Dear All
this is a copy of an article that I received as a weekly newsletter. This
newsletter is free and if you go to the site
www.epodiatry.com
you can register for the newsletter. The newsletter comes weekly and is a
fantastic source for the latest research/articles.
Regards
Graeme
Sacroiliac Joint Pain Syndrome in Active Patients
A Look Behind the Pain
Yung C. Chen, MD; Michael Fredericson, MD; Matthew Smuck, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 11 - NOVEMBER 2002
For CME accreditation information, instructions and learning objectives,
click here.
--------------------------------------------------------------------------------
In Brief: The bones, ligaments, muscles, and nerves of the sacroiliac joint
(SIJ) may be damaged by direct trauma or by smaller, repetitive stresses.
Injury to many complex adjacent structures can refer pain to the SIJ, and
SIJ pathology can refer pain elsewhere. Because of the varied and
overlapping presentation of symptoms, a precise diagnosis of SIJ pain
syndrome is often challenging. Physicians who recognize the condition early
and offer prompt treatment (eg, physical therapy, corrective exercises with
mobilization, and, if necessary, corticosteroid injection) will make a
definite contribution to improving their patients' athletic performance.
Various athletic activities, including walking, running, jumping, leaping,
and squatting, can produce unwanted motion or stress in the sacroiliac joint
(SIJ) and surrounding tissues. Soft-tissue failure, overload injures, and
direct trauma provide mechanisms for the evolution of SIJ pain syndrome.
Clinical symptoms or dysfunction may directly relate to intra-articular SIJ
sources, extra-articular sources, or soft tissues around the SIJ, including
muscles, tendons, ligaments, and neurovascular structures. Each has a
specific function, mechanism of injury, and healing response to a given
injury. SIJ pain syndrome may also be a distant manifestation of a
musculoskeletal injury in other parts of the kinetic chain that are stressed
during sports activities.
Anatomy
Bones. The pelvic ring includes two innominate bones and the sacrum. The
innominate bones are the most proximal portion of the lower-extremity
skeleton. They articulate at the pubic symphysis and with the spine at the
sacroiliac joints. The sacrum joins the lumbar spine at one pseudojoint, the
L5-S1 disk, and two synovial joints, the L5-S1 facets. The SIJ is also a
true synovial joint,1 with many irregularities in the joint surface. Based
on cadaver studies,2 the most common sacral segments involved in a disease
process are S-1, S-2, and a portion of S-3.
The SIJ is C-shaped, with the convexity toward the pubis and concavity
toward the posterior superior iliac spine. Gravity would force the
wedged-shaped sacrum inferiorly and posteriorly between the pelvic bones if
not for the strong ligamentous support provided by the thin anterior
ligament (considered a thickening of the joint capsule) and the strong
posterior and interosseous ligaments that permit only a small degree of
motion in the joint. These three ligaments receive further support from the
iliolumbar, sacrotuberous, and sacrospinous ligaments.2 Athletic activity
that exerts either a single strong force or repetitive lower-intensity
forces across these ligaments can injure the ligaments or the SIJ.
Muscles. The SIJ is surrounded by many powerful muscles of the spine, lower
limbs, pelvis, and hips. However, none of these muscles act directly on the
joint, with an origin from the pelvis and insertion to the sacrum. The long
head of the biceps femoris, the gluteus maximus, and the piriformis muscles
often have attachments to the sacrotuberous ligament that supports the SIJ.
