eMedicine Specialties > Sports Medicine > Spine

Sacroiliac Joint Injury: Differential Diagnoses & Workup

Author: Andrew L Sherman, MD, MS, Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, Leonard A Miller School of Medicine, University of Miami
Coauthor(s): Robert Gotlin, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine; Director of Orthopaedic and Sports Rehabilitation, Department of Orthopedic Surgery, The Continuum Center for Health and Healing, Beth Israel Medical Center
Contributor Information and Disclosures

Updated: Apr 28, 2008

Differential Diagnoses

Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy
Lumbosacral Radiculopathy
Hip Fracture
Piriformis Syndrome
Hip Overuse Syndrome
Sacroiliac Joint Infection
Iliotibial Band Syndrome
Seronegative Spondyloarthropathy
Lumbosacral Discogenic Pain Syndrome
Superior Cluneal Nerve (Iliac crest) Syndrome
Lumbosacral Facet Syndrome
Trochanteric Bursitis

Other Problems to Be Considered

Crohn disease
Infection
Inflammatory spondyloarthropathies
Malignancy/metastasis
Psoriatic arthritis
Reiter syndrome
Stress fracture

Workup

Laboratory Studies

In a patient with sacroiliitis, inflammatory origins (eg, ankylosing spondylitis [AS], psoriatic arthritis) must be considered. The following laboratory studies are appropriate when an inflammatory disorder is suspected in a young patient:

  • Complete blood cell (CBC) count
  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP) level
  • Antinuclear antibody (ANA) profile
  • Human leukocyte antigen (HLA)-B27 status
  • Rheumatoid factor (RF) value

In patients in whom the pain has become chronic, clinicians need to consider whether the patients may have secondary reactive depression. Testing for hypothyroidism, cortisol abnormalities, or other metabolic or endocrine imbalances may be appropriate as part of the workup for a patient with depression.

Prostate-specific antigen (PSA) testing, serum protein electrophoresis/urine protein electrophoresis, and other laboratory tests used to investigate for malignancy are appropriate for older patients who have not improved with initial care and may have symptoms warranting further investigation.

Related Medscape topics:
Resource Centers Diabetes & Endocrinology 
Resource Centers Hematology-Oncology
Resource Centers Pathology & Lab Medicine

Imaging Studies

  • Use of imaging studies when evaluating sacroiliac pathology is a source of controversy among clinicians because whether normal and abnormal radiographic studies can help differentiate symptomatic versus nonsymptomatic patients is unclear. This is probably due to the great variability in joint anatomy among patients. Additional disagreement exists on the significance of inflammatory findings and degenerative findings (sclerosis) being diagnostic of pain within the joint.
  • The usual SIJ examination is performed using anteroposterior pelvis/lumbar spine radiography. Sclerosis or obliteration of the SIJ can be observed in older patients.
  • Patients with AS usually have normal radiographic findings; in older patients with this disease, the joint can appear fused.
  • Specific sacroiliac views superimpose the anterior and posterior joint margins, which may increase the sensitivity for detecting abnormalities. These radiographs are taken at a 25-30° angle to the anteroposterior plane. Joint widening with erosive and sclerotic changes at the bony margins may be suggestive of inflammatory sacroiliitis.
  • Computed tomography (CT) scanning can often be used to document reactive spurring, sclerosis, or even subluxation. Many clinicians believe reactive spurring is due to prolonged abnormal motion within the joint.
  • In persons with inflammatory conditions (eg, AS), bone scanning can show enhancement within the SIJ (often bilaterally).
    • Nuclear medicine bone scanning with single photon emission computed tomography (SPECT) can also be used to rule out femur and pelvic stress fractures and most bony metastatic disease.
    • Some clinicians view enhancement observed in the SIJ unilaterally in a patient with suspected SIJ conditions as an indicator of SIJ dysfunction or inflammation. Slipman et al found nuclear imaging under these circumstances to be very low in sensitivity but high in specificity for sacroiliac-mediated pain.16 Painful SIJs were confirmed with an intra-articular injection of anesthetic. Therefore, bone scanning was of little value in the diagnostic algorithm for SIJ pain.
    • Adding SPECT scanning may increase the sensitivity of nuclear imaging for SIJ injuries; however, this has not been studied.
  • Magnetic resonance imaging (MRI) is not generally used for evaluating the SIJ, although it can be a valuable tool to help exclude disc herniation (especially at L5-S1) as part of the SIJ dysfunction differential diagnosis (see Differentials and Other Problems to Be Considered). MRI can occasionally show inflammatory signs within the SIJ. MRI can also be used to investigate pelvic stress fracture, femoral neck stress fracture, or femoral head avascular necrosis.

Related eMedicine topics:
Acetabulum Fractures
Femoral Head Avascular Necrosis
Femoral Neck Stress and Insufficiency Fractures
Pelvic Fractures
Stress Fractures

Procedures

More on Sacroiliac Joint Injury

Overview: Sacroiliac Joint Injury
Differential Diagnoses & Workup: Sacroiliac Joint Injury
Treatment & Medication: Sacroiliac Joint Injury
Follow-up: Sacroiliac Joint Injury
Multimedia: Sacroiliac Joint Injury
References
[ CLOSE WINDOW ]

References

  1. Goldwaith JH, Osgood RB. A consideration of the pelvic articulations from an anatomical pathological and clinical standpoint. Boston Med Surg J. 1905;152(21):593-601.

