Sacroiliac Region - Clinical Tree

Clinical Summary and Recommendations

Patient History
Questions	The question “Is pain relieved by standing?” is the only question studied to demonstrate some diagnostic utility (+LR [likelihood ratio] of 3.5) for sacroiliac joint pain.
Pain Location	Recent evidence suggests that patients with sacroiliac joint pain commonly experience the most intense pain around one or both sacroiliac joints, with or without referral into the lateral thigh.
Physical Examination
Pain Provocation Tests	Pain provocation tests generally demonstrate fair to moderate reliability and some exhibit moderate diagnostic utility for detecting sacroiliac joint pain. Clusters of pain provocation tests consistently demonstrate good diagnostic utility for detecting sacroiliac joint pain. Using a cluster of four to five tests, including the distraction test, thigh thrust test, sacral thrust test, and compression test after a McKenzie-type repeated motion examination, seems to exhibit the best diagnostic utility (+LR of 6.97) and is recommended.
Motion Assessment and Static Palpation	Motion assessment and static palpation tests generally demonstrate very poor reliability and almost no diagnostic utility for either sacroiliac joint pain or innominate torsion and, therefore, are not recommended for use in clinical practice. Lumbar hypomobility is the one exception that, although exhibiting questionable reliability, demonstrates some diagnostic utility when used as part of a cluster to determine which patients will respond to spinal manipulation.
Interventions	Patients with low back pain of less than 16 days’ duration and no symptoms distal to the knees, and/or who meet four out of five of the Flynn and colleagues criteria, should be treated with a lumbosacral manipulation.

Anatomy

Osteology

Arthrology

Region	Joint	Type and Classification	Closed Packed Position	Capsular Pattern
Sacroiliac region	Sacroiliac joint	Plane synovial	Has not been described	Considered a capsular pattern if pain is provoked when joints are stressed
Lumbosacral region	Apophyseal joints	Plane synovial	Extension	Equal limitations of side-bending, flexion, and extension
Lumbosacral region	Intervertebral joints	Amphiarthrodial	Not applicable	Not applicable

Ligaments

Sacroiliac Region Ligaments	Attachment	Function
Posterior sacroiliac	Iliac crest to tubercles of S1-S4	Limits movement of sacrum on iliac bones
Anterior sacroiliac	Anterosuperior aspect of sacrum to anterior ala of ilium	Limits movement of sacrum on iliac bones
Sacrospinous	Inferior lateral border of sacrum to ischial spine	Limits gliding and rotary movement of sacrum on iliac bones
Sacrotuberous	Middle lateral border of sacrum to ischial tuberosity	Limits gliding and rotary movement of sacrum on iliac bones
Posterior sacrococcygeal	Posterior aspect of inferior sacrum to posterior aspect of coccyx	Reinforces sacrococcygeal joint
Anterior sacrococcygeal	Anterior aspect of inferior sacrum to anterior aspect of coccyx	Reinforces sacrococcygeal joint
Lateral sacrococcygeal	Lateral aspect of inferior sacrum to lateral aspect of coccyx	Reinforces sacrococcygeal joint
Anterior longitudinal	Extends from anterior sacrum to anterior tubercle of C1. Connects anterolateral vertebral bodies and discs	Maintains stability of vertebral body joints and prevents hyperextension of vertebral column

Muscles

Sacroiliac Region Muscles	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Gluteus maximus	Posterior border of ilium, dorsal aspect of sacrum and coccyx, and sacrotuberous ligament	Iliotibial tract of fascia lata and gluteal tuberosity of femur	Inferior gluteal nerve (L5, S1, S1)	Extension, external rotation, and some abduction of the hip joint
Piriformis	Anterior aspect of sacrum and sacrotuberous ligament	Superior greater trochanter of femur	Ventral rami of S1, S2	External rotation of extended hip, abduction of flexed hip
Multifidi	Sacrum, ilium, transverse processes of T1-T3, articular processes of C4-C7	Spinous processes of vertebrae two to four segments above origin	Dorsal rami of spinal nerves	Stabilizes vertebrae
Longissimus	Iliac crest, posterior sacrum, spinous processes of sacrum and inferior lumbar vertebrae, supraspinous ligament	Transverse processes of lumbar vertebrae	Dorsal rami of spinal nerves	Bilaterally extends vertebral column Unilaterally side-bends spinal column
Iliocostalis		Inferior surface of ribs 4-12	Dorsal rami of spinal nerves

