Sacroiliac Joint Dysfunction Symptoms and Treatment Options

Ross A. Hauser, MD, Danielle Steilen-Matias, PA-C

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 (SI 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.

Article outline:

Part 1: The difficulty in the diagnosis of Sacroiliac Joint Dysfunction

  • “I have an MRI that shows degenerative disc disease. No one said anything to me about sacroiliac joint dysfunction.”
  • A painful unknown: sacroiliac joint diagnosis and treatment.”
  • “Although Sacroiliac joint dysfunction accounts for a large portion of chronic low back pain prevalence, it is often overlooked or underdiagnosed and subsequently undertreated.”
    • Is Sacroiliac Joint Dysfunction really ligament damage, muscle weakness, and fatigue?
    • Is Sacroiliac Joint Dysfunction really from lumbar spinal pain? Hip pain?

Part 2: Conservative care treatments

  • Physical therapy and exercise.
  • Anti-inflammatories for Sacroiliac joint inflammation – Sacroiliitis.
  • Cortisone Sacroiliac Joint Injections.
  • Cooled radiofrequency

Part 3: Surgical care

  • When to send a patient to sacroiliac joint surgery.
  • “Underwhelming treatment efficacy of medical treatment.” Because many conservative care options do not work, there are more fusions.
  • “Minimally invasive sacroiliac joint fusion is probably more effective than conservative care.”
  • Sacroiliac Joint Dysfunction surgery helps, but not all.
    • Sacroiliac Joint Dysfunction Surgical improvement in 81% of patients. No improvement in 19% of patients.
  • Challenges facing doctors and patients in treating Sacroiliac Joint Dysfunction planning big surgeries that may not be the correct surgery.
  • “Sacroiliac Fusion: Another Magic Bullet Destined for Disrepute.”
  • When surgery makes back pain worse – Focus on Lumbar Decompression Surgery and sacroiliac joint dysfunction.
    • Spinal surgery that makes sacroiliac joint dysfunction worse is a very difficult concept for many people to understand.
  • Comparing complication rates for minimally invasive sacroiliac joint fusion versus open sacroiliac joint fusion.
  • The current rate of severe complications for sacroiliac joint (SIJ) fusions.
  • Hardware and failure to fuse complications.

Part 4 Spinal and pelvic ligament weakness and laxity as a cause of Sacroiliac joint dysfunction

  • Ligaments are bands of fibrous tissue that connect bones to each other, like the vertebrae to each other and the sacrum to the pelvis.
  • No one is looking at the ligaments of the Sacroiliac Joint – that is why “nothing is working.”
  • Failed prior Sacroiliac Joint Dysfunction treatments may have failed because of the focus on discs, not ligaments.
  • SI joint dysfunction is defined as spinal instability from deficient ligament strength in the posterior elements of the SI joint.
  • Spinal ligaments are identified as a point of interest in treating Sacroiliac joint dysfunction treatment.
  • Spinal ligaments are identified as a point of interest in treating groin pain related to sacroiliac joint dysfunction.
  • 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.

Part 5 Therapeutic injections for sacroiliac instability

  • Prolotherapy Injections are a non-surgical alternative for SI pain
  • Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction
  • Research: the case for Prolotherapy as a non-surgical treatment of sacroiliac joint dysfunction and low back instability
  • Further research on Sacroiliac joint-mediated pain and Prolotherapy injections.
  • Platelet Rich Plasma and Prolotherapy Injections a non-surgical alternative for SI pain and long-term results?
  • One PRP injection can be effective for sacroiliac joint pain and improve patient function.
  • More than one PRP injection can be more effective.
  • Prolotherapy vs PRP Injections.

Sacroiliac Joint Dysfunction

“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. (Please see our article Is your MRI or CT Scan sending you to a back surgery you do not need?) Most people who injure their back significantly enough to visit a healthcare provider think that this injury is an acute event. For many patients, this is an acute event occurred as the final straw of years of degenerative wear and tear. The straw has finally broken the camel’s back or, in this instance, the sacroiliac joint.

“A painful unknown: sacroiliac joint diagnosis and treatment.”

Many people we see have a long history of lower back and pelvic pain and many years of varying diagnoses. Why did they have a problem getting an accurate diagnosis? Let’s look at the answers given by doctors in medical research. In October 2020, (1) researchers published a paper in the EFORT open reviews a publication of the European Federation of National Associations of Orthopaedics and Traumatology, with the title, “A painful unknown: sacroiliac joint diagnosis and treatment.” Here are the learning points and some possible explanations why an accurate diagnosis can be considered elusive in some cases of sacroiliac joint dysfunction:

  • Micro-traumatic Sacroiliac joint disorders are very difficult to diagnose and require a complete clinical and radiological examination.
    • Comment: As implied, injury to the sacroiliac joint can be missed, especially those injuries on the “micro” scale. These injuries can include those of the very elusive micro-ligament damage. Ligament damage is discussed below at length.
  • To diagnose micro-traumatic sacroiliac joint pain, the study authors recommended to the health care provider that he/she performs 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 during these tests, the authors suggest that then imaging tests should be conducted.

