Screening the sacrum and

sacroiliac
Syeda Sukaina Mazhar.
18232. (Final year).
Submitted to: Dr. Haris.
Clinical Decision Making and Differential Diagnosis.
 Contents:

• Introduction to sacrum and sacroiliac joint.

• Screening for cause of sacral/ sacroiliac pain.
• Introduction to coccyx and causes of coccygeal pain.
• Cases.
 Introduction to sacrum and SIJ:
Evaluating the sacroiliac (SI) joint can be difficult in that no single physical examination
finding can predict a disorder of the SI joint.

Pain originating from the SI joint can mimic pain referred from:
• lumbar disc herniation,
• spinal stenosis,
• facet joint dysfunction,
• disorder of the hip.
 Infectious/ inflammatory:
• Spondyloarthropathy: Ankylosing spondylitis,Reiter's
syndrome,Psoriatic arthritis, Inflammatory bowel disease.
• Vertebral osteomyelitis
• Endocarditis
• Tuberculosis (uncommon)

Causes of sacral • Ulcerative colitis

Gastrointestinal:

and SI pain •
•
Colon cancer
Irritable bowel syndrome
• Crohn's disease (regional enteritis)
(systemic)
Spondylogenic:
• Fracture (traumatic, insufficiency, pathologic),
• Osteoporosis (insufficiency fractures)
• Paget's disease
• Osteodystrophy
• Osteoarthritis
 Gynecologic:
• Reproductive cancers
• Retroversion of the uterus
• Uterine fibroids
• Ovarian cysts
• Endometriosis
• Pelvic inflammatory disease (PID)

Causes of sacral and •

•
Incest/sexual assault
Rectocele, cystocele

SI pain •
•
Uterine prolapse
Normal pregnancy; multiparity

(systemic) Cancer:
• Primary tumors (rare: giant cell, chondrosarcoma, synovial
villoadenoma)
• Metastatic lesions (history of cancer)
• Prostate cancer
• Colorectal cancer
• Multiple myeloma
 • Idiopathic (unknown)
• Trauma
• Myofascial or kinetic chain imbalance
• Enthesis (tendon insertion)/ligamentous sprain
• Degenerative joint disease
• Bone harvesting for grafts (may cause secondary

Causes of sacral •
•
instability)
Lumbar spine fusion or hip arthrodesis
Myofascial syndromes (mimics SI joint pain)

and SI pain:
(neuromuscular/musculoskeletal)
•
•
Discogenic disease (mimics SI joint pain)
Nerve root compression (mimics SI joint pain)
• Zygapophyseal joint pain (mimics SI joint pain)
Screening for Infectious/Inflammatory Causes of
Sacroiliac Pain:
• Joint infections spread hematogenously through the body and can affect the sacroiliac joint.
Usually, the infection is unilateral and is caused by Pseudomonas aeruginosa, Staphylococcus
aureus, Cryptococcus organisms, or Mycobacterium tuberculosis.
• Risk factors for joint infection include trauma, endocarditis, intravenous drug use, and
immunosuppression.
• Infection can cause distention of the anterior joint capsule, irritating the lumbrosacral nerve roots.
• Inflammation of the sacroiliac joint may result from metabolic, traumatic, or rheumatic causes.
Sacroiliitis is present in all individuals with ankylosing spondylitis.
Screening for Spondylogenic Causes of sacral/Sacroiliac
Pain:
Metabolic bone disease (MBD) such as osteoporosis, Paget's disease, and osteodystrophy can
result in loss of bone mineral density and deformity or fracture of the sacrum.
The therapist should review cases of sacral pain for the presence of risk factors for any of
these metabolic bone diseases.

Metabolic Bone Disease:

Mild to moderate MBD may occur with no visible
signs. Advanced cases of MBD include constipa?tion, anorexia, fractured bones, and
deformity.
Osteoporosis, Paget's disease, Fracture.
 Screening for Gastrointestinal Causes of
Sacral/Sacroiliac Pain:
• The primary pain pattern for gastrointestinal (GI) disease involves the midabdominal region around the
umbilicus.
• When a client relates symptoms associated with the viscera or abdomen, the therapist must think in terms
of screening questions to discern whether these symptoms require immediate medical assessment and
intervention. The therapist is more likely to see clients with referred low back or sacral pain from the
small or large intestine as it presents in the low back or sacral area.
• Sacral pain from a GI source may be reduced or relieved after the person passes gas or completes a
bowel movement. It may be appropriate to ask a client the following:
• Is your pain relieved by passing gas or having a bowel movement? The patient may have a history of
GI disease or medication use to treat conditions such as • Ulcerative colitis •Crohn's disease •Irritable
bowel syndrome (IBS) •Colon cancer •Long-term use of antibiotics (colitis).
 Screening for Tumors as a Cause of Sacral/Sacroiliac
Pain:
• Primary sacral tumors include benign and malignant growths. Benign neoplasms include osteochondroma,
giant cell tumor, and osteoid osteoma. The more common primary malignant lesions directly affecting the
sacrum include chordoma, osteosarcoma, and myeloma.
• Giant cell tumor is a highly aggressive local tumor of the bone. The sacrum is the third most common site of
involvement. Clients present with localized pain in the lower back and sacrum that may radiate to one or both
legs. Swelling may be noted in the involved area. When asked about the presence of other symptoms
anywhere in the body, the client may report abdominal complaints and neurologic signs and symptoms (e.g.,
bowel and bladder or sexual dysfunction, numbness and weakness of the lower extremity).

• Colorectal or anorectal cancer as a cause of sacral pain is possible as the result of local invasion. Severe
sacral pain in the presence of a previous history of uterine, abdominal, prostate, rectal, or anal cancer requires
immediate medical referral.
 Coccyx:
The coccyx or tailbone is a small triangular bone that articulates with the bottom of the
sacrum at the sacrococcygeal joint. Injury or trauma to this area can cause coccygeal pain
called coccygodynia.
 Coccydynia:
• Most cases of coccygodynia or coccydynia (pain in
the region of the coccyx) seen by the physical
therapist occur as a result of trauma such as a fall
directly on the tailbone or events associated with
childbirth.
• Symptoms include localized pain in the tailbone
that is usually aggravated by direct pressure such as
that caused by sitting, passing gas, or having a
bowel movement.
• Moving from sitting to standing may also
reproduce or aggravate painful symptoms.
 Coccydynia:
• In the case of persistent coccygodynia with a history of trauma, the therapist must keep in mind the
possibility of rectal or bladder lesions. When asked about the presence of other symptoms, clients with
coccygodynia after a trau?matic fall may also report bladder, bowel, or rectal symptoms.
• The therapist must ask whether bladder, bowel, or rectal symptoms were present before the fall. Because
50% of all clients with back or sacral pain from a malignancy have preceding trauma or injury, the
apparent trauma (especially if the client reports associated symptoms that were present before the trauma)
may be something more serious.
• Blood in the toilet after a bowel movement may be a sign of anal fissures, hemorrhoids, or colorectal
cancer and requires medical evaluation.
Coccydynia:
 Case :
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 Case :
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Reference:
Differential Diagnosis for physical therapists by Goodman snyder.
THANK YOU!