2016.04.23 si joint dx

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SI Joint: Diagnosis and Management

Fred Flandry, M.D., F.A.C.S., F.A.A.O.S., F.A.C.S.M.The Hughston Clinic

Columbus GA

Disclosures

I have no financial arrangement or affiliation with any corporate organization or with any product manufacturer of any medical device related to this topic.

I have endeavored to keep this presentation free of commercial bias and any product depicted or discussed is done so solely for illustrative purpose and should not be construed as a product endorsement.

Some of the images used in this presentation have been provided by and are used with the permission of SI Bone, a medical device manufacturer, and are considered proprietary


What is the SI Joint?

What causes SI Joint pain?

How common is SI joint dysfunction?

How is SI Joint dysfunction diagnosed?

How is SI Joint dysfunction treated?

Conservative

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What is the SI Joint?

Anatomy

Sacroiliac Joint

Articular Surface

Anatomy

"Arch voussoirs" by Jhbdel ‐ inkscape. Licensed under CC BY‐SA 3.0 via Commons ‐ https://commons.wikimedia.org/wiki/File:Arch_voussoirs.svg#/media/File:Arch_voussoirs.svg

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Anatomy

"Arch voussoirs" by Jhbdel ‐ inkscape. Licensed under CC BY‐SA 3.0 via Commons ‐ https://commons.wikimedia.org/wiki/File:Arch_voussoirs.svg#/media/File:Arch_voussoirs.svg

Anatomy

Anterior Ligaments Posterior Ligaments

Form Closure/Structural Integrity:

The shape of the sacrum and the integrity of the supporting ligaments

contribute to SI joint stability (11‐13)

Integrated Model of SIJ Function (11‐16)

Force Closure/Joint Compression: The external dynamic forces created by contraction of the stabilizing muscles and their fascial and ligamentous attachments (11‐13)

Motor Control: Nervous System Coordination / Co‐activation of deep stabilizing muscles

(onset, duration, timing) (14‐16)

11. Lee DG, Vleeming. 199812 Vleeming A, Stoeckart R, Volkers ACW, Snijders CJ. Spine. 1990a: 15(2): 130 13. Vleeming A, Stoeckart R, Volkers ACW, Snijders CJ. Spine. 1990b: 15(2): 13314. Snijders CJ, Vleeming A, Stoeckart R. 199315. Hodges P W, Richardson C A 199616. Richardson C A, Snijders C J, Hides J A, Damen L, Pas M S, Storm J 2002

Components

Local Core Muscles: Transversus, Rectus Abdominus, Multifidus, Pelvic Floor Muscles

Core Muscles should contract before load reaches the low

back and pelvis so as to prepare the system for impending load.

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Biomechanics

Nutation: Sacral base movement

anteroinferior (9)

Counternutation: Sacral base movement

poster superior (9)

Translation: Linear motion; motion in

any one direction

Nutation

Counternutation

9. Frost, Wheeler, Fortin: The Sacroiliac Joint: Anatomy, Physiology and Clinical Significance. Pain Physician 2006

SI Joint Motion

Multi‐planar motion Simultaneously rotate and

translate through 3 axes of motion

Motions (<4° in any plane)• Nutation/Counternutation

- Primary motion- Males: 1 ‐ 2°

- Females: 2 ‐ 4°

Sacral Translation • (A‐P motion) up to 1.6mm

Sturesson B et al :Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine 1989 Feb;14(2):162‐5.

What causes SI Joint pain?

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Potential Causes of SIJ Pain

Inflammation

Arthrosis

Instability

Trauma: Chronic sprain

• First: establish that it is the SI Joint,

• Then : determine if it is primary or secondary

Potential Causes of SIJ Pain: Traumatic

MVA: Foot on Brake

Slip and Fall

Lifting and Twisting

Traction Injuries

Potential Causes of SIJ Pain: Gradual Onset

Laxity of the SIJ / Multiple Pregnancies

Repetitive Forces on SIJ and Supporting Structures

Biomechanical Abnormalities

Leg Length Inequality

Pelvic Obliquity/Scoliosis

Iliac crest bone graft

Arthritis: Ankylosing Spondylitis

Post Infection Degeneration

Adjacent Segment Degeneration

After Lumbar Spinal Fusion

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SIJ & Adjacent Segment Degeneration

Ha et al: Degeneration of the Sacroiliac Joint After Instrumented Lumbar or Lumbosacral Fusion. Spine 2008; 33 11:1192‐1198Ivanov et al: Lumbar Fusion Leads to Increases in Angular Motion and Joint Stress Across the Sacroiliac Joint. Spine. 2009; 34: E162‐169.

