The evidence for Sacroiliac Joint Dysfunction as the cause of your continued low back pain
In this article, Ross Hauser, MD updates information based on new research on the problems of low back pain as it relates to sacroiliac joint dysfunction. Dr. Hauser will explore research on surgery and non-surgical options treatment including the use of Comprehensive Prolotherapy, Platelet Rich Plasma Prolotherapy, and Stem Cell Prolotherapy.
The hunt for a disc problem leads many to an inconclusive diagnosis and treatments destined to fail people with low back pain.
No one is looking at the ligaments of the Sacroiliac Joint
The treatment and diagnosis of sacroiliac joint dysfunction are complex and confusing. This is why there is no gold standard of treatment. However, there is no gold standard of treatment if you are hunting disc disease as the problem.
- I am going to start presenting evidence in this article that many people can have their sacroiliac joint dysfunction healed if the focus of their treatment turns from looking at disc disease to looking at spinal ligament damage and weakness. Further, we will discuss new and archival research which shows Prolotherapy injections to be a “high value,” treatment.
I have an MRI that shows degenerative disc disease. No one said anything to me about sacroiliac joint dysfunction.
Often people will come into our office with an MRI that shows disc herniation, disc protrusion or bulging disc, or degenerated discs. The MRI is all about the disc, disc, and disc. Most people who injure their back significantly enough to visit a health care provider think that this injury is an acute event. For those of us in the regenerative medicine field, for the many patients we see, this is an acute event that sits on top of years of degenerative wear and tear. The straw has finally broken the camel’s back or, in this instance, the sacroiliac joint.
The center of the spine is where the discs are. The sides of the spine are where the ligaments are. If pain is from the side, your pain is likely a ligament problem.
When people injure their lower back acutely enough to seek medical care, they usually injure it when they bend and twist to the side. When they come into our office and we perform a physical examination, the patient will complain that the pain is coming from the side, not the center of the back. Why is this designation important? Because the center is where the discs are. The sides are where the ligaments are.
The Sacroiliac joint is a huge joint that sits in a sea of ligaments that holds the lower back in place. Yet when people come into our office seeking a non-surgical option to their back pain they do not even know what the sacroiliac joint is because no one has discussed this joint as being a problem. Only the discs.
You are here because of failed prior treatments that focused on your discs. Challenges facing doctor and patient in treating Sacroiliac Joint Dysfunction
In December 2017, doctors at the University of Colorado published in The Journal of Bone and Joint Surgery, their paper “Diagnosis and Management of Sacroiliac Joint Dysfunction.” Here they summarized the challenges facing doctor and patient in treating Sacroiliac Joint Dysfunction.
Symptoms that suggest that the sacroiliac joint (SIJ), as opposed to the pathology of the lumbar spine or hip, may be a source of pain include pain with:
- position changes, such as standing from a seated position or sitting on a hard surface.
- Radiation to the groin or Fortin area (the low back area that signals Sacroiliac Joint Dysfunction in provocative testing such as the Fortin Finger test) also suggest sacroiliac joint as a source.
- Doctors should explore various methods of determining Sacroiliac Joint Dysfunction, including pain referral patterns, provocative maneuvers (a physical examination that tries to isolate the pain source, as in the Fortin finger Test), and response to injections.
Suggestion of treatments
- While its effectiveness remains unsubstantiated, manipulation of the Sacroiliac Joint is noninvasive and warrants consideration as an initial treatment. (Please see our companion article Why physical therapy and yoga did not help your low back pain).
- The diagnostic validity of local anesthetic and/or corticosteroid injections is difficult to assess as the criteria for a positive response are not uniform in the literature, and evidence to support intra-articular injections (anti-inflammatories) for therapeutic purposes is weak.
- SIJ fusion appears to be emerging as an acceptable treatment for patients with difficult to treat SIJ dysfunction; however, only a few long-term outcome studies have been done. (This is discussed below)
- New minimally invasive fusion techniques appear to decrease the morbidity of open procedures with at least comparable outcomes.(1) (Please see our companion article Minimally invasive spinal surgery procedures research).