Nerves. The SIJ is richly innervated by nociceptors that sense and transmit
pain.3,4 Unmyelinated free nerve endings terminate in the joint capsule and
overlying ligaments.5,6 In addition, the joint capsule contains nerve fibers
that transmit pressure and proprioception.5 Innervation of the SIJ is from
the posterior primary rami of L-4 through S-3 posteriorly, and the anterior
primary rami from L-2 through S-2 anteriorly.2,5 Various studies6,7 have
also demonstrated the close physical relationships between the sacroiliac
joint capsule and adjacent neural structures, including the lumbosacral
nerves and sympathetic nerves. Given the wide range of innervation of the
SIJ and its adjacent neural structures, SIJ capsular stimulation may refer
various pain patterns to the buttock, groin, thigh, calf, or foot.4,8,9
Biomechanic Interplay
During walking, running, or jumping, the SIJ transmits gravity forces from
the vertebral column to the pelvis and transmits ground reaction forces from
the lower limbs to the spine.10 Complex relationships between coordinated
movement patterns and forces in the SIJ are observed in various athletic
activities11 that integrate movements of the two sacroiliac joints, the
symphysis pubis, the spine, and the hip joints. A detailed explanation of
the various movements is beyond the scope of this article.
Movement of the SIJ is so small that controversy surrounds the topic. The
primary movements are rotation and translation, and together they are called
"nutation." The joint does not move around a single, clearly identified
axis.12,13 The axes of motion for the SIJ are not straightforward and
largely depend on the surface topography of the joints.14 The best in vivo
studies of SIJ motion were done radiographically by implanting metal markers
under local anesthesia.12,13 The greatest degree of motion was observed from
straight standing into hyperextension. Average rotation was 2°, with a
maximum of 4°. Average translation was 0.5 mm, with a maximum of 1.6 mm.
Sports physicians should be aware of the importance of the SIJ in athletic
performance. The SIJ does not move in isolation; it is one link in a kinetic
chain. Distant structural or mechanical alterations, such as leg-length
discrepancy, muscle imbalance, trunk and hip hyperflexibility or
hypoflexibility, or improper sport-specific mechanics, can increase stress
on the SIJ and adjacent structures. Joint and soft-tissue stresses can lead
to subclinical mechanical adaptations that may impair future performance and
increase the risk of injury to the SIJ and other supporting structures in
the kinetic chain. Small aberrations in movement may damage the joint or its
supporting tissues. The SIJ can also be injured directly via a fall or a
direct blow over the joint.
Clinical Presentation
History. Because the SIJ is part of a kinetic chain, athletes may report a
history of ankle, foot, knee, hip, or spine injuries before the SIJ pain
syndrome manifests. A patient's pain drawing, in conjunction with a careful
clinical history, may help in the initial screen for SIJ pain syndrome.
Although not pathognomonic for the syndrome, pain in the region of the
sacral sulcus is nearly always present.3,4 Fortin et al4 showed that medial
buttock pain (SIJ pain that is generally inferior and medial to the
posterior superior iliac spine) is the most classic presentation. However,
athletes may report buttock and lower lumbar pain15-28 with or without
referred pain to the greater trochanter17,22,28; groin22,29; lower
abdomen20,22,29; anterior, lateral, or posterior thigh16,17,21,24,28,30,31;
or calf.16,24,28,31 The distinguishing feature for SIJ pain is lack of pain
above the L-5 level.9 This variable pattern of pain and pain referral may be
caused by multilevel innervation, irritation of adjacent neural elements and
soft tissues, or varying locations of injury within the SIJ.32
Physical exam. Any physical exam for evaluation of SIJ syndrome should first
screen for more obvious sources of low-back or hip pathology that can refer
pain to the SIJ region, including posterior facet syndrome, disk disease,
lateral recess spinal stenosis, and degenerative joint disease of the hip.
Full lumbar spine and hip range of motion are expected with primary SIJ pain
syndrome in athletes, although unilateral external rotation deficits of the
hip have been associated with SIJ dysfunction.32,33 The hamstring may also
be tight. The neurologic exam is usually normal, with negative nerve-root
tension signs.
The hip abductors are the main coronal plane stabilizers of the pelvis, and
any weakness leads to increased pelvic drop during the stance phase of gait
and increased shear forces across the pelvis. Gluteus medius (the main hip
abductor) weakness is often combined with overactivity and tightness in the
piriformis muscle.34 The piriformis and the hamstring muscles have
attachments to the sacrotuberous ligament, and any tightness can adversely
affect forces in the SIJ. Tightness in the quadratus lumborum may also be
present. When the gluteus medius is weak, the quadratus lumborum may
compensate with excessive hip hiking, and it can become a source of pain
caused by overactivity and resultant trigger points that refer into the SIJ
region.
