Sacroiliac pain: How to get relief? (Causes and treatment)

Article reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine

Sacroiliac pain often manifests as discomfort in the buttocks. It is often confused with the sciatica, and deserves special attention, especially if the pain persists.

What exactly is sacroiliac pain, and where does it come from? How do you know if the symptoms come from a dysfunction of this joint? And above all, how to relieve incapacitating pain or blocked sacroiliac sensation?

This popular article explains everything you need to know about the sacroiliac joint and the pain that results from it, with an emphasis on treatment strategies that can help you reduce your pain.

Sacroiliac joint definition and anatomy

It is believed that the sacroiliac joint is responsible for 15 to 30% cases of low back pain. 

Before discussing sacroiliac joint pain (also called sacroiliitis), it is worth explaining the sacroiliac joint from an anatomical and physiological perspective.

The sacroiliac joint connects the bones of the pelvis (called the iliac) to the sacrum, a triangular bone located below the vertebrae lumbar. The main function of the sacroiliac joints is to absorb shocks, and to increase the stability of the trunk.

The sacroiliac joint normally has very little mobility, which means that there is very little movement at this level. If the joint is considered hypomobile (lack of physiological movement), it is considered more likely to generate sacroiliac pain. The same is true for a hypermobile joint, that is to say one that moves more than necessary.

6 causes of sacroiliac pain

Besides hypo or hypermobility, sacroiliac pain can arise from several causes. Here are the main ones:

1. trauma

Any direct or indirect impact to the sacroiliac joint can irritate the joint and cause pain. In addition, repeated attacks can wear out the joint and cause sacroiliac osteoarthritis.

2. Scoliosis

Scoliosis is a deviation of the spine in the 3 planes of space. Basically, one or more vertebrae are deviated in the frontal, sagittal, and horizontal plane.

This torsion of the column will inevitably affect the pelvis and the sacroiliac joints. This increase in stress at this level can sometimes be responsible for pain.

However, it must be understood that scoliosis is not always symptomatic. This means that there are scoliosis that cause no lumbar or sacroiliac pain, in particular because of the human body's ability to adapt.

To know everything about the scoliosis in children and its support, see the following article.

3. Lower limb length difference

If you have one leg shorter than the other, this difference may increase stress on the sacroiliac joint. This inequality can be functional (caused by a muscular imbalance), or structural (due to trauma, surgery, or congenital).

On the other hand, it is not uncommon to observe people with different leg lengths without having any pain. It is generally accepted that if the difference is minimal (less than 1-2 cm), it is not not necessarily significant.

One way to determine if sacroiliac pain is due to lower extremity length discrepancy is to prescribe a corrective brace for a while. If we observe a relief of the symptoms, we can then think that this difference in length was the source of the problem.

4. Inflammatory disease

Several inflammatory conditions are responsible for sacroiliac pain. This is the case for example of the ankylosing spondylitis.

5. Pregnancy

The sacroiliac joints are modified during pregnancy to allow childbirth.

During pregnancy, the release of the hormone relaxin causes the ligaments to relax. In addition, the expansion of the uterus compromises the stability around the pelvis. The muscles must then compensate for the misalignment of the pelvis, which increases muscle tension and stress on the sacroiliac.

Le Lacomm syndromee describes a stretching of the sacroiliac joints causing pain. This occurs under the influence of increased growth of the baby and increased secretion of pregnancy hormones.

The approach is also different during this period. If we add the fact that the extra weight increases the load on the joints, it is not uncommon to observe sacroiliac pain in pregnant women.

6.Infection

In rare cases, the sacroiliac joint can become infected. It could be bacteria, septic arthritis, spondylodiscitis, etc.

Sacroiliac pain is often associated with fever. Symptoms usually resolve after taking antibiotics, although the diagnosis usually takes a long time to establish.

Symptoms of the disease

Lower back and buttock pain is the primary sign of sacroiliac joint dysfunction.

