Jenny Niedenfuehr, MPH, CHES®, CPH

Sacroilliac Joint Dysfunction and Inflammation
Sacroiliac (SI) joint pains are reported as one of the most common reasons for having low back pain, especially in athletes and post-partum women (Fiani et al., 2021; Whitney et al., 2022). It is often under-diagnosed, under-treated, and not treated effectively by many providers.
In a review by Buchanan et al. (2021), the authors suggested further treatments and assessments including taking a patient's complete medical history, fully evaluating the patient and their pain, observing gait patterns, and focusing on key physical areas. Schmidt et al. (2018) discussed that guided injections under fluoroscopy can serve as a diagnosis and are often therapeutic for the patient. Additionally, SI joint belts, NSAIDS, and physical therapy are recommended. As a last resort, SI joint fusion may be recommended if the patient has failed all other conservative treatments (Jonely et al., 2015). However, SI joint fusion remains as a controversial procedure (Martin et al., 2020). The SI joint is often aggravated from sitting, standing, injuries, pregnancies, inflammatory conditions, or connective tissue disorders (Ehlers-Danlos syndrome)
Fiani et al. (2021) revealed that SI joint pain is common and affects at least half of pregnant people due to increased weight, posture changes, and pressure in the abdomen and pelvis. Female sacrums have been characterized as more wide, more tilted (posterior and less curved). More research is needed to effectively create more positive outcomes for people with SI joint pain. The authors also suggested that people who have a uterus have increased mobility in their SI joint, which could be due to hormones, relaxin and estrogen (Fiani et al., 2021).
In a study by Jonely et al. (2015), a woman with 14 years of sacroilliac joint pain (on her right side) finally got her pain under control after attending 20 sessions of physical therapy. Her pain decreased to 0/10 from an average of 4/10. She also underwent prolotherapy injections, sacroilliac joint manipulation, pelvic girdle belting, and stabilization exercises. While this was a case study, the findings cannot be generalized to the rest of the population. However, these methods only work when there are no hip abnormalities that may be causing the SI joint issues.
In a study by Whitney et al. (2022), running gait mechanics were assessed with runners who had SI joint pain. These runners who had SI joint pain were reported to have less knee flexion, greater tibial over stride, and greater ankle dorsiflexon (Whitney et al., 2022). In addition, these people had contralateral pelvic drop.
SI Joint Dysfunction and Hip Dysplasia
In addition, people with SI joint dysfunction often have hip abnormalities. Unstable hips caused by bilateral hip dysplasia or osteoarthritis, secondary to development dysplasia of the hip (DDH) has been reported to show degenerative changes in the SI joint (Okuzu et al., 2021; Toyohara et al., 2022). In a study by Okuzu et al. (2021), patients that had worse SI joint degeneration (longer leg) were characterized as having more hip subluxation. The shorter leg side were reported to have more spinal imbalance. It's important to screen for both as you often can learn about one issue before the other one. Orthopedics often question which issue came first.
In my personal experiences, I was first diagnosed with "SI joint inflammation" in my MRI in 2020. I was told to go to pelvic floor PT for this. I was given alignment after alignment, and nothing ever improved. I was told they could help me, and I just needed time. However, I got worse from the treatments because we did not know that I had hip dysplasia at the time and I could barely walk. Worse, all of these people believed they were competent at assessing the hips. I was told my leg-lengths were uneven multiple times and I was given SI joint belts. Within five minutes of the sessions, I could feel my body coming out of alignment as my hips had subluxed to be in the "alignment." I would not recommend SI joint belts for people with hip abnormalities as it caused additional pain in the hip area. A few months later, I got another imaging test (3D CT scan) which indicated I may have SI joint degeneration and to correlate clinically. After my first periacetabular osteotomy and arthroscopy for hip dysplasia, femoral acetabular impingement, and chondral labral separation, my SI joint inflammation/degeneration decreased.
If you are suffering with this, I would highly recommend you go to an orthopedist for this issue, no pelvic pain clinics or pelvic floor PTs for this. As a note to providers, please be careful with patients who have bilateral SI joint inflammation or degeneration. It may be due to another structural abnormality.
Sacroiliitis
Sacroiliitis is defined as the inflammation of the sacroilliac joints, which is quite painful for people who have this issue (Buchanan & Varacallo, 2022). It can occur in either one, or both joints (Buchanan & Varacallo, 2022). The prevalence of sacroiliitis is 10-25%, specifically in people who suffer from lower back pain. Most interestingly, 6% report having pain in the lumbar spine, 4% in the groin, and 2% in the lower abdomen (Buchanan & Varacallo, 2022; Kocak et al., 2017).