Pain provocation tests. No single test is sufficiently sensitive to
accurately identify SIJ symptoms.9,24-33,35-39 Most physical examination
procedures used for diagnosing sacroiliac dysfunction attempt to define
abnormal motion or position of the SIJ. These tests induce shearing or
rotational forces through the SIJ, with the force applied to either the
sacrum or the innominate bone in an attempt to stress inflamed structures,
thus provoking pain.
All of these tests will stress a combination of adjacent structures,
including the lower lumbar spine, the hip joint, and the femoral or sciatic
nerves. Although many practitioners use these tests, scientific studies have
found numerous problems with reliability, sensitivity, and specificity. Of
these, the thigh thrust and Gaenslen's sign have the greatest
reliability.40,41 Studies41,42 have shown that the predictive value of these
tests is maximized when a combination of tests are used. The tests are
positive if back or buttock pain is elicited. The most common provocation
tests are:
Posterior pelvic pain provocation test (thigh thrust). With the patient
supine, the hip is flexed to 90° and the knee is bent (figure 1). The
examiner applies posterior shearing stress to the SIJ through the femur.
Excessive adduction of the hip is avoided, as combined flexion and adduction
is normally painful.
Gaenslen's sign. With the patient supine, the hip is maximally flexed on one
side, and the opposite hip is extended (figure 2). This maneuver stresses
both SIJs simultaneously by counterrotation at the extreme range of motion.
This test also stresses the hip joints and stretches the femoral nerve on
the side of hip extension, so care should be taken to ensure normal hip
findings and the absence of neurologic conditions affecting the femoral
nerve.
Patrick's test. This test stresses the hip and SIJ by flexion, abduction,
and external rotation of the hip. A positive test reproduces back or buttock
pain, whereas groin pain is more indicative of hip joint pathology.
Sacroiliac shear test. With the patient prone, the palm of the examiner's
hand is placed over the posterior iliac wing, and an inferiorly directed
thrust produces a shearing force across the SIJ.
Compression test. With the patient in a side-lying position, downward
pressure is applied to the uppermost iliac crest, directed toward the
opposite iliac crest. It is intended to stretch the posterior sacroiliac
ligaments and compress the anterior SIJ.
Distraction test (gapping). With the patient supine, a posterior and lateral
force is applied to both anterior superior iliac spines to stretch the
anterior sacroiliac ligaments and synovium.
Imaging Considerations
Certain studies are more useful than others for diagnosing SIJ pain
syndrome.
X-ray and computed tomography (CT). Conventional radiologic tests are rarely
diagnostic in SIJ pain syndrome. Interpretations of degenerative changes of
the SIJ on x-ray have proven clinically insignificant because they are
commonly observed in asymptomatic individuals.28
CT is a very good method to demonstrate previously established bony changes
but also offers little diagnostic value.42 Single-photon emission CT offers
high sensitivity but low specificity in seronegative spondyloarthropathies
and are, therefore, useful tests in suspected cases.42-47
Nuclear medicine. Despite its good specificity, bone scanning is not
recommended in the diagnostic algorithm for evaluation of possible SIJ pain
syndrome because of its very low sensitivity.48
Magnetic resonance imaging (MRI). Good visualization of the complicated
soft-tissue anatomy of the SIJ and the ability to see septic, inflammatory,
or stress-related changes in the bones make MRI advantageous.42,47-51
Stress-related bone changes are very important in the differential diagnosis
of SIJ pain because they are well documented, especially in female
athletes.52 MRI can detect both stress reaction and stress fractures.
However, for typical SIJ pain syndrome, MRI specificity is low, offering
little diagnostic value for determining if the SIJ is the true pain
generator.