This pain may also radiate to the thigh, hip, oldest boy, Calf, and even the foot. It is usually aggravated by:

• prolonged standing
• weight bearing on one leg
• stairs
• the race
• walking (especially if you increase the length of the steps)

If sacroiliac pain is present even at rest, it is usually a sign that the condition is more severe. This is especially true if the symptoms limit daily activities.

If the pain is present during the night, it is important to talk to a healthcare professional. Pain at night can exceptionally come from cancer, especially if it is associated with characteristic symptoms.

For symptoms indicative of a serious condition (such as cancer), see next article.

If the pain comes from a hypomobile sacroiliac joint, stiffness in the hips, lumbar region or pelvis may be observed.

If it is hypermobility that causes sacroiliac pain, then the patient will complain of instability of the pelvis and leg when walking, standing or during certain movements.

Diagnostic

Sacroiliac pain can be difficult to diagnose because it is often confused with other conditions.

There are several clinical examinations, tests ofmedical imaging or other to investigate sacroiliac pain. Here are the most important:

Sacroiliac Test Cluster

As sacroiliac damage can reproduce lower back pain, in the buttock or lower limb, the ability to accurately differentiate damage to this joint from other causes is important. This will make it possible in particular to eliminate another attack that could reproduce similar symptoms such as:

• herniated disc
• disc protrusion
• inflammatory low back pain
• myofascial syndrome
• degenerative disc disease
• sciatica
• gluteus medius tendonitis
• piriformis syndrome
• narrow lumbar canal
• spondylolisthesis
• Maigne syndrome
• fibromyalgia
• etc.

Un sacroiliac test cluster is a group of clinical tests developed to guide the diagnosis of sacroiliac disease to aid in clinical decision making. Essentially, the more positive tests that are identified, the greater the likelihood of sacroiliac involvement.

It should be noted that for a test to be considered positive, it must reproduce the patient's characteristic pain (the one he complains about on a daily basis) in the sacroiliac joint. Commonly used tests are:

Sacroiliac distraction test

• The patient lies on his back with a pillow under his knees. The patient is sometimes asked to place their hands on the lower back in order to maintain the lumbar spine in a lordotic position.
• The examiner places his hands in front of the iliac crests, more specifically on the anterior-posterior iliac spines. The evaluator's arms are crossed, and his elbows are kept extended.
• A slow and gradual downward distraction force is applied (sacroiliac joint distraction force) while leaning toward the patient.

Sacroiliac compression test

• The patient is placed in a lateral decubitus position (on the side) facing the examiner. The symptomatic side is positioned up, and a pillow is placed between the knees as needed.
• The examiner applies progressive downward pressure by pushing on the ilium, more specifically between the iliac crest and the greater trochanter (force of compression of the sacroiliac joint).

Thigh Thrust Test

• The patient lies supine (on the back) with the hip on the affected side flexed 90 degrees. The knees are completely bent.
• The examiner stands on the affected side. He stabilizes the pelvis of the pelvis at the level of the antero-superior iliac spines (ASIS) with his hand.
• The examiner then exerts a progressive pressure in the axis of the femur with his hand and the weight of his body, so as to create an antero-posterior shearing force of the sacral iliac.

Gaenslen's test

• The patient lies supine (on his back), with the leg on the affected side sticking out of bed so that it hangs down.
• The patient places the unaffected leg in full hip flexion keeping the knee flexed. This creates posterior rotation of the ilium.
• The examiner helps stabilize the leg and pushes the unaffected leg downward. This creates a twisting force at the sacroiliac.

Faber test

• The patient is placed in the supine position (on the back). The assessed leg is placed in position so as to form a 4 (more specifically, the hip is positioned in flexion, abduction and external rotation). The outer side of the assessed ankle should rest on the opposite thigh after positioning the leg for the Faber test.
• While stabilizing the opposite side of the pelvis (at the level of the antero-superior iliac spine), the evaluator exerts a force aimed at pushing the knee of the affected leg towards the table. This is equivalent to a combined movement of flexion, abduction and external rotation.

Other

There are other lesser-known tests that help clarify sacroiliac involvement. Some studies include them in their diagnostic cluster. These include the following tests, among others:

• flamingo test
• Posteroanterior sacroiliac shear
• Gillet's test
• “Sacral Thrust0” test
• Palpation of the sacroiliac
• etc.

