Sacroiliac Joint Dysfunction Symptoms and Treatment Options
Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C., Brian Hutcheson, DC.
Sacroiliac Joint Dysfunction Treatment – What can help you, what may not
Many patients that email or call our office are under the impression that Sacroiliac Joint Dysfunction can only be cured with spinal fusion surgery. So they are going to wait for one. The reason they call our office is that they have time to think about the surgery option and they have time to research and they are developing concerns.
In this article, we are going to talk about sacroiliac joint dysfunction treatments that may help you avoid fusion surgery. Some people who have fusion surgery for problems of sacroiliac joint dysfunction have a very successful surgery and their pain has been eliminated or greatly reduced. For some people, despite being told that their surgery was very successful, they still have pain. For some people, the surgery did not go as planned at all. We usually see the post-surgical patients in the last two groups.
Surgical improvement in 81% of patients. No improvement in 19% of patients.
Let’s quickly look at a March 2021 study from the Department of Neurosurgery, Faculty of Medicine, Palacky University, and Olomouc University Hospital. In this study 20 patients who had SI joint fusion were observed for one year following their fusion. (1)
“The purpose of this study was to evaluate the effectiveness of the minimally invasive sacroiliac joint stabilization by triangular titanium implants (fusion surgery) in patients with sacroiliac joint dysfunction.”
- “The (study) group was composed of 20 patients, of whom 4 men and 16 women. The (average) age was 48.9 years. The surgeries covered 21 sacroiliac joints.”
- “Improvement of the clinical condition was reported in 17 cases (81.0%), no relief was observed in 4 cases (19%).”
- The average VAS (Visual analog scale) score was 6.1 points (a score of moderate pain on the upper end of the scale) preoperatively and decreased to 2.9 points postoperatively (a score of moderate pain on the lower end of the scale or mild pain on the higher end of the mild score scale).
- The reporting surgeons suggested: “The minimally invasive sacroiliac joint stabilization should be reserved for patients experiencing an intractable pain originating from the sacroiliac joint (in this case an average score of high-end moderate pain), in whom all non-operative therapy failed.”
In other words, the right people will get benefits, the not-so-good candidates will likely have a failed surgery.
Surgery helps, but not all
In over more than 28 years of helping people with low back pain and sacroiliac joint dysfunction, we have heard a lot of stories, especially from patients for whom fusion surgery was not the answer they had hoped for. Here are some of the things people have said.
- I still have a lot of pain in my low back and hip. According to my surgeon, the MRIs and x-rays show that my surgery was a complete success. I don’t feel like a success story, I feel like a failure. I can’t sit for any length of time, travel is impossible. I still have a lot of pain. I take a lot of pain medications and use ice packs every day.
- I had a fusion at L5/S1 it resulted in terrible SI joint pain. My surgeon says the fusion was successful, but now I have new and intense pain. How was this a successful surgery? Now I am being recommended to SI fusion. I don’t want to do it.
- I had SI fusion three years ago. I still have intense pain in my lower back that radiates into the groin area. Sleeping, driving, standing for any length of time is near impossible for me. My surgeon says that the surgery was a complete success. All my “abnormalities were corrected.” Yet I still have intense pain. Surgery did not help my pain.
The recurrent theme we see in patients following an SI fusion is a correction by the surgery of structural abnormalities as seen on MRI, yet a continuation of their pain. How can this be? In so many people we see, no one had discussed with them prior to surgery the problems of the SI joint and untreated, damaged pelvic ligaments, and the combined instability and pain they can create before and after surgery.
In our years of practice, we have found that pain after successful surgery is damaged ligaments. Further, if you treat these damaged ligaments with the right treatments, you can avoid fusion surgery.
“A painful unknown: sacroiliac joint diagnosis and treatment.”
In October 2020, (2) researchers published a paper in the EFORT open reviews a publication of the European Federation of National Associations of Orthopaedics and Traumatology, the title, “A painful unknown: sacroiliac joint diagnosis and treatment.” Here are the learning points:
- Micro-traumatic SIJ disorders are very difficult to diagnose and require a complete clinical and radiological examination.