75% of post lumbar fusion patients showed SIJ degenerative changes on CT scan five (5) years after lumbar fusion.

75% of post lumbar fusion patients showed SIJ degenerative changes on CT scan five (5) years after lumbar fusion.

Lumbar fusion leads to increases in angular motion and increases in joint stress at the sacroiliac joint.

Lumbar fusion leads to increases in angular motion and increases in joint stress at the sacroiliac joint.

The corollary also exists for degenerative hip disease or more distal disease, deformity, or dysfunction of the lower extremity.

The corollary also exists for degenerative hip disease or more distal disease, deformity, or dysfunction of the lower extremity.

How common is SI Joint

Dysfunction?

Prevalence of SI Joint Pain

As a Component of LBP

22.6%

14.5%

21.0%

18.5%

0%

5%

10%

15%

20%

25%

Bernard1987

(n=1293)

Sembrano/Polly 2009(n=200)

Schwarzer1995(n=43)

Maigne1996(n=54)

In symptomatic patients after Lumbar Fusion

35‐43% Patients with LBP after lumbar fusion.

43% DePalma 20115

40% Liliang 20116

35% Maigne 20054

I s the S I Jo int t ru ly a prob lem?

1 2 3 4

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Diagnosis &

Diagnostic Challenges

“Doctor, I have hip and leg pain…”

Clinical History

A Typical patient history

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History and Complaints

HISTORY

When did the pain start? Diagnosis is usually delayed

Prior trauma A fall on the buttock

Car accident (T‐bone, rear‐end, head‐on)

Lift/Twist

Other

Prior lumbar fusion Prior iliac bone graft harvest

Pregnancy

COMPLAINTS

Lower back pain

Lower extremity pain (numbness, tingling, weakness)

Pelvis / buttock pain

Hip / groin pain

Unilateral leg instability (buckling, giving way)

Disturbed sleep patterns

Disturbed sitting patterns (unable to sit for long periods, on one side)

Pain going from sitting to standing

Exacerbating Activities

Unilateral Weight Bearing ‐ Putting on Socks/Shoes

‐ Ascending/Descending Stairs

‐ Getting in and out of Car

‐ Prolonged Walking

‐ 85% of Gait is Single leg Stance (22)

Sexual Intercourse

Pain with Transitional Motions‐ Supine to painful side ‐ Sit to stand‐ Rolling over in bed‐ Getting in /out of bed

Pain while Stationary‐ Sitting on affected side‐ Prolonged standing/sitting

Pain with Transitional Motions‐ Supine to painful side ‐ Sit to stand‐ Rolling over in bed‐ Getting in /out of bed

Pain while Stationary‐ Sitting on affected side‐ Prolonged standing/sitting

Janda, V. On the concept of postural muscles and posture in man. Aust J Physiotherapy 1983;29:83‐90

Relieving Activities

Bearing weight on unaffected side

Lying on unaffected side

Manual or belt stabilization

Bearing weight on unaffected side

Lying on unaffected side

Manual or belt stabilization

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History

Pain Diagram

• Pain in buttock and posterior thigh

• Usually not midline

• Usually below L5

• At or lateral to PSIS

• Occasionally groin

• Secondary pain in lateral thigh, groin, and/or lateral calf

Pain Diagram

• Pain in buttock and posterior thigh

• Usually not midline

• Usually below L5

• At or lateral to PSIS

• Occasionally groin

• Secondary pain in lateral thigh, groin, and/or lateral calf

Overlapping Pain Diagrams

18 18

Differential Diagnosis: Shooting at the Right Target

Multiple possible pain generators

HipLumbar Spine SI Joint

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Differential Diagnosis: Rule out Lumbar Spine

Premise: Pain is coming from lumbar spine until proven otherwise

Compressed nerve

Stenosis: central, lateral recess, foraminal

Herniated nucleus pulposus

Disc damage, annulus tear

Lumbar instability (Spondylolisthesis)

Facet

Differential Diagnosis: Rule out the Hip

Premise: Pain may be coming from the hip!

