The challenges of diagnosis and management of Sacroiliac joint dysfunction

Patients will often come into our office with a lumbar spine MRI, low back pain and a diagnosis of sacroiliac joint dysfunction. They are in our office because they may have been told that they should consider a surgical recommendation to spinal surgery. For many of these people, the MRI was the confirmation that their surgeon needed to go ahead with the surgical recommendation. For many patients, this may have been the same doctor who had taken them through a course of conservative treatments including long bouts with anti-inflammatory medications, back braces, physical therapy, and cortisone injections.

The question then to ask is, if these people do not respond to treatment, do they even have sacroiliac joint dysfunction?

Sacroiliac joint dysfunction patients do not get treatment relief because they do not have sacroiliac joint dysfunction

A recent study in the Clinical Spine Journal (1) offers the suggestion that sacroiliac joint dysfunction patients do not get treatment relief because they do not have sacroiliac joint dysfunction. This may be somewhat difficult for you to believe because all along you have been told you have sacroiliac joint pain.

Look at what the doctors of this study reported: Confusion and a lot of it.

A person goes to the doctor for pain in the pelvic / hip / groin lower back region.

The currently reported incidence of primary sacroiliac joint ranges from 15% to 30%. (In other words 15% to 30% of these people will get a diagnosis of sacroiliac joint dysfunction.)

When they do not get a diagnosis of sacroiliac joint dysfunction, they may get a diagnosis of:

  • pain generated from the lumbar spine (degenerative disc disease),
  • sacroiliac joint dysfunction, (but not as the primary cause of their pain and therefore not the primary target),
  • and pain coming from the the hip joint.

When these researchers re-examined these patients, with the goal of proving or disproving sacroiliac joint as the primary cause, what they found after a complete diagnostic workup was:

  • 112 (90%) had lumbar spine pain,
  • 5 (4%) had hip pain,
  • 4 (3%) had primary sacroiliac joint dysfunction pain, and
  • 3 (3%) had an undetermined source of pain upon initial diagnosis.

Patients did not have sacroiliac joint dysfunction as the primary source of their pain.

In fact the sacroiliac joint was found to be a rare pain generator (3%-6%) in patients complaining of more than 50% sacroiliac joint region related pain. Pain in the sacroiliac joint area is commonly a referral pain from the lumbar spine (88%-90%).

This is why treatments including the use of cortisone will not work in patients with sacroiliac joint dysfunction. The wrong area is getting treated OR the right areas are not getting treated. The right areas may include:

  • The axial low back,
  • buttock/leg region
  • groin/anterior thigh region.

The challenges of diagnosis and management of Sacroiliac joint dysfunction

A October 2021 paper (2) discusses the problem of Sacroiliac joint dysfunction being “often overlooked or under diagnosed and subsequently under treated.”

“Sacroiliac joint (SIJ) pain is one of the most common causes of low back pain, accounting for 15 to 30% of all cases. Although Sacroiliac joint dysfunction accounts for a large portion of chronic low back pain prevalence, it is often overlooked or under diagnosed and subsequently under treated.”

Next the authors offered guidelines to their fellow practitioners:

“The practitioner must focus on the history, location of pain, observed gait pattern, and perform key points of the physical exam including sacroiliac provocative maneuvers. If the patient exhibits at least three provocative maneuvers (movements that cause pain in the SI joint) then the Sacroiliac joint may be considered as a possible source of pain. Additionally, a thorough review of the imaging should be performed to rule out other etiologies of low back pain. In the absence of any pathognomonic tests or examination findings, diagnostic Sacroiliac joint blocks have evolved as the diagnostic standard.


“The diagnosis of SIJ pain is a multifaceted process that involves a careful assessment including differentiating other pain generators in the region. This involves careful history taking, appropriate physical examination including provocative maneuvers and diagnostic injections. Once the diagnosis is confirmed, long-term solutions may be considered, including recent advances in sacral lateral branch denervation and sacroiliac joint fusion.”

Here the conclusion ended with the possibility of surgical recommendation.

Why did researchers find so many poor sacroiliac joint pain treatment results? The chances are the patient did not have sacroiliac joint dysfunction.

We will often receive an email that will describe cortisone injections or nerve blocks that did not help the e-mailer with their low back pain. As we have seen in many patients, the hip-spine-sacroiliac joint complex is a challenging one to differentiate where the pain is coming from. Injections into the hip may not provide relief if the pain is in the sacroiliac joint region. Injections into the sacroiliac joint region may not work if the pain is from the hip or groin.