- To diagnose micro-trauma SIJ pain it is recommended to have at least three positive provocative specific maneuvers (you may have had these tests already, typically the pressing down on your pelvis in various positions to try to generate a pain source, pushing your knee into your chest while lying prone, etc.) If pain is generated then imaging tests should be conducted.
- Conservative treatment combining physiotherapy and steroid injections is the most common therapy but has a low level of efficiency.
- SIJ thermolysis (burning the nerves) is the most efficient non-invasive therapy.
- SIJ fusion using a percutaneous technique (minimally invasive surgery) is a solution that has yet to be confirmed on a large cohort of patients resistant to other therapies.
No one is looking at the ligaments of the Sacroiliac Joint – that is why “nothing is working”
When patients talk to us, the reason they are sitting on our exam table is that they have had many treatments and they report, “nothing is working.” Part of the reason nothing is working is that the treatment plan they have been given is not addressing the correct problem. 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 because of failure to identify the source of low back pain as sacroiliac (SI) joint dysfunction.
- We are 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 causing sacroiliac (SI) joint instability, weakness, and pain. Further, we will discuss new and archival research that 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.
Is no one looking because Sacroiliac Pain is really rare? Is that why you are not getting help?
In October 2018 a study in the journal of Clinical Spine Surgery (3) from The Steadman Clinic and Steadman Philippon Research Institute, researchers looked at the currently reported incidence of primary sacroiliac joint pain and it reported 15% to 30% of low back pain complaints. The study noted that the origins of sacroiliac joint pain and dysfunctions are controversial and pain generation from this joint has been questioned.
- 124 patients, chief complaint sacroiliac joint pain.
- After complete diagnostic workup, 112 (90%) had lumbar spine pain
- 5 (4%) had hip pain,
- 4 (3%) had primary sacroiliac joint pain,
- and 3 (3%) had an undetermined source of pain upon initial diagnosis.
- Conclusion: Sacroiliac joint dysfunction is a rare pain generator (3%-6%) in patients complaining of sacroiliac joint region pain and is a common site of referral pain from the lumbar spine (88%-90%).
- Clinicians ought to quantify areas of pain (via a percent of overall complaint) when interviewing their patients complaining of low back pain to distinguish potential pain generators. Recommended breakdown of areas of interest includes axial low back, sacroiliac joint region, buttock/leg, groin/anterior thigh.
It is not the SI joint, it is the ligaments that connect the SI joint that may be causing your problems.
What is stressed here is in agreement with what we suggest to patients: it is not the SI joint, rather, the ligaments that connect and stabilize the SI joint which is connected to the lumbar spine, the groin area, the buttock area, and the front thigh area. Sacroiliac joint pain rarely is an isolated problem.
The center of the spine is where the discs are located. The sides of the spine are where the ligaments are located.
In this video, Ross Hauser, MD gives an introduction to our treatment philosophies in the diagnosis and treatment of Sacroiliac Joint Dysfunction
Here is a summary of this video:
- People will come into our office with MRIs that show a herniated disc, disc protrusion, or degenerative disc disease, and think that is the cause of their problem. There has been no discussion with the patient of the pain culprit possibly coming from the sacroiliac joint. When we ask patients if they had their sacroiliac joint examined, they often tell us that they do not even know what the sacroiliac joint is.
- When most people injure their back, they usually do it from a bending and twisting motion. When they come into our office they describe their back pain as the lower left side of the lower right side. They rarely say it is right down the middle.
- The sacroiliac joint is a very large joint that sits in a sea of spinal and pelvic ligaments, the tough connective tissue that holds bone to bone. In the illustration below the white bands of tissue that hold the sacroiliac joint are the ligaments. They sit on the left and right sides of the spine.
- In our office, we offer Prolotherapy injections. This treatment can stimulate the repair of the spinal ligaments and bring pain-free stability back to the lower back. pelvic, and sacroiliac joint.
What are we seeing in this image?
In this illustration, white bands of tissue that hold the sacroiliac joint are the ligaments. They sit on the left and right sides of the spine. In this image, arrows signify points of irritation to the sciatic nerve caused by excessive movement and instability in the Sacroiliac Joint. This can cause various symptoms in the patient including low back and leg pain, numbness down the leg, and general instability and weakness from the spine to toes.