Next, the authors discussed treatment options.

  • Conservative treatment combining physiotherapy and steroid injections is the most common therapy but has a low level of efficiency.
  • Sacroiliac joint thermolysis (burning the nerves) is the most efficient non-invasive therapy.
  • Sacroiliac joint 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.

It is possible to summarize this research in one sentence? Perhaps, as “hard to diagnose, hard to treat.”

Let’s take this research a little closer to 2023.

The articulation of the SI Joint on MRI
The articulation of the SI Joint on MRI

“Although Sacroiliac joint dysfunction accounts for a large portion of chronic low back pain prevalence, it is often overlooked or underdiagnosed and subsequently undertreated.”

The theme here continues as sacroiliac joint dysfunction is hard to diagnose and hard to treat. The challenges of diagnosis are discussed in a more recent October 2021 paper published in the Journal of Pain Research (2) which comes to us from the Spanish Hills Interventional Pain Specialists, Michigan State University, the Division of Pain Medicine, Mayo Clinic, and other institutions. Here the authors discuss the challenges of correct diagnosis and management of sacroiliac joint dysfunction, but also of its prevalence in affecting many people.

“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 underdiagnosed and subsequently undertreated.”

The authors continue: “The diagnosis of Sacroiliac joint (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.”

Again we are back to trying to replicate the pain, and, if the pain is replicated the treatment suggestion is burning the nerves or fusion surgery.

Is Sacroiliac Joint Dysfunction really ligament damage, muscle weakness, and fatigue?

Above we discussed the problems of the diagnosis. That means people are told it may be one diagnosis and then after failed treatments, by told they had another diagnosis and that is why their treatment programs failed. Later in this article, we will discuss the problems of spinal ligament damage. Here we will give a brief introduction to this problem.

An August 2019 paper in the PM & R: The Journal of Injury, Function, and Rehabilitation, (3) noted how complex a diagnosis of sacroiliac joint dysfunction is and gives a glimpse into the world of soft-tissue damage and ligament problems. One point we will stress in this article is the undiagnosed and untreated ligament problem many low back and sacroiliac joint dysfunction patients suffer from.

“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.

Is Sacroiliac Joint Dysfunction really from lumbar spinal pain? Hip pain?

In a July 2019 study in the Journal of Clinical Spine Surgery (4) 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.

Study outline:

  • 124 patients, chief complaint sacroiliac joint pain.
    • After a 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 complaints) 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.

At this point, we can see that there is a lot of controversy surrounding the correct diagnosis and the correct pain generators in low back / sacroiliac joint region pain. This controversy extends to the conservatives care treatment options prescribe to patients.

Part 2: Conservative care treatments

General recommendations for treating sacroiliac joint dysfunction typically follow the same conservative care treatment guidelines for low back pain. For more acute injury or pain patients tend to ice and take pain and anti-inflammatory medications. In some cases, muscle relaxants are prescribed if the spasm is a significant pain-causing problem. In more chronic cases, physical therapy and core strengthening exercises are recommended. Low-back braces and belts may also be recommended.

Physical therapy

Physiotherapy si joint

Physical therapy may incorporate a wide variety of treatments. The goal of physical therapy, like all treatments, is to reduce pain and restore function. Included in physical therapy care is an exercise to strengthen supporting muscles, Manual therapy such as massage, activity modification to prevent worsening of injury and pain, and the use of supportive braces and change in footwear. Many of you reading this article have likely gone through this process with mixed or limited results. Others get very good results.

A May 2021 paper in the journal Pain Physician (5) describes the use of manual (muscle message or activation) therapy, exercise therapy, and the combination of these two treatments for sacroiliac joint dysfunction syndrome. In this paper, 69 women diagnosed with sacroiliac joint dysfunction were evenly divided into three groups. The first group (23 patients) was assigned manual therapy and a sacroiliac joints home-based exercise program, the second group (23 patients) was assigned sacroiliac joints manual therapy and a home-based lumbar exercise program, and the third group (23 patients) was assigned a home-based lumbar exercise program. The patients were then assessed on the twenty-eighth and ninetieth day following the start of treatments. The researchers found that all three groups showed a significant decrease in the sacroiliac joints -related pain parameter Manual therapy is effective in the long term in sacroiliac joint dysfunction syndrome. Adding specific exercises for sacroiliac joints to the sacroiliac joint manipulation treatment further increases this effectiveness.