Possible Hip Conditions: Labral tear Chondral pathology Ligamentum teres injury AVN, Occult fracture, DJD Pre‐arthritic hip conditions (FAI)

Work Up: MRI Sensitive for hip pathology Differential Diagnostic injections

• Lumbar spine pathology• Maigne’s Syndrome• Gluteus maximus / minimus syndrome• Quadratus lumborum syndrome• Pyriformis syndrome• Hamstring origin syndrome• Tensor fascia lata syndrome• Ankylosing spondylitis• Other arthropathies• Hip pathology• Tumor

Differential Diagnosis: Rule out other Mimes

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ObjectivePhysical Exam

Findings

Fortin Finger Test

Point to pain while standing • Able to localize with one finger

• Within 1 cm of PSIS (inferomedial)

• Consistent over at least 2 trials

Ask patient to point to location of primary pain• Below L5: Consider SIJ

• Above L5: Consider lumbar spine etiologies

Neurologic Basis of the Arthrokinetic reflex: Hilton’s Law (1863)

The same trunk of nerves whose branches supply the groups of muscles moving a joint also:

– Furnishes a distribution of nerves to the skin over the insertion of the same muscles

– Furnishes a distribution of nerves to the interior of the joint

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Arthrokinetic Reflex

• Overlying muscles affect the underlying joint

• Joint affects overlying muscles

• Normal sacroiliac joint kinematics exists when the arthrokinetic reflex is balanced

• Imbalanced arthrokinetic reflex opens the gate to nociceptive input and sacroiliac joint dysfunction

Testing Normal SIJ Function: Hip Rotation Test (Bernard)

Sacroiliac Provocation Tests

The following provocative tests, when performed in combination are proven to have a high degree of sensitivity and specificity:

1. Direct tenderness

2. Arthrokinetic reflex

3. Distraction

4. Thigh Thrust

5. Compression *

6. Patrick‐FABER

7. Gaenslen’s Maneuver

Laslett: Evidence Based Diagnosis and treatment of the painful Sacroiliac Joint . Journal of Manual & Manipulative Therapy, 2008,Szadek et al: Diagnostic Criteria for Sacroiliac Pain, a Systemic Review. J Pain. 2009;Apr:10(4):354-68.

* Most sensitive

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Sacroiliac Provocation Test Tips

Start with light pressure and gradually increase, keeping hands cupped to minimize local contact pressure (30 second max).

Keep arms straight and lean forward with your upper body to create gentle steady force.

Stabilize patient on the table to prevent muscle guarding.

Stabilize contralateral ASIS during Thigh Thrust and FABER tests.

If pain is provoked with test, ask patient to identify pain location to confirm it is their typical pain.

Distraction

Thigh Thrust

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Compression

Patrick ‐ FABER

Gaenslen’s

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Sacroiliac Provocation TestsThe following five provocative tests, when performed in combination are proven to have a high degree of sensitivity and specificity:

1. Distraction* (Highest PPV**)

2. Thigh Thrust*

3. Compression *

4. Patrick‐FABER

5. Gaenslen’s Maneuver

Laslett (23) Szadek (24)

Sensitivity 91% 85%

Specificity 78% 76%

23. Laslett: Evidence Based Diagnosis and treatment of the painful Sacroiliac Joint . Journal of Manual & Manipulative Therapy, 2008,24. Szadek et al: Diagnostic Criteria for Sacroiliac Pain, a Systemic Review. J Pain. 2009;Apr:10(4):354-68.

*Most sensitive of tests.

**PPV (positive predictive value)

Reliability and Specificity

• Specificity increases when symptoms don’t centralize or peripheralize with repeated trunk flexion/ extension (23,25)

• In some cases a patient may not tolerate having five (5) tests performed. Therefore, it’s recommended that the three (3) most sensitive, specific and reliable tests be performed first.

