SI joint pain, sacroiliac joint, movement pain, pelvic pain, stiffness, aging, degenerative changes, inflammation, radiating pain, hip pain, limb pain, range of motion restriction

The SI joint, also known as the sacroiliac joint, is located between the pelvis and the spine. It connects the sacrum to the ilium and allows for a stable yet flexible pelvis.
SI joint dysfunction refers to abnormal movement or other issues within the SI joint, which can cause discomfort or pain in the lower back and pelvic region. Pain from the SI joint can also radiate down the leg, leading to confusion with possible neuropathic radiating pain.
Pain associated with SI joint dysfunction typically manifests as a dull, aching sensation in the lower back or buttocks. Weight-bearing activities and movements in an upright position, such as standing, walking or climbing stairs, can exacerbate the pain, while rest or lying down may provide temporary relief. Patients often report accompanying feelings of stiffness and range of motion restrictions in the back and hip.
SI joint pain can occur in individuals across all age groups regardless of gender, but it is most common in pregnant women and those who participate in activities that repeatedly stress the pelvis. Timely initiation of appropriate treatment improves prognosis and reduces the risk of complications.
Typically, pain in the SI joint is not due to inflammation but rather results from overuse or insufficient recovery, leading to irritation and pain in the joint. However, inflammation is also a possibility, but when this occurs, the condition is referred to as sacroiliitis, which is often a sign of underlying rheumatic disease. For example, ankylosing spondylitis often begins with inflammation of the SI joint. The initial symptoms of ankylosing spondylitis typically include severe morning pain and stiffness in the lower back and buttocks. Ankylosing spondylitis is significantly more common in men than in women and it almost invariably begins before the age of 40. However, this text will focus on non-inflammatory causes of SI joint pain.
Clinically Relevant Anatomy
The SI joint is located between the pelvis and the spine, playing a crucial role in stabilizing the pelvis and facilitating movement. The movement of the SI joints is minimal but sufficient enough to allow for independent movement of the iliac bones without causing torsion of the pelvis. Without the SI joints, our pelvis would be too rigid, making movement difficult and ultimately leading to stress fractures of the pelvic bones.
To understand the mechanisms underlying SI joint dysfunction, it is essential to familiarize ourselves with the anatomy of the area:
SI Joint: The sacroiliac joint is essential for connecting the pelvis and lower back. It consists of the articulations between the sacrum and the iliac bones. The surface of the SI joint is uneven, helping to reduce friction and enhance stability. The movement allowed by the SI joints is only a few degrees, but this is sufficient to facilitate the coupled movement between the iliac bones and the sacrum during both spinal and leg movements.
Pelvis and SI joints viewed from the front Ligaments: The SI joint is supported by several ligaments on its anterior and posterior sides. These ligaments stabilize the joint's function and limit excessive mobility. Increased tension on the ligaments or other irritation can lead to their inflammation. The SI joint is one of the most supported structures in the body.
Pelvis and SI joints viewed from behind Muscles: Several muscles also influence the function of the pelvis and the SI joint. These muscles not only generate movement but also contribute to the stabilization of joint function. Overuse or insufficient recovery of these muscles can weaken joint support and cause increased strain on structures such as the ligaments.
Etiology
Pain and dysfunction of the SI joint can arise from a variety of causes. The most common factors include trauma, overuse and pregnancy. Below are several reasons behind SI joint pain and how they may potentially affect the function of the joint and the onset of pain.
Injuries or Trauma: Most cases of SI joint pain result from either a single injury or the accumulation of microtraumas. Falling onto the pelvis, stepping into a hole, landing on a straight knee or experiencing traffic accidents can alter the function of the pelvis or damage the tissues that maintain stability.
Overuse: Repeated movements or activities that stress the SI joint can lead to overuse injuries and dysfunction. This can occur from lifting heavy objects or excessive repetitions. Sports that place increased forces on the pelvic region are particularly prone to causing SI joint pain.
Pregnancy: During pregnancy, the hormone relaxin prepares the body for childbirth. This results in increased laxity in the joints and weakened support of the pelvis. Increased mobility or decreased control of movement may increase the load on the SI joint, leading to pain. Read more about what happens to the joints during pregnancy here.
Diseases: Conditions that cause inflammation, such as rheumatoid arthritis or ankylosing spondylitis, can lead to SI joint pain.