The presence of bilateral sacroiliitis can be a precursor for ankloysing spondylitis, an autoimmune disease (Baronio et al., 2020). If your MRI or CT scan notates this, go to a rheumatologist and request multiple blood tests: ANA, Sed Rate, ESP and C-Reactive Protein (CRP) and Rheumatoid Factor.
Symptoms
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Lower back pain, often described as sciatic like pain
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Buttock pain
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Upper back
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Groin pain
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Hip pain
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Weakness in the leg
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Tingling in the leg
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Associated with pelvic floor dysfunction (instability) and hip abnormalities (hip dysplasia, FAI)
Treatments: Similar treatments as SI joint dysfunction
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Orthopedic physical therapy - strengthening (lower extremities, core activation)
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SI belts - use with caution
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Steroid pills to reduce the inflammation
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Cortisone injections
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Blood tests to rule out an autoimmune disease
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3D CT, X-ray, and pelvis MRI to rule out hips and another abnormalities
References
Baronio, M., Sadia, H., Paolacci, S., Prestamburgo, D., Miotti, D., Guardamagna, V. A., Natalini, G., & Bertelli, M. (2020). Etiopathogenesis of sacroiliitis: implications for assessment and management. The Korean journal of pain, 33(4), 294–304. https://doi.org/10.3344/kjp.2020.33.4.294
Buchanan, B. K., & Varacallo, M. (2022). Sacroiliitis. In StatPearls. StatPearls Publishing.
Buchanan, P., Vodapally, S., Lee, D. W., Hagedorn, J. M., Bovinet, C., Strand, N., Sayed, D., & Deer, T. (2021). Successful Diagnosis of Sacroiliac Joint Dysfunction. Journal of pain research, 14, 3135–3143. https://doi.org/10.2147/JPR.S327351
Buchanan BK, Varacallo M. Sacroiliitis. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448141/
Fiani, B., Sekhon, M., Doan, T., Bowers, B., Covarrubias, C., Barthelmass, M., De Stefano, F., & Kondilis, A. (2021). Sacroiliac Joint and Pelvic Dysfunction Due to Symphysiolysis in Postpartum Women. Cureus, 13(10), e18619. https://doi.org/10.7759/cureus.18619
Jonely, H., Brismée, J. M., Desai, M. J., & Reoli, R. (2015). Chronic sacroiliac joint and pelvic girdle dysfunction in a 35-year-old nulliparous woman successfully managed with multimodal and multidisciplinary approach. The Journal of Manual & Manipulative Therapy, 23(1), 20–26. https://doi.org/10.1179/2042618614Y.0000000086
Kocak, O., Kocak, A. Y., Sanal, B., & Kulan, G. (2017). Bilateral Sacroiliitis Confirmed with Magnetic Resonance Imaging during Isotretinoin Treatment: Assessment of 11 Patients and a Review of the Literature. Acta dermatovenerologica Croatica : ADC, 25(3), 228–233.
Martin, C. T., Haase, L., Lender, P. A., & Polly, D. W. (2020). Minimally Invasive Sacroiliac Joint Fusion: The Current Evidence. International journal of spine surgery, 14(Suppl 1), 20–29. https://doi.org/10.14444/6072
Okuzu, Y., Goto, K., Shimizu, Y., Kawai, T., Kuroda, Y., & Matsuda, S. (2021). Sacroiliac joint degeneration is common in patients with end-stage hip osteoarthritis secondary to unilateral developmental dysplasia of the hip: Factors associated with its severity and laterality. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association, 26(1), 135–140. https://doi.org/10.1016/j.jos.2020.02.005
Schmidt, G. L., Bhandutia, A. K., & Altman, D. T. (2018). Management of Sacroiliac Joint Pain. The Journal of the American Academy of Orthopaedic Surgeons, 26(17), 610–616. https://doi.org/10.5435/JAAOS-D-15-00063
Toyohara, R., Kaneuji, A., Takano, N., Kurosawa, D., Hammer, N., & Ohashi, T. (2022). A patient-cohort study of numerical analysis on sacroiliac joint stress distribution in pre- and post-operative hip dysplasia. Scientific Reports, 12(1), 14500. https://doi.org/10.1038/s41598-022-18752-1