Previously, a January 2019 paper in the journal Pain Physician (6) compared the effectiveness of exercise therapy, manipulation therapy, and a combination of the treatments in treating sacroiliac joint dysfunction. In this study, 51 patients with lower back or buttock pain from sacroiliac joint dysfunction were randomly assigned to an exercise therapy group, a manipulation therapy group, and a combination of treatments group. Pain and disability were assessed at 6, 12, and 24 weeks after the interventions.

The researchers reported that all three study groups demonstrated significant improvement in pain and disability scores compared to the baseline. At week six, manipulation therapy showed notable results, but at week 12, the effect of exercise therapy was remarkable. Finally, at week 24, no significant difference was observed among the exercise therapy, manipulation therapy, and a combination of the treatment groups. The researchers concluded: “Exercise and manipulation therapy appears to be effective in reducing pain and disability in patients with sacroiliac joint dysfunction. However, the combination of these two therapies does not seem to bring about significantly better therapeutic results than either approach implemented separately.”

The subject of physical therapy, exercise, and yoga is covered extensively in our article Why physical therapy and yoga did not help your low back pain.

Anti-inflammatories for 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 may be 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 effectsIn the July 2022 update of the publication STATPearls (7) housed at the National Library of Medicine, the list of Disease-modifying antirheumatic drugs that may help Sacroiliac joint inflammation include; infliximab, adalimumab, etanercept, rituximab, abatacept, rituximab, tocilizumab, tofacitinib, among others. Biologic Disease-modifying antirheumatic drugs (DMARDs) are highly specific and target a specific pathway of the immune system.

Cortisone Sacroiliac Joint Injections

We have many articles on our website that discuss corticosteroids and cortisone injections. In our article Alternatives to Epidural Steroid Injections, we noted that it is common for doctors to use epidural or other steroid injections to treat pinched nerves in the spine. We do occasionally, more so very rarely, use cortisone, epidural injections, facet blocks, and a host of other injection techniques to help patients who may be suffering from severe pain in the lumbar and SI joint region. However, without treating the ultimate cause of the inflammation in the area, the beneficial effects will only be temporary and the person will be left with the same symptoms once the steroid shot wears off. That is exactly what the scientific literature shows and has been demonstrated in the research. . . no evidence exists supporting injections of steroids into and around the nerve for long-term benefit.

Here we will present a brief review of this research both for and against the use of corticosteroid or epidural injection.

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, 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 in 2015. (8). Multiple applications of steroid is usually not something that doctors are eager to do nor do patients seemingly want.

Built on this research is a November 2022 study from the University of California San Diego (9) examined why some people respond to cortisone injections and why some people need multiple injections or do not respond at all. This is what they found: “Intra-articular or peri-articular corticosteroid injections are often used for the treatment of sacroiliac joint (SIJ) pain. However, response to these injections is variable and many patients require multiple injections for sustained benefit.” The purpose then of this study was to see if the doctors could come up with a screening process that would help other doctors understand who the cortisone injections would help and those the injection would not help. In looking at 100 patients, the patients who did not respond or had limited response suffered from a history of depression and anxiety. They also found older patients did not respond as well.

The researchers also pointed out an enigmatic finding. They found that “the associated Numerical Pain Rating Scale (NPRS (A scoring system of 0 – 10 with 10 being intolerable pain)) score change for SIJ injection responders was less than the minimally clinically significant value of a 2-point differential, suggesting that reported changes in pain scores may not accurately represent a patient’s perception of success after SIJ injection.”

What does this mean? A minimally clinically significant value of a 2-point differential, if you had 9 out of 10 pain you should have seen it reduced to 7 – or – if you had a 6 out of 10 level pain, that should have reduced to 4 level pain. Was in fact not being achieved. In other words, the patients did not believe that the cortisone worked as well as they thought it would. However, a February 2022 paper in the journal Advanced biomedical research (10) evaluated the effects of corticosteroid intra-articular injections on 27 patients with sacroiliac pain and noted pain and disabilities of patients reduced significantly after injections and these results continued for up to within 6 months after interventions.

A June 2023 paper in the Journal of Ultrasound (11) also noted that the combination of non-steroidal anti-inflammatory drugs (NSAIDs) and biological disease-modifying drugs does not achieve desired pain relief for the patient. In this study of 26 patients (average age 55 years old with 25 patients being females and 1 male, the researchers found ultrasound-guided sacroiliac joint injections were effective and a safe technique for patients who have active sacroiliitis yet are ineligible or do not respond to non-steroidal anti-inflammatory drugs (NSAIDs) and biological disease-modifying drugs.