Research like that above shows that there is no consensus in the medical community, based on very most recent research, that can quantify the amount of pain symptoms sacroiliac joint dysfunction causes or even determine if that pain is, in fact, coming from the sacroiliac joint. This understanding of the non-understanding of where sacroiliac joint comes from has concerned some researchers about recommending patients for sacroiliac joint fusion surgery and, further, why it should not be recommended.
If the research above makes Sacroiliac Joint Dysfunction sound confusing listen to what research published in the International Journal of Spine Surgery suggests about nerve blocks.
The research clinicians say to diagnose sacroiliac joint dysfunction as the cause of pain, you need to be able to find, treat, and alleviate that pain. Typically this is done with a nerve block that offers some degree of sacroiliac pain relief. But . . .
- “The degree of pain relief required to diagnose sacroiliac joint dysfunction following a diagnostic Sacroiliac joint block is not known. No gold standard exists. . . ” and
- “The degree of pain improvement during Sacroiliac joint block did not predict improvements in pain or ODI scores (levels of disability scoring) after spinal fusion.”
- Finally, the determination that “A 50% Sacroiliac joint block threshold (pain reduction) resulted in excellent post-Sacroiliac joint fusion responses. Using overly stringent selection criteria (i.e. 75% in pain reduction) to qualify patients for Sacroiliac joint fusion has no basis in evidence and would withhold a beneficial procedure from a substantial number of patients with SIJ dysfunction.”(2)
- if a nerve block was seen to offer a 50% reduction in pain, then surgeons should proceed with fusion.
- In our office, we would try much less invasive Prolotherapy first. Because the study above still recommends patients should get spinal fusion surgery even without clear evidence to suggest it would work. Please also see my article Failed Back Surgery Syndrome.
If making the diagnosis is difficult, why are doctors rushing to send their patients to unnecessary and possibly dangerous spinal fusion surgery? “Sacroiliac Fusion: Another Magic Bullet Destined for Disrepute”
In the July 2017 edition of the medical journal Neurosurgery clinics of North America, doctors at the Division of Neurosurgery, Banner University Medical Center, in Arizona said this about sacroiliac joint pain, draw your own conclusion:
“Pain related to joint dysfunction can be treated with joint fusion; this is a long-standing principle of musculoskeletal surgery. However, pain arising from the sacroiliac joint is difficult to diagnose. Several implant devices (fusion techniques) are available that promote fusion by simply crossing the joint space.
(However) Evidence establishing (successful fusion) outcomes is misleading because of vague diagnostic criteria, flawed methodology, bias, and limited follow-up.
Because of nonstandardized indications and historically inferior reconstruction techniques, SI joint fusion should be considered unproven. The indications and procedure in their present form are unlikely to stand up to close scrutiny or weather the test of time.”
I want to point out that the title of the above research is “Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute.”(3)
When successful spinal surgery causes sacroiliac joint-related pain
Doctors in Germany examined a potential connection between lumbar decompressive surgery and new onset of sacroiliac joint-related pain causing a diagnosis of “failed-back-surgery.”
Here is what they said in their published research in the medical journal Clinical neurology and neurosurgery:
- Patients with lumbar stenosis do have substantially positive results from decompressive surgery.
- HOWEVER, the change of body position and walking behavior (anatomical alteration) after successful surgery might lead to changed force effects on the entire spine and on the sacroiliac joint in the future.
In other words, lumbar decompression surgery changed the patient’s natural movement to one that irritated the and caused Sacroiliac joint pain-related pain after surgery. HOW is this successful surgery?
- The doctors concluded that: “Lumbar decompression patients should be informed about this possible condition to avoid uncertainty, discontent, unnecessary diagnostics and to induce a quick, specific treatment.”(4) In other words a diagnosis of a “failed-back-surgery.”
Sacroiliac joint inflammation – Sacroiliitis
- A patient suffering from Sacroiliac joint dysfunction symptoms may have pain from inflammation, commonly referred to as sacroiliitis.