Nerves

Nerve	Segmental Level	Sensory	Motor
Superior gluteal	L4, L5, S1	No sensory	Tensor fasciae latae, gluteus medius, gluteus minimus
Inferior gluteal	L5, S1, S2	No sensory	Gluteus maximus
Nerve to piriformis	S1, S2	No sensory	Piriformis
Sciatic	L4, L5, S1, S2, S3	Hip joint	Knee flexors and all muscles of leg and foot
Nerve to quadratus femoris	L5, S1, S2	No sensory	Quadratus femoris, inferior gemellus
Nerve to obturator internus	L5, S1, S2	No sensory	Obturator internus, superior gemellus
Posterior cutaneous	S2, S3	Posterior thigh	No motor
Perforating cutaneous	S2, S3	Inferior gluteal region	No motor
Pudendal	S2, S3, S4	Genitals	Perineal muscles, external urethral sphincter, external anal sphincter
Nerve to levator ani	S3, S4	No sensory	Levator ani
Perineal branch	S1, S2, S3	Genitals	No motor
Anococcygeal	S4, S5, C0	Skin in the coccygeal region	No motor
Coccygeal	S3, S4	No sensory	Coccygeus
Pelvic splanchnic	S2, S3, S4	No sensory	Pelvic viscera

Patient History

Sacroiliac Pain and Sacroiliac Dysfunction

There has been considerable controversy surrounding the contribution of the sacroiliac joint in low back pain syndromes. Recent research suggests that the sacroiliac joint can be a contributor to low back pain and disability and can certainly be a primary source of pain. The concept of “sacroiliac joint dysfunction” is distinct from “sacroiliac joint pain” and is hypothetical at best. Sacroiliac joint dysfunction is usually defined as altered joint mobility and/or malalignment, neither of which have been consistently linked to low back or sacroiliac joint pain.

Figure 5-9, Common cause of sacroiliac injury. Falling and landing on the buttock.

Pain Location and Aggravating Factors

Dreyfuss and colleagues performed a prospective study to determine the diagnostic utility of both the history and physical examination in determining pain of sacroiliac origin. The diagnostic properties for the aggravating and easing factors and patient-reported location of pain are below.

Question and Study Quality	Population	Reference Standard	Sens	Spec	+LR	−LR
Pain relieved by standing?	85 consecutive patients with low back pain referred for sacroiliac joint blocks	90% pain relief with injection of local anesthetics into sacroiliac joint	.07	.98	3.5	.95
Pain relieved by walking?			.13	.77	.57	1.13
Pain relieved by sitting?			.07	.80	.35	1.16
Pain relieved by lying down?			.53	.49	1.04	.96
Coughing/sneezing aggravates symptoms?			.45	.47	.85	1.17
Bowel movements aggravate symptoms?			.38	.63	1.03	.98
Wearing heels/boots aggravates symptoms?			.26	.56	.59	1.32
Job activities aggravate symptoms?			.20	.74	.77	1.08
Pain aggravated by sitting in a chair?	154 patients with low back pain	Unilateral buttock pain, positive Patrick or SIJ shear test, and at least 70% pain relief with analgesic SIJ injection	.65 (.45, .81) ^†	.62 (.53, .70) ^†	1.69 (1.20, 2.38) ^†	.57 (.35, .94) ^†

† Values calculated by book authors.

Patient Report of Pain Location and Study Quality	Population	Reference Standard	Sens	Spec	+LR	−LR
Sacroiliac joint pain	85 consecutive patients with low back pain referred for sacroiliac joint blocks	90% pain relief with injection of local anesthetics into sacroiliac joint	.82 ^∗	.12 ^∗	.93	1.50
Groin pain			.26 ^∗	.63 ^∗	.70	1.17
Buttock pain			.78 ^∗	.18 ^∗	.95	1.22
Points to posterior superior iliac spine (PSIS) as main area of pain			.71 ^∗	.47 ^∗	1.34	.62
Groin pain	154 patients with low back pain	Unilateral buttock pain, positive Patrick or SIJ shear test, and at least 70% pain relief with analgesic SIJ injection	.39 (.22, .58) ^†	.78 (.70, .85) ^†	1.76 (1.01, 3.07) ^†	.79 (.58, 1.05) ^†

∗ Mean of chiropractor and physician sensitivity and specificity scores.

† Values calculated by book authors.

Sacroiliac Joint Pain Referral Patterns

Figure 5-10, Jung and associates 12 determined the most common pain distribution patterns in patients with sacroiliac joint pain. They then prospectively tested the ability of the pain distribution patterns to diagnose the response to sacroiliac joint radiofrequency neurotomies in 160 patients with presumed sacroiliac joint pain. The pain distribution patterns with the best diagnostic utility are depicted, with colors representing pain intensity (scale, 1-5). Left, red = 4; right, blue = 5, purple = 4.

Figure 5-11, In a study similar to the one in Fig. 5-10, van der Wurff and colleagues 13 compared pain distribution maps compiled from patients who responded to double-block sacroiliac joint injections with maps from patients who did not respond. The researchers found no differences in the locations of pain distribution but did find differences in the pain intensity locations. Patients with sacroiliac joint pain reported the highest-intensity pain overlying the sacroiliac joint, as depicted, with colors representing pain intensity (scale, 1-5). Left, pink = 5, purple = 4, green = 3, orange = 2, red = 1; right, blue = 2, purple = 1.

Physical Examination Tests

Palpation

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