Steroid injections or neurotomy

Doctors at the Boston University School of Medicine and Massachusetts General Hospital evaluated the effectiveness of intraarticular steroid injections with lateral branch radiofrequency neurotomy (the nerves from the sacroiliac joint are burned out). This March 2022 (51) study in the journal Pain Physician found both sacroiliac joint intraarticular steroid injections and sacroiliac joint  lateral branch radiofrequency neurotomy demonstrated significant pain relief with sacroiliac joint  lateral branch radiofrequency neurotomy providing a longer duration of pain relief (82 days) versus sacroiliac joint  intraarticular steroid injection (38 days).

Cooled radiofrequency for Sacroiliac Joint Dysfunction

Cooled radiofrequency is the heating of the nerves carrying pain signals to destroy them or disrupt pain messages. It is called cooled because water is circulated into the treatment area to prevent the tissue from being overheated or damaged. An October 202o study (12) wrote: “Cooled radiofrequency is an effective treatment for sacroiliac pain. In contrast to conventional radiofrequency denervation, this technique allows enlarging the area of denervation by cooling the radiofrequency probe.”

The purpose of this research according to the authors was to evaluate the outcome of cooled radiofrequency in chronic pain patients regarding the psychological outcomes of anxiety, depression, sleep quality, and pain-related disability. What they found was that depression in the patients improved for a time but did not remain significant. Anxiety did not show a statistically significant change. No statistically significant improvement was observed in the pain disability index. Patients reported fewer sleep disorders after treatment. Average pain scores were statistically significantly reduced one-week post-intervention and at the time of follow-up. There was no clear reduction of analgesic medication.

An April 2023 paper in the journal BioMed Central Musculoskeletal Disorders (13) followed 81 patients (59 females and 22 males with an average age of about 55) who underwent cooled radiofrequency ablation, 22 of the patients had previously undergone lumbar fusions. The researchers were looking for pain that returned in patients following the procedure. They also looked for how many patients had to move to fusion or revision fusion surgery. After radiofrequency ablation, 7 patients progressed to fusions, and 6 patients had to have the procedure done again to relieve their pain.

Nerve blocks

In a 2016 paper, (14) 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.”

In summary:

Building on the research is a December 2021 paper in the medical journal Diagnostics (15) which examined the results of nerve blocks used in patients with SI joint pain. Here are the learning points of this research:

  • The fluoroscopy-guided (nerve) block is the gold standard for diagnostic or therapeutic purposes when treating SI joint pain.
  • Generally, a 75% reduction of pain following a diagnostic SI joint block is considered positive (for the SI joint pain being the main cause of the pain).
  • If 50–75% of the pain is reduced, the SI joint may be considered a major contributor to pain in the lower back.
  • (studies) demonstrated a good response to SI joint fusion in patients with 50% relief from diagnostic SI joint block, suggesting that those patients with a 50–74% reduction in pain may find further intervention, such as SI joint fusion, beneficial.

Part 3: Surgical Care for Sacroiliac Joint Dysfunction

Surgical care for Sacroiliac Joint Dysfunction

When to send a patient to sacroiliac joint surgery

A 2023 paper in  The Journal of Medical Investigation (16) discussed when to send a patient to sacroiliac joint surgery. The telltale signs were pain and functional difficulties after six months of continued and substantial conservative treatment. If the patient continued to have these problems:

  • Being unable to sit for more than 15 minutes.
  • Needing a cane to walk.
  • Pain in the supine or laying on your back position.
  • Pain while lying on the painful side.
  • Numbness in the lower limbs and a history of any accident that induced sacroiliac joint pain may be considered as indicators for surgery after more than 6 months of continued substantial conservative treatment.

“Underwhelming treatment efficacy of medical treatment.” Because many conservative care options do not work, there are more fusions.

Above we described the various conservative care treatments for sacroiliac joint dysfunction. A December 2020 study in the Journal of Pain Research (17) called this an “underwhelming treatment efficacy of medical treatment.” Here are the learning points of this paper:

  • “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 sacroiliac joint.
  • 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.

Because many conservative care options do not work, there are more fusions

The conclusion of this study states: “Sacroiliac joint 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 sacroiliac joint pathology and the underwhelming treatment efficacy of medical treatment. This has led to an increase in sacroiliac joint fixation.”

“Minimally invasive sacroiliac joint fusion is probably more effective than conservative care”

In an August 2022 paper in the Spine Journal (18)  researchers from the Advocate Aurora Research Institute examined minimally invasive SI joint fusion, which they note is being increasingly used to relieve chronic SI joint pain among patients who do not respond to nonsurgical treatment.