Sacroiliac joint inflammation is a difficult diagnosis to determine as it may come from an infectious disease or be caused by a rheumatology disorder. For many patients, inflammation of the sacroiliac joint is NOT caused by infectious disease but by chronic degenerative inflammation including ankylosing spondylitis (chronic joint inflammation between the vertebrae between the spine and pelvis). In some cases, a rheumatologist will be consulted.
Sacroiliitis pain and symptoms include pain on one side of the lower back (unilateral sacroiliitis – one of the SI joints is inflamed) or both sides (bilateral sacroiliitis, both SI joints are inflamed).
Sacroiliitis can also be brought on by wear and tear osteoarthritis, by impact or acute traumatic injury. Pregnancy may also be a cause.
The first thing the doctor may offer you is anti-inflammatory medications, a sacral belt (low spine support brace), and a recommendation to change your activities and/or lifestyle to avoid more stress on the sacroiliac joint. Some doctors may suggest cortisone into the sacroiliac joint and warn the patients of possible cortisone injection side effects.
However, this approach may not be addressing the problems that weakened or damaged spinal ligaments are the cause of sacroiliac joint instability and chronic inflammation. This will be addressed below.
SI joint dysfunction defined as spinal instability from deficient ligament strength in the posterior elements of the SI joint
In the journal Clinical Medicine Insights. Arthritis and musculoskeletal disorders, Danielle Steilen-Matias, PA-C described the source of low back and buttock pain as related to the sacroiliac (SI) joint is present in as many as 15%–30% of back pain patients and perhaps up to 40% in patients who have had a previous lumbar fusion.
- SI joint dysfunction may also produce pain similar to a herniated lumbar disk along the same sciatic nerve distribution.
- Low back pain patients who remain symptomatic despite tailored physiotherapy are believed to possess deficient ligament strength in the posterior elements of the SI joint, resulting in insufficient stability to permit effective muscle recruiting strategies.
- Experimental studies have found prolotherapy effective in stimulating the production of collagen fibers, thus strengthening ligaments.(5)
Before I continue with the research on Prolotherapy for sacroiliac joint dysfunction, I would like to reinforce the argument that we need to shift focus away from the problems of the discs to problems of the ligaments in treating Sacroiliac joint dysfunction.
Spinal ligaments identified as a point of interest in treating Sacroiliac joint dysfunction treatment
Doctors from the Low Back Pain and Sacroiliac Joint Center, Sendai Shakaihoken Hospital in Japan wrote of their findings in the European Spine Journal, that said referred pain from the sacroiliac joint can be isolated to the anterior ligament sacroiliac joint region, and that by treating the ligaments pain can be alleviated. (6)
This is an interesting study in that it discusses referral pain patterns. It has been well established that an injury in one part of the body can affect other, distant body parts, especially in regard to a ligament injury.
Here the Japanese doctors speculated that the sacroiliac joint may be the cause of pain in other parts of the pelvic region and that these pain origins may be centralized to the joint’s posterior ligamentous region.
The doctors divided the posterior sacroiliac joint into four sections-upper = section 1, middle = section 2, lower = section 3, and other (cranial portion of the ilium outside the SIJ – in the illustration above that would be the left most white band in the left side panel) = section 0.
- Referred pain from SIJ section 0 was mainly located in the upper buttock along the iliac crest;
- Referred pain from section 1, around the posterosuperior iliac spine; (the low back area of the iliac)
- Referred pain from section 2, in the middle buttock area;
- Referred pain from section 3, in the lower buttock.
- In all, 22 (44.0 %) patients complained of groin pain, which was slightly relieved by lidocaine injection into SIJ sections 1 and 0.
The research team concluded: “Dysfunctional upper sections of the sacroiliac joint are associated with pain in the upper buttock and lower sections with pain in the lower buttock. Groin pain might be referred from the upper SIJ sections.”
There is so much to discuss here.
- Foremost, the patients in this study had pain from the ligaments of the sacroiliac joint region.
- What if they were sent to traditional treatment, that is a spinal fusion surgery?
- Will the fusion help or hurt these patients?
- If anything the surgery will damage already damaged ligaments and create a high risk for Failed Back Surgery Syndrome.
