eMedicine Specialties > Sports Medicine > Spine
Sacroiliac Joint Injury: Treatment & Medication
Updated: Apr 28, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Acute Phase (1-10 d)
Subacute phase (if acute phase does not resolve; 10-180 d)Chronic phase (>6 mo of pain)
Rehabilitation Program
Physical Therapy
Physical therapy focuses on pain control in the acute phase. Modalities such as ultrasonography with or without phonophoresis, deep and superficial heat, and superficial cold treatments can reduce pain. Neural therapies such as deep tissue massage, myofascial release, and muscle energy stretching techniques can also help. Pelvic myofascial stretching in the neutral spine position can be used for immediate, short-term relief of discomfort. By identifying activities that aggravate the condition, the physician or therapist can have the patient avoid these activities.
Related eMedicine topics:
Massage, Traction, and Manipulation
Superficial Heat and Cold
Osteopathic/chiropractic treatment
Although in the acute-phase muscle spasms may prevent frank manipulation, less aggressive techniques such as muscle energy stretching can be very helpful.
Medical complications
Patients may experience difficulty or even worsening symptoms with physical therapy treatments in certain cases. In these patients, reevaluate the diagnosis and consider other diagnostic possibilities (eg, infection, inflammatory disease, malignancy, neural [lumbosacral root] injury). Patients with acute inflammatory disorders or infections should not usually be administered heat treatments. Patients who cannot perform physical therapy may also have a functional component to their disorder or an underlying psychologic disorder, which needs to be addressed.
Medical interventions
Often, oral medications can be quite effective in the acute phase. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used judiciously in this phase, often with good results. In the first 24-72 hours, a muscle relaxant can be quite effective if a myofascial component to the pain is present. Ice can be considered in the first 48-72 hours; then, the typical switch to heat or contrast treatments is warranted.
Oral medication management may change if the pain persists into the subacute and especially the chronic phase. Chronic lower back pain from any source often leads to the development of a cognitive/behavioral component. In such cases, the use of antidepressants, anticonvulsants, and antiarrhythmic topical and oral medications has been reported to benefit certain selected patients. Because the potential benefits of any of these medications is uncertain, their use must be balanced against their potential adverse effects.
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Surgical intervention
Surgical intervention is rarely used for nontraumatic SIJ pain.4,17 Surgery is considered only in patients with chronic pain that has lasted for years, has not been effectively treated by other means, and has led to an extremely poor quality of life. The procedure is a fusion across the joint; however, although the surgery has been reported to result in benefit in selected cases or small case series, no randomized controlled study has shown reliable pain reduction with SIJ fusion.
Consultations
Consultation with a rheumatologist is necessary when the possibility of an underlying inflammatory disorder exists. Consultation with a musculoskeletal specialist is often helpful. The musculoskeletal specialist should provide each patient with a functional assessment, can direct nonoperative treatment, and can communicate with the entire treatment team (eg, physical therapists, trainers). Often, a physiatrist (specialist in the field of physical medicine and rehabilitation) can provide a unique, functional-based history and examination that can lead to an accurate diagnosis and a holistic treatment program.
Related eMedicine topic:
Adult Physiatric History and Examination
Related Medscape topics:
Resource Center Spinal Disorders
Resource Centers Rheumatology
Other Treatment (Injection, manipulation, etc.)
In the immediate acute phase, treatment consists of pain reduction through pain medications, rest, and avoidance of the inciting activity. Anti-inflammatory treatment with NSAID medications and externally applied ice is often helpful. Recommend the patient return to usual activities as soon as possible, usually within 24-48 hours. Sometimes a local trigger point injection into the muscle can relieve symptoms.
If the pain does not resolve well in the first 2-3 weeks, an intra-articular injection under fluoroscopic guidance should be considered. SIJ injection is frequently performed with a mixture of anesthetic and steroid, as described by Fortin in 1994 and others.8,18,19,20,21 When the actual source of the patient’s discomfort is unclear, postinjection pain reduction offers significant diagnostic information. Fluoroscopic guidance is important because, although a local blind injection into the area of maximal pain can be temporarily effective, the needle rarely enters the joint. CT scanning or MRI can also be used to guide injections into the SIJ, with excellent reliability.
