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Rapid response to:

Clinical Review

Low back pain

BMJ 2004; 328 doi: (Published 06 May 2004) Cite this as: BMJ 2004;328:1119

Rapid Response:

Low back pain: Sacroiliac joint pain should not be considered a myth


I read with interest Dr Speed’s review (1) including her
reference to sacroiliac joint (SI) pain due to mechanical
stresses. I do not agree with Dr Bamji (2) that
"sacroiliac strain really represents injuries of the gluteal
region". Clinicians who manipulate the SI joint,
following a careful history, physical examination and
appropriate radiology to exclude pathology, know that
patients may derive considerable, if not complete, relief
from a dysfunctional SI joint. An example of SI joint
dysfunction was documented by me (3). In summary, a
25 year old woman who fell onto her right buttock four
years previously presented with constant chronic low
back pain that included the right SI joint, with radiation
into the right buttock, the right leg posteriorly and into
the sole of the right foot. She was neurologically intact,
had a normal lumbar MRI and her right SI joint pain
could be aggravated by mechanically straining the joint.
She had obtained no relief from various NAISDs,
paracetamol, endep and a CT guided right SI joint
steroidal injection. However, she received great relief
from manipulation of the painful SI joint, although she
found the initial manipulation to be very painful. She
had one further manipulation three days later, another
one month later for a minor recurrence of right SI joint
pain, and a further manipulation two months later for a
similar occurrence – each treatment provided excellent
relief. The patient’s husband asked why several
specialists to whom she had been referred had
suggested her symptoms were in her head and he
stated that her condition had almost wrecked their
marriage. In view of this, I believe clinicians should
include manipulation as a useful management
procedure for mechanical dysfunction of the SI joint.
Also, it should be noted that SI joint pain may be
referred as far as the foot, although some authors
consider that the pain is most often referred to the
groin, buttocks, and posterior thigh and less often to the
lower extremity (4).

Lynton Giles, Consultant Clinical Anatomist
Brisbane, Queensland, Australia

(1) Speed C. ABC of Rheumatology. Low Back Pain.
BMJ 2004; 328: 1119-1121. (8 May.)

(2) Bamji AN. Low back pain. Sacroiliac joint pain may
be a myth. Letter. BMJ 2004; 329: 232 (24 July.)

(3) Giles LGF. 50 Challenging Spinal Pain Syndrome
Cases. Edinburgh, Butterworth-Heinemann, 2003:

(4) Quon JA, Bernard NT, Burton CV, Kirkaldy-Willis WH.
The site and nature of the lesion. In Managing Low
Back Pain (Kirkaldy-Willis WH and Bernard NT (eds)),
4th edition, Edinburgh, Churchill Livingstone, 1999:

Competing interests:
None declared

Competing interests: No competing interests

23 July 2004
Lynton G Giles
Consultant Clinical Anatomist
Brisbane, Queensland, Australia 4068