Diagnostic injection. The gold standard for the diagnosis of SIJ pain
syndrome is diagnostic injection under fluoroscopic guidance.4,31,35,40 It
is an invasive procedure and should not be used as a first-line diagnosis or
treatment. Controlled-block technique is preferred in which the diagnosis is
confirmed by reproducing symptoms with provocative analgesic injection and
relieving symptoms with an anesthetic block.4,8,9,36,53-56 This is the most
reliable method to establish the diagnosis of intra-articular SIJ pain and
allows immediate interpretation of SIJ arthrography (figure 3).
Intra-articular sacroiliac injections, however, do not assess all
periarticular or extra-articular structures, such as muscles, ligaments, or
tendons, which may also be sources of pain.9
Differential Diagnosis
A myriad of possible conditions make diagnosis challenging, especially
because pain may be referred from other sites.
Sacral stress fractures should be considered in any athlete, especially
distance runners, who report pain in the sacral region.47,50-52,57 Our
series with the Stanford University track team has now identified 17 cases
(2 recurrences) in 5 years. Ten of these occurred in women, all of whom were
either amenorrheic or oligomenorrheic and had suboptimal bone density.
Spondyloarthropathies often begin with symptoms of sacroiliitis. Ankylosing
spondylitis typically produces symmetric findings, as does the
spondyloarthropathy associated with inflammatory bowel disease, such as
Crohn's disease or ulcerative colitis. Sacroiliitis with psoriatic arthritis
and Reiter's syndrome is more often asymmetric and usually involves other
signs of the disease, such as conjunctivitis, uveitis, cystourethritis,
peripheral arthritis, and enthesopathies. Radiographic findings seen in
enthesopathies include whiskering of the ilium and ischium and plantar heel
spurs.
Osteitis condensans ilii typically occurs in young, multiparous women. It is
presumably linked to increased laxity and stress to the joint during
pregnancy and parturition. It is distinguished radiographically from
sacroiliitis by bilaterally increased radiodensity on the iliac, as opposed
to the sacral side, of the SIJ.19
Myofascial pain caused by trigger points in the piriformis, gluteus maximus,
or quadratus lumborum muscles can refer pain into the SIJ. Local soft-tissue
injections with an anesthetic agent can be used for diagnostic purposes. The
needle should be inserted into the point of maximal tenderness, most
commonly in the belly of the muscle. Other than local tenderness, no direct
evidence of pathology typically exists in trigger point areas.
Other conditions that can cause primary pain in the SIJ are less likely in a
young athletic population. These include degenerative joint disease of the
SIJ, infection by hematogenous spread from typically cutaneous sources,
tumors, and metabolic conditions such as gout, pseudogout, and
hyperparathyroidism. Finally, trauma with contusion or fracture of the
sacrum or pelvic ring can also produce SIJ pain.
Treatment Options
Because the SIJ and its surrounding structures have various responses to
injury, a wide array of treatments may prove beneficial.
Rehabilitation. Thorough rehabilitation requires complete and accurate
diagnosis that goes beyond the recognition of clinical symptoms and tissue
injury. The SIJ is the main link between the spine, hip, and lower
extremities, and treatment needs to address functional biomechanic deficits
and subclinical adaptations throughout the kinetic chain. Working directly
with a physical therapist who is skilled in this area is recommended. One
must determine if any motion restricts the pelvis and which planes of
movement are restricted; whether the SIJ is compensating for a
lower-extremity deficit in range of motion, strength, or coordination; or
whether the inflammation is caused by disturbance in gait.58 Improper or
repetitive sport-specific motions can increase stress on the SIJ or adjacent
structures; therefore, a detailed history of sports activities is essential.
Strengthening and stabilization. The ligaments of the SIJ and the lumbar
spine mesh with the thoracolumbar fascia. These ligaments and fascia are the
primary attachments for the main movers and stabilizers of the spine and
lower extremities. Thus, coordinated muscle contraction causes compression
of the surfaces of the SIJ. The major muscles and fascia involved include
the gluteus maximus and medius, latissimus dorsi, hamstrings, abdominals,
back extensors, and the thoracolumbar fascia.59
Weakness or inhibition of the hip muscles, especially the hip abductors,
should be addressed. Functional exercise programs can create a self-bracing
mechanism to stabilize the SIJ against large shear stresses applied to the
joints under various loading conditions.60 Appropriate recruitment and
sequencing of neuromuscular patterns are considered more important than the
development of absolute strength.
