SI Joint Pain, What is it and Who Can Treat it?

If you are suffering from back pain that has not been treated successfully by your health care provider of choice, at your next office visit ask: "Could my SI joint be part of the problem, and do you know how to assess and treat it?"  Get prepared for the twisting of the brow from your average MD as they tell you that is not a common source of back pain, or a stream of babble from your PT or chiropractor about what they can do for you (more on that in a minute).

The truth is, very few people know how to assess this problem, much less treat it.

Finding a qualified health care agent to help you out is like finding a needle in a haystack.  I wish I could post a link to a website or group of qualified treatment professionals that I can comfortably recommend regarding this area, but I haven't found one to date.

Because the waters are murky regarding this topic, I thought I'd help you be a more educated consumer when it comes to this problem.  By asking the right questions and knowing some of the common signs and symptoms, you might be able to help your healthcare professional treat your back/ buttock pain.

Before I get started, it goes without saying that if you are having chronic low back pain or pain in your leg, you should have the requisite tests performed to rule out other pathologies that can cause similar symptoms.  But if you have exhausted the list of possible tests (namely blood tests, MRI, and X-Ray) with your doctor and are still in pain, this discussion might be very helpful.

Here are some facts that might help you decide if you are suffering from this problem and if the person you are seeing is helping you or wasting your time.

• SI joint pain is usually found to cause pain in the buttock area and very often felt on one or both sides of your sacrum "your tailbone."  Depending on how irritated the area is, you may have pain that radiates into your lateral hip and hamstring area, have tightness and pain in the muscles of the buttocks, but rarely does this problem refer pain below the knee level into your calf and foot.  You may experience knee pain on the effected side.
• Sitting on hard surfaces usually is uncomfortable.  You will shift a lot when sitting to find comfort.  Standing will often relieve pain as will walking short to moderate distances.  Arching backwards is usually tight and painful.  Forward bending in most cases will not be limited significantly.
• You may have impaired balance and experience difficulty standing on one leg (the side of your pain) due to weakness at your hip.  In chronic cases that aren't acutely painful, you might simply notice that you sway more on that side compared to the other side.
• Often the pain is described as being deep in the buttock, and is annoying, but not debilitating to the average healthy person.  Due to the mechanical nature of this problem, certain motions of the trunk or leg will usually promote the pain.   The specific motion can vary depending on how the joint is positioned.  

The most difficult task in treating back pain as a health professional is figuring out what is causing the pain.  To be successful in defining back pain you need to work with a health professional that is a skilled problem solver, not a pain chaser.  They must be very good at deductive reasoning and when they are explaining how they are going to help you, should be doing so in a very logical fashion.  If the entire discussion is centered around your pain and how they will address it by working on your soft tissues, BEWARE!  This is a mechanical problem and needs to be addressed as such.  That's not to say that there isn't a time and place for addressing muscle spasms and pain, but at some point, there should be a discussion about the mechanical dysfunction of your Sacrum (tailbone) and your Ilium, i.e. the SI joint.  If this part of the discussion is absent, you can bet they are not highly knowledgable in this area.

In reviewing a couple websites on back pain from The American Academy of Orthopaedic Surgeons and the National Institute of Neurologic Disorders and Stroke, they didn't even mention the SI joint as a possible cause of back pain!  So am I on some crazy tangent regarding back pain or is there a reason why this might be the case.  It depends who you ask.
If you were to ask a group of average family practitioners or even orthopedic surgeons about the SI joint, they will probably blow off the topic, stating that the small amount of motion at the SI joint (9 mm of motion to be exact) is insignificant and, therefore, really couldn't be the source of your pain.  If that were the case, I wouldn't see patients get relief on a daily basis by restoring motion to this joint.  So don't believe that line for a minute.
That being said, if you inquire about the SI joint to a group of doctors called Physiatrists (physical medicine doctors) or skilled orthopedic physical therapists who deal with a lot of patients with lumbar dysfunction, your comment might not get trivialized.  Here's why:

• I once asked a good friend of mine who is an orthopedic MD how much education they got on the SI joint?   He said less than 2 hours of lecture on the topic during medical school.  That might sound surprising, but when you realize the small number of patients that would ever get surgery to this area of the spine, it begins to make sense.  Due to the inherent stability of this joint and lack of intervertebral discs in the normal Sacrum, there isn't much that can be done with a scalpel (except in radical cases).  Since it generally isn't a surgical problem, and is usually addressed with anti-inflammatory and pain medications, it gets blown off as an aside to other back problems.   
• Treating this problem almost always requires some kind of physical medicine; specifically manipulation/ mobilization of the SI joint.  MD's generally don't get this training.  DO's (Doctors of Osteopathy) do get this training, but rarely apply it in their clinical settings, possibly due to the time constraints of an average office visit.  Either way, I believe the lack of treatment capacity by the primary care doctors is another barrier to it being properly diagnosed. 
• Probably the biggest reason SI joint dysfunction doesn't get the press it deserves is that there is not a Gold Standard Test for this problem.  That's right, MRI's and X-Rays are not sensitive to this problem.  I believe this is this reason why it is probably the most underrated back pathology out there.  Don't be fooled when your chiropractor holds up your radiograph and says, "look, your sacrum is off."  If he really believes he can read that from an X-Ray, you should start looking for the door.  
• The closest thing to a gold standard test is a direct injection of the SI joint with a numbing agent.  If you get 80-85% relief, that is considered a positive test and confirms a SI joint problem.  It isn't perfect, but if your doctor goes down this road you at least know he is knocking on the right door (if other pathology has been ruled out).  
• From an office evaluation with your MD or PT, there are a series of tests that can be performed that are called provocation tests because they provoke the pain being caused at the SI joint.    If you get 3 out of 5 positive tests from a select group of these tests, you can also be diagnosed with a SI dysfunction with pretty high reliability.  Which tests are the best is a topic of debate in the literature.  How to treat it is even less defined and is the next major hurdle to getting better.

I will address some of the treatment ideas I use in future blogs.  If you read my previous blog, you are already aware of some of my assessment tests.  If you are a keen observer, you will have noticed that they were not provocation tests and might be thinking isn't that a contradiction to his last point listed above?  This interesting area will also be addressed down the road in future discussions in more detail.  

After reading a few of these SI related blogs you might start thinking there are some ideas out there that haven't made it to main street that could greatly help clarify how to address this tricky dysfunction.  And to that, I would say "I agree whole heartedly!"  Give me a chance, I plan to start working on this issue in the near future.