J Neurosurg Pediatrics 9:602607, 000000, 2012

Sacroiliac joint pain in the pediatric population

Clinical article
Ivan Stoev, M.D.,1 Alexander K. Powers, M.D.,1,2 Joan A. Puglisi, P.T., P.C.S., 2 Rebecca Munro, M.A., 2 and Jeffrey R. Leonard, M.D.1,2
1

Department of Neurological Surgery, Washington University in St. Louis; and 2St. Louis Childrens Hospital, St. Louis, Missouri

Object. The sacroiliac (SI) joint can be a pain generator in 13%27% of cases of back pain in adults. These numbers are largely unknown for the pediatric population. In children and especially girls, development of the pelvic girdle makes the SI joint prone to misalignment. Young athletes sustain repeated stress on their SI joints, and sometimes even minor trauma can result in lasting pain that mimics radiculopathy. The authors present a series of 48 pediatric patients who were evaluated for low-back pain and were found to have SI joint misalignment as the cause of their symptoms. They were treated with a simple maneuver described in this paper that realigned their SI joint and provided significant improvement of symptoms. Methods. A retrospective review of the electronic records identified 48 patients who were referred with primary complaints of low-back pain and were determined to have SI joint misalignment during bedside examination maneuvers described here. Three patients did not have a record of their response to treatment and were excluded. Patients were evaluated by a physical therapist and had the realignment procedure performed on the day of initial consultation. The authors collected data regarding the immediate effect of the procedure, as well as the duration of pain relief at follow-up visits. Results. Eighty percent of patients experienced dramatic improvement in symptoms that had a lasting effect after the initial treatment. The majority of them were given a home exercise program, and only 2 of the 36 patients who experienced significant relief had to be treated again. Fifty-three percent of all patients had immediate and complete resolution of symptoms. Three of the 48 patients had missing data from the medical records and were excluded from computations. Conclusions. Back pain is multifactorial, and the authors data demonstrate the potential importance of SI joint pathology. Although the technique described here for treatment of misaligned SI joints in the pediatric patients is not effective in all, the authors have observed significant improvement in 80% of cases. Often it is difficult to determine the exact cause of back pain, but when the SI joint is suspected as the primary pathology, the authors have described a simple and effective bedside treatment that should be attempted prior to the initiation of further testing and surgery. (http://thejns.org/doi/abs/10.3171/2012.2.PEDS11220)

Key Words sacroiliac joint bedside treatment spine pediatric population

pain is multifactorial in any population. There are about 10 distinct syndromes described in the literature.1,15 It is often difficult to pinpoint the cause of pain, especially when confounding radiographic findings and an inconsistent physical examination are present. Radicular pain from a bulging disc, facet joint pain, and SI joint pain present in similar fashions but require very different treatments. Making the correct diagnosis can avoid subjecting patients to unnecessary procedures. Although the numbers are somewhat controverAbbreviation used in this paper: SI = sacroiliac.

L
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ow-back

sial, the SI joint in adults may be the cause of low-back pain in 13%27% of cases.13,16 These numbers are largely unknown for the pediatric population. Hill and Keating11 reported that low-back pain increases in prevalence from 1% at 7 years of age to 17% at 12 years of age and to 53% at 15 years of age. Many pediatric patients with SI jointrelated low-back pain present for neurosurgical evaluation after spending months undergoing conservative therapy and invasive proThis article contains some figures that are displayed in color on line but in black-and-white in the print edition.

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Sacroiliac joint pain in the pediatric population