Here is what they wrote: “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. Fusion with (device hardware) iFuse and Rialto appear to have similar effectiveness. Adverse effects (side effects/complication)  appear to be higher for minimally invasive SI joint fusion than conservative management through six 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. (There are more adverse effects than are being reported in medical research). The incidence of revision surgery is likely no higher than 3.8% at 2 years.”

Sacroiliac Joint Dysfunction surgery helps, but not all

In over more than 30 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.

Or –

  • I had a fusion at L5/S1 which 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 for SI fusion. I don’t want to do it.

Or –

  • I had SI fusion three years ago. I still have intense pain in my lower back that radiates into the groin area. Sleeping, driving, and 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.

Sacroiliac Joint Dysfunction 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. (19)

“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.

Challenges facing doctors and patients 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 (20). 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 caused 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.”

“Sacroiliac Fusion: Another Magic Bullet Destined for Disrepute”

In the July 2017 edition of the medical journal Neurosurgery Clinics of North America (21), 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 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.” Let’s point out that the title of the above research is “Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute.”

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.

We are going to explore the most recent eight years of research in the discussion of failed surgery and SI joint involvement.

In 2015, 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.”(22)

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)

RESULTS:

  • 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.

CONCLUSION:
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, and 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.”

A January 2024 study from doctors at Tufts University School of Medicine (52) addressed the incidence of Sacroiliac joint dysfunction following lumbar surgery.  The researchers reviewed data from seventeen previously published studies and found after lumbar fusion “the incidence of new onset Sacroiliac joint dysfunction was 7.0%.”

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

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 for 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, frustration, anxiety, and depression.

Comparing complication rates for minimally invasive sacroiliac joint fusion versus open sacroiliac joint fusion.

A March 2022 study in the European spine journal (23) comes to us from the Keck School of Medicine, University of Southern California. In this study, the researchers examined sacroiliac joint fusion and postoperative complications.

  • The researchers assessed the two main surgical approaches for fusing the sacroiliac joint (SIJ): an open surgery or a minimally invasive (MIS) approach.
  • 2521 patients either received an open Sacroiliac Joint Dysfunction fusion (1990 patients) or minimally invasive surgery (531 patients) approach for diagnosed sacrum pain, sacroiliitis, sacral instability, or spondylosis.

Findings:

  • Patients who received the open approach for sacrum pain had significantly higher rates of new post-procedural pain and new lumbar pathology within 30 days.
  • On the 30-day follow-up, patients with sacroiliitis treated with open SIJ fusion had significantly higher rates of new postprocedural pain compared to those treated with MIS fusion.
  • Patients who received the open approach for spondylosis resulted in significantly higher rates of non-elective readmission within 30 days compared to the MIS approach.
  • In addition, the open technique for spondylosis resulted in significantly higher rates of non-elective readmissions for infection within 30 days.
  • On the 30-day follow-up, patients with sacral instability treated with open SIJ fusion had significantly higher rates of urinary tract infections.

The current rate of severe complications for sacroiliac joint (SIJ) fusions

An April 2022 study in the Clinical Spine Surgery (24) from Western Michigan University School of Medicine presented an unbiased report of the current rate of severe complications for sacroiliac joint (SIJ) fusions and investigate the underlying cause of these complications.

  • Patient injury (caused by surgery) was the most common type of event reported at 97.5% of all complications.
  • Death was reported in (0.3% or 3 in 1000).
  • Malposition was the most common device problem at 49.5% (the fusion hardware was not placed correctly).
  • The root cause of these events was primarily surgeon error at 58.2%
  • Revision surgery or reoperation occurred in 92.8% of the patients with complications in the patients assessed in this study.
  • Further: These complications are likely underreported, and there is currently no formal tracking system of total SIJ fusions performed to calculate accurate complication and revision rates.

Hardware and failure to fuse complications

The start of this April 2023 research paper (25) from doctors at the Mayo Clinic opens like this: “Sacroiliac joint fusion has been established as an effective treatment for sacroiliac joint dysfunction. However, failure necessitating revision has been reported in up to 30% of cases. Little is known regarding outcomes of revision Sacroiliac joint fusion.” In other words, there is a 30% failure rate and there is not much research to suggest if having the revision surgery is of any benefit. In this paper, doctors examined 18 eighteen revision sacroiliac joint fusions performed in 13 patients. The average age of the patient was 55.8 years with the youngest being 35 and the oldest 75 and almost 2 out of three patients were women.

Why were these people sent for the second and sometimes a third surgery?