How to Interpret Your Results: (23,25)

1 Positive Test – Suspicion

2 Positive Tests ‐ Fair Confidence

3+ Positive Tests – High Confidence

23. Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man & Manip. Ther. 2008;16:142-152.25. Laslett et al , Diagnosis of sacroiliac joint pain: validity of individual and composite provocation tests. Man Ther. 2005; Aug;10(3):207-8.

Differential Diagnosis:Physical Exam: Hip, Lumbar, SIJ

Lumbar SPINE Exam:

Range of Motion: Forward flexion, extension, lateral flexion, rotation, combination

Neuro Exam

– Motor, Sensory, Deep Tendon Reflexes (DTRs)

– Dural tension tests

SI JOINT EXAM:

Palpation

– PSIS

– Iliac crest

– Dorsal Ligament

– Sacral Sulcus

Provocative Tests

ASLR

HIP and Pelvis Exam:

Range of Motion: Flexion, extension, internal / external rotation

Scour Test: (loaded circumduction)

Gait evaluation

Palpation: Piriformis, trochanteric area

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What’s the Gold Standard for Diagnosis?

Diagnostic Injection• Confirm with contrast and

imaging

• Low volume, local anesthetic

• 50‐75% pain reduction

Therapeutic Injection• Local anesthetic +

corticosteroid

• May provide intermediate or long term relief

• Results of therapeutic injections can be unpredictable

Injection Under Fluoroscopy

Justification for SIJ Injection

Negative lumbar and hip exam

Positive History

Positive Fortin Finger test and physical exam

Positive pain provocation tests

Injection Assessment

Patient pain diary

Significant positive clinical response 50‐75% VAS reduction indicates positive diagnosis of SI joint as pain generator

Obtain copy of arthrogram to ensure accuracy

Equivocal or no relief < 50% VAS reduction indicates a non‐significant clinical response

May have SIJ pain, but consider other pain sources

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NO

YES

Significant Positive Clinical Response?

Diagnostic Algorithm for SI Joint PainHistory

Physical Exam

Provocative Tests

Diagnostic Injections

Treatment OptionsMedication(s), PT, SIJ Injections, RF Denervation, MIS SI Joint Fusion

Other possible pain generator;Continue workup

Conservative treatment of

SI Joint Dysfunction?

Conservative Treatment Options

Sembrano: Diagnosis and Treatment of SI Joint Pain. Current Orthopedic Practice 2011Cohen*: Sacroiliac joint pain; a comprehensive review of anatomy, diagnosis and treatment. Anesth Analg, 2005.

Symptom Management • Medications (Non Steroidal anti‐inflammatory, non‐narcotic analgesics, Topical)

• External SI joint stabilization (belting?)

• Therapeutic SI Injections (<4 per year)

Physical Therapy (Patient Specific)

• Motor control & core strength

• Restore normal functional movement patterns / proper gait

• Soft tissue mobilization

• Restore muscle length and balance

• Manual therapy (muscle energy techniques/ SI joint mobilization etc.)

• Modification of ADLs (Patient education on posture, body mechanics, positioning)

• Targeted exercise program

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The Cycle of SI Joint Dysfunction

Thomas Boers, R.P.T., Fellow American Academy of Orthopedic Manual Therapists

Hamilton Medical Center, Dalton GA

Sacroiliac Joint Function NormalPain Free CycleNormal Muscle Function

Predisposing factors:TraumaDegenerative diseasePregnancyPoor Conditioning


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Sacroiliac Joint DysfunctionPainful CycleMuscle Dysfunction

Arthrokinetic Reflex Imbalance




Mobilization of Muscle or Joint

Anti Inflammatory agents


Exercise





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Exercise



Manipulation of Muscle or Joint




Exercise




Joint InjectionMobilization of Muscle or Joint



Arthrokinetic Reflex Balanced

Exercise







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Arthrokinetic Reflex Balanced

Exercise







Why exhaust conservative measures?

SI Joint Arthrodesis


Fred Flandry, M.D., F.A.C.S., F.A.A.O.S., F.A.C.S.M.The Hughston Clinic

Columbus GA

2016.04.23 si joint dx

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