Sacroiliac Joint Pain in the Athlete

Physical Therapy

For athletes with core/hip weakness or lack of endurance, PT should be encouraged.⁶ In general, the goals of PT are core and pelvic stabilization, muscular imbalance corrections, and posture training.^2,6,7,10 We interpret endurance in this context as the muscle strength needed to maintain pelvic neutral and core/pelvic stabilization during patient-dependent aggravating activities. In a study by Hungerford et al comparing 14 male subjects with SIJ pain to age-matched controls, researchers placed surface electrodes over 7 different hip and trunk muscles and measured the response and timing of muscle activation.¹¹ The study showed significant delay of onset of the obliquus internus abdominis, multifidus, and gluteus maximus, with earlier biceps femoris electromyographic activity on the symptomatic side of those with SIJ pain.¹¹ The authors proposed that the slowed firing of multiple hip and trunk muscles with earlier hamstring activation in the symptomatic group leads to suboptimal lumbopelvic stabilization that disrupts normal load transference through the pelvis and leads to SIJ pain.¹¹ Up to 95% of patients with SIJ pain report good to excellent functional improvement with PT at 2-year follow-up.¹²

Manual Manipulation

Manipulation is usually performed by osteopathic physicians, chiropractors, and physical therapists.⁴ A study of 69 patients showed that 95% of patients got excellent short-term results with manipulation; however, long-term benefits were not proven.¹² Kamali and Shokri used 2 different manipulation protocols for patients with SIJ pain: one group received high-velocity low-amplitude (HVLA) treatments to the SIJ, and the other group received HVLA treatment to the SIJ and the lumbosacral spine.⁴ Both groups showed significant improvements on the visual analog scale (VAS) and Oswestry Disability Index (ODI)^13,14 at 48 hours and 1 month postmanipulation.⁴ However, the study lacked a control group, as sham therapy is difficult to conduct.⁴ Appropriate patients must be chosen to undergo manipulation, as patients with significant muscle weakness, poor endurance, or both may need to focus on stabilization through strengthening rather than repetitive mobilization.⁶

Medications

Evidence for the use of medications to treat SIJ pain is limited. Some evidence suggests a stepwise approach, starting with over-the-counter topicals (ie, lidocaine 5% 2 to 3 times daily, diclofenac 1% 2 to 4 times daily) and progressing to NSAIDs in the acute phase of SIJ pain (up to 6 weeks).^2,15 NSAIDs (ie, ibuprofen 600 mg twice daily, diclofenac 50 mg twice daily) should not be used long term, specifically with senior athletes because of the significant side effects.¹⁰

Injections

Injections are used both for diagnostic and therapeutic purposes in patients with SIJ pain.¹⁶ Corticosteroid injections are often considered the next step in treatment for athletes who do not improve with conservative measures or are unable to tolerate PT.^3,6,7,10,17 Injections should always be done under image guidance (ultrasound or fluoroscopy) because intra-articular needle placement is rarely (0% to 22%) accomplished with blind injections.^5,18 Jee et al compared fluoroscopy- to ultrasound-guided steroid injections with contrast in 120 subjects with noninflammatory sacroiliac arthritis and found fluoroscopic guidance to be more accurate than ultrasound guidance (98.2% vs 87.3%).¹⁹ However, after confirming placement of the needle, the researchers injected 1 mL of 0.5% lidocaine with dexamethasone 10 mg and found that the ultrasound and fluoroscopy groups had no statistical difference in improvement of pain on the VAS and ODI at 2- and 12-week follow-up.¹⁹

Kennedy et al found the effectiveness of SIJ injections to be highest in patients with ankylosing spondy-loarthropathies.²⁰ For patients without the diagnosis of spondyloarthropathy, which is likely the case for most athletes with SIJ pain, the evidence for steroid injections is less clear.²⁰ Studies investigating the efficacy of intra-articular injections in the SIJ often have differing outcome measures and medication protocols, so they are difficult to compare.²⁰ For instance, most studies that used a single diagnostic anesthetic injection to diagnose patients with SIJ pain found patients had an average of 76 to 94 days of relief after their therapeutic SIJ injections; however, only 19% had lasting relief, and 32% had >14 days of relief.²⁰

Comparatively, Liliang et al studied 150 patients who underwent dual SIJ block injections (2 intra-articular injections of 1 mL 0.5% bupivacaine or 0.2% lidocaine with 1 mL triamcinolone acetonide 40 mg) to diagnose and treat SIJ pain (39 patients were diagnosed).²¹ Patients’ pain and disability were assessed on the VAS and modified Oswestry Low Back Pain Disability Questionnaire.^21,22 Statistically significant pain reduction was observed in mean VAS scores (P<0.0001) of the 39 patients diagnosed with SIJ pain. Of these patients, 66.7% had >50% pain reduction for more than 6 weeks, and 33% responded to the injection for only approximately 1 to 6 weeks with a mean of 4.4 ± 1.8 weeks.²¹ Of the patients who had >50% pain reduction for more than 6 weeks (n=26), their overall mean duration of pain reduction was 36.8 ± 9.9 weeks, with a range of 12 to 60 weeks.²¹

Complications related to SIJ injections are rare, but technical issues leading to unsuccessful injections (10% to 18%), temporary sciatic palsy (4.4% to 8%), increased pain (3%), and vasovagal reaction (2.5%) have been reported, as well as one case of pyogenic sacroiliitis and one reactivation of herpes simplex.²⁰

More invasive procedures for chronic SIJ pain are outside the scope of this article, but these procedures include prolotherapy, radiofrequency denervation of the lateral branches (L5 dorsal ramus and lateral branches of the S1, S2, and S3 dorsal rami), and sacroiliac joint stabilization and fusion surgeries.^2,3,7