A study in the medical journal Pain Physician (3) looked at various treatment recommendations for patients suffering from sacroiliac joint pain. These treatments included burning the nerves, freezing the nerves, applying cortisone and Botox.

The researchers found the following:

  • “The evidence for cooled radiofrequency neurotomy (freezing the nerve) in managing sacroiliac joint pain is fair.
  • The evidence for effectiveness of intraarticular steroid injections is poor.
  • The evidence for periarticular injections of local anesthetic and steroid or botulinum (Botox) toxin is poor.
  • The evidence for effectiveness of conventional radiofrequency neurotomy (burning the nerves) is poor.
  • The evidence for pulsed radiofrequency is poor.”

Why did they find so many poor results? The chances are the patient did not have sacroiliac joint dysfunction.

Let’s look at another study. This time from June 2017 in the journal Medicine.(4) In this research, doctors investigated the degree of pain reduction following intra-articular pulsed radiofrequency stimulation of the sacroiliac joint in patients with chronic sacroiliac joint pain that had not responded to corticosteroid injection.

These research too found disappointing results:

  • Intra-articular pulsed radiofrequency stimulation of the sacroiliac joint was not successful in most patients (80% of all patients). Based on our results, we cannot recommend this procedure to patients with chronic sacroiliac joint pain that was unresponsive to corticosteroid injection.

Here is where treatments that are not helping the sacroiliac joint can become dangerous. How so? Because they will lead to a surgery that will not work either.

This was also suggested by a late 2019 study.(5)

  • “The rationale for SI joint fusion is to relieve pain created by the movement of a joint through the removal of movement by arthrodesis (fusion) of the joint space. Only few comparative studies of percutaneous SI joint fusion and denervation have been reported, and they had limited clinical evidence.”

“The sacroiliac joint 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. . . “

This is a study from December 2020. The doctors in this study use a much stronger language to describe the overreliance of SIJ Fusion. The paper was published in the Journal of pain research. (6)

“The sacroiliac joint 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. . . “

Here are some of the points provided by this study:

  • “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.
  • 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 underwhelming treatment efficacy of medical treatment. This has led to an increase in SI joint fixation (fusions).”

Many do not respond to corticosteroid injections for sacroiliac joint pain

A November 2022 study (7) “Intra-articular or peri-articular corticosteroid injections are often used for treatment of sacroiliac joint pain. However, response to these injections is variable and many patients require multiple injections for sustained benefit.” In this study, the researchers aimed to see if they could predict who would respond and who would not respond to sacroiliac joint injections. Who was at risk for not responding as well?

  • Patients with a history of depression and anxiety
  • Older patients

Of note is that the researchers speculated that the patients who did not have clinically significant pain relief scores did not accurately record perception of success after sacroiliac joint injection (on patient outcome self-reporting surveys). The researchers suggest their pain relief should have been greater.

But let’s point out that steroid injections can provide short-term relief. The injections can be more effective when combined with nerve blocks as shown in a March 2022 (8) study which evaluated the effectiveness of intraarticular steroid injections with lateral branch radiofrequency neurotomy for sacroiliac joint pain. The researchers found both sacroiliac joint intraarticular steroid injections and sacroiliac joint  lateral branch radiofrequency neurotomy demonstrated significant pain relief for patients with sacroiliac joint  pain. Sacroiliac joint  lateral branch radiofrequency neurotomy provided a longer duration of pain relief (82 days) versus sacroiliac joint  intraarticular steroid injection (38 days).

In the studies we just examined, the surgeons wrote there are many factors that would effect the outcome including finding the patient’s true source of pain. Let’s look at a relatively unexplored source of pain. The spinal ligaments.

Doctors at the Mayo Clinic (9) have published a paper entitled: Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. In this paper the Mayo Clinic researchers wanted to make a clear definition between two problems affecting low back pain patients.

  • First, that pain could be coming from the discs.
  • Second that pain could be coming from the spinal ligaments.

The Mayo researchers suggest that recognizing how the spine moves is essential for distinguishing between the many different types of spinal disorders, and a diagnosis which may ultimately, and erroneously lead to back surgery.

  • If a patient has instability, excessive movement, and decreased stiffness, doctors should examine for ligament damage.
  • If the opposite, less movement, more stiffness, the doctor should look for disc disease.

This information can help determine the true cause of a patient’s sacroiliac joint dysfunction. When nothing is working, look at the ligaments. How do you look at the ligaments? Through physical examination.

A diagnosis which may ultimately, and erroneously lead to back surgery.

In our own published peer-review research appearing in the July 2018 in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018, (10) we examined treating spinal ligaments with low back pain. Below is an explanatory adaption of the introductory paragraph of that study. It gives a good understanding of the importance of understanding that we should be looking at the ligament problems in back pain.

