Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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C.H. Li et al.
Physical Exam Most of SI joint pain is referred to the buttocks (94
%), lower lumbar region (72 %), and lower extremities (50 %) [ 6 ]. Pain
that is localized to the groin is an unusual presentation, seen in around 14
% cases [ 6 ]. There are extensive innervations in the hip and groin area,
making physical examination difficult and nonspecific. Three provocative
SI joint movements can detect SI joint dysfunction with a sensitivity of
77–87 % [ 7 ]. Common tests of SI joint function include Laguere, Gillette,
Patrick, and the Gaenslen tests [ 7 – 9 ]. Further, radiographic exam may be
helpful in corroborating physical exam findings, but radiology alone is
not sufficient for diagnosis [ 4 ]. Elgafy et al. [ 10 ] showed that CT scans
for SI joint dysfunction had a sensitivity of 57.5 % and a specificity of 69
%. SI joint blocks can be used as a diagnostic tool and have been
associated with a positive predictive value of 60 % when used with three
physical exam tests [ 6 , 11 ].
Treatment Patients with SI joint dysfunction should be treated with a
multimodal approach. Results of treatment consisting of physical
therapy, orthotics, joint blocks, surgery, and neuroaugmentation have
been highly variable [ 4 ]. Physical therapy exercises focus on movements
that can strengthen the hip muscles and stabilize the pelvis [ 12 ].
Placement of an orthotics belt has also been useful in some treatments as
a way of limiting further motion that can cause increased injury to the
joint [ 13 ]. Several studies have also noted relief of symptoms and
improvement in function with intraarticular injections of the SI joint
[ 14 – 17 ]. This can further be followed with radiofrequency rhizotomies
of the innervation to the SI joint for more lasting analgesia. There is no
class I evidence to support this procedure.
Historically, surgical treatment was used only when the SI joint was
proven to be unstable [ 18 ]. Traditional techniques for SI joint fusion
involved large open procedures, which introduced a great amount of
morbidity and were of limited clinical benefit. With the recent advent of
minimally invasive techniques to fuse the SI joint, there is growing
interest among spine surgeons to pursue this technique. However, to date
there is not a great deal of high-level evidence to support this procedure.
Neuroaugmentation is a new modality for treatment of SI joint pain, and
case reports [ 19 , 20 ] have suggested that it may be a standard treatment
option in the future .