Spinal ligaments identified as a point of interest in treating groin pain related to sacroiliac joint dysfunction
The investigation expanded. In a paper from October 2017, the same Japanese research team publishing in the medical journal Clinical neurology and neurosurgery looked to identify the prevalence of groin pain in patients with sacroiliac joint dysfunction, lumbar spinal canal stenosis, and lumbar disc herniation who did not have hip disorders.
They looked at:
- 127 patients (57 men, 70 women, average age 55 years) with sacroiliac joint dysfunction
Then they looked at
- the pain areas in the buttocks and back; including pain increase while in positions such as sitting, lying supine, and side-lying; an sacroiliac joint dysfunction shear test (manual physical examination of range of motion); and four tender points composed of the posterior superior iliac spine (PSIS), long posterior sacroiliac ligament (LPSL), sacrotuberous ligament (STL), and iliac muscle.
- Fifty-nine (46.5%) patients with sacroiliac joint dysfunction had groin pain, In these patients, pain provoked by the sacroiliac joint dysfunction shear test and the tenderness of the posterior superior iliac spine and long posterior sacroiliac ligament were significant physical signs that differentiated sacroiliac joint dysfunction from lumbar stenosis and lumbar disc herniation.
- The prevalence of groin pain in patients with sacroiliac joint dysfunction dysfunction was higher than in those with lumbar stenosis and lumbar disc herniation.
- When patients who do not have hip disorders complain of groin and lumbogluteal pain, not only lumbar disorders but also sacroiliac joint dysfunction should be considered.
In other words, there was a link up between groin pain and low back pain.(7)
Treating the ligaments also presents a pain solution in sacroiliac joint pain treatment where some doctors say a solution does not exist.
Recently, published research in the medical journal Pain Physician said:
- Doctors generally accept that approximately 10% to 25% of patients with persistent low back pain may have pain arising from the sacroiliac joints.
- Despite understanding this, there are currently no definite conservative, interventional, or surgical management options for managing sacroiliac joint pain in these persistent low back pain 10% to 25% of patients. (8)
Further, the paper documents treatments that they assess as fair or poor treatments for Sacroiliac joint dysfunction
- The evidence for cooled radio frequency neurotomy in managing sacroiliac joint pain is fair.
- The evidence for the effectiveness of intraarticular steroid injections is poor.
- The evidence for periarticular injections of local anesthetic and steroid or botulinum toxin is poor.
- The evidence for the effectiveness of conventional radiofrequency neurotomy is poor.
- The evidence for pulsed radio frequency is poor.
- A lot of poor results.
Are poor sacroiliac joint pain treatments better than no treatments?
Recently doctors said that image-guided injections of the epidural space and of the sacroiliac joints are effective techniques for the treatment of pain; their effectiveness is sometimes not lasting for long periods of time, but considering the low associated risk when performed by trained personnel, they can be easily repeated. That was published in the European journal of radiology.(9)
Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction
We have found that it is fairly rare for people’s SI/back pain to be caused by a pinched nerve or by a slipped or herniated disc. Much more common is a ligament injury which caused ligament laxity or ‘looseness.’
In the scholarly journal Spine, a 1995 article written by A. Schwarzer wrote:
- “ligament laxity in the sacroiliac joint is the number one reason for ‘Sciatica’, or pain radiating down the side of the leg, and is one of the most common reasons for chronic low back pain.”(10)
Our clinical experience has been that if we treat back pain with Prolotherapy, administering injections into the lumbar and SI ligament attachments that exhibit tenderness, the pain and referred pain diminishes, even when MRI’s showed disc abnormalities. The injections are not given near the discs yet the back pain is completely healed.
Ligaments are bands of fibrous tissue that connect bones to each other, like the vertebrae to each other and the sacrum to the pelvis. The sacrum is the part of the spine below the fifth and last lumbar vertebrae and above the coccyx. The uppermost portion of our pelvis is called the ilium. The area that connects these structures is the sacroiliac joint (SI): sacro from the sacrum, iliac from the ilium.
