The sacroiliac joint is a diarthrodial articulation that transmits loads between the upper body and the lower extremities. In this capacity, this cartilage-lined joint—hyaline cartilage on the sacrum and fibrocartilage on the ilium—experiences multiplanar motion limited by an extremely sturdy multiligamentous complex. Biomechanical calculations by Vleeming et al. determined that these movements can generate high friction at the articular surface that may, understandably, culminate in age-related degenerative changes. Since Goldwaite and Osgood, in 1905, first suggested that the sacroiliac joint could be the potential cause of pain, clinicians have struggled to determine when these degenerative changes constitute true debilitating pathology versus the forgiving adaptations of an aging joint.

In contrast to the clinical emphasis given to other major joints, the sacroiliac joint has been virtually forgotten historically. Our interest in the physiologic function and pathologic potential as well as surgical indications for nontraumatic conditions of the sacroiliac joint over the past several decades, however, has intensified. This heightened awareness was probably initiated by our appreciation of the hazards of adjacent motion segment deterioration associated with long and/or rigid lumbosacral instrumented fusions, likely propelled by the proliferation of diagnostic imaging and provocative testing modalities for low back pain, and possibly sustained by the persistent pain experienced by the increasing number of patients having lumbar fusion who develop failed back syndrome. Furthermore, in a recent editorial, the current and seemingly relentless clinical fixation on the sacroiliac joint has been tactfully described by Shaffrey and Smith as a “rekindled enthusiasm” with the advent of new minimally invasive procedures and implants.

However, the continued challenge of our quest to satisfactorily address sacroiliac joint dysfunction is the difficulty of establishing an accurate diagnosis. Its clinical features and pain patterns are nonspecific, the commonly employed physical examination maneuvers have not been validated, and the sensitivity of radiography is lacking. Quantitative and qualitative degenerative changes in the sacroiliac joint are exceptionally well visualized with computed tomography (CT), and the prospect that this modality may objectively guide our sacroiliac joint management decisions certainly has great appeal. Unfortunately, a relatively small study by Vogler et al., published three decades ago, suggested that CT-detected degenerative changes of the sacroiliac joint did not necessarily correlate with the pain related to the sacroiliac joint. Despite the renewed efforts of some to perhaps attribute low back pain to CT evidence of sacroiliac joint degeneration, the study by Eno et al. suggests that this approach could be misleading.