Günaydin and colleagues reported that 20 of 31 patients with spondylarthropathy reported subjective improvement after the first SIJ injection of MRI-guided corticosteroid, and 9 of 15 patients reported subjective improvement after the second injection.20 The improvement lasted for a mean of 8.7 for the first group and 16.1 months for the second group.
Luukkainen and colleagues reported that periarticular injection of methylprednisolone may be effective in the treatment of pain in the region of the SIJ in nonspondyloarthropathy patients from a study of 24 consecutive patients.22
Although these studies are promising, they are not randomized, placebo-controlled studies. Therefore, before efficacy can be established, randomized, placebo-controlled studies must be undertaken.
Even if the injections do relieve the patient's pain, the relief from the injections alone is very often short-lived. Therefore, using the injections only as part of an interdisciplinary rehabilitation program is important. The pain relief offers a window of opportunity to increase the rehabilitation. The point in the course of recovery when a second or even third injection should be attempted is unclear. Most clinicians wait 2-4 weeks before proceeding with a repeat injection.
Manipulation has been reported in multiple studies as effective treatment for acute lower back pain. However, studies specifically on SIJ syndrome are less abundant. The SIJ is accessible to manipulation treatments and these may be extremely effective. As with other passive modalities, these treatments should be coupled with an extensive active rehabilitative program. Manipulation following intra-articular injection has been reported anecdotally to be beneficial in selected cases.
In chronic conditions, some practitioners believe that SIJ pain is due to hypermobility of the joint, which occurs because of laxity in the ligamentous complex. Prolotherapy is a series of saline and glucose injections applied to the SIJ ligaments to cause an inflammatory reaction, which results in scarring and tightening of the ligaments and a reduction in pain. However, no satisfactory outcome investigations have been performed on prolotherapy for this condition.
A relatively more recent procedure, radiofrequency denervation, has been advocated for the treatment of especially recalcitrant sacroiliac dysfunction.23,24 The procedure was thought to be ineffective for SIJ pain because the innervation to the joint is so diffuse. However, in a study by Gevargez and colleagues, the authors reported that 3 months after the procedure, 13 patients (34.2%) were completely free of pain. Twelve patients (31.6%) reported substantial pain reduction, 7 patients (18.4%) had slight pain reduction, and 3 patients (7.9%) had no pain reduction. No longer-term follow-up data are available; further study regarding this procedure is needed.
Recovery Phase
Rehabilitation Program
Physical Therapy
The recovery phase cannot proceed without an active, aggressive rehabilitation program. Often, SIJ injury leaves patients with significant deconditioning and muscle imbalances. These functional muscular deficits were sometimes present before the injury and may have predisposed the patient to injury. Some muscles are known to be functioning in a tight or shortened position, such as the hip flexors, hamstrings, tensor fascia lata, obturator internus, and rectus femoris. Other muscles are weak or inhibited, such as the gluteal and abdominal muscles.
Begin physical therapy by correcting any mechanical or leg-length asymmetries (eg, orthotic/shoe lift), stretching overly tight lumbopelvic muscles, and strengthening weak and inhibited muscles. All of this should begin in the neutral spine position or a pelvic position, which minimizes acute discomfort.
The patient is asked to take on more challenging tasks while progressing through the program. Stabilization exercises are performed with the patient in a more dynamic, functional position and often include balance and proprioceptive activities. Strengthening of the core muscles surrounding the spine can be achieved in various ways. In the past several years, Pilates training has become very popular for this purpose. Finally, the patient should graduate to sport- or work-specific training designed to return the patient to his or her previous level of functioning.
Braces and belts
In patients who develop chronic injuries, an SIJ belt can provide compression and feedback to the gluteal muscles. Patients with ligamentous hypermobility can especially benefit from this apparatus because the belt can reduce SIJ rotation. The belt differs from a generalized lumbar orthosis because it is much thinner and thus secures across the anterior superior iliac spines.