The challenge of sacroiliac joint dysfunction may be a ligament problem.

  • An Orthopaedic Knowledge Update from the American Academy of Orthopedic Surgeons tells its surgeon members that muscle strains, ligament sprains, and muscle contusions account for up to 97% of low back pain in the adult population (11)
  • Additionally, researchers wrote in the Spine Journal that spinal ligaments are often neglected compared to other pathology that account for low back pain (12). This could be due to the over-reliance of MRIs to guide physicians to correct diagnoses. They write: The influence of the posterior pelvic ring ligaments on pelvic stability is poorly understood. Low back pain and sacroiliac joint pain are described being related to these ligaments. When these ligaments are damaged or weakened, they serve as generators of low back pain.

Sacroiliac joint dysfunction following lumbar surgery

A January 2024 study (13) addressed the incidence of Sacroiliac joint dysfunction following lumbar surgery. Sacroiliac joint dysfunction (SIJD) after lumbar/lumbosacral fusion has become increasingly recognized as a problem following lumbar fusion. Despite the significant pain and dysfunction associated with Sacroiliac joint dysfunction, uncertainty regarding its diagnosis and treatment remains. To help answer the question of Sacroiliac joint dysfunction following lumbar fusion. The researchers assessed data from seventeen previously published studies and found after lumbar fusion “the incidence of new onset Sacroiliac joint dysfunction was 7.0%.” The average age of the patients were 56 years old, and the follow-up length was 30 months. Intra-articular injection for pain decreased the Visual Analogue Scale (VAS 0 – 10 pain score) score by 75%, while radiofrequency ablation (RFA) reduced the score by 90%.

Conclusions: “Lumbar fusion predisposes patients to SIJD, likely through manipulation of the SIJ’s biomechanics” (the surgical disruption of the sacroiliac joint.)

SI Fusion is probably better than traditional conservative care treatments

An August 2022 study (14) found that: “Among patients meeting diagnostic criteria for SI joint pain and who have not responded to conservative care, minimally invasive SI joint fusion is probably more effective than conservative management for reducing pain and opioid use and improving physical function and Quality of Life.” Also noted from these researchers is that side effects and complications “appear to be higher for minimally invasive SI joint fusion than conservative management through 6 months. Based on evidence from uncontrolled studies, serious adverse effects from minimally invasive SI joint fusion may be higher in usual practice compared to what is reported in trials.”

Neurosurgeons suggest that treatment for sacroiliac joint pain should not include spinal fusion.

This is the title of a paper published in the journal Neurosurgery clinics of North America : “Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute.”(15)

This is what the paper says:

“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. . . Evidence establishing (successful) outcomes (of spinal fusion) is misleading because of vague diagnostic criteria, flawed methodology, bias, and limited follow-up. Because of non-standardized 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.”

There are many people who may disagree that fusion will not help sacroiliac joint pain. Many people do in fact do get pain relief and benefit from surgery. I don’t see this people in my office. I see the people who did not do well after surgery. A December 2019 still asked “What do we know about the biomechanics of the sacroiliac joint and of sacropelvic fixation?” (16)

Here is an explanation of why this surgery may work for some, but may not work for others. “The sacroiliac joint is characterized by a large variability of shape and ranges of motion among individuals. Although the ligament network and the anatomical features strongly limit the joint movements, sacroiliac displacements and rotations are not negligible. 

Currently available treatments for sacroiliac joint dysfunction include physical therapy, steroid injections, Radio-frequency ablation of specific neural structures, and open or minimally invasive SIJ fusion. Several studies reported the clinical outcomes of the different techniques and investigated the biomechanical stability of the relative construct (the construct being the fusion itself), but the effect of sacropelvic fixation techniques on the joint flexibility and on the stress generated into the bone is still unknown. In our opinion, more biomechanical analyses on the behavior of the sacroiliac joint may be performed in order to better predict the risk of failure or instability of the joint.”

Failed sacroiliac joint fusion surgery

Failed sacroiliac joint fusion surgery affects a little less than 3% of patients undergoing sacroiliac joint fusion surgery. In a January 2024 study (17) doctors wrote of their analysis of patient outcome data in this group of failed surgery patients.

Our study demonstrates patients undergoing revision surgery have moderate improvement in low back pain, however, few have complete resolution of their symptoms. Specific patient factors, such as chronic opiate use and female sex may decrease the expected improvement in patient-reported outcomes following surgery. Failure to obtain relief may be due to incorrect indications, lack of biologic fusion and/or presence of co-pathologies.”