  • The indications for revision were pseudarthrosis (not enough bone formation) without fixation failure (the fusion did not hold) in 14 cases (77.8%), hardware failure (loosening) in 3 cases (16.7%), and continued pain after partial fusion in 1 case (5.6%).
  • In this study, the doctors found that the second and third revisions to correct the above problems resulted in significant statistical and clinical improvements at 12 months with an 88.9% fusion rate across the sacroiliac joint.

A January 2024 study in the European spine journal (48) assessed what to do with the patient who had a failed sacroiliac joint fusion surgery. In this paper, doctors at the The Department of Orthopedic Surgery, University of Minnesota reviewed the data on patient outcomes following a revision sacroiliac joint fusion surgery. Here are some of the learning points:

  • Clinical improvement following SI joint fusion was seen in 83.1% of patients, revision rates of 2.9% within 2 years have been reported.
  • Fifty-two patients (77% female) with an average age of 49.1 years were included. Forty-four had single sided revisions and eight bilateral revisions.
  • For these patients there was no significant improvements in pain or disability as measured by patient reported outcome scores at one year follow up.
  • Patients with chronic opioid use were 8.5 times less likely to achieve minimal clinical improvement in pain and disability.

The authors suggest that their study: “demonstrates patients undergoing revision surgery have moderate improvement in low back pain, however, few have complete resolution of their symptoms. . . . Failure to obtain relief may be due to incorrect indications (poor patient selection), lack of biologic fusion and/or presence of co-pathologies (something else may have been causing the pain or the patient had poor general health).

Part 4 Spinal and pelvic ligament weakness and laxity as a cause of Sacroiliac joint dysfunction

We are going to start this section with a March 2022 paper in the journal Spine Surgery and related research. (26) What is being said in the research is that despite six months of conservative care and ultimately surgery, the treatments failed the patient. Why? It was a ligament injury, let’s read the research.

“Most sacroiliac joint  disorders are conservatively treated; however, patients with severe pain occasionally require SIJ arthrodesis (fusion) after the failure of continuous conservative management for more than 6 months.”

What the researchers here focused on was ligaments, the tough bands of connective tissue that hold bones in place.

“(The researchers) investigated the incidences of preoperative tenderness in the sacrotuberous ligament (the ligament that connects the bones of the pelvis to lumbar vertebras) and postoperative lower-buttock pain originating from the sacrotuberous ligament to determine the best way to manage these symptoms to achieve good outcomes.”

Post-surgical pain is something we see frequently in patients. In many cases that we treat, there is almost always a ligament problem that went undetected through the entire conservative care-surgical process and was then revealed after the surgery when the surgical procedure corrected all the problems on MRI. The problem is that micro or small tear damage may not be picked up on MRI. Please see our article Is your MRI or CT Scan sending you to a back surgery you do not need? for an expanded discussion on this topic.

In this study, the researchers examined the records of 33 patients (14 men and 19 women) with an average age of 47.7 years (range: 25-79 years) who underwent SIJ fusion for severe pain. Here are the outcome observations.

  • In many patients, significant pain relief was acquired after surgery.
  • Before the surgery, tenderness of the sacrotuberous ligament was identified in 21 of 33 patients (63.6%).
    • The sacrotuberous ligament tenderness resolved after surgery in 12 of these 21 patients (57.1%); however, it persisted in nine patients (42.9%), all of whom were women.
    • Of the 12 patients who did not have preoperative sacrotuberous ligament tenderness, 4 (33.3%) developed lower-buttock pain and had sacrotuberous ligament tenderness.
    • In total, 9 (27.3%) of the 33 patients whose progress could be followed up after SIJ arthrodesis (fusion) had pain originating from the sacrotuberous ligament; the sacrotuberous ligament pain in 8 of the 9 patients was relieved after the sacrotuberous ligament injections and physical therapy.

Here is the conclusion of this paper: “The sacrotuberous ligament pain can occur pre- and postoperatively, and management of both persisting and new-onset sacrotuberous ligament pain after SIJ arthrodesis (fusion) should be considered to achieve better outcomes.”

Let’s take a moment to review the conclusion. Many patients achieve successful surgeries. Some people do not. In people without successful surgical outcomes, a problem with the sacrotuberous ligament (the ligament that connects the bones of the pelvis to the lumbar vertebras) has been identified. Managing sacrotuberous ligament pain origins, those that continued from before surgery, and new pain attributable to occurring post-surgery. The pain of the patient and the success of the treatment depends on ligament treatments.

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, and iliac from the ilium.

In a December 2019 study, (27) doctors 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.