You are here because of failed prior treatments that focused on your discs.
Challenges facing doctor and patient in treating Sacroiliac Joint Dysfunction
planning big surgeries that may not be the correct surgery
Here is an April 2020 article that was published in the medical journal Spine (4). The challenge that these doctors are warning about is aggressive and invasive (big surgeries) that may not be addressing the right problem.
Here are the learning points of this study:
- The study wanted to evaluate the prevalence of sacroiliac joint dysfunction in patients with lumbar disc herniation and examine the variations in clinical parameters cause by this combination. (Our note: the researchers are exploring low back diagnosis confusion).
- The researchers noted: Although one of the many agents leading to lumbar pain is sacroiliac dysfunction, little progress has still been made to evaluate mechanical pain from sacroiliac joint dysfunction within the context of differential diagnosis of lumbar pain. (Our note again: the researchers are exploring low back diagnosis confusion).
- Two hundred thirty-four patients already diagnosed with lumbar disc herniation were included in the study. During the evaluation, the researchers also looked for the presence of sacroiliac joint dysfunction. They found sacroiliac joint dysfunction in 33.3% of the research population.
We hope to help patients avoid a big unnecessary surgery that will not help them.
- CONCLUSION: Here is the benefit of this study as presented by the research team: “Our study results will be useful in attracting the attention of clinicians away from the intervertebral disc to the sacroiliac joint in order to avoid unnecessary and aggressive treatments.” In other words, we hope to help patients avoid a big unnecessary surgery that will not help them.
In December 2017, doctors at the University of Colorado published in The Journal of Bone and Joint Surgery, (5) their paper “Diagnosis and Management of Sacroiliac Joint Dysfunction.” Here they summarized the challenges facing doctors and patients in treating Sacroiliac Joint Dysfunction.
Is it really Sacroiliac Joint Dysfunction that is causing your problems, or is it the discs, or is it the hip?
An August 2019 paper in the PM & R: the journal of injury, function, and rehabilitation, (6) noted how complex a diagnosis of sacroiliac joint dysfunction is.
“Sacroiliac joint dysfunction is complex with numerous etiologies. Proper stabilization of the sacroiliac joint allows for effective transfer of loads between the trunk and the lower extremities during static and dynamic activities while maintaining a freely nutating motion. (Explanatory note: Nutating motion is how the sacrum absorbs stress forces or shock. In this “shock-absorbing” capacity the sacrum moves downward to absorb the weight from the trunk, then it slides forward, and rotates opposite to the side of the force. If the force is on the right side sacrum, the sacrum moves to the left).
“A loss of integrity of the stabilizing soft-tissue structures inhibits the ability to transmit axial loads and creates uneven stresses on the joint and surrounding tissues. Hypermobility of the sacroiliac joint can be caused by ligamentous instability or secondary to adaptive biomechanical changes (muscle weakness and fatigue from muscle stress for one) and increased stresses affecting the joints of the pelvis.”
Symptoms that suggest that the sacroiliac joint (SIJ), as opposed to the problems of the lumbar spine or hip, include:
- Pain when shifting positions such as standing from a seated position.
- Radiation to the groin or Fortin area (the side of the low back).
- 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. (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 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.
In this video Prolotherapist Danielle Matias, MMS, PA-C discusses a pretty common scenario of patients who are diagnosed with sacroiliac joint dysfunction but whose MRI is normal and they try some physical therapy but it doesn’t resolve the issue. The reason for this is most frequently underlying ligament laxity in the region causing SI joint instability. When ligament laxity/joint instability is found, Prolotherapy is a great option worth exploring because it stimulates ligament repair and tightening.
Having an MRI that shows nothing while still having back pain can be incredibly frustrating for patients. They are suffering from all this pain and they have this negative MRI meaning treatments to help them will be limited. Their doctors may send them to physical therapy to see if that helps. In cases of SI joint dysfunction physical therapy can potentially be very beneficial assuming that the ligaments of the SI joint are intact and they have a lot of integrity. (They can hold the SI joint in place).
