Why misdiagnoses of sacroiliac joint pain occur

Patients with SIJ pain tend to present with chronic or grumbling symptoms around the lower back. Some patients will also present with leg pain and undergo investigations for spinal nerve compression first. Often, these aches and pains have been going on for quite some time, and can manifest as tingling, numbness or pain-related weakness.

Degeneration or inflammation can cause pain in the SIJ. Patients can experience difficulties with prolonged sitting, standing, walking or climbing stairs.  They may have considerable discomfort or aches when transitioning from sitting to standing positions, difficulties getting in/out of the car or getting on/off public transport. Other difficulties may include lifting their children or heavy items, and pain turning over in bed.

When it comes to issues with the SIJ, there tends to be four common groups of patients we see in clinic:

• Patients with inflammatory joint conditions. Typically, when they undergo MRI and CT scans, the signs of inflammation around the SIJ are identified. The next step here would be conduct blood tests to screen for any previously undiagnosed inflammatory joint conditions, and refer to a rheumatologist to provide systemic care and treatment if required
• Younger females are the next group, many of whom have had children. During pregnancy, a women’s pelvis expands and the SIJ configuration may change, as well as due to the numerous hormonal changes that occur. There may be excessive movement in the joints in the pelvis including the SIJ, causing pain
• We have patients aged 65 and over who will suffer from natural degenerative decline, or “wear and tear” of the SIJs
• There is also a  group of patients gaining increasing recognition for being at risk of suffering from SIJ pain. Patients with previous lumbar fusion are at risk, as their lower back can become increasingly stiff from previous surgeries, and the burden on the SIJ as a result is higher.

Hypermobility, and particularly the form that comes from the connective tissue condition, Ehlers-Danlos syndrome (EDS), is now also being widely discussed amongst spinal specialists, osteopaths, rheumatologists, GPs and physios. The ability of joints to move beyond their normal degree of motion and flexibility can vary widely in patients. It can often be inherited, but in some cases can be strengthened through physio which can improve any impact on the SIJ.

EDS is diagnosed predominantly by rheumatologists and can be a significant risk factor for developing SIJ problems. The difficult thing here is that all the joints in the body are already lax and surgery is not a preferred option given that making one area more robust can add more pressure onto others. Treating conservatively is key, and local anaesthetic and steroid injections can help, as can staying as active as possible in combination with physiotherapy treatment.

Diagnosing SIJ issues follows a well-established pathway in my practice – and non-operative intervention should always be advised in the first instance. SIJ fusion surgery should only be the last resort, where other treatments have failed.

It’s likely that the first person a patient will see is their GP who will go through the symptoms, the exact location, the intensity of the pain, any past traumas the patient may have experienced or any past surgeries. A referral to a physiotherapist is then likely to be made who will check the range of motion, palpate the area to check for tenderness or swelling. Five tests are typically performed, also known as provocative tests, which include:

• The FABER (Patrick’s test) – flexing or externally rotating the hip, where possible, which will put pressure/tension on the SIJ to see how it handles it  
• The thigh thrust test – an anteroposterior (both front and back) shear stress is applied to the SIJ by flexing the hip and knee
• Gaenslen’s test - extends the hip and knee on one side while simultaneously flexing the other hip and knee to add pressure to the SIJ
• The compression test – distributes a compressive force across front of the hips onto the SIJ to detect irregularities within the ligaments
• The distraction test – pushes down on the iliac crests, the curved and largest bone of the hip bone to see how the SIJ responds

If three or more are positive, it’s highly likely that there is a SIJ problem. If a patient doesn’t respond to conservative treatment including physiotherapy, the patient will then be referred to a specialist and sent for an MRI and a CT scan; an MRI scan will indicate the presence of bony oedema (bone swelling), or any signs of inflammation. A CT visualises any degenerative changes including extra bits of bones (osteophytes) growing around the joint, or if it has become narrower - an indication that the SIJ has degenerated.

The patient may opt to have local anaesthetic and steroid injections as the next step in their treatment plan. Performed under imaging guidance to ensure improved accuracy of positioning and the effectiveness of treatment, if this helps, then treatment is deemed to be complete. If not, patients can undergo radiofrequency ablations under sedation through our pain management referrals, to burn the nerve endings away around the joint. Most patients do benefit from this treatment long-term and find relief or a complete cessation of symptoms/pain – but a small number may not. If no relief has been felt by the patient, the next treatment option is SIJ fusion surgery.

The road to diagnosis and treatment for SIJ pain and conditions can often be complicated – especially if the right referral for spinal treatment is not forthcoming or realised early on. For some patients who need to wait for the various stages of treatment and results to be confirmed, you could be looking at four to five years of investigations. Many of our patients self-refer (almost 50%) and if you require further information, we’re here when you need us. Across our private hospital network, we’re able to see, process results and get you back to enjoying life in a few months – sacroiliac pain can be dealt with quickly if you have the right tools at your disposal.

Find out more about our spinal care.  At HCA UK we offer over 30 spinal treatments across our private hospital network.