Note: To know the metrological qualities of the previous tests (inter-evaluator reliability, kappa score, LR+, LR-, etc.), see the following article.

Essentially, scientific research findings show that when three or more of these pain provocation tests are positive, there is a high likelihood that sacroiliac dysfunction is present.

Medical imaging

As clinical tests have limitations, it is not uncommon for the doctor to order tests formedical imaging to investigate sacroiliac pain.

An X-ray of your pelvis may show signs of sacroiliac joint damage. If the doctor suspects soft tissue involvement or an inflammatory condition, they may also order an MRI.

Diagnostic infiltration

In some cases, the doctor opts for a diagnostic infiltration. Basically, it involves injecting a local numbing agent (such as lidocaine or bupivicaine) into the sacroiliac joint to see if it provides temporary relief from symptoms.

After the diagnostic infiltration, the doctor might re-test movements that were previously painful. If the condition improves, then it can be concluded that the sacroiliac joint was responsible for the symptoms.

We will then concentrate the treatment around the sacroiliac, for example with subsequent infiltrations. If, on the contrary, there is no therapeutic effect, this would mean that your symptoms come from another structure, or from another cause.

Treatment: Relieve sacroiliac pain

Once it is determined that the sacroiliac pain is indeed originating from this joint (and not from a related structure), a consistent treatment plan can be established.

The specialists who treat this condition are mainly the doctor (general practitioner, rheumatologist, orthopaedist), the physiotherapist (physiotherapist), osteo, and chiropractor.

Here are the treatment modalities often used

heat and ice

These modalities, while usually not solving the source of the problem, can relieve symptoms when they become incapacitating. This makes it possible in particular to reduce (or avoid) the taking of medication.

Medication

If the pain persists, it is not uncommon to have recourse to medication. Typically, the doctor will start with a series of pills aimed at controlling pain and reducing inflammation.

Infiltration

As mentioned, infiltration can be used to diagnose sacroiliac pain. In the event of favorable results, subsequent infiltrations make it possible to control the symptoms.

To learn all about sacroiliac infiltration, see the following article.

Manual therapy

A trained therapist can relieve pain by applying manual therapy techniques to their patient.

If the pain is thought to be due to a hypomobile sacroiliac joint, mobilizations of the lumbar region and the sacroiliac joint may be beneficial.

If, on the contrary, the pain is attributed to hypermobility of the sacroiliac joint, the mobilizations will be minimized in order to concentrate on an active work of reinforcement and stabilization.

Be careful, do not think that the sacrum is displaced. The movements of the sacrum (called nutation and counter-nutation) as well as the sacroiliac amplitude are very minimal. This makes the displaced sacrum theory improbable.

Thus, the therapist cannot “unblock the sacroiliac”. On the other hand, manipulations can reduce muscle tension, and act by desensitizing the nervous system (which causes relief of sacroiliac pain).

Exercices

When a patient consults a physiotherapist, he will benefit from an exercise program aimed at correcting the identified dysfunctions. On the other hand, we will aim to tone the gluteal muscles, make the hips more flexible, stabilize the lumbar region, etc.

It should be understood that the cause of sacroiliac pain can be different for everyone. This is why it is important to consult in order to benefit from an individualized program.

Here are some exercises often prescribed to correct sacroiliac dysfunction:

Hip extension (quadruped position)

1. Position yourself on all fours (hands under shoulders, knees under hips).
2. Then find the neutral position corresponding to the position of the pelvis halfway between the anteversion and the posteroversion of the pelvis.
3. In this position, extend one leg back, making sure to point the foot as far behind as possible.
4. Slowly return to the starting position, and repeat with the other leg.
5. Repeat these movements for ten repetitions per leg.

One-sided bridge

1. Lie on your back
2. Extend the non-painful leg so that the knee is straight and maintain full extension.
3. Raise the buttocks off the ground by pushing off with the heels of the affected leg.
4. Slowly lower back to the starting position.
5. Do these movements for about twenty repetitions. Take breaks as needed.