Mobilization. Many theories exist regarding the benefits of
mobilization.34,61-64 Corrective exercises in conjunction with mobilization
may be useful when movement impairments are caused by muscle dysfunction or
shear dysfunction. In addition to the presumed improvements in joint
mechanics, one study65 associated a consistent reflex response with spinal
manipulative treatments. Reflex pathways evoked systematically during spinal
manipulative treatment might produce some of the clinically observed
benefits, such as pain reduction and decreased muscle hypertonicity.
Pelvic belts. Hypermobility, although rare in an athletic population, is
usually seen in patients who have traumatic instability, multiparous women,
and people with muscular atrophy from prolonged bed rest or lower motoneuron
injuries. Pelvic belts may be used as an adjunct to other treatments to add
stability and support.
Heel lifts and orthoses. Abnormal posture or leg-length discrepancy can
cause the sacrum to sit askew and contribute to excessive shear force. To
help distinguish functional from true leg-length discrepancy, a standing
anteroposterior radiograph of the pelvis is indicated. The distance from the
top of the femoral head to the bottom of the film is measured and compared
side-to-side. Heel lifts and orthoses can help correct true leg-length
discrepancy, if the condition is detected on the physical exam.
Injections. Although diagnostic injection is invasive, when it is performed
by a skilled clinician, associated risks are extremely low. Some authors
recommend diagnostic SIJ injection for athletes who have not responded to
comprehensive therapeutic rehabilitation after approximately 3 to 4
weeks.1,53-56, If the athlete responds favorably to the anesthetic block of
the joint, corticosteroids can be injected for prolonged pain reduction.
Other treatments. A recent article66 suggests that intra-articular
hyaluronic acid injections help relieve pain; however, long-term studies are
still warranted. Prolotherapy (a treatment in which a sclerosing solution is
injected into ligaments to stimulate hypertrophy and stability) is often
recommended for patients who have SIJ hypermobility.66,67 However, it is has
not been proven either specific or sensitive for distinguishing pain
generators from the SIJ ligaments, and its therapeutic effects remain
controversial in the medical literature.
For intractable SIJ pain, neuroaugmentation and surgical fusion have been
proposed as treatment options.68,69 Both, however, lack long-term studies
and have never been tested in an athletic population. Therefore, we do not
recommend either technique for athletes who have SIJ pain.
The Lowdown on Sacral Pain
Diagnosis of the athlete who reports pain in the SIJ region remains a
challenge to sports medicine physicians. A detailed history and
neuromusculoskeletal exam can help rule out other potential sources of pain.
For the primary care physician, we recommend two tests that have proven more
reliable when evaluating SIJ dysfunction: provocation testing and injections
under fluoroscopy. Pain provocation tests are used to confirm the SIJ as the
primary source of pain. The physician working closely with a well-trained
physical therapist can then treat muscle imbalances, joint dysfunctions, or
other alterations in the kinetic chain that predispose athletes to SIJ
injuries. If a conservative course of treatment consisting of physical
therapy does not lead to improvement, fluoroscopically guided injection of
the SIJ by a skilled physician should be considered for both diagnostic
confirmation of the pain source and potential improvement of pain to
facilitate rehabilitation.