Orthotics can decrease leg-length inequalities; these items include custom-fitted orthotics, internal shoe lifts, and external shoe lifts.
Related eMedicine topic:
Lower Limb Orthotics
Related Medscape topic:
Resource Center Exercise and Sports Medicine
Medical Issues/Complications
SIJ dysfunction usually improves significantly, relatively quickly. Reexamine patients whose pain persists, despite treatment, for longer than 4 weeks and consider other diagnostic possibilities.
Other Treatment
Perform injection under fluoroscopic guidance (see Image 1). SIJ injection is frequently performed with a mixture of anesthetic and steroid, as described by Fortin in 1994 and others.8 Postinjection pain reduction offers significant diagnostic information when the actual source of the patient’s discomfort is unclear. Although a local blind injection into the area of maximal pain can be temporarily effective, the needle rarely enters the joint. CT scanning or MRI can also be used to guide injections into the SIJ, with excellent reliability.18,19,20,21
Unfortunately, injections usually offer only temporary relief. Therefore, couple injections with physical therapy and exercise to achieve more durable pain relief. The point in the course of treatment when a second or even third injection should be attempted is unclear. Most clinicians wait at least 2-4 weeks before proceeding with a repeat injection.
In a subset of patients who had temporary relief, Vallejo and coauthors performed pulsed radiofrequency denervation (PRFD) of lateral branches from L3-S2 and found good or excellent results in 16 of 22 subjects for 6-32 weeks.23
Manipulation has been reported in multiple studies as effective treatment for acute lower back pain. However, studies specifically on SIJ syndrome are less abundant. The SIJ is accessible to manipulation treatments, and these may be extremely effective. As with other passive modalities, these treatments should be coupled with an extensive active rehabilitative program. Manipulation following intra-articular injection has been reported anecdotally to be beneficial in selected cases.
In chronic conditions, some practitioners believe that SIJ pain is due to hypermobility of the joint, which occurs because of laxity in the ligamentous complex. Prolotherapy is a series of saline and glucose injections applied to the SIJ ligaments to cause an inflammatory reaction, which results in scarring and tightening of the ligaments and a reduction in pain. However, no satisfactory outcome investigations have been performed on prolotherapy for this condition.
Maintenance Phase
Rehabilitation Program
Physical Therapy
After the patient's pain resolves and he or she has regained sufficient strength, therapy should be transitioned from the therapy office to the gym or home gym. The therapist should teach the patient a home gym or gym program, and the patient should perform stabilization and general training at least 3 times per week to prevent recurrence.
Related Medscape topic:
Resource Center Exercise and Sports Medicine
Medication
As in most conditions involving acute and even chronic musculoskeletal pain, many oral medications can provide initial pain relief. NSAIDs are a mainstay and can be combined with acetaminophen for added effect. When the injury is acute and associated with secondary muscle spasm, muscle relaxants, light narcotics (eg, hydrocodone), or benzodiazepines are reasonable options. However, these medications should be administered cautiously and only for the initial acute phase of pain because dependence and tolerance can quickly occur.
Chronic SIJ dysfunction is more difficult to treat. Numerous medications are dispensed in a generic manner. Antidepressants, antiseizure agents, and antiarrhythmic agents are thought to be effective in neuropathic or nerve-related pain (radicular pain) and are not usually indicated for SIJ dysfunction pain.
Analgesics
For most episodes of SIJ pain, oral outpatient analgesics can achieve adequate pain control.
Acetaminophen (Tylenol, FeverAll)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
375-650 mg PO q4-6h prn or 1000 mg PO q6-8h prn; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity; known G6PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses exceeding the recommended maximum dose.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs work by decreasing inflammatory reactions and providing direct pain relief. Numerous choices are available, and they are separated into different families of agents. If an NSAID is ineffective, another agent from a different family can often provide relief. Efficacy and adverse effect profiles differ among agents and families.