cedures. To compound the problem, they have been taken away from physical education classes and have had their activity restricted. Sacroiliac joint dysfunction can be seen in young athletes who sustain some mild form of trauma. Young females seem particularly vulnerable because of the laxity of their developing pelvic girdle. Small misalignment of the SI joint can mimic radiculopathy and can generate disabling pain. Because the incidence of degenerative disc disease and facet arthropathy is quite low in the pediatric population, surgeons should keep this in mind as a potential cause. Understanding the anatomy of the SI joint and the changes it undergoes with aging is important in differentiating it as a cause of back pain from muscular, discogenic, or degenerative joint problems. The role of imaging is to rule out causes other than the SI joint. Certain diagnostic algorithms have been proposed that narrow down the causes of back pain that are likely to originate from the SI joint. In the physical therapy and rehabilitation medicine literature, a cluster of provocation tests has been described including thigh thrust, distraction, compression, sacral thrust, and Gaenslens maneuver.12 Patients with SI joint pain are neurologically intact but may have some pain-related weakness. Electromyography can help differentiate between radiculopathy and SI joint pain. Only 4% of patients with pain related to the SI joint report pain above L-5.7 The majority of the pain is in the buttocks, and it rarely radiates below the knee. In a study of 54 patients, only 13% had pain in the foot or ankle, while 94% had pain in the buttocks.17 Results of the straight leg raise test were negative; however, the results may be false positive if the leg is elevated more than 60, as this places stress on the SI joint. The most sensitive physical examination finding is the presence of pain/tenderness at the sacral sulcus. Although this finding has poor specificity, Dreyfus et al.6 demonstrated that 89% of patients with SI joint pain have tenderness at the sacral sulcus, which is the soft-tissue depression just medial to the posterior superior iliac spine. When combined with the presence of maximal pain below L-5, these findings provide the highest positive predictive value of any other physical examination test.7,18 The only definitive diagnostic test remains the SI joint block. It is done under fluoroscopic guidance in patients with sacral sulcus tenderness and is considered diagnostic if there is greater than 75% improvement in pain.6 Treatment strategies for SI joint pain include medications, physical therapy, manual therapy/manipulation, injections, radiofrequency neurotomy of the L-5 dorsal ramus and its branches to the SI joint, and the lateral branches of the S13 dorsal rami and arthrodesis. Unfortunately, some patients undergo lumbar fusion procedures, which increase the stress forces on the SI joint and lead to further increase in pain. In the pediatric population, the most common cause of SI joint is minor or repetitive trauma often sustained by athletes. The pain is a result of minor misalignment of the SI joint and is aggravated by load bearing. A simple bedside manipulation procedure can be used to realign the SI joint and, combined with a physical therapy regimen, can provide lasting benefits to patients. In this paper, we present a group of patients who were treated with this technique, who often achieved dramatic results. The technique that we describe is done in less
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than 10 minutes, is easy to perform, and, in properly selected patients, can have immediate relief of symptoms with lasting effects. Although the technique does not work in all patients, it should be a recognized entity for any neurosurgeon evaluating pediatric spine patients.

A retrospective analysis of the electronic records of all pediatric patients who presented with complaints of back pain to the clinic of the senior author between 2005 and 2011 was performed after approval was obtained from the Washington University in St. Louis Institutional Review Board. From this database, patients who underwent manual therapy for suspected SI joint pain were identified. Part of the selection criteria was that all patients underwent the physical therapy treatment for SI joint misalignment described in this paper. The patients electronic medical records were reviewed for physical examination findings, characteristics of the back pain, precipitating factors, level of pain before and after treatment, lower-extremity numbness, pain radiation below the knee, SI joint tenderness to palpation, pain with bridging, discrepancy in leg length with straight sit, presence of comorbidities, number and type of radiographic tests with pertinent findings performed prior to visit, prior chiropractic or physical therapy consultation, use of analgesic medications, missing school classes, prior surgeries, duration of symptoms, and age at presentation. Forty-eight patients between the ages of 10 and 20 years were seen for evaluation of low-back pain that was attributed to the SI joint. All patients were evaluated by a single pediatric neurosurgeon over the course of 6 years at St. Louis Childrens Hospital. At time of initial consultation, patients were evaluated by a single physical therapist. Three patients had missing data from their medical records and were excluded from the computations. Patients were evaluated for presence of the following: focal tenderness over the SI joint, lower-extremity numbness, pain radiation below the knee, disparity of leg length during the long sit test, radicular pain with the straight leg raise maneuver, and pain with the bridging maneuver. All patients were referred with a primary complaint of low-back pain. All had focal tenderness over the SI joint, some had numbness in a lower extremity, and none had pain radiating below the knee. The long sit test is done initially with the patient in a supine position. The legs are noted to be at an equal length as measured by the medial malleoli. The patient is then asked to sit up, keeping the legs straight (Fig. 1). Due to involuntary guarding on the side of the affected SI joint, one leg appears to shorten as the medial malleolus moves up 0.51 in. The bridging maneuver consists of the patient lifting the buttocks from a supine position (Fig. 2). This exacerbates the SI joint pain and reproduces the symptoms. Forty-eight patients met the above inclusion criteria and were selected to undergo bedside manual therapy to realign the problematic SI joint, but only 45 patients had complete records including initial improvement scores. During the initial office consultation, all patients were evaluated by a physical therapist and underwent SI joint
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Methods

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Fig. 3. Isometric hip extension to realign the SI joint. The arrow indicates the resistance against the patients leg. Fig. 1. Long sit test. The leg on the affected side appears shorter as the medial malleolus moves up when changing from supine to sitting position.