Returning to the opening of this article – the diagnosis of sacroiliac (SI) pain is tricky.
Doctors from the Netherlands wrote in the journal Pain Physician: Although the prevalence of sacroiliac joint pain is relatively high there is no unambiguous reference standard to diagnose sacroiliac joint pain pain. Pressure tenderness (palpitation) in the sacroiliac joint pain region is used for diagnostic purposes and it appears to be a reliable method.(11)
There are several diagnostic clues that low back pain (and referral pain into the buttock or leg) is related to the sacroiliac joint and the ligaments
The prefered diagnostic method of a skilled Prolotherapist has always been palpitation – gently press down with your thumb to reproduce pain. “X” then makes that spot. See our article on the Accuracy of MRI for assessing treatment.
There are several diagnostic clues that low back pain (and referral pain into the buttock or leg) is related to the sacroiliac joint:
- When asked to pick the spot from which pain emulates, people almost always point to the top of the sacroiliac joint.
- When asked when makes the pain worse, patients usually mention positions that increase the force on the sacroiliac joint, such as sitting.
- When asked which positions make the pain better, patients will describe positions that decrease the force on the sacroiliac joint, such as lying down with the knees bent or on their sides with a pillow between the legs.
- When describing their pain, it is mostly in the lower back, off midline, and in a sacroiliac ligament referral pattern that is almost always very low in the back and involves the buttocks. The pain pattern involves a numb feeling but no true numbness, and it skips the knee. True nerve entrapment involving the sciatic nerve from a herniated disc or a pinched nerve from a bone spur characteristically is most severe down the leg, involving the knee and going into the foot, and the patient has some true loss or decrease in feeling (sensation).
- Physical examination stressor maneuvers on the sacroiliac joint.
- Plain radiographs show sclerosis on one (or both) of the sacroiliac joints, indicating increased force on the subchondral bone there
Research: the case for Prolotherapy as non-surgical treatment of sacroiliac joint dysfunction and low back instability
As far back as 2009, Caring Medical has published research on outcome results in patients receiving Prolotherapy for low back pain. Here are the findings reported on 145 patients with unresolved lower back pain in the Journal of Prolotherapy:
- One hundred forty-five patients, who had been in pain an average of four years and ten months, were treated quarterly with Prolotherapy.
- This included 55 patients who were told that there were no other treatment options for their pain and 26 patients who were told by their doctor(s) that surgery was their only option.
In these 145 low backs:
- pain levels decreased after Prolotherapy; 89% experienced more than 50% pain relief with Prolotherapy;
- more than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability;
- 75% percent were able to completely stop taking pain medications.
The decrease in pain reached statistical significance for the 145 low backs, including the subset of patients who were told there was no other treatment options for their pain and those who were told surgery was their only treatment option.(12)
April 2018 Department of Veterans Affairs research on Prolotherapy
Doctors from the Department of Veterans Affairs, Northern California Health Care System, examined the role of Prolotherapy injections in helping patients with sacroiliac joint instability. Publishing in the journal Complementary therapies in medicine, the researchers were able to conclude that “a satisfactory proportion of patients with symptomatic sacroiliac joint instability as an etiology of low back pain can have clinically meaningful functional gains with prolotherapy treatment. The patients who are not likely to improve with prolotherapy are generally evident by lack of improvement following the initial prolotherapy injection.”(13)
- In this study, patients referred for low back pain and diagnosed with SI joint instability received a series of three sacroiliac joint prolotherapy injections (15% dextrose in lidocaine) at approximately a one-month interval.
- Of 103 treated patients returning for post-treatment follow-up at a median of 117 days:
- 24 (23%) showed a minimum clinically important improvement despite an average 2 years with low back pain
- Much of the improvement was evident after the initial prolotherapy injection.
More research Prolotherapy Injections a non-surgical alternative for SI pain
Research appearing in the Journal of Alternative and Complementary Medicine from doctors at the Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital in Korea, stated that “Prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections”(14)
Also in 2010, a well-received study from Dr. Manuel F Cusi, of the Sydney School of Medicine, the University of Notre Dame published in the British Journal of Sports Medicine found positive clinical outcomes for the 76% of patients with sacroiliac joint problems.(15)
- In this study, all patients included in this study attended at least one follow-up visit at 3, 12 or 24 months.