Lumbar twist

1. Lie on your back with your legs straight.
2. In a twisting motion, extend one arm to the side and bring the leg to the opposite side.
3. Using the other arm, add extra pressure at the thigh to increase the level of twisting stretch as tolerated.
4. Hold the stretch for about 30 seconds and do 3 sets.

Piriformis stretch

1. Lie on your back.
2. Cross the symptomatic leg so that the heel rests on the opposite leg.
3. Pull the non-symptomatic leg towards you. At this point, you should feel a stretching sensation behind the symptomatic buttock.
4. Hold the stretch for 30 seconds, then repeat 3 times, taking breaks between each set

Accessories and tools

There are several products and accessories available on the market to relieve sacroiliac pain. It should be remembered that these tools generally provide temporary relief, and should be used sparingly. Among the products recommended by our professionals, we have:

• acupressure mat

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• Heated lumbar belt and sacroiliac belt

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• Ergonomic back cushion

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• massage gun

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• Spinal decompression table

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• Foam roller (sport massage roller)

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• Compex

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surgery

This is the last resort. It involves a sacroiliac arthrodesis, that is, the fusion of the sacroiliac joint (iliac bone and sacrum).

What about natural remedies?

Although they are not supported by solid scientific evidence, several natural products and home remedies are used to treat various body pains, especially for their anti-inflammatory power.

Here is a non-exhaustive list of plants and essential oils that are effective in controlling pain and inflammation:

• Turmeric : Thanks to its antioxidant and anti-inflammatory powers very powerful, turmeric is one of the most used plants in a culinary and therapeutic context. The composition of turmeric is essentially made of essential oils, vitamins (B1, B2, B6, C, E, K) and trace elements. But it is to its composition rich in curcumin and curcuminoids that we owe them and calm skin of this spice.

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• Ginger : In addition to the special flavor it brings to the kitchen and its aphrodisiac properties, ginger is a root well known for its anti-inflammatory powers. THE gingerol gives it its anti-inflammatory action. It is an active component acting on the inflammatory pain related to chronic joint inflammatory diseases, including rheumatoid arthritis, lupus, rheumatic diseases, etc. It has been proven that this active element is also effective in acting on the inflammation linked to arthritis and sciatica. Ginger also has other benefits thanks to its high potassium content and its richness in trace elements (calcium, magnesium, phosphorus, sodium) and vitamins (provitamin and vitamin B9).

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• Omega-3s : Omega-3 are polyunsaturated fatty acids that play a very important role in the functioning of our body. They are provided by food in three natural forms: docosahexaenoic acid (DHA), alpha linolenic acid (ALA) and eicosapentaenoic acid (EPA). Beyond their action on the brain and the cardiovascular system, omega-3s prove very effective against inflammation. Indeed, they have the ability to act on the inflammatory mechanisms in osteoarthritis by slowing down cartilage destruction, thus they reduce the intensity of osteoarthritis pain. Since sciatica is most often linked to inflammation secondary to a herniated disc, it can also respond to omega-3s if you consume them regularly. 

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• Lemon eucalyptus: Eucalyptus is a plant most often used in the form of herbal tea or essential oil. She would have anti-inflammatory effects which give it the ability to act on the bone and joint pain in general and the pain of sciatica in particular.

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• wintergreen : Wintergreen is a shrub from which a very interesting essential oil is extracted. It is one of the most used essential oils in aromatherapy. This oil extracted from the shrub bearing the same name, is used in massage to relieve sciatica and act like a analgesic. Indeed, it provides a heating effect thanks to its ability toactivate blood circulation locally.

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Conclusion

When you suffer from low back pain, you should not rule out the possibility that sacroiliac pain is the cause of the symptoms.

This joint can be the site of dysfunction causing pain in the lower back, as well as radiating pain in the leg.

The diagnosis of this condition takes into account a clinical examination (including a neurological examination), medical imaging tests, and even infiltrations in some cases.

The treatment approach aims to reduce inflammation and mechanical stress around the sacroiliac joint. A healthcare professional is the most qualified to help you manage your sacroiliac pain.

Good recovery !