334
Sacroiliac Joint Pain Referral Zones
Curtis W. Slipman, MD, Howard B. Jackson, MD, Jason S. Lipetz, MD, Kwai T. Chan, MD, David Lenrow, MD,
Edward J. Vresilovic, MD, PhD
ABSTRACT. Slipman CW, Jackson HB. Lipetz JS, Chan
KT, Lenrow D, Vresilovic EJ. Sacroiliac joint pain referral
zones. Arch Phys Med Rehabil2000;8 1:334-8.
Objective: To determine the patterns of pain referral from
the sacroiliac joint.
Study Design: Retrospective.
Participants/Methods: Fifty consecutive patients who satis-
fied clinical criteria and demonstrated a positive diagnostic
response to a fluoroscopically guided sacroiliac joint injection
were included. Each patient’s preinjection pain description was
used to determine areas of pain referral, and I8 potential
pain-referral zones were established.
Outcome Measures: Observed areasof pain referral.
Results: Eighteen men (36.0%) and 32 women (64.0%) were
included with a mean age of 42.5 years (range, 20 to 75 yrs) and
a mean symptom duration of 18.2 months (range, I to 72 mo).
Forty-seven patients (94.0%) described buttock pain, and 36
patients (72.0%) described lower lumbar pain. Groin pain was
described in 7 patients (14.0%). Twenty-five patients (50.0%)
described associated lower-extremity pain. Fourteen patients
(28.0%) described leg pain distal to the knee,‘and 6 patients
(14.0%) reported foot pain. Eighteen patterns of pain referral
were observed. A statistically significant relationship was
identified between pain location and age, with younger patients
more likely to describe pain distal to the knee.
Conclusions: Pain referral from the sacroiliac joint does not
appear to be limited to the lumbar region and buttock. The
variable patterns of pain referral observed may arise for several
reasons, including the joint’s complex innervation, sclerotomal
pain referral, irritation of adjacent structures, and varying
locations of injury with the sacroiliac joint.
Key Words: Low back pain; Sacroiliac joint syndrome;
Sacroiliac joint block.
0 2000 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
ACROILIAC JOINT SYNDROME (SIJS) is an extraspinal
S cause of low-back and lower-extremity pain that can present
in a myriad of ways. The constellation of symptoms attributed
to SIJS includes pain referral to numerous anatomic regions.
Specific pain referral zones reported include the posterior
superior iliac spine (PSIS),’ lower lumbar region,*-” but-
tock,3.4*6.‘2-‘8 groin and medial thigh,*.i3.i5.‘* posterior
thigh,‘3*14*t9-23
lower abdomen,6.‘4.24calf, and foot.i*
From the Department of Rehabilitation Medicine (Drs. Slipman, Jackson, Lipetz.
Ghan. Lenrow) and the Deparlmenr of OrIhopaedic Surgery (Dr. Vresilovic). Hospital
of the University of Pennsylvania, Philadelphia, PA.
Submitted for publication June 15. 1999. Accepted in revised form August 10, 1999.
No commercial party having a direct financial imerest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which Ihe authors are associated.
Reprint requesls to Cunis W. Slipman, MD, Director. The Penn Spine Center,
Ground Floor White Building, Hospital of the University of Pennsylvania, 3400
Spruce Streel. Philadelphia, PA I9 104.
0 2OOO by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
OOO3-9993/00/8103-5687$3.00/O
Arch Phys Med Rehabil Vol81, March 2000
There are several potential explanations for the apparent
varied pain complaints presenting in SIJS. The sacroiliac joint’s
variable innervation has been previously described and may
result in complex symptom referral.“-” Varying scleroto-
mal?s~‘”pain referral patterns may also arise from injury to
distinct locations in the sacroiliac joint.3” Additionally, the
piriformis muscle. situated in close proximity to the sacroiliac
joint, may be affected by intrinsic joint pathology, resulting in
pain of muscular origin and/or associated sciatic nerve irrita-
tion.‘?
Previous descriptions of sacroiliac joint pain referral zones
have been based upon a diagnosis of SIJS established through
history and physical-examination findings. Using provocative
intra-articular injections, the pain referral patterns of the
sacroiliac joint in asymptomatic individuals has been demon-
strated.’ Patterns of pain referral, encompassing the entire lower
limb. have also been described in symptomatic individuals
responding to intra-articular diagnostic injections.‘” It was the
purpose of this retrospective study to further investigate and
characterize the pain referral patterns of patients with SIJS who
demonstrated a positive response to a fluoroscopically guided
diagnostic sacroiliac joint injection.