- In patients where they have suffered an injury to the ligaments (acute injury or degenerative wear and tear) of the SI joint, these people can have inherent instability and their MRI is still normal or shows negative or no findings. When they go to physical therapy, it will fail them and now these people lose hope. You can’t build muscles around your SI joint if you don’t have strong ligaments. Physical therapy may help a little bit, but it may not be able to resolve your pain if you’re suffering from underlying ligament instability
People can also have low back pain that radiates into the butt or the back of the leg and again nothing might show up on MRI but what could be happening is an intermittent pressure caused by the weak or damaged ligaments allowing the SI joint to become hypermobile and press on the sciatica nerve and give you temporary sciatic symptoms.
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.”(7)
- 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 our 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.”(8)
When surgery makes back pain worse – Focus on Lumbar Decompression Surgery and sacroiliac joint dysfunction
- Lumbar Decompression surgery can be one procedure or it can be a combination of three procedures. It can be a traditional open spine procedure or a minimally invasive procedure, (Minimally invasive lumbar decompression or MILD).
- The components of the procedure may include:
- Laminectomy. Laminotomy is the removal of all or part of the lamina, the flattened or arched part of the vertebral arch. Complete laminectomy or bilateral laminectomy means the removal of the spinous process and the entire lamina on each side of it. Hemilaminectomy or unilateral laminectomy means the removal of the lamina on one side of the spinous process only. When the opening to the nerve root is enlarged, this is called a foraminotomy. For the right indications, spinal surgery can resolve symptoms.
- Discectomy. This procedure cuts away the disc material pressing on the nerves. Please see our article Discectomy or Microdiscectomy for more research.
- Spinal Fusion. Spinal fusion has probably been explained to use as the “fusing” of the vertebrae at more than one segment. Please see our article The evidence against spinal fusion surgery.
Doctors in Germany examined a potential connection between lumbar decompressive surgery and the new onset of sacroiliac joint-related pain causing a diagnosis of “failed-back-surgery.”(9)
Here is what they said in their published research:
Patients with lumbar stenosis do have substantially positive results from decompressive surgery. HOWEVER, the change of body position and walking behavior after successful surgery might lead to changed force effects on the entire spine and on the sacroiliac joint (SIJ).
The authors analyzed the records of 100 consecutive patients from three institutions, who underwent decompressive surgery without instrumentation. The diagnosis of SIJ-related pain was confirmed by periarticular infiltration. The radiological changes of the sacroiliac joint were assessed in plain radiographs in both groups: patients with SIJ pain (group 1) and patients without SIJ pain (group 2)
- 22 patients required medical attention due to SIJ-related pain after surgery.
- While the walking distance increased substantially in both groups without a difference, the analysis of overall satisfaction favored group 2 patients without SIJ pain.
- Female patients suffered more from SIJ pain after surgery.
- The severity of radiological changes or the number of operated-on segments appeared not to trigger SIJ-related pain.
The adaptation of a changed body posture and gait could lead to a transient overload of the SIJ and surrounding myofascial structures.
The patients should be informed about this possible condition to avoid uncertainty, discontent, unnecessary diagnostics and to induce a quick, specific treatment.
Non-diagnosed sacroiliac joint-related pain could be a possible, but reversible, reason for the diagnosis of a “failed-back surgery.”
Can back surgery create new and more complex sacroiliac joint pain?
Here is the opening statement from an August 2018 study published in The Journal of the American Academy of Orthopaedic Surgeons. (10)
- “The initial phase of (sacroiliac joint) treatment involves nonsurgical modalities such as activity modification, use of a sacroiliac (SI) belt, NSAIDs, and physical therapy. Prolotherapy (which we will discuss below) and radiofrequency ablation (burning out the nerves) may offer a potential benefit as therapeutic modalities, although limited data support their use as a primary treatment modality.
- Surgical treatment is indicated for patients with a positive response to an SI (painkiller) injection with greater than 75% relief, failure of nonsurgical treatment, and continued or recurrent sacroiliac joint pain.
- Percutaneous (Minimally invasive spinal procedure) SI arthrodesis (fusion surgery) may be recommended as a first-line surgical treatment because of its improved safety profile compared with open (spine fusion surgery) however, in the case of (failed surgery), nonunion, and aberrant anatomy, open (spinal fusion) should be performed.”