manipulation via isometric hip contraction and extension. Among physical therapists, this maneuver is known as the muscle energy technique. The patients were asked to flex and more importantly extend their hips against resistance in an isometric fashion, forcing the SI joint into realignment (Figs. 3 and 4). Initially, the patients were asked to flex their hips and knees on the symptomatic side in a supine position. Hip extension was resisted by the therapist, targeting the gluteus maximus, as the participants pushed their leg into extension. This allowed the gluteus maximus to isometrically contract, pulling the pelvis into a posterior tilt. If the symptoms persisted, the same technique was applied to the opposite side. If symptom improvement was still not seen, hip flexion was resisted on the symptomatic side, thus targeting the iliopsoas and rectus femoris to pull the pelvis into an anterior pelvic tilt. After this their leg length discrepancy resolved, and most patients reported immediate complete or significant pain relief. The patients were also given an exercise program by the physical therapist to continue at home. Some patients (2 of 45) had recurrence of their symptoms and required retreatment, but the majority did not require additional treatment. The visual analog pain scale was used before and after the treatment to rate pain intensity. A phone questionnaire was conducted after the procedure. It included current pain level, any change in functional

level, and surgical status. Sixteen patients underwent follow-up via telephone survey, and only 7 patients returned to the clinic. Two of the 9 patients who did not respond to treatment returned for a follow-up visit but received no further treatment. The other 5 patients who returned did so for other reasons or for retreatment (Chiari malformation, intracranial arachnoid cyst, bilateral pars defects and Grade I spondylolisthesis, and 2 patients for retreatment). Patients who responded to treatment were instructed to return for reevaluation if they had symptom recurrence. Those who did not respond and had no abnormalities on their imaging examinations were unlikely to benefit from future visits to a neurosurgeon and were referred back to their pediatricians for continued conservative care.

Between 2005 and 2011, 48 patients underwent treatment of SI joint pain by using the aforementioned procedure (Table 1). All were referred with the primary complaint of low-back pain. Three patients had missing information regarding the initial and follow-up outcomes of bedside treatment and were therefore excluded. There were 37 females and 11 males in the group, with an average age of 15.7 years (range 1020.6 years). The average

Results

Fig. 2. Bridging maneuver. This places stress on the SI joint, thus exacerbating symptoms on the affected side.

Fig. 4. Isometric hip flexion to realign the SI joint. The arrow indicates the resistance against the patients leg.

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TABLE 1: Measured variables and their respective incidences in 48 patients with SI joint pain Measured Variable prior MRI pain medications prior treatment w/ chiropractor prior physical therapy missing school prior injections prior electrical stimulation treatments prior spinal cord detethering prior microdiscectomy back pain leg pain pain radiating below knee lower-extremity numbness SI joint tenderness to palpation prior motor vehicle accident sport-related injury no precipitating event abnormal imaging findings disc bulge lumbar spine fractures spondylolisthesis scoliosis No. of Patients (%) 36 (75) 29 (60.4) 5 (10.4) 21 (43.8) 4 (8.3) 6 (12.5) 20 (41.7) 2 (4.2) 3 (6.2) 48 (100) 16 (33.3) 5 (10.4) 11 (22.9) 46 (95.8) 6 (12.5) 18 (37.5) 24 (50) 10 (20.8) 2 (4.2) 4 (8.3) 2 (4.2)

Fig. 5. Pain outcomes after treatment.

duration of symptoms prior to presentation to the senior author was 7 months (range 0.2548 months). During that time, 5 patients were seen by a chiropractor, 21 patients underwent physical therapy, and 6 patients received injections. Three patients had microdiscectomy surgeries and 2 had spinal cord detethering procedures in their past. All patients had back pain, none had groin pain, 16 had leg pain, and 11 had lower-extremity numbness. Sixty percent of patients were on pain medications. Thirty-six patients (80%) had significant improvement in symptoms, and 24 patients (53%) had immediate and complete resolution (Fig. 5). Three patients had missing data on pain improvement and were not included in the computations. The average pretreatment pain score was 5.7 on the 10-point visual analog scale (range 39.5). The average posttreatment pain score was 1.8 (range 09). Individual pain score improvement of 28 points was seen. The pain scale data were not available for 16 patients; however, there was a description of pain improvement without quantification. Nine patients (20%) had minimal to no relief of symptoms. All but 1 of those patients had positive straight leg raise tests, 2 had spondylosis, 2 had microdiscectomies, and 1 had spina bifida surgery as part of their surgical history. Patients who benefited from the treatment had sustained symptomatic relief, with only 2 requiring repeated treatment. The biomechanics of the SI joint are complex. DurJ Neurosurg: Pediatrics / Volume 9 / June 2012