References
Calvillo O, Skaribas I, Turnipseed J: Anatomy and pathophysiology of the
sacroiliac joint. Curr Rev Pain 2000;4(5):356-361
Solonen KA: The sacroiliac joint in the light of anatomical,
roentgenological and clinical studies. Acta Orthop Scand
1957;27(suppl):1-127
Bernard TN, Cassidy JD: The sacroiliac joint syndrome, in Frymoyer JW (ed):
The Adult Spine: Principles and Practice. New York, Raven Press, 1991, pp
2111-2112
Fortin JD, Dwyer AP, West S, et al: Sacroiliac joint: pain referral maps
upon applying a new injection/arthrography technique: part 1, asymptomatic
volunteers. Spine 1994;19(13):1475-1482
Fortin JD, Kissling RO, O'Connor BL, et al: Sacroiliac joint innervation and
pain. Am J Orthop 1999;28(12):687-690
Fortin JD, Washington WJ, Falco FJ: Three pathways between the sacroiliac
joint and neural structures. AJNR Am J Neuroradiol 1999;20(8):1429-1434
Atlihan D, Tekdemir I, Ates Y, et al: Anatomy of the anterior sacroiliac
joint with reference to lumbosacral nerves. Clin Orthop
2000;376(Jul):236-241
Schwarzer AC, Aprill CN, Bogduk N: The sacroiliac joint in chronic low back
pain. Spine 1995;20(1):31-37
Dreyfuss P, Michaelsen M, Pauza K, et al: The value of medical history and
physical examination in diagnosing sacroiliac joint pain. Spine
1996;21(22):2594-2602
DonTigny RL: Function and pathomechanics of the sacroiliac joint: a review.
Phys Ther 1985;65(1):35-44
Hoek van Dijke GA, Snijders CJ, Stoeckart R, et al: A biomechanical model on
muscle forces in the transfer of spinal load to the pelvis and legs. J
Biomech 1999;32(9):927-933
Sturesson B, Uden A, Vleeming A: A radiostereometric analysis of the
movements of the sacroiliac joints in the reciprocal straddle position.
Spine 2000;25(2):214-217
Sturesson B, Selvik G, Uden A: Movements of the sacroiliac joints: a
roentgen stereophotogrammetric analysis. Spine 1989;14(2):162-165
Harrison DE, Harrison DD, Troyanovich SJ: The sacroiliac joint: a review of
anatomy and biomechanics with clinical implications. J Manipulative Physiol
Ther 1997;20(9):607-617
Albee S: The study of the anatomy and the clinical importance of the
sacroiliac joint. JAMA 1909;16:1273-1276
Bernard TN Jr, Kirkaldy-Willis WH: Recognizing specific characteristics of
nonspecific low back pain. Clin Orthop 1987;217(Apr):266-280
Bohay DR, Gray JM: Sacroiliac joint pyarthrosis. Orthop Rev
1993;22(7):817-823
Cibulka MT: The treatment of the sacroiliac joint component to low back
pain: a case report. Phys Ther 1992;72(12):917-922
Daly JM, Frame PS, Rapoza PA: Sacroiliac subluxation: a common, treatable
cause of low-back pain in pregnancy. Fam Pract Res J 1991;11(2):149-159
DonTigny R: Anterior dysfunction of the sacroiliac joint as a major factor
in the etiology of idiopathic low back pain syndrome. Phys Ther
1990;70(4):250-265
Harvey J, Tanner S: Low back pain in young athletes: a practical approach.
Sports Med 1991;12(6):394-406
LeBlanc KE: Sacroiliac sprain: an overlooked cause of back pain. Am Fam
Physician 1992;46(5):1459-1463
Mooney V: The subacute patient: to operate or not to operate-this is the
question, in Mayer TG, Mooney V, Gatchel RJ (eds): Contemporary Conservative
Care for Painful Spinal Disorders. Philadelphia, Lea & Febiger, 1991, p 1260
Potter NA, Rothstein JM: Intertester reliability for selected clinical tests
of the sacroiliac joint. Phys Ther 1985;65(11):1671-1675
Russel AS, Maksymowych W, LeClercq S: Clinical examination of the sacroiliac
joints: a prospective study. Arthritis Rheum 1981;24(12):1575-1577
Walker JM: The sacroiliac joint: a critical review. Phys Ther
1992;72(12):903-916
Yeoman W: The relation of arthritis of the sacroiliac joint to sciatica,
with an analysis of 100 cases. Lancet 1928;1119-1122
Norman G: Sacroiliac disease and its relationship to lower abdominal Surg
1958;116:54- [Only page 54 or were there more pages?]