Decreased Control and Altered Kinematics: Impaired core stability or alignment issues in the lower limbs can increase or alter the load on the pelvis, which may result in overloading and pain.
Exercise and Lifestyle Factors: A sedentary lifestyle can lead to muscle weakening and restrictions in mobility, which may diminish the stability of the SI joint and increase the load on the area. Conversely, excessive physical strain can lead to muscle fatigue and overuse, causing the muscles to be unable to support the pelvis normally.
Gender and Age: SI joint pain is more common in women than in men. This is partly influenced by hormonal changes during pregnancy and menopause. Older adults tend to experience more SI joint issues and pain than younger individuals, often due to age-related degenerative changes, other diseases or lifestyle factors.
Idiopathic Pain: Approximately 5% of all SI joint pain cases are idiopathic, meaning no tissue-related cause can be identified.
To ensure the most effective treatment, it is important to identify the underlying cause of the pain. Only then can something be done about the so-called root cause, resulting in pain relief and maintaining it over time.
Symptoms
The symptoms associated with SI joint pain can sometimes be difficult to distinguish from other types of lower back pain, making diagnosis challenging. Typical symptoms include sharp pain in the upper part of the buttock that usually worsens with movement or changes in position. The SI joint area is often tender to the touch and the worst pain is usually felt around the joint, although radiating pain down the back of the thigh is also possible. Below are several typical symptoms that indicate SI joint-related pain:
Pain: The pain is generally quite intense, sharp and localized to the SI joint or buttock. Patients often describe it as sharp, stabbing or radiating pain that can extend from the lower back down to the back of the thigh. Radiating pain rarely goes below the knee, which is common in lower back-related radiating pain.
Misdiagnosis: Radiating pain in the back of the thigh is often confused with radicular back pain, which is usually caused by either spinal stenosis or radiculopathy resulting from a herniated disc. However, SI joint-related radiating pain does not include neurological or neurodynamic findings, so the presence of these symptoms should raise suspicion of back-related causes.
Difficulty Sitting: Many individuals find that pain makes it difficult to sit in one place for extended periods. This may lead to the need to change positions or get up for relief.
Local Tenderness: A characteristic feature of SI joint pain is that the most intense pain occurs specifically in the joint itself. When asked to point to where the pain is located, patients can often indicate the exact area affected, which is typically small and can be pointed to with one finger between the ilium and sacrum.
Increased Pain with Load: Pain often manifests when the joint is mechanically stressed, such as during forward bending.
Difficulty Finding a Pain-Free Sleeping Position: Pain felt in the SI joint often worsens when lying on the affected side, changing position or staying in one position for too long, which complicates falling asleep and staying asleep. Small continuous movements often provide relief, although starting moving can be difficult due to pain.
Recognizing these symptoms is crucial, as they can help differentiate SI joint pain from other causes of discomfort in the lower back and pelvic region, thereby guiding appropriate treatment.
Treatment
The primary treatment for SI joint pain and dysfunction is conservative. Treatment typically combines pharmacological and non-pharmacological pain management methods alongside physical therapy. SI joint dysfunction rarely leads to serious tissue damage, so non-surgical treatment options should always be attempted before considering surgery.
The goal of conservative treatment is to relieve pain and enhance functional and work capacity. This is often achieved through a combination of guidance and counseling, a carefully designed and individualized exercise program and manual therapy. Supportive braces for the pelvis and SI joint may also be utilized. These help stabilize the pelvis and reduce the load on the SI joint.
Commonly used pharmacological treatments include a combination of pain relievers and nonsteroidal anti-inflammatory drugs (NSAIDs). In more severe cases, medications that alleviate neural pain or raise pain thresholds may be considered. Effective pain management is crucial for rehabilitation. Persistent pain can worsen recovery prognosis, increase tension in surrounding muscles, and sensitize the nerve tissues in the area, resulting in heightened pain sensitivity.
Surgical treatment should only be considered if conservative methods fail to yield the desired results or if symptoms continuously worsen despite treatment. However, SI joint surgeries are very rare, and most patients improve with conservative treatment. Treatment periods often extend over several months, requiring patience from the patient.