Post-operative opioid use

In December 2023 researchers (18) evaluated the duration and magnitude of post-operative opioid prescriptions after minimally invasive surgical sacroiliac joint fusion as compared to other common spine surgeries. The researchers acknowledge that minimally invasive surgical sacroiliac joint fusion “has been reported to significantly improve quality of life and reduce pain. However, there is a (lack) of reported data on post-operative opioid use in patients undergoing minimally invasive surgical sacroiliac joint fusion for sacroiliac joint dysfunction. In a survey of  4,666 patients who underwent minimally invasive surgical sacroiliac joint fusion, the researchers found patients “continued to fill opioid prescriptions 1-year post-operatively at significantly higher proportions than those undergoing other common spine procedures . . . pre-surgery chronic opioid users filled the highest opiate dosages during the 30-day post-operative period. The conclusion of this research was “minimally invasive surgical sacroiliac joint fusion may result in less effective pain reduction when compared to other common spine surgeries. . . ”

Platelet Rich Plasma vs cortisone for Sacroiliac Joint Injection

In May of 2024, the American Society of Pain and Neuroscience Best Practice (ASPN) Guideline for the Treatment of Sacroiliac Disorders was published in the Journal of Pain Research (19). Among the management options for sacroiliac disorders was a discussion on regenerative medicine.

“When patients with confirmed SIJ pain do not obtain satisfactory pain relief with conservative measures or intra-articular steroid injections, and want to avoid more invasive options, intra-articular regenerative medicine injections may be considered. Specifically, this term refers to platelet-rich plasma (PRP), bone marrow aspirate stem cell concentrate (BMAC), stromal vascular fraction (SVF), or a combination of these injectates. These options aim to reverse the underlying causative pathology by healing the damaged tissues. The two options most commonly utilized and well-studied are PRP and bone marrow aspirate stem cell concentrate (BMAC). . . Unfortunately, there is a scarcity of peer-reviewed published data pertaining to regenerative medicine injections for SIJ-related pain, and there is no evidence to suggest that one regenerative medicine injectate is superior to another.”

PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration.

The platelets contain healing agents, or “growth factors.” Let’s look at some of the growth factors and what they do:

  • Platelet-derived growth factor (PDGF) is a protein that helps control cell growth and division, especially blood vessels. When more blood (and the oxygen it carries) is delivered to the site of a wound, there is more healing.
  • Transforming growth factor beta (or TGF-β) is a polypeptide and is important in tissue regeneration.
  • Insulin-like growth factors are signaling agents. They help change the environment of the damaged joint from diseased to healing by “signaling” the immune system to start rebuilding tissue.
  • Vascular endothelial growth factor (VEGF) is an important protein that brings healing oxygen to damaged tissue where blood circulation might be damaged or inadequate.
  • Epidermal growth factor plays a key role in tissue repair mechanisms.

A study published in Pain practice : the official journal of World Institute of Pain (20) compared the effectiveness of these two injection treatments. These are the paper’s main points:

  • “Despite widespread use of steroids to treat sacroiliac joint (SIJ) 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.
  • Forty patients with chronic low back pain diagnosed with SIJ pathology were randomly allocated into 2 groups.
    • Group S received methylprednisolone
    • Group P received PRP
  • After treatment:
    • Intensity of pain was significantly lower in the PRP group at 6 weeks  and 3 months as compared to the steroid group.
    • The efficacy of steroid injection was reduced to only 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 of pain of more than 50% from baseline. Pain and function scores favored the PRP treatment as well. In the steroid group pain reduction and function improvements were seen up until 4 weeks after treatment and then the effectiveness declined. While the PRP group saw pain and function scores steadily increase at the three month marker.

Conclusion: “The intra-articular PRP injection is an effective treatment modality in low back pain involving SIJ.”

Fluoroscopically-guided intra-articular injection of steroid or platelet rich plasma injection

Giving another opinion is a November 2021 (21) paper. Here doctors compared outcomes with a fluoroscopically-guided intra-articular injection of steroid or platelet rich plasma injection. Follow-up was at 1-month, 3 months, and 6-months.

Results: “At one, three, and six months, both groups improved, however subjects who received steroid injections reported lower pain scores than subjects who received platelet rich plasma. Using categorical data, we observed significantly more responders (defined as pain scores which improved by 50% or more from baseline) at one and three months in the group that received steroids compared to the group that received platelet rich plasma. Conclusion: While both groups showed improvements in pain and function, the steroid group had significantly greater response and significantly more responders than the PRP group. “

In our office, we do not consider PRP a one shot treatment. Often the treatment requires a peppering of numerous PRP injections into the back and more than one treatment occasion. Our process is described below.

