Sacroiliac joint dysfunction and focus on spinal ligaments instability | Prolotherapy and PRP Prolotherapy treatments

Sacroiliac joint dysfunction treatment

Ross Hauser, MD

In this article, Ross Hauser, MD updates information based on new research on the problems of low back pain as it relates 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 an answer for sacroiliac joint dysfunction leads many to a inconclusive diagnosis and treatments destined to fail

The treatment and diagnosis of sacroiliac joint dysfunction is 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.

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. We will return to this paper later in this article.

Symptoms that suggest that the sacroiliac joint (SIJ), as opposed to pathology of the lumbar spine or hip, may be a source of pain include pain with:

Suggestion of treatments

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 this sounds confusing listen to what research published in the International Journal of Spine Surgery suggests:

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 . . .

In summary:

If making the diagnosis is difficult, why are doctors rushing to send their patients to unnecessary and possibly dangerous spinal fusion surgery? Draw your own conclusion from this research

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:

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?

Sacroiliac joint dysfunction

Sacroiliac joint inflammation – Sacroiliitis

Sacroiliac joint inflammation is a difficult to determine diagnosis 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 in between the spine and pelvis). In some causes 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.

Making the case for treating sacroiliac joint dysfunction by treating the spinal ligaments

Sacroiliac joint dysfunction | PRP and Prolotherapy

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  described the 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.

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 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.

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.

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 dysfunctionlumbar spinal canal stenosis, and lumbar disc herniation who did not have hip disorders.

They looked at:

Then they looked at

RESULTS:

Conclusion:

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:

Further, the paper documents treatments that they assess as fair or poor treatments for Sacroiliac joint dysfunction

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:

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)

Sacroiliac joint dysfunction 2

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:

  1. When asked to pick the spot from which pain emulates, people almost always point to the top of the sacroiliac joint.
  2. When asked when makes the pain worse, patients usually mention positions that increase the force on the sacroiliac joint, such as sitting.
  3. 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.
  4. 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).
  5. Physical examination stressor maneuvers on the sacroiliac joint.
  6. 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 is what was reported on findings of 145 patients with unresolved lower back pain in the Journal of Prolotherapy:

In these 145 low backs:

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)

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 and cited study from Dr Manuel F Cusi, of the Sydney School of Medicine, 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)

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.

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.

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

1 Ou-Yang DC, York PJ, Kleck CJ, Patel VV. Diagnosis and Management of Sacroiliac Joint Dysfunction. JBJS. 2017 Dec 6;99(23):2027-36. [Google Scholar]
2 Polly D, Cher D, Whang PG, Frank C, Sembrano J, INSITE Study Group. Does level of response to SI joint block predict response to SI joint fusion?. International journal of spine surgery. 2016;10. [Google Scholar]
3 Bina RW, Hurlbert RJ. Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute. Neurosurgery Clinics of North America. 2017 Jul 31;28(3):313-20. [Google Scholar]
4 Schomacher M, Kunhardt O, Koeppen D, Moskopp D, Kienapfel H, Kroppenstedt S, Cabraja M. Transient sacroiliac joint-related pain is a common problem following lumbar decompressive surgery without instrumentation. Clinical neurology and neurosurgery. 2015 Dec 31;139:81-5. [Google Scholar]
5 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2016 Jan;9:CMAMD-S39160. [Google Scholar]
6 Kurosawa D, Murakami E, Aizawa T. Referred pain location depends on the affected section of the sacroiliac joint. European Spine Journal. 2015 Mar 1;24(3):521-527. [Google Scholar]
7 Kurosawa D, Murakami E, Aizawa T. Groin pain associated with sacroiliac joint dysfunction and lumbar disorders. Clinical Neurology and Neurosurgery. 2017 Aug 30. [Google Scholar]
8 Hansen H, Manchikanti L, Simopoulos TT, Christo PJ, Gupta S, Smith HS, Hameed H, Cohen SP. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2012 May-Jun;15(3):E247-78. [Google Scholar]
9 D’Orazio F, Gregori LM, Gallucci M. Spine epidural and sacroiliac joints injections–when and how to perform. European journal of radiology. 2015 May 31;84(5):777-82. [Google Scholar]
10 Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine. 1995 Jan 1;20(1):31-7. [Google Scholar]
11 van Leeuwen RJ, Szadek K, de Vet H, Zuurmond W, Perez R. Pain pressure threshold in the region of the sacroiliac joint in patients diagnosed with sacroiliac joint pain. Pain physician. 2016 Mar 1;19(3):147-54. [Google Scholar]
12 Hauser R, Hauser M, Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study Journal of Prolotherapy. 2009;3:145-155. [Google Scholar]
13 Hoffman MD, Agnish V. Functional outcome from sacroiliac joint prolotherapy in patients with sacroiliac joint instability. Complementary therapies in medicine. 2018 Apr 1;37:64-8. [Google Scholar]
14 Kim WM, Lee HG, Won Jeong C, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. The Journal of Alternative and Complementary Medicine. 2010 Dec 1;16(12):1285-90. [Google Scholar]
15 Cusi M, Saunders J, Hungerford B, Wisbey-Roth T, Lucas P, Wilson S. The use of prolotherapy in the sacroiliac joint. British journal of sports medicine. 2010 Feb 1;44(2):100-4. [Google Scholar]
16 Hackett G. Referred pain and sciatica in diagnosis of low back disability. JAMA. 1957; 163:183-185. [Google Scholar]
17 Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid versus Platelet-Rich Plasma in Ultrasound-Guided Sacroiliac Joint Injection for Chronic Low Back Pain. Pain Pract. 2016 Sep 27. [Google Scholar]
18 Ko GD, Mindra S, Lawson GE, Whitmore S, Arseneau L. Case series of ultrasound-guided platelet-rich plasma injections for sacroiliac joint dysfunction. J Back Musculoskelet Rehabil. 2016 Jun 30. NU3617 [Google Scholar]

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