Cibulka MT, Delitto A: A comparison of two different methods to treat hip
pain in runners. J Orthop Sports Phys Ther 1993;17(4):172-176
Schuchmann JA, Cannon CL: Sacroiliac strain syndrome: diagnosis and
treatment. Tex Med 1986;82(6):33-36
Slipman CW, Jackson HB, Lipetz JS, et al: Sacroiliac joint pain referral
zones. Arch Phys Med Rehabil 2000;81(3):334-338
Cibulka MT, Sinacore DR, Cromer GS, et al: Unilateral hip rotation range of
motion asymmetry in patients with sacroiliac joint regional pain. Spine
1998;23(9):1009-1015
Dreyfuss P, Dryer S, Griffin J, et al: Positive sacroiliac screening tests
in asymptomatic adults. Spine 1994;19(10):1138-1143
Liebenson C: Rehabilitation of the Spine: A Practitioner's Manual.
Baltimore, Williams & Wilkins,1996
Maigne JY, Aivaliklis A, Pfefer F: Results of sacroiliac joint double block
and value of sacroiliac pain provocation tests in 54 patients with low back
pain. Spine 1996;21(16):1889-1892
Slipman CW, Sterenfeld EB, Chou LH, et al: The predictive value of
provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac
joint syndrome. Arch Phys Med Rehabil 1998;79(3):288-292
Laslett M, Williams M: The reliability of selected pain provocation tests
for sacroiliac joint pathology. Spine 1994;19(11):1243-1249
van der Wurff P, Hagmeijer RH, Meyne W: Clinical tests of the sacroiliac
joint: a systematic methodological review: Part 1, reliability. Man Ther
2000;5(1):30-36
Bogduk N: Pain provocation tests for the assessment of sacroiliac joint
dysfunction. J Spinal Disord 1999;12(4):357-358
Broadhurst NA, Bond MJ: Pain provocation tests for the assessment of
sacroiliac joint dysfunction. J Spinal Disord 1998;11(4):341-345
Kristiansson P, Svardsudd K: Discriminatory power of tests applied in back
pain during pregnancy. Spine 1996;21(20):2337-2344
Braun J, Sieper J, Bollow M: Imaging of sacroiliitis. Clin Rheumatol
2000;19(1):51-57
Goldberg RP, Genant HK, Shimshak R, et al: Applications and limitations of
quantitative sacroiliac joint scintigraphy. Radiology 1978;128(3):683-686
Lantto T: The scintigraphy of sacroiliac joints: a comparison of 99mTc-DPD
and 99mTc-MDP. Eur J Nucl Med 1990;16(8-10):677-681
Lentle BC, Russell AS, Percy JS, et al: The scintigraphic investigation of
sacroiliac disease. J Nucl Med 1977;18(6):529-533
Verlooy H, Mortelmans L, Vleugels S, et al: Quantitative scintigraphy of the
sacroiliac joints. Clin Imaging 1992;16(4):230-233
Marymont JV, Lynch MA, Henning CE: Exercise-related stress reaction of the
sacroiliac joint: an unusual cause of low back pain in athletes. Am J Sports
Med 1986;14(4):320-323
Slipman CW, Sterenfeld EB, Chou LH, et al: The value of radionuclide imaging
in the diagnosis of sacroiliac joint syndrome. Spine 1996;21(19):2251-2254
Sturzenbecher A, Braun J, Paris S, et al: MR imaging of septic sacroiliitis.