What does all this mean to the patient being recommended to spinal surgery or with continued sacroiliac joint dysfunction after surgery?
- You have failed conservative non-surgical treatments
- Prolotherapy (our treatments of therapeutic injections) and radiofrequency ablation can be of help but were not the primary focus of this study, surgery was. You may want to explore these options before the surgery.
- If you had a positive response to painkiller injection, you would be a good candidate for surgery. In our opinion, if you had a positive response to painkiller injections you would likely be a good candidate for more injections, Prolotherapy, and not need the surgery at all.
- The study continues with recommendations for surgery and what to do if the first surgery fails.
Spinal surgery that makes sacroiliac joint dysfunction worse is a very difficult concept for many people to understand
Lumbar decompression surgery that makes sacroiliac joint dysfunction worse is a very difficult concept for many people to understand. The reason these people went to lumbar decompression surgery was to relieve sacroiliac joint dysfunction. The fact that conservative treatments failed and then minimally invasive lumbar decompression surgery failed and that their own back pain/sacroiliac joint-related pain was now worse can lead to great confusion and frustration.
“Underwhelming treatment efficacy of medical treatment”
A December 2020 study in the Journal of Pain Research (11) tries to help doctors understand the difficult concept of failed sacroiliac joint dysfunction treatments. Here are the learning points:
- “The sacroiliac joint (SIJ) has been estimated to contribute to pain in as much as 38% of cases of lower back pain. There are no clear diagnostic or treatment pathways.”
The researchers of this study then reviewed the medical literature to provide insights into the biomechanics, as well as establish the various diagnostic and treatment options. Treatment options reviewed include conservative measures, as well as interventional and surgical options.
- Results: “Proposed criteria for diagnosis of sacroiliac joint dysfunction can include pain in the area of the sacroiliac joint, reproducible pain with provocative maneuvers, and pain relief with a local anesthetic injection into the SIJ.
- Conventional non-surgical therapies such as medications, physical therapy, radiofrequency denervation, and direct SI joint injections may have some limited durability in therapeutic benefit.
- Surgical fixation can be by a lateral or posterior/posterior oblique approach with the literature supporting minimally invasive options for improving pain and function and maintaining a low adverse event profile.
All roads do not lead to fusion surgery
The conclusion of this study states: “SIJ pain is felt to be an underdiagnosed and undertreated element of low back pain. There is an emerging disconnect between the growing incidence of diagnosed SI pathology and the underwhelming treatment efficacy of medical treatment. This has led to an increase in SI joint fixation.”
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, 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 is 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 with 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. (12)
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
The opening statement of a recent research article from doctors at the Mayo Clinic brings all these concerns together when the researchers state: “Understanding spinal kinematics (the movement of the spine) is essential for distinguishing between pathological conditions of spine disorders, which ultimately lead to low back pain.
It is of high importance to understand how changes in mechanical properties affect the response of the lumbar spine, specifically in an effort to differentiate those associated with disc degeneration from ligamentous changes (problems of the spinal ligaments), allowing for more precise treatment strategies.”(13)
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. (14)
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 (the cranial portion of the ilium outside the SIJ – in the illustration above that would be the leftmost 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 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 (15) 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; a 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 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 between groin pain and low back pain.
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. (16)
Further, the paper documents treatments that they assess as fair or poor treatments for sacroiliac joint dysfunction
- The evidence for cooled radiofrequency 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 radiofrequency 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. (17)
Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction
We treat the whole low back area to include the sacroiliac or SI joint.
Summary and Learning Points of Prolotherapy to the low back
- Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
- Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate repair of the ligament attachment to the bone.
- We treat the whole low back area to include the sacroiliac or SI joint. In the photo above, the patient’s sacroiliac area is being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
- Why the black crayon lines? This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
- After treatment we want the patient to take it easy for about 4 days.
- Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.
“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 that caused ligament laxity or ‘looseness.”
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 that 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.”(18)
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 MRIs 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.
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.
In a December 2019 study, (19) doctors in China made these observations concerning Prolotherapy and Platelet Rich Plasma (PRP) Injections. Platelet Rich Plasma (PRP) Injections are considered a type of Prolotherapy when applied in a similar manner. These injections are explained further below.