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.” Some have had the surgeries, denervation, physical therapy, and cortisone mentioned above. Part of the reason nothing is working is that the treatment plan they have been given is not addressing the correct problem. This is evident because they have continued pain. As mentioned, 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 true 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.

Failed prior Sacroiliac Joint Dysfunction treatments may have failed because of the focus on discs, not ligaments.

In the next section, we are going to discuss the spinal ligaments that may be impacting your continued pain. First, 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.

Having an MRI that shows nothing “that can be fixed” while still having back pain can be incredibly frustrating for patients. These people 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).

  • Patients who 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.

The problems with ligaments after physical therapy after sacroiliac joint treatment are noted in a September 2021 paper in the Journal of physical therapy science. (28) After physical therapy, the incidence of residual sacrotuberous ligament pain in the persisting lower-buttock pain was 57.9%.

Radiating pain

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 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.

SI joint dysfunction is defined as spinal instability from deficient ligament strength in the posterior elements of the SI joint.

We are now presenting our own 2016 medical research published in Clinical Medicine Insights, Arthritis, and Musculoskeletal Disorders. (29) In this research, 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. We also discuss dextrose Prolotherapy injections as a viable treatment option.

First, observations:

  • 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.

Before we continue with the research on Prolotherapy for sacroiliac joint dysfunction, we 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.

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 the toes.

Sacroiliac instability. 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 spine to toes.

Spinal ligaments identified as a point of interest in treating Sacroiliac joint dysfunction treatment

The opening statement of a 2015 research article from doctors at the Mayo Clinic (30) 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.”

Doctors from the Low Back Pain and Sacroiliac Joint Center, Sendai Shakaihoken Hospital in Japan wrote of their findings in the European Spine Journal, (31) 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.

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 (32looked to identify the prevalence of groin pain in patients with sacroiliac joint dysfunctionlumbar 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 the 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.

RESULTS:

  • 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.

Conclusion:

  • 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.

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:

  1. When asked to pick the spot from which pain emulates, people almost always point to the top of the sacroiliac joint.
  2. When asked what makes the pain worse, patients usually mention positions that increase the force on the sacroiliac joint, such as sitting.
  3. 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.
  4. 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 decreases in feeling (sensation).
  5. Physical examination of stressor maneuvers on the sacroiliac joint.
  6. Plain radiographs show sclerosis on one (or both) of the sacroiliac joints, indicating increased force on the subchondral bone there.

Part 5 Therapeutic injections for sacroiliac instability

In May of 2024, published in the Journal of Pain Research (53) doctors issued the American Society of Pain and Neuroscience Best Practice  Guideline for the Treatment of Sacroiliac Disorders. 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.” Let’s explore some of the options.

Prolotherapy Injections are a non-surgical alternative for SI pain

Prolotherapy is an injection treatment that stimulates the repair of connective tissues such as tendons and ligamentsIt 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. (33)

Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction

  • 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 the 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.

For more information please see Prolotherapy treatments for lumbar instability and low back pain.

Research: the case for Prolotherapy as a 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:(34)

  • One hundred forty-five patients, who had been in pain for 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.

Further research on Sacroiliac joint-mediated pain and Prolotherapy injections.

In our own December 2021 paper published in the Journal of Back and Musculoskeletal Rehabilitation (35) on the effectiveness of Prolotherapy for sacroiliac joint pain, we cited the results of previously published research. These papers are summarized here:

A 2010 paper published in The Journal of Alternative and Complementary Medicine (36) compared the pain relief effects of Prolotherapy to corticosteroid injection. At 15 months, 58% of the patients treated with Prolotherapy reported that more than half of their pain was relieved, which was statistically significant compared with only 10% in the corticosteroid group who reported that same level of pain relief. The researchers here concluded: “Intra-articular Prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections. Further studies are needed to confirm the safety of the procedure and to validate an appropriate injection protocol.”

An earlier study in the Journal of Spine Disorders (37) demonstrated that for patients with chronic low back pain who had failed to respond to previous conservative care, Prolotherapy could be an effective treatment. Patients were randomly assigned to receive a double-blind series of 6 injections at weekly intervals of either a xylocaine/proliferant or a xylocaine/saline solution into the posterior sacroiliac and interspinous ligaments, fascia, and joint capsules of the lower back from L4 to the sacrum. Of the 39 patients assigned to the proliferant group, 30 achieved a 50% or greater reduction in both pain and disability scores at 6 months compared with 21 of 40 in the group receiving the saline solution. The proliferant group also achieved greater improvements on the visual analog, pain, and disability scales.