Skeletal Radiol 2000;29(8):439-446
Major NM, Helms CA: Sacral stress fractures in long-distance runners. AJR Am
J Roentgenol 2000;174(3):727-729
Stewart IE, Fallon K: Unusual stress fracture in an athlete. Clin Nucl Med
1999;24(4):280-281
Major NM, Helms CA: Pelvic stress injuries: the relationship between
osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities
in athletes. Skeletal Radiol 1997;26(12):711-717
Maldjian C, Mesgarzadeh M, Tehranzadeh J: Diagnostic and therapeutic
features of facet and sacroiliac joint injection: anatomy, pathophysiology,
and technique. Radiol Clin North Am 1998;36(3):497-508
Hodge JC: Miscellaneous procedures: sacroiliac joint arthrography, in Hodge
JC (ed), Musculoskeletal Imaging: Diagnostic and Therapeutic Procedures. New
York City, Karger Landes Systems, 1997, pp 226-227
Dreyfuss P, Cole AJ, Pauza K: Sacroiliac joint injection techniques. Phys
Med Rehabil Clin N Am 1995;6:785-813
Kinard RE: Diagnostic spinal injection procedures. Neurosurg Clin N Am
1996;7(1):151-165
Eller DJ, Katz DS, Bergman AG, et al: Sacral stress fractures in
long-distance runners. Clin J Sport Med 1997;7(3):222-225
Jackson R: Diagnosis and treatment of pelvic girdle dysfunction. Ortho
Physical Therapy Clin North America 1998;7(3): 413-445
Dreyfuss P, Michaelsen M, Pauza K, et al: The value of medical history and
physical examination in diagnosing sacroiliac joint pain (letter). Spine
1997;22(14):1673-1674
Aitken GS: Syndromes of lumbopelvic dysfunction, in Grieve GP (ed): Modern
Manual Therapy of the Vertebral Column. New York, Churchill Livingstone,
1986, pp 473- 478
Fowler C: Muscle energy techniques for pelvic dysfunction, in Grieve GP
(ed): Modern Manual Therapy of the Vertebral Column. New York City,
Churchill Livingstone, 1986, pp 805-818
Greenman P: Osteopathic manipulation of the lumbar spine and pelvis, in
White AH, Anderson RT (eds): Conservative Care of Low Back Pain. Baltimore,
Williams and Wilkins, 1991, pp 220-215
Greenman PE: Principles of Manual Medicine. Baltimore, Williams and Wilkins,
1989, p 230
Lee D: The Pelvic Girdle: An Approach to the Examination and Treatment of
the Lumbo-Pelvic-Hip Region. New York City, Churchill Livingstone, 1989, pp
107-120
Herzog W, Scheele D, Conway PJ: Electromyographic responses of back and limb
muscles associated with spinal manipulative therapy. Spine
1999;24(2):146-153
Klein RG, Eek BC, DeLong WB, et al: A randomized double-blind trial of
dextrose-glycerine-phenol injections for chronic, low back pain. J Spinal
Disord 1993;6(1):23-33
Ongley MJ, Klein RG, Dorman TA, et al: A new approach to the treatment of
chronic low back pain. Lancet 1987;2(8551):143-146
Calvillo O, Esses SI, Ponder C, et al: Neuroaugmentation in the management
of sacroiliac joint pain: report of two cases. Spine 1998;23(9):1069-1072
Smith-Peterson MN, Rogers WA: End results of arthrodesis of the sacroiliac
joint for arthritis, traumatic and untraumatic. J Bone Joint Surg
1920;8:118-136
--------------------------------------------------------------------------------
Dr Chen is a physiatrist at the Spinal Diagnostic and Treatment Center in
Daly City, California. Drs Fredericson and Smuck are physicians in the
Department of Functional Restoration at the Stanford University School of
Medicine in Stanford, California.
Address correspondence to Yung C. Chen, MD, Spinal Diagnostic and Treatment
Center, 901 Campus Dr, Suite 310, Daly City, CA 94015; e-mail to
[log in to unmask] Disclosure information: Drs Chen, Fredericson, and
Smuck disclose no significant relationship with any manufacturer of any
commercial product mentioned in this article. No drug is mentioned in this
article for an unlabeled use.
_________________________________________________________________
The new MSN 8: advanced junk mail protection and 2 months FREE*
http://join.msn.com/?page=features/junkmail
|