“SI joint pain can be generated from extra-articular elements including ligaments and capsules. (The SI joint pain does not necessarily have to come from the joint itself). Prolotherapy involves the injection of hyperosmolar dextrose or Platelet-Rich Plasma (PRP) into the area where repairing and strengthening are thought to be needed. The application of Prolotherapy for SI joint pain consists of making injections in the periarticular and intra-articular areas to treat pain and sacral ligament laxity. Some studies reported the positive clinical outcomes of Prolotherapy for SI joint pain and even a superior effect and longer duration for relief of SI joint pain compared to the injection of a steroid into the joint. In recent studies, a significant reduction in the pain scores of SI joint pain was observed in patients receiving intra-articular PRP injections compared to those receiving steroid injections.
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. Pressure tenderness (palpitation) in the sacroiliac joint pain region is used for diagnostic purposes and it appears to be a reliable method. (20)
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 preferred 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 were no other treatment options for their pain and those who were told surgery was their only treatment option. (21)
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.”(22)
- 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 of 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”(23)
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 76% of patients with sacroiliac joint problems. (24)
- 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, “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. (25)
Platelet Rich Plasma and Prolotherapy Injections a non-surgical alternative for SI pain and long-term results
In this video, Ross Hauser, MD explains the use of Platelet Rich Plasma in treating this patient with problems of the sacroiliac instability caused by sacroiliac ligament damage.
The actual treatment begins at 3:15 of the video
Summary learning points:
- Platelet Rich Plasma or PRP involves the application of concentrated platelets, which release growth factors to stimulate recovery in non-healing injuries.
- At 3:15 of the video, the pain is numbed and the injections begin
- Prolotherapy is used to treat the ligaments. PRP is used to more specifically treat the attachments of the SI Joint and Pelvis. The treatment is designed to correct SI joint instability by addressing the damaged and weakened ligaments of the SI / Pelvic region.
PRP vs. Corticosteroid Injections
Research from a team of university researchers in India, writing in the journal Pain Practice says that “Despite the 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: the steroid group and the PRP group.
- The 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.”(26)
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 the 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 in 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. (27)
More than one PRP injection
Many of the “Prolotherapy failures” from other clinics that we see at Caring Medical 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.
Prolotherapy vs PRP Injections
A 2018 study published in the Journal of Prolotherapy (28) compared Prolotherapy and PRP in sacroiliac joint dysfunction. Here are the summary learning points:
- This study demonstrates a good response to PRP injection into the dorsal interosseous sacroiliac ligaments (among the main supportive ligaments of the sacroiliac joint) with improvement in pain and function in patients who fail to respond to appropriate physical therapy.
There are fundamentally two methods for achieving stability of the sacroiliac joint. Surgical fusion is the extreme solution that is rarely required. Other less invasive techniques include Prolotherapy or the current method of PRP injection.
- The injection of Prolotherapy promotes an inflammatory response in the tissues. This attracts platelets and growth factors and promotes the activity of fibroblasts (the cells that rebuild and regenerate connective tissue such as ligaments. The healing process of Prolotherapy has three phases:
- The injections start an inflammatory phase that lasts approximately 2-3 days.
- Followed by a repair phase (the ligaments are repairing wounds or damage) that may last up to 6 weeks with subsequent remodeling (the laying of new connective tissue) that may take a further 2 to 3 months.
- PRP has the advantage of delivering more platelets to the region and therefore more growth factors to promote the healing response.
- The current study shows a significant improvement in the clinical and functional status of patients treated with PRP over the Prolotherapy group.
- The other advantage of PRP was the use of a mean of 1.6 injections versus 3.0 for the Prolotherapy injections.
- PRP speeds up the healing process, a critical issue for elite athletes.
At our center, we do not use PRP as a stand-alone treatment. PRP is given with Prolotherapy to make sure that all areas that may cause instability in the region are addressed. This is what we call Comprehensive PRP Prolotherapy.
Summary and contact us. Can we help you?
We hope you found this article informative and it helped answer many of the questions you may have surrounding your Sacroiliac Joint Dysfunction challenges. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated July 20, 2021