If conservative treatment does not produce the desired outcome, the surgical method is chosen individually based on the identified contributing factors to pain. The primary goal of surgery is to relieve the load on the SI joint or possibly to correct the structural issues of the joint. The most common surgery for SI joint pain is joint fusion. Fusion surgery effectively reduces movement and load on the affected joint, often resulting in pain relief. Post-surgery physical therapy enables the best possible treatment outcome and recovery from the procedure.
Physical Therapy
Physical therapy always begins with a thorough assessment of the underlying factors, based on which an individualized rehabilitation program can be developed. The symptom profile, clinical findings and patient goals are always considered when designing the content of physical therapy, ensuring that the treatment plan is as effective as possible.
The content of physical therapy is therefore always tailored to the individual, but it often includes a combination of the following methods:
Manual Therapy: Soft tissue treatments and joint mobilization help reduce muscle tension, promote fluid and blood circulation and improve fascial function.
Movement and Postural Therapies: The aim is to reduce unnecessary stress on the SI joint and provide time for muscles and ligaments to recover.
Activation Exercises: These exercises aim to maintain muscle and nerve function as well as to promote tissue fluid and blood circulation.
Pain Management Techniques: Heat or cold therapy, manual therapy, acupuncture or self-directed exercises can be used to relieve pain. Additionally, mobilization techniques can help ease pain symptoms.
Biomechanical Assessment: Identifying and addressing potential biomechanical issues can reduce load peaks and alleviate the burden on irritated tissues.
The combination of manual therapy, a home exercise program and time has proven effective in treating SI joint dysfunction.
Below are several physiotherapy treatment modalities and their primary objectives in the context of SI joint dysfunction treatment:
Progressive Exercise and Load Modification aim to:
Manage overall load
Reduce compression and tensile load on irritated nerve tissues
Increase fluid and blood circulation in the affected tissues
Alleviate pain
Improve the gliding properties of irritated nerves through neural mobilization and nerve glide exercises
Manual Therapy Aims to:
Relieve pain and activate descending pain pathways
Decrease friction and pressure on irritated nerves
Reduce muscle tension
Enhance the performance of muscles and joints
Decrease cortisol release in the treated tissues
Improve circulation in the affected tissues
Enhance mobility
Reduce pain interference
Guidance and Counseling Aim to: Provide sufficient information about the nature of the issue, underlying factors and prognosis, so that pain does not cause excessive worry or fear. Knowledge about the healing process and treatment prognosis increases motivation for self-directed rehabilitation and improves self-efficacy. Additionally, factors that can positively or negatively affect the treatment prognosis and timeline are addressed, allowing for necessary adjustments. This reduces patient uncertainty and potential worry, making it easier to live with pain.
Self-Care
Rest and Load Modification: Give your lower back and SI joint sufficient rest and avoid activities that exacerbate your pain. This may include prolonged standing, heavy lifting or sudden movements that place stress on the pelvic and lower back regions.
Practice Mobility: Work on mobility exercises gradually to restore any limitations. Start with light and easy movements and only progress to more demanding exercises once the pain has eased somewhat.
Strengthen Muscles: Develop core and pelvic support by strengthening the deep abdominal muscles, gluteal muscles and deep back muscles. Exercises that improve lower limb alignment and enhance balance and control are also effective. Start cautiously and gradually increase the load over time.
Try Cold Therapy: Cold treatment can help relieve pain and possible inflammation. You can use a cold pack applied to the affected area for about 15-20 minutes at a time, multiple times a day.
Pain Medication: Ibuprofen or acetaminophen can alleviate pain and inflammation. Always follow the recommended dosage and consult a healthcare professional if you are uncertain.
Ergonomics: Aim to maintain good posture and avoid positions that strain the SI joint. Favor sitting in supportive chairs and ensure your feet are firmly on the ground. Using a backrest when seated can reduce the need for superficial back muscles to tense the back, therefore reducing perceived discomfort.
Take Breaks: If your work involves a lot of sitting or repetitive movement, take regular breaks to change your position or mobilize your pelvis and lower back. This promotes circulation and helps keep the muscles relaxed.
Sleeping Ergonomics: Find a comfortable sleeping position that does not aggravate your pain. Use an extra pillow to support your knees and pelvis or try changing positions.
Consult a physiotherapist if pain persists despite self-care efforts or if it interferes with your daily activities.
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