METHODS
Fifty consecutive patients satisfying inclusion criteria were
included. Patients eligible for inclusion were referred to our
Spine Center with complaints of low-back or buttock pain
regardlessof associated hip or leg symptoms. Physical examina-
tion had to demonstrate a positive response to a minimum of 3
widely accepted maneuvers typically used to diagnose SIJS.
Two of the 3 positive responseshad to include 2 specific stress
maneuvers: Patrick’s test, and pain with pressure application to
the sacroiliac ligaments at the sacral sulcus while in the prone
position. Other maneuvers we performed, which are believed to
be indicative of SIJS, were shear test, Gaenslen’s maneuver,
and Yeoman maneuver.
Patients with a history of spondylarthropathy, urethritis,
peripheral arthritis, psoriasis, inflammatory bowel disease, pain
associated with early-morning stiffness that resolved with
exercise, positive root tension signs, or a neuromuscular deficit
were excluded. Patients with electrodiagnostic evidence of an
acute lumbosacral radiculopathy or peripheral neuropathy or
radiographic evidence of spondylolisthesis or lumbar instability
were similarly excluded.
Patients who satisfied inclusion criteria and were not previ-
ously enrolled in a physical-therapy program began a regimen
consisting of lumbar spine stabilization techniques, upper- and
lower-extremity conditioning, and enhancement of soft tissue
pliability. Those who failed to improve following at least 4
weeks of the above regimen and still met our inclusion criteria
underwent a fluoroscopically guided diagnostic sacroiliac joint
block (SIJB). Approximately 15 minutes before this procedure,
a preinjection pain drawing and visual analogue scale (VAS)
rating was completed. Each pain drawing and VAS was
administered by a trained nurse or medical technician.
 SACROILIAC JOINT
Injection Technique
Fluoroscopically guided diagnostic sacroiliac joint injections
were performed using the technique of Hendrix and cowork-
ers.j’ While all injections were performed with fluoroscopic
guidance, slight modifications were incorporated, because a
rotating myelogram table was used in place of a C-arm. During
each injection. blood pressure and pulse were recorded in
3-minute cycles. Patients were prepped and draped in the usual
sterile manner. A skin weal was raised with I % xylocaine at the
needle insertion site. A 3.5in 22-gauge needle was used for thin
or moderate-sized patients, and a 5-in needle was used for
larger patients. The needle was advanced in a medial-to-lateral
direction to achieve joint entry at the medial aspect of the
medial or posterior joint line. After infusing 0.5~~ of Iohexola
300mg/mL into the most caudal aspect of the sacroiliac joint
and establishing proper needle position, 2cc of 2% lidocaine
hydrochloride was injected. Within 30 minutes of the SIJB,
each patient completed a postinjection VAS supervised by a
trained nurse or medical technician. Immediately preceding
completion of this VAS, the patient was required to assume any
position or perform any maneuver that typically provoked
low-back pain. A minimum reduction of 80% in the VAS rating
was required to be considered a positive response. Those
patients demonstrating a positive diagnostic response were
included in the study.
Data Collection
All data collection and analysis was performed by an
independent reviewer. Initial data recorded included the pa-
tients’ age, sex, and symptom duration before treatment. Each
patient’s prediagnostic injection pain description as recorded by
their examiner was used to determine areas of pain referral.
Pain referral zones were first categorized into 9 primary
anatomic regions: upper lumbar, lower lumbar, buttock, groin.
abdomen, thigh, lower leg, ankle, and foot. The upper lumbar
region was defined as that lumbar area above the level of the
iliac crests.The lower lumbar region was defined as that lumbar
area above the posterior superior iliac spines extending superi-
orly to the level of the iliac crests.
Upper lumbar, lower lumbar, and buttock complaints were
further categorized as ipsilateral, bilateral, and midline. Through
a further anatomic division of the thigh, lower leg, and foot, a
total of 18 potential pain referral zones were established. The
thigh and lower leg were anatomically subdivided into anterior,
posterior, medial, and lateral regions. The foot was similarly
subdivided into dorsal, plantar, medial, and lateral regions.
Statistics
Relationships between patient age, sex, symptom duration,
and pain distribution were investigated with the use of t tests
and chi-squared tests.
RESULTS
Fifty consecutive patients were included in the study. The
mean age of the patient population was 42.5 years (range, 20 to
75 yrs). Eighteen males (36.0%) and 32 females (64.0%) were
included. The mean symptom duration before diagnostic injec-
tion was 18.2 months (range, I to 72 mo).