Cyclooxygenase (COX)–2 inhibitors had been shown to reduce certain adverse effects (eg, gastrointestinal [GI] bleeding) and provide similar efficacy to standard agents. Unfortunately, 2 of the 3 agents (ie, rofecoxib [Vioxx], valdecoxib [Bextra]) were voluntarily removed from the market by their parent companies when an increased potential risk of adverse cardiovascular events was identified in an increased number of patients taking the drugs. Dosing requirements are usually individualized, based on the individual patient and patient response.
Related eMedicine topic:
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topic:
Resource Center Adverse Drug Events Reporting
Celecoxib (Celebrex)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200 mg PO qd or bid
Pediatric
Not usually recommended for pain control
Probenecid may increase the concentrations and possibly the toxicity of NSAIDs; may decrease the effect of concurrently administered loop diuretics; PT duration may increase when administered concurrently with anticoagulants; closely monitor PT duration and instruct patients to watch for signs and symptoms of bleeding
Documented hypersensitivity to aspirin, sulfa-based drugs, or other NSAIDS
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with renal impairment, hepatic or cardiac dysfunction, and decreased hemoglobin values; monitor serum electrolytes in long-term use (>3 mo); caution in the presence of peptic ulcer disease, recent GI bleeding or perforation, or renal insufficiency
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-600 mg PO q4-6h prn
Pediatric
Not usually recommended for pain control; however, often taken by adolescents in OTC form
Probenecid may increase the concentrations and possibly the toxicity of NSAIDs; may decrease the effect of concurrently administered loop diuretics; PT duration may increase when administered concurrently with anticoagulants; closely monitor PT duration and instruct patients to watch for signs and symptoms of bleeding; H2 antagonists and Carafate (active ingredient sucralfate) may decrease the risk of GI ulcer when administered concurrently with NSAIDs
Documented hypersensitivity to aspirin, iodides, or other NSAIDS
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with renal impairment, hepatic or cardiac dysfunction, and decreased hemoglobin; monitor serum electrolytes in long-term use (>3 mo); caution in the presence of peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding
Naproxen (Anaprox, Naprelan, Naprosyn)
Common NSAID family used for relief of mild to moderate pain.
Adult
250-500 mg PO q8-12h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Probenecid and lithium may increase the concentrations and possibly the toxicity of NSAIDs; PT duration may increase when administered concurrently with anticoagulants
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; low WBC counts occur rarely and usually return to the reference range in ongoing therapy.
Ketorolac tromethamine (Toradol)
Used primarily for control of hyperacute severe pain. Potency is higher than other NSAIDs, and use results in more marked GI upset, platelet inhibition, and renal effects.
Adult
30 mg IV q6h prn; alternatively, 30-60 mg IM q6h prn
Pediatric
Not established
May prolong the PT duration when administered concurrently with anticoagulants; may increase the risk for methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity); phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur.
Muscle relaxants
Muscle relaxants can provide adjunctive pain relief in the acute setting. These agents usually should not be used in protracted courses.
Cyclobenzaprine hydrochloride (Flexeril)
Centrally acting relaxant of skeletal muscle. Usually gains most of its analgesic effect indirectly as a general relaxant and sedative. Structurally related to TCAs.
Adult
10 mg PO up to tid prn
Pediatric
Not established
May enhance the effects of alcohol, barbiturates, or CNS depressants; may decrease the effectiveness of antihypertensives
Documented hypersensitivity; administration of MAOIs within previous 14 d; hyperthyroidism
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Exercise caution in patients with angle-closure glaucoma and urinary hesitance; may impair consciousness, reactions, and ability to operate machinery
Metaxalone (Skelaxin)
Prescribed for use as a muscle relaxant. Mechanism of action not firmly established but may act as a CNS depressant and direct pain reliever. No direct action on the contractile mechanism of striated muscle. Can be used short term as an adjunct pain reliever in situations of severe myofascial strain.
Adult
800 mg (2 tab) PO tid/qid
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
None reported
Documented hypersensitivity; drug-induced anemia, hemolytic anemia, or other anemias
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with known liver disease; perform serial LFTs in extended use
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 |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
sacroiliitis, SIJ injury, lower back pain, low back pain, LBP, back pain, low back injuries, lower back injuries