In a 2004 (38) audit of conservative treatments for low back pain, patients who were diagnosed with sacroiliac pain via diagnostic block were treated either by corticosteroid injection to the sacroiliac joint or by Prolotherapy to the sacroiliac ligaments. Long-term improvement was assessed at 6 months, after which 63% of the Prolotherapy group reported a substantial drop in pain severity compared with only 33% in the corticosteroid group

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.”(39)

  • 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.

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”(40)

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. (41) This study was conducted to determine whether prolotherapy is effective in the treatment of deficient load transfer of the sacroiliac joint in 25 patients. In this study, 3 injections at 6-week intervals of a hypertonic dextrose solution were given into the dorsal interosseous ligament of the affected sacroiliac joint of each patient. Outcome measures standard test scoring to determine pain and function as well as an independent clinical examination by the paper’s two authors. The authors concluded that their descriptive study of prolotherapy in private practice showed 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).

Platelet Rich Plasma and Prolotherapy Injections a non-surgical alternative for SI pain and long-term results?

A January 2021 paper in the journal Regenerative medicine (49) reviewed seven previously published papers on PRP interventions on the SIJ or ligaments. Five of the studies demonstrated clinical effectiveness of PRP of more than 50% in their primary outcome measures. The paper also noted “inconsistent and insufficient evidence for a conclusive recommendation for or against SIJ PRP.”

In this video, Ross Hauser, MD explains the use of Platelet Rich Plasma in treating this patient with problems of 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.

A case history published in the journal Military Medicine, (42) a publication of the Association of Military Surgeons of the United States described a patient who had chronic low back pain localized to the sacroiliac joint and subsequent functional disability managed with high-dose opioids. After the 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. The case continues that the patient had symptom relief more than one year after the injection. The doctors of this case suggested that “this case demonstrates the potential of ultrasound-guided PRP injections as a long-term treatment for chronic low back pain caused by sacroiliac joint dysfunction in military service members, which can also aid in the weaning of chronic opioid use. ”

A March 2023 paper in the Frontiers in endocrinology (50) gives a summary overview in the use of PRP in SI joint disorders. “Initial treatment of SIJ disease is usually conservative and includes physical therapy, massage therapy, and drug therapy. However, these treatments are often aimed at pain relief, rather than eradication (repairing and alieviating the pain generators). Other treatment options, such as periarticular injection, intraarticular injection, or nerve block, are generally administered if there is no improvement in symptoms after 6 weeks of conservative treatment. Surgery is considered when all treatments fail. PRP can be used as a new treatment modality for the treatment of SIJ disease. (Based on reviewed research in this study) it can be concluded that ultrasound-guided PRP injection is a safe and effective treatment for SIJ disease and can reduce dysfunction and low back pain.”

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.”(43)

Doctors at the University of Toronto have published four case studies investigating the long-term benefit of Platelet-Rich Plasma (PRP) injections in reducing SI joint pain, improving quality of life, and maintaining a clinical effect.

At the 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 an improvement in the quality of life.

The clinical benefits of PRP were still significant 4 years post-treatment. Platelet-Rich Plasma therapy exhibits clinical usefulness in both pain reduction and 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. (44)

A November 2021 paper in the journal Pain Medicine (54) compared patient reported outcomes with a fluoroscopically-guided intra-articular injection of steroid or platelet rich plasma injection.

Results: “At one, three, and six months (follow up), 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. “

One PRP injection can be effective for sacroiliac joint pain and improve patient function.

An August 2020 study published in the American Journal of Physical Medicine & Rehabilitation (45) investigated the effectiveness of ultrasound-guided platelet-rich plasma in managing or even reducing sacroiliac joint pain and improving patient function.

  • Platelet-rich plasma injections into the sacroiliac joint under ultrasound guidance. The patients were measured for treatment outcomes at baseline, two weeks, four weeks, three months, and six months after injection. (Please note after “injection.”)

These researchers found that standard pain and disability self-reported scoring was significantly reduced at six months after injection compared with the baseline value. All survey scoring taken at two weeks, four weeks, three months, and six months after injection showed a significant reduction of self-reported pain and disability compared with baseline. But overall improvement tapers off after four weeks with no statistically significant reduction from the four-week survey score to 3 months or three to six months. Conclusion: “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.”

More than one PRP injection can be more effective.

Many of the “PRP 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.

A November 2021 paper comes to us from the Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Columbia University Medical Center, and Cornell University Medical Center. It was published in the journal Pain Medicine (46). This research shows that one injection of PRP is not as effective as one cortisone injection.

Results: “At one, three, and six months, both groups (13 patients in the cortisone and 13 in the PRP group) 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 that 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 a significantly greater response and significantly more responders than the PRP group.”

Prolotherapy vs PRP Injections

A 2018 study published in the Journal of Prolotherapy (47) 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 that 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

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