- This descriptive study of prolotherapy in private practice has shown positive clinical outcomes for the 76% of patients who attended the 3-month follow-up visit (76% at 12 months and 32% at 24 months).
Prolotherapy Injections a non-surgical alternative for SI pain
Prolotherapy is an injection treatment that stimulates the repair of connective tissues such as tendons and ligaments. It causes a mild inflammatory response which initiates an immune response. This mimics what the body does naturally to heal soft tissue injuries.
The most common pelvic instability is sacroiliac instability, caused by injuries to the stabilizing ligaments of the sacroiliac joint. These ligaments are typically injured through the combined movements of spinal flexion and rotation.
In 1956, George S. Hackett, M.D. introduced the term “Prolotherapy” in the first edition of his book, entitled “Ligament and Tendon Relaxation Treated by Prolotherapy.”
In it, he stated, “A joint is only as strong as its weakest ligament.” This was the first comprehensive text describing the research and technique of using Prolotherapy to cure chronic pain. In regards to low back pain, Dr. Hackett found that about 90 percent of the patients had evidence of some type of ligament laxity, typically of the sacroiliac joint.
- In one of his analyses, of the 1857 patients treated for ligament laxity in the lower back, 1583 experienced sacroiliac ligament relaxation.
- In his experience, 82 percent of people with this condition are cured with Prolotherapy. As he stated it, “At the end of 14 years, a survey revealed that 82 percent of 1,178 patients treated with Prolotherapy considered themselves cured. I believe that I am now curing about 90 percent of the patients with instability of joints due to ligamentous relaxation to their satisfaction.”
Dr. Hackett’s results were published in the Journal of the American Medical Association in 1957.(16)
Platelet Rich Plasma and Prolotherapy Injections a non-surgical alternative for SI pain and long-term results
Platelet Rich Plasma or PRP involves the application of concentrated platelets, which release growth factors to stimulate recovery in non-healing injuries.
New research from a team of university researchers in India, writing in the journal Pain Practice says that “Despite widespread use of steroids to treat sacroiliac joint pain, their duration of pain reduction is short. Platelet-rich plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain.”
In this research, Forty patients with chronic low back pain diagnosed as sacroiliac joint pain were divided into 2 groups, steroid group and PRP group.
- Intensity of pain was significantly lower in the PRP group 6 weeks after treatment as compared to the steroid group.
- The efficacy of steroid injection was reduced to 25% at 3 months while it was 90% in the PRP group.
- A strong association was observed in patients receiving PRP and showing a reduction in pain scores. The researchers concluded: The intra-articular PRP injection is an effective treatment modality in low back pain involving sacroiliac joint pain.”(17)
Doctors at the University of Toronto have published four case studies investigating the long-term benefit of platelet-rich plasma (PRP) injections reducing SI joint pain, improving quality of life, and maintaining a clinical effect.
At follow-up 12-months post-treatment, pooled data from all patients reported a marked improvement in joint stability, a statistically significant reduction in pain, and improvement in quality of life.
The clinical benefits of PRP were still significant at 4-years post-treatment. Platelet-rich plasma therapy exhibits clinical usefulness in both pain reduction and for functional improvement in patients with chronic SI joint pain. The improvement in joint stability and low back pain was maintained at 1- and 4-years post-treatment.(18)
More than one PRP injection
Many of the “prolotherapy failures” from other clinics that we see at Caring Medical Regenerative Medicine Clinics are not because of the wrong diagnosis but from the treatment not being thorough enough. Since anatomically there is a continuous connection from the iliolumbar-sacroiliac-sacrotuberous-sacrospinous ligaments it is important to treat these ligaments thoroughly with Prolotherapy and PRP in order for the whole ligament complex to regain its tautness and strength.
If you have questions about Sacroiliac joint pain, Get Help and Information from our Caring Medical staff
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