Discussion

ing flexion of the hip, the ipsilateral ilium glides backward and downward. During extension, the ilium glides forward and away from the sacrum.2 Pain and thermal sensation from the SI joint are transmitted by the L5 S2 ventral rami of the sacral plexus anteriorly and by the S14 dorsal rami posteriorly. There is some debate in the literature on the exact innervation, and some authors suggest that there is contribution from only the sacral dorsal rami.9,10 From a biomechanical standpoint, the SI joint can withstand significant medially directed force but fails at axial load and axial torsion. Such forces stress the anterior joint capsule and ligaments.5,6 Changes in the joint position or mechanics can be a pain generator resulting from joint capsule or ligamentous tension and resultant inflammation. Other causes of SI joint pain are degenerative changes, infection, insufficiency fractures (which can occur even with minor trauma, especially in the elderly), gout or osteoarthritis, and childbirth. Pregnancy induces laxity of the joint and predisposes to painful sprain.6 There are no imaging tests or physical examination findings that will unequivocally diagnose the SI joint as the pain generator. Pain from disc disease, nerve root compression, zygapophysial joints, and myofascial pain syndrome can have similar distribution. Imaging is used to rule out pathology other than the SI joint. Although the majority of patients underwent prior MRI, none had any identifiable pathology of their SI joints. The incidence of back pain in the pediatric population is unknown. Approximately 150 patients presented for evaluation of back pain to our clinic, and about onethird of them had the SI joint as a pain generator. The SI joint has been noted in the literature as a pain generator in 13%27% of adults.13,14,16 Almost 21% of our patients had confounding disc bulges on MRI, and although small in size, these findings can misdirect the surgeons focus, leading to unnecessary surgery. In cases of suspected SI joint disease, imaging is used to rule out other causes of pain rather than to rule in SI joint etiology. Seventy-five percent of our patients underwent lumbar spine MRI; however, no pathology could be found pertaining to the SI joint. This largely becomes a clinical diagnosis. By the time these patients reach the spine surgeons office, they have endured weeks or months of pain, have been taken away from their physical education classes, have undergone painful injections, and have suffered side effects of
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medications. While not every patient with SI joint pain responds to this maneuver, those who do often have lasting relief. Two of the initial responders had to be re-treated and were given a home exercise program developed by a physical therapist. There are virtually no side effects to this treatment or danger of significant injury. We have noticed a high degree of improvement in our series of patients by using this simple bedside technique. Fifty-three percent of patients experienced instantaneous and complete resolution, and 80% had dramatic improvement of symptoms. There was no correlation between the duration of symptoms and improvement in pain level. The patients flex and extend the hips against resistance in an isometric contraction and in effect provide themselves the force for SI joint realignment. Because this maneuver is not time consuming or costly and its failure has no negative consequences to the patient, it warrants a trial in those with suspected SI joint misalignment. Unfortunately, these results cannot be extrapolated to the adult population because of the different pelvic and SI joint anatomy, as well as the different disease processes affecting adults. The SI joint is relatively stable in adults, allowing for 2 mm of movement. Preadolescents and adolescents have a more flattened articular surface, enabling more translatory motions and possibly more range of motion, putting them at increased risk for SI joint misalignment.3,8 The stability of the joint increases by the 3rd and 4th decades of life with the formation of bony ridges, elevations, and depressions.6 Until puberty, the surface of the joint is flat. Stability of the SI joint is enhanced by muscles and fascia. The gluteus maximus and medius, erector spinae, latissimus dorsi, biceps femoris, psoas, piriformis, and oblique and transversus abdominis muscles provide support for the joint. Fascial reinforcements are greatest posteriorly with a major contribution by the thoracodorsal fascia.6 Of note, we found that the female patients (77%) seem to be more frequently affected by SI joint misalignment than male patients. In half of our cases, there was no precipitating event, although there have been some reports of an increased incidence in athletes.4 We realize that this is a retrospective study of a fairly small group of patients. Sixteen patients had a follow-up telephone survey addressing the amount of improvement they had after the treatment, as well as their return to sport activities and duration of relief. This was discounted from the analysis of the paper, as there is recall bias (patients were contacted during a range of 2 weeks to 2 years), and this information was unavailable for the majority of patients. The effectiveness of the maneuver was not recorded in 3 of the patients, and they were removed from the data analysis. There was no gold-standard test or treatment against which the maneuver can be compared. This case series illustrates a treatment option for some SI jointrelated back pain in the pediatric population. As apparent from the results, not all SI joint pain can be treated successfully this way. There is also a fair amount of difficulty in making the correct diagnosis of back pain due to SI joint pathology. Fortunately, in the pediatric population the incidence of degenerative joint disease is low, as are the incidences of gout, joint infections, and other adult causes of SI joint arthropathy. When properly diagnosed,
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and in the absence of fractures, it is likely that the cause of the SI joint pathology is due to misalignment or small subluxation, and the knowledge of this technique can be a valuable treatment modality or adjunctive therapy as well as a diagnostic tool.