  2. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine. Jan 1 1995;20(1):31-7. [Medline].

  3. Bernard TN Jr, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop Relat Res. Apr 1987;217:266-80. [Medline].

  4. Edge-Hughes L. Hip and sacroiliac disease: selected disorders and their management with physical therapy. Clin Tech Small Anim Pract. Nov 2007;22(4):183-94. [Medline].

  5. Foley BS, Buschbacher RM. Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment. Am J Phys Med Rehabil. Dec 2006;85(12):997-1006. [Medline].

  6. Frieberg AH, Vinke TH. Sciatica and the sacroiliac joint. Clin Orthop Relat Res. 1974;16:126-34.

  7. Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine. Jul 15 2003;28(14):1593-600. [Medline].

  8. Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part I: Asymptomatic volunteers. Spine. Jul 1 1994;19(13):1475-82. [Medline].

  9. Fortin JD, Falco FJ. The Fortin finger test: an indicator of sacroiliac pain. Am J Orthop. Jul 1997;26(7):477-80. [Medline].

  10. Freburger JK, Riddle DL. Using published evidence to guide the examination of the sacroiliac joint region. Phys Ther. May 2001;81(5):1135-43. [Medline]. [Full Text].

  11. Stuber KJ. Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. JCCA J Can Chiropr Assoc. Mar 2007;51(1):30-41. [Medline].

  12. Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. Oct 2007;16(10):1539-50. [Medline].

  13. Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E. The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome. Arch Phys Med Rehabil. Mar 1998;79(3):288-92. [Medline].

  14. Dreyfuss P, Dryer S, Griffin J, Hoffman J, Walsh N. Positive sacroiliac screening tests in asymptomatic adults. Spine. May 15 1994;19(10):1138-43. [Medline].

  15. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. Nov 15 1996;21(22):2594-602. [Medline].

  16. Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E. The value of radionuclide imaging in the diagnosis of sacroiliac joint syndrome. Spine. Oct 1 1996;21(19):2251-4. [Medline].

  17. Prather H, Hunt D. Conservative management of low back pain, part I. Sacroiliac joint pain. Dis Mon. Dec 2004;50(12):670-83. [Medline].

  18. Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine. Jul 15 2007;32(16):1754-60. [Medline].

  19. Murakami E, Tanaka Y, Aizawa T, Ishizuka M, Kokubun S. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. J Orthop Sci. May 2007;12(3):274-80. [Medline].

  20. Günaydin I, Pereira PL, Fritz J, König C, Kötter I. Magnetic resonance imaging guided corticosteroid injection of sacroiliac joints in patients with spondylarthropathy. Are multiple injections more beneficial?. Rheumatol Int. Mar 2006;26(5):396-400. [Medline].

  21. Pulisetti D, Ebraheim NA. CT-guided sacroiliac joint injections. J Spinal Disord. Aug 1999;12(4):310-2. [Medline].

  22. Luukkainen RK, Wennerstrand PV, Kautiainen HH, Sanila MT, Asikainen EL. Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondylarthropathic patients with chronic low back pain in the region of the sacroiliac joint. Clin Exp Rheumatol. Jan-Feb 2002;20(1):52-4. [Medline].

  23. Vallejo R, Benyamin RM, Kramer J, Stanton G, Joseph NJ. Pulsed radiofrequency denervation for the treatment of sacroiliac joint syndrome. Pain Med. Sep-Oct 2006;7(5):429-34. [Medline].

  24. Gevargez A, Groenemeyer D, Schirp S, Braun M. CT-guided percutaneous radiofrequency denervation of the sacroiliac joint. Eur Radiol. Jun 2002;12(6):1360-5. [Medline].

  25. Akbas M, Yegin A, Karsli B. Superior cluneal nerve entrapment eight years after decubitus surgery. Pain Pract. Dec 2005;5(4):364-6. [Medline].

  26. Smuck M, Christensen S, Lee SS, Sagher O. An unusual cause of S1 radicular pain presenting as early phantom pain in a transfemoral amputee: a case report. Arch Phys Med Rehabil. Jan 2008;89(1):146-9. [Medline].

  27. Yeoman W. The relation of arthritis of the sacroiliac joint to sciatica with analysis of 100 cases. Lancet. 1928;2:1119-22.

  28. Ziran BH, Heckman D, Smith WR. CT-guided stabilization for chronic sacroiliac pain: a preliminary report. J Trauma. Jul 2007;63(1):90-6. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

sacroiliitis, SIJ injury, lower back pain, low back pain, LBP, back pain, low back injuries, lower back injuries

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Andrew L Sherman, MD, MS, Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, Leonard A Miller School of Medicine, University of Miami
Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Paraplegia Society, American Spinal Injury Association, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Coauthor(s)

Robert Gotlin, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine; Director of Orthopaedic and Sports Rehabilitation, Department of Orthopedic Surgery, The Continuum Center for Health and Healing, Beth Israel Medical Center
Robert Gotlin, DO is a member of the following medical societies: American Academy of Pain Management, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Henry T Goitz, MD, Fellowship Director, Sports Medicine, Department of Orthopedic Surgery, Henry Ford Hospital
Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.