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Case

Sacroiliac joint dysfunction

COMMENT
Clinicians treating low back pain syndromes should be
appropriately trained in the diagnosis and management
of such conditions.

PROFILE
A 25-year-old married housewife with three young children was referred by her general medical practitioner for
evaluation and treatment.

She sleeps with a pillow between her knees in an

attempt to get some relief from the right-sided low back
pain. There is no night pain other than her constant rightsided low back pain. Coughing and sneezing cause an
increase in the low back pain.
She had been investigated with a CT myelogram
(Fig. 7.2A) and a lumbar MRI study. A steroid and anaesthetic injection into the right sacroiliac joint had not
provided any benefit (Fig. 7.2B).

PAST HISTORY
Her surgical history was that of an appendectomy 7 years
ago and two Caesarean sections; otherwise she had been
healthy.
Four years ago she fell onto her right buttock in particular and this caused her central to right-sided low back pain
syndrome.

PRESENTING COMPLAINT(S) (Fig. 7.1)

Constant chronic low back pain following a fall 4 years ago,
that is central to right sided, including the sacroiliac joint. This
pain radiates into the right buttock, the right leg posteriorly
and into the sole of the right foot. The pain prevents her from
playing with her young children and undertaking normal
home duties because of constant aggravation of the chronic
low back pain syndrome. She said her appetite is reduced
and that she has inexplicably lost 5 kg in weight during the
last few weeks. Domestic relations are becoming strained
because she feels her husband is sick and tired of my pain
and he asks why cant doctors fix it?. At presentation she
was tearful and anxious. She moved slowly and stiffly.
Extensive neurological investigations had apparently
found no organic cause for the intolerable pain. She was
taking OxyContin (20 mg, 12 per day) and Endep (150 mg
at night). She had tried various non-steroidal anti-inflammatory drugs, paracetamol, diazepam, and pethidine injections
without relief.

Figure 7.1

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LUMBAR SPINE

Figure 7.2 (A) CT myelogram axial image through the lower region of the lumbosacral zygapophysial joints and through the corresponding
sacroiliac joint (SI) level which is above the synovial part of the sacroiliac joint. D dural tube containing contrast material and some
cauda equina nerve roots (grey dots) with adjacent nerve roots in the dural sleeve on the left and right sides, respectively. (B) CT image of the
right sacroiliac joint showing needle placement for injection of the joint. I ilium; S sacrum. (C) Erect posture anteroposterior plain
X-ray image (viewed from behind) showing the sacroiliac joints and the mild idiopathic scoliosis of the lumbar spine. R patients right side.

She was dismayed at having been told that the pain was
psychological and her husband was distressed by her
pain and incapacity.

AETIOLOGY
A fall 4 years ago.

EXAMINATION
In the erect posture there was some clinical evidence of an
idiopathic lumbar scoliosis, convex to the right side. Toe
walking (S1) and heel walking (L5) power were normal. Erect
posture straining of the left and right sacroiliac joints, respectively, elicited a significant increase in right sacroiliac joint
pain. Active lumbar spine ranges of movement were all

Case 7

limited due to significant pain on the right side of the lumbosacral joint and over the right sacroiliac joint. The deep tendon reflexes at the knees and ankles were normal. Pinprick
sensation of the lower extremities was normal, as was vibration sensation. Sitting in the slumped forward position
aggravated the pain on the right of L5S1 and over the right
sacroiliac joint; the addition of right straight leg raising elicited an aggravation of this pain. Supine SLR on the right
was limited to approximately 25 elevation due to similar
pain. The Valsalva manoeuvre elicited a significant increase
in her pain. The abdomen was normal on examination.

IMAGING REVIEW
Supine plain film radiographs showed a minor right convex thoracolumbar junction scoliosis. The CT lower lumbar
myelogram and the lumbar spine MRI were normal.

CLINICAL IMPRESSION
Chronic right sacroiliac joint strain/subluxation in view of
the history and normal neurology, in spite of the positive
SLR on the right side.

WHAT ACTION SHOULD BE TAKEN?

An erect posture pelvis and lumbar spine radiograph
(Fig. 7.2C) was taken to evaluate the degree of idiopathic
scoliosis and to complement existing supine radiographs.
Although the diagnosis of sacroiliac joint strain was made,
because of the history of the right sacroiliac joint injection
having not provided any relief and because her condition
was so acute, it was considered prudent to perform a bone
scan (reported as normal) and a full blood count as well as
ESR and C-reactive protein tests; all the results were within
normal limits.

Treatment, to ensure that the likely cause of symptoms

was understood. It was considered safe to manipulate the
sacroiliac joint, although she found it intolerably painful
to be positioned for the manipulation. In spite of her pain,
the sacroiliac joint moved easily and an audible release
was heard. The patient found the manipulation to be very
painful but said she felt better on getting off the manipulating table. She was advised to speak to her referring family
doctor about stopping all narcotics but advised to continue
with the non-steroidal anti-inflammatory drug until her reassessment. She was told not to lift the young children or
perform any housework or shopping before returning for
a re-assessment 3 days later.
At the following visit 3 days later it was gratifying to see
the cheerful grin on her face and she stated that she was
very much better. A follow-up manipulation resulted in a
slight audible release and she was advised to return if
her symptoms persisted. Both she and her husband were
delighted at the result. The patients husband asked why
several specialists to whom she had been referred had suggested her symptoms were in her head and stated that this
had almost wrecked their marriage.
The patient did stop taking OxyContin and Endep medication following the first sacroiliac joint manipulation.
This case is a good example of multidisciplinary cooperation leading to a satisfactory outcome for the patient.
The patient returned voluntarily 1 month later for a
minor recurrence of right sacroiliac joint pain due to turning over in bed. Erect posture straining test for the sacroiliac joint caused pain over the right sacroiliac joint, so the
joint was manipulated once more. She returned again
approximately 2 months later with a further minor recurrence of symptoms in the right sacroiliac joint and one
manipulation again provided relief. She was advised to
return should symptoms recur, which she did on one occasion some 5 months later.

DIAGNOSIS

KEY POINTS

Right sacroiliac joint strain causing dysfunction of the joint.

1. Sacroiliac joint stress tests can localize pain to a

TREATMENT AND RESULTS

particular sacroiliac joint.

2. No improvement in sacroiliac joint pain following a
steroid and anaesthetic injection into the joint does not
mean that the joint is not the site of pain.

The patients condition was clearly explained to the patient

using the approach outlined in the Introduction, under

Further reading
Giles L G F, Crawford C M 1997 Sacroiliac joint. In: Giles L G F , Singer K P
(eds) Clinical anatomy and management of low back pain.
Butterworth-Heinemann, Oxford, p 173182.
McKenzie-Brown A M, Shah R V, Sehgal N et al 2005 A systematic
review of sacroiliac joint innervations. Pain Physician 8: 115125.
Mior S A, Ro C S, Lawrence D 1999 The sacroiliac joint. In: Cox J M
(ed) Low back pain: mechanism, diagnosis and treatment, 6th edn.
Williams & Wilkins, Baltimore, p 209234.

Walker J M 1992 The sacroiliac joint: a critical review. Physical Therapy

72: 903916.
Yong-Hing K 1994 Sacro-iliac joint pain: etiology and conservative
treatment. La Chirugia degli Organi di Movimento 79: 3545.

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