysfunction

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 reserve minimally invasive SI joint fusion only for patients with confirmed diagnosis (≥3 positive provocative tests AND >70-80% relief with diagnostic blocks) who fail all conservative and interventional treatments. 1

Initial Conservative Management

Start all patients with NSAIDs combined with active physical therapy as first-line treatment. 1, 2

• NSAIDs are strongly recommended as first-line pharmacological treatment for SI joint pain with demonstrated efficacy in reducing pain and improving function 3, 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agent or selective COX-2 inhibitor 3
• Supervised exercise programs (land-based physical therapy) are strongly recommended over passive interventions and should focus on pelvic girdle stabilization with targeted stretching 1, 4
• Land-based physical therapy is conditionally recommended over aquatic therapy interventions 1
• Patient education regarding the condition and self-management strategies should be incorporated 3
• Continue this conservative approach for 4-6 weeks before escalating treatment 1

Interventional Treatment for Inadequate Response

If conservative management fails after 4-6 weeks, proceed to intra-articular or peri-articular SI joint corticosteroid injection. 1, 2

• Intra-articular SI joint injections with corticosteroids have moderate-level evidence for short-term effectiveness 1
• Peri-articular (extra-articular) injections may also be therapeutic, with some evidence suggesting potentially greater response rates compared to intra-articular injections 1
• If initial injection provides ≥50% relief for ≥2 months, repeat injection with steroid is appropriate 2
• Consider prolotherapy with dextrose water as an alternative, which has shown superior results (64% achieving 50% pain relief at 6 months) compared to corticosteroid injections (27%) 2

Radiofrequency Ablation for Persistent Pain

For patients who fail SI joint corticosteroid injections, cooled radiofrequency ablation has the strongest evidence among RFA techniques. 1, 5

• Cooled RFA targeting the L5 dorsal ramus and S1-3 (or S4) lateral branches demonstrates the strongest evidence for efficacy 1, 5
• Extensive lesioning strategies with cooled RFA are preferred over conventional RFA techniques 5
• The reported complication rate for SI joint radiofrequency treatment is low 5

Special Considerations for Inflammatory Sacroiliitis

For patients with inflammatory sacroiliitis (associated with spondyloarthropathy) who fail NSAIDs, TNF inhibitors are strongly recommended. 3, 2

• Adding TNF inhibitors (etanercept, adalimumab, infliximab, golimumab) is strongly recommended over continued NSAID monotherapy for active sacroiliitis despite NSAIDs 3, 2
• Bridging therapy with limited course of oral glucocorticoids (<3 months) during initiation or escalation of therapy is conditionally recommended 3
• Intra-articular glucocorticoid injection of the sacroiliac joints as adjunct therapy is conditionally recommended 3
• IL-17 inhibitors (secukinumab or ixekizumab) are conditionally recommended as alternatives to TNF inhibitors, though TNF inhibitors are preferred as first-line biologic therapy 2
• Systemic glucocorticoids for ongoing management are strongly recommended against 2
• Sulfasalazine is conditionally recommended for patients who have contraindications to or have failed TNF inhibitors 3
• Methotrexate monotherapy is strongly recommended against for sacroiliitis 3

Surgical Fusion: Strict Criteria Required

Minimally invasive SI joint fusion should only be considered for patients meeting ALL of the following criteria: 1, 6, 2

Mandatory Diagnostic Requirements:

• At least 3 positive provocative physical examination tests (provides 94% sensitivity and 78% specificity) 1, 6, 2
• Dual diagnostic blocks with >70-80% concordant pain relief to confirm SI joint as primary pain generator (diagnostic specificity 78%) 6, 2
• Pain relief must last at least the duration of the local anesthetic to be considered valid 6

Mandatory Treatment Failures:

• Failed adequate trial of NSAIDs and supervised physical therapy 1
• Failed therapeutic SI joint corticosteroid injections 1, 2
• Failed cooled radiofrequency ablation 1
• For inflammatory sacroiliitis: failed TNF inhibitor therapy 2

Key Point on Fusion:

Minimally invasive SI joint fusion shows effectiveness in reducing pain and improving function, but patient selection based on validated diagnostic criteria is critical for success 1, 6

Common Pitfalls to Avoid

Do not proceed with interventional treatments without confirming the SI joint as the primary pain generator. 1, 6

• Using fewer than 3 positive provocative tests dramatically reduces specificity (drops to 66% with 2 tests, 44% with only 1 test), increasing risk of misidentifying the pain generator 6
• A single therapeutic injection does not meet diagnostic criteria for surgical fusion 2
• Proceeding with SI joint fusion without meeting strict diagnostic criteria exposes patients to surgical risks without high likelihood of benefit 1, 6
• Failing to consider inflammatory causes of sacroiliitis (spondyloarthropathy) that require disease-modifying biologic treatments can lead to inadequate treatment 1, 2
• The presence of confounding factors (lumbar spinal stenosis, post-laminectomy syndrome, bilateral conditions) can reduce diagnostic precision and increase surgical complication risk 6