PRP treatment for a patient’s sacroiliac joint pain who has fluoroquinolone-related mitochondrial dysfunction

An  April 2022 case history (22) presents the case of using ultrasound-guided platelet-rich-plasma injections for reducing sacroiliac joint pain. In this case a  52-year-old Caucasian male with fluoroquinolone-related mitochondrial dysfunction  complained of severe SIJ pain. He was treated with two bilateral PRP ultrasound-guided injections at the sacroiliac level. PRP is a simple, efficient, and minimally invasive approach. After the first PRP injection, there was a considerable reduction of pain. The second PRP infiltration was performed after 2 weeks and in both cases no adverse events. At the 6-month follow-up evaluation, the patient showed good physical recovery, with the absence of pain.

A case history from the US military – PRP treatment for a soldier’s sacroiliac joint pain who was taking high-dose opioids

A case history was given in August 2020 in the journal Military medicine (23) of a soldier with sacroiliac joint pain. Here is a summary of this case:

“Back pain and its associated complications are of increasing importance among military members. The sacroiliac joint is a common source of chronic low back pain and functional disability. Many patients suffering from chronic low back pain utilize opioids to help control their symptoms. Platelet-rich plasma (PRP) has been used extensively to treat pain emanating from many different musculoskeletal origins; however, its use in the sacroiliac joint has been studied only on a limited basis.

The patient in this case report presented with chronic low back pain localized to the sacroiliac joint and subsequent functional disability managed with high-dose opioids. After failure of traditional treatments, she was given an ultrasound-guided PRP injection of the sacroiliac joint which drastically decreased her pain and disability and eventually allowed for complete opioid cessation. Her symptom relief continued one year after the injection. This case demonstrates the potential of ultrasound-guided PRP injections as a long-term treatment for chronic low back pain caused by SIJ dysfunction in military service members, which can also aid in the weaning of chronic opioid use.”

An August 2020 study (24) investigated the efficacy of ultrasound-guided platelet-rich plasma in reducing sacroiliac joint disability and pain. in 50 patients diagnosed  with low back pain secondary to sacroiliac joint dysfunction.

“Platelet-rich plasma was injected into the sacroiliac joint under ultrasound guidance. Oswestry Disability Index and Numeric Rating Scale were measured at baseline, 2 weeks, 4 weeks, 3 months, and 6 months after injection.

  • Results: The mean reduction in Oswestry Disability Index and Numeric Rating Scale scores were significantly reduced at 6 months after injection compared with baseline values. All timeframes showed significant mean reduction compared with baseline, but overall improvement tapers off after 4 weeks with no statistically significant reduction from 4 weeks to 3 months or three to six months.
  • Conclusions: Ultrasound-guided platelet-rich plasma injections in the sacroiliac joint are effective at reducing disability and pain with most improvement seen within 4 weeks after injection and with sustained reduction at 6 months.”

We usually ask the patients to return for more treatment if initial results were good and then being to taper off. In our years of experience and as documented in our medical research, we usually find multiple PRP treatments to be more effective than a single treatment. But, people do vary, some may derive benefit from one treatment.

A 2019 study in the journal Pain Physician (25)  posted the following guideline recommendations from the American Society of Interventional Pain Physicians (ASIPP) Guidelines.

“Based on the evidence. . . there is Level III evidence for intradiscal injections of PRP and MSCs, whereas the evidence is considered Level IV for lumbar facet joint, lumbar epidural, and sacroiliac joint injections of PRP, (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis.

Regenerative therapy should be provided to patients following diagnostic evidence of a need for biologic therapy, following a thorough discussion of the patient’s needs and expectations, after properly educating the patient on the use and administration of biologics and in full light of the patient’s medical history.

Regenerative therapy may be provided independently or in conjunction with other modalities of treatment including a structured exercise program, physical therapy, behavioral therapy, and along with the appropriate conventional medical therapy as necessary. Appropriate precautions should be taken into consideration and followed prior to performing biologic therapy.”

A January 2021 paper (26) came to inconclusive results when assessing the effectiveness of PRP for sacroiliac joint (SIJ) dysfunction. The authors wrote: “A review of the literature on PRP interventions on the SIJ or ligaments was performed. Seven studies had improvements in their respective primary end point and demonstrated a strong safety profile without any serious adverse events. Only five articles demonstrated clinical efficacy of  more than 50% in their primary outcome measures. There appears to be inconsistent and insufficient evidence for a conclusive recommendation for or against sacroiliac joint PRP”

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