Eighteen patients (36.0%) demonstrated a positive diagnostic
injection response bilaterally, and 32 (64.0%) demonstrated
unilateral involvement. Patients with bilateral involvement
generally demonstrated symmetric pain complaints, and pain
referral zones in these individuals were therefore not described
independently for each side of involvement.
The frequency of pain referral to the lumbar, buttock, groin,
PAIN, Slipman 335
and abdominal areas is summarized in table I. Only 3 patients
(6.0%) demonstrated upper lumbar pain. In 2 individuals, this
pain was reported ipsilateral to the side of sacroiliac joint
involvement, and the other reported more midline upper lumbar
pain. Thirty-six patients (72.0%) described lower lumbar pain.
Except for I patient, bilateral lower lumbar pain was described
only in those individuals demonstrating a positive diagnostic
injection response bilaterally. In 3 patients, the lower lumbar
pain was midline in location, and in 2 cases,this was associated
with a unilateral positive diagnostic injection response.
Forty-seven patients (94.0%) reported buttock pain. Bilateral
buttock pain was described only in those individuals demonstrat-
ing a positive diagnostic injection response bilaterally. One
individual demonstrating a positive bilateral diagnostic injec-
tion response described asymmetric buttock involvement, with
right-sided buttock pain only.
Seven patients (14.0%) reported groin pain. Abdominal pain
was observed in I patient (2.0%) in the study group.
The frequency of pain referral to the lower extremity is
summarized in table 2. Overall, 25 patients (50.0%) reported
associated lower-extremity pain. Twenty-four patients (48.0%)
described thigh pain, with complaints most commonly localized
to the posterior or lateral thigh. One individual demonstrating a
positive bilateral diagnostic injection response described asym-
metric thigh involvement, with right-sided posterior thigh pain
only.
Overall, 18 patterns of pain referral were observed. These are
listed in order of decreasing frequency of presentation in
table 3.
No significant relationship between patient sex or symptom
duration and the presence of pain in any anatomic region was
identified. Statistically significant relationships were identified
between patient age and the presence of pain distal to the knee,
and these are described in table 4.
DISCUSSION
Our findings demonstrate that SIJS may involve pain referral
to various sites not limited to the lower lumbar region and
buttock. Fortin and colleagues’ previously described pain
referral zones resulting from provocative intra-articular injec-
tions. A common area of resultant pain was located over the
PSIS, extending lOcm caudally and 3cm laterally. In our study,
no attempt was made to provoke symptoms during injection.
Rather, patients’ pain referral regions were recorded after
establishing a diagnosis of SIJS through physic&examinaGon
findings and a positive response to an intra-articular diagnostic
injection.
Several previous studies have attempted to describe sacro-
iliac joint pain referral zones with a diagnosis of SIJS estab-
lished by history and physical-examination findings alone.*-
14.19-23 Subsequent to those reports, it has been demonstrated
that historical and clinical features have proven unreliable in the
diagnosis of sacroiliacjoint pain. The sacroiliac joint is mobile,
albeit limited to only a few millimeters of glide and 3” of
rotation,33.34but physical-exam maneuvers employed to detect
Table 1: Frequency of Pain Referral to the Lumber, Buttock, Groin,
and Abdominal Regions
Anatomic Region Percentage of Patients With Pain
Upper lumbar 6
Lower lumbar 72
Buttock 84
Groin 14
Abdomen 2
Arch Phys Med Rehabil Vol81, March 2ooo
336 SACROILIAC JOINT PAIN, Slipman

Table 2: Frequency of Pain Referral to the Lower Extremity Table 4: Relationship Between Patient Age and Pain Distribution
to the Leg, Ankle, and Foot
Anatomic Region Percentage of Patients With Pain
Number of Patients Pain Mean Age (yrs)
Thigh 48
Posterior 30 Leg
Lateral 20 44 Absent 43.7 z-11.7)
Anterior 10 6 Present 30.5 -‘lO.l)
Medial 0 p = .0118
Lower leg 28 Ankle
Posterior 18 44 Absent 43.4 z-12.2)
Lateral 12 6 Present 32.8 ~8.7)
Anterior 10 p = .0468
Medial 0 Foot
Ankle 14 36 Absent 44.3 211.8)
Foot 12 14 Present 36.6 ~12.41
Lateral a p = .0477
-
Plantar 4
Dorsal 4
Medial 0
While the most commonly observed pattern of pain distribu-
tion was that involving the buttock and lower lumbar region
motion abnormalities have demonstrated poor intertester and alone. observed in 30.07~ of the patient population. associated
intratester reliability.9~‘sAdditionally. it has been demonstrated symptoms were not confined to a proximal distribution. Lower-
that motion-abnormality testing may be positive in 20% of extremity pain complaints were common, reported in 50.0% of
patients who are asymptomatic.’ patients. Pain complaints in the lower leg and as distal as the
Diagnostic intra-articular injections were first described in foot were reported in 28.0% and 12.0%. respectively.