In our experience, low-back pain in children is fairly common. Most cases result from trauma,1 as this population does not have the ailments that come with aging such as degenerative disc and joint disease. Back pain is a complex and multifactorial entity, and determining the exact etiology of symptoms can be very challenging in any population. Failure to make an accurate diagnosis can cause prolonged suffering, low self-esteem, drug dependence, and sometimes unnecessary surgery. It is important to recognize the SI joint as a pain generator. The simple bedside maneuver that we describe here can be used safely in a time-efficient manner with profound improvement of symptoms in the majority of pediatric patients.
Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Author contributions to the study and manuscript preparation include the following. Conception and design: Leonard. Acquisition of data: Stoev, Powers, Puglisi, Munro. Analysis and interpretation of data: Stoev. Drafting the article: Stoev. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Study supervision: Leonard. References 1. Bogduk N: The anatomical basis for spinal pain syndromes. J Manipulative Physiol Ther 18:603605, 1995 2. Bogduk N: The sacroiliac joint, in Bogduk N (ed): Clinical Anatomy of the Lumbar Spine and Sacrum, ed 4. New York: Elsevier, 2005, pp 173180 3. Bowen V, Cassidy JD: Macroscopic and microscopic anatomy of the sacroiliac joint from embryonic life until the eighth decade. Spine (Phila Pa 1976) 6:620628, 1981 4. Brolinson PG, Kozar AJ, Cibor G: Sacroiliac joint dysfunction in athletes. Curr Sports Med Rep 2:4756, 2003 5. Dreyfuss P, Cole AJ, Pauza K: Sacroiliac joint injection techniques. Phys Med Rehabil Clin N Am 6:785813, 1995 6. Dreyfuss P, Dreyer SJ, Cole A, Mayo K: Sacroiliac joint pain. J Am Acad Orthop Surg 12:255265, 2004 7. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N: The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976) 21: 25942602, 1996 8. Egund N, Olsson TH, Schmid H, Selvik G: Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. Acta Radiol Diagn (Stockh) 19:833846, 1978 9. Fortin JD, Kissling RO, OConnor BL, Vilensky JA: Sacroiliac joint innervation and pain. Am J Orthop 28:687690, 1999 10. Grob KR, Neuhuber WL, Kissling RO: [Innervation of the sacroiliac joint of the human.] Z Rheumatol 54:117122, 1995 (Ger) 11. Hill JJ, Keating JL: A systematic review of the incidence and prevalence of low back pain in children. Phys Ther Rev 14: 272284, 2009

Conclusions

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12. Laslett M, Aprill CN, McDonald B, Young SB: Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 10:207218, 2005 13. 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 (Phila Pa 1976) 21:18891892, 1996 14. Manchikanti L, Singh V, Pampati V, Damron KS, Barnhill RC, Beyer C, et al: Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 4:308316, 2001 15. Newton W, Curtis P, Witt P, Hobler K: Prevalence of subtypes of low back pain in a defined population. J Fam Pract 45:331335, 1997 16. Schwarzer AC, Aprill CN, Bogduk N: The sacroiliac joint in chronic low back pain. Spine (Phila Pa 1976) 20:3137, 1995 17. Slipman CW, Jackson HB, Lipetz JS, Chan KT, Lenrow D, Vresilovic EJ: Sacroiliac joint pain referral zones. Arch Phys Med Rehabil 81:334338, 2000 18. Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E: The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome. Arch Phys Med Rehabil 79:288292, 1998

Manuscript submitted August 25, 2011. Accepted February 7, 2012. Current address for Dr. Powers: Wake Forest Baptist Health, Winston-Salem, North Carolina. Please include this information when citing this paper: DOI: 10.3171/2012.2.PEDS11220. Address correspondence to: Jeffrey R. Leonard, M.D., Department of Neurological Surgery, St. Louis Childrens Hospital, One Childrens Place, Suite 4 S 20, St. Louis, Missouri 63110. email: leonardj@wudosis.wustl.edu.

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