1938,37 with the use of fluoroscopic guidance introduced in The clinical significance of the increased frequency of distal
1979.38The detection of joint motion abnormalities,36 response pain complaints in younger patients remains questionable. This
to pain provocation tests,24.39.J0 and historical features’8.‘4 have may represent a pure mathematical construct, because multiple
all correlated poorly with the response to fluoroscopically analyses were performed in an attempt to identify relationships
guided intra-articular diagnostic injections, which have arisen between patient characteristics and pain distribution. If true.
as the gold standard for diagnosing sacroiliac joint pain. It was this finding would suggest that older patients with distal
the purpose of this article to describe pain referral zones of the extremity pain, such as that associated with lumbar spinal
sacroiliac joint with a diagnosis of SIJS established by a stenosis and neurogenic claudication, should be less often
fluoroscopically guided diagnostic injection, and not through confused with pain secondary to SIJS.
lessreliable physical-examination and historical findings. The diffuseness of the sacroiliac joint pain referral zones may
Variable and diffuse patterns of pain referral were observed arise for several reasons: (I) the joint’s innervation is highly
in our patient population. The majority of patients reported pain variable and complex; (2) pain may be referred in a sclerotomal
involving the lower lumbar region and buttocks, 72.0% and fashion: (3) adjacent structures may be affected by intrinsic
94.0%, respectively. Groin pain was described by 14.0% of the joint pathology and become active nociceptors; and (4) pain
patient population. referral patterns may be dependent on the distinct locations of
injury in the sacroiliac joint.
Table 3: Eighteen Observed Patterns of Sacroiliac Pain Referral It remains unclear precisely how the anterior and posterior
in Order of Decreasing Frequency aspects of the sacroiliac joint are innervated.?’ The anterior
Percent portion of the sacroiliac joint likely receives innervation from
Pattern of Pain Referral of Patients the posterior rami of the L2-S2 roots. The contributions from
these root levels are highly variable and may differ in the 2
Lower lumbar and buttock 30
12
joints of a given individual.Z4,3ZAdditional innervation to the
Buttock alone
anterior joint may arise directly from the obturator nerve,
Lower lumbar, buttock, and thigh 10
superior gluteal nerve, and lumbosacral trunk.3’~4’.JZ The poste-
Lower lumbar, buttock, thigh, and leg 10
rior portion of the joint is innervated by the posterior rami of
Lower lumbar alone 6
Buttock and thigh 4
L4-S3,3Z with a particular contribution from S 1 and S2.J’-J3An
Buttock, groin, and thigh 4
additional autonomic component of the joint’s innervation
4
further increasesthe complexity of its neural supply and likely
Buttock, thigh, leg, ankle, and foot
adds to the variability of pain referral patterns.4’
Buttock and leg 2
A sclerotome has been defined as the ventral and medial
Lower lumbar, buttock, and groin 2
portion of the embryonic somite. The cells in this portion of the
Buttock, groin, thigh, leg, ankle, and foot 2
Lower lumbar, buttock, thigh, leg, and ankle 2
somite evolve to form the vertebral column, while the dorsolat-
2
era1 cells form the musculature of the trunk and extremity.JJ
Lower lumbar, buttock, abdomen, and thigh
When an osseous or ligamentous structure of the vertebral
Lower lumbar, buttock, thigh, leg, ankle, and foot 2
column, such as the sacroiliac joint, is injured, it may refer pain
Lower lumbar, buttock, groin, thigh, leg, and foot 2
along its path of embryonic growth. This has been referred to as
Upper lumbar, lower lumbar, buttock, thigh, and leg 2
sclerotomal pain referral. *a.*9 The resultant pain referral pat-
Upper lumbar, lower lumbar, buttock, groin, and thigh 2
Upper lumbar, lower lumbar, buttock, groin, thigh, leg,
terns may be quite complex. involving local and distal sites in
2
the lower extremity.‘O
ankle, and foot
The piriformis muscle is situated in close proximity to the

Arch Phys Med Rehabil Vol81, March 2000

 SACROILIAC JOINT PAIN, Slipman 337

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