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Pain related to sacroiliac joint dysfunction that typically arises from disruption of the architecture of the joint due to hyper- or hypo-mobility of the joint and the subsequent inflammation that is produced.


SI joint pain may result from axial loading, abrupt rotation, traumatic events (falls on the buttocks, motor vehicle accidents with the foot of affect SI joint on the brake), joint stress (prolonged strenuous exercise, obesity, leg length discrepancy, gait abnormalities, etc.), fracture, inflammatory arthropathies (seronegative and HLA B27 associated), degenerative changes (osteoarthritis), pregnancy (weight gain, enhanced lordosis, and hormone related ligamentous laxity), and following lumbar spinal fusion surgery.1,2,3

Epidemiology including risk factors and primary prevention

Prevalence studies have thus far exhibited variable results based upon the method of diagnosis (physical examination versus diagnostic injection methods). Historical estimates of prevalence range between 10 and 27% percent when utilizing localized anesthetic blockade. More recent reviews obtained an estimate of ~20 – 25% of low back pain sufferers having an element of SI joint pain. As with many arthritic conditions, SI joint pain prevention is predominately related to lifestyle.4,5 Weight loss, stretching exercises and yoga, and maintaining proper spinal alignment and posture are recommended strategies to prevent further pain. In those affected by systemic inflammatory conditions, the utilization of systemic NSAIDs or disease modifying agents may prevent worsening of pain later.6,7


The SI joint is a unique diarthrodial joint and is the largest axial joint in the body. The anterior third, the interface of the sacrum and the ilium, is a true synovial joint while the posterior two-thirds is composed of ligamentous connections. The connections become increasingly complex moving posteriorly along the joint and becoming a syndesmosis of the sacroiliac ligament, gluteus medius/minimus, and the piriformis muscle. The posterior elements function to limit motion in all planes. The innervation of the joint remains controversial with multiple contradicting studies. These include strictly dorsal rami innervation, ventral rami involvement, nearby dorsal root ganglia innervation, spinal nerve involvement, etc. Overall, research opinion suggests that innervation arises from an area between L2 and S3.1,4,8,9,10

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  • New onset/acute – (dysfunction). Duration: 1 to 4 weeks. Characterized by minor pathology causing abnormal motion and resultant pain. Clinical features include pain, spasm of surrounding musculature, and abnormal SI joint motion.
  • Subacute – (instability or intermediate). Duration: 1 to 3 months. There is further disruption in SI joint stability with potential gait dysfunction and persistent pain. Features include pain with functional impairment.
  • Chronic/stable (stabilization). Duration: more than 3 months. Degenerative changes can occur and manifest as sclerosis, joint erosion, and eventually ankylosis. The contralateral joint may also become affected from alterations of lifestyle patterns related to the pain.

Specific secondary or associated conditions and complications

SI pain due to isolated SI joint dysfunction or sacroiliitis is often a diagnosis of exclusion. Ruling out other inflammatory diseases such as ankylosing spondylitis, Reiter syndrome, psoriatic arthritis, enteropathic arthropathies, or other spondyloarthritis is necessary. Anatomic abnormalities such as leg length discrepancies or scoliosis, soft tissue or bone malignancies, post-surgical changes after lumbar spinal fusion surgery, or traumatic events must also be ruled out if clinical suspicion is present.



History of presenting illness for lower back pain, including SI joint pain, is often variable. A typical pain pattern is difficult to describe, but pain in the buttocks, near the posterior iliac spine, radiating into the hip, thigh, or groin has been described. Some studies suggest that the prevalence of groin pain is much more common in SI joint mediated pain than in spinal stenosis or discogenic pain.11 Patients may notice a worsening of pain with prolonged sitting or performing spinal/pelvic rotation motion. Pain quality is typically described as sharp or stabbing. Monitor for symptoms of systemic illness such as fever or weight loss, younger age of presentation, significant pain relief with NSAIDs, immobility causing worsening of pain, or improvement of pain with activity in consideration of inflammatory conditions.

Physical examination

The physical examination begins as the patient is ambulating into the exam room and may exhibit slight forward flexion of the body away from the painful SI joint (if unilateral involvement) or with a slow, methodical pace with short strides (if bilateral involvement).12 Next is inspection which may reveal asymmetry of the bony pelvis. The length of each limb should also be noted and measured to discover any discrepancy. Palpation of the lower back along the posterior superior iliac spine (PSIS) may reveal pain in a focal point.

The Fortin Finger Sign test is positive when the patient reports maximal pain elicitation upon palpation to be within 1 cm inferomedial of the PSIS. Testing for sensation and muscle group strength should be performed to evaluate for other pathology as these should remain relatively normal with isolated SI joint involvement. Provocative tests such as distraction (apply pressure to anterior superior iliac spine), Gaenslen test (apply downward pressure to the affected limb as it hangs down off the exam table which provides SI joint torsion), Compression test (the patient is side lying and the examiner’s hands are placed on the upper part of the iliac crest and are pressing to the floor), Thigh thrust test (the patient lies supine with the hip flexed to 90 degrees and the examiner applies downward force along the length of the femur with the other hand beneath the sacrum to fix its position), and the FABER test (Flexion, abduction, and external rotation of the affected side extremity) will be positive with pain elicited at the typical area. Individual sensitivity and specificity of SI joint provocative tests is relatively poor and several examination techniques should be employed to increase clinical suspicion.13,14, 43

Functional assessment

Typical assessment of impairments as a structural abnormality regarding impaired joint mobility, motor function, muscle performance, range-of-motion, and sensation should be performed. Self-reporting measures are also employed to understand the patient’s viewpoint of their functional limitations and may be helpful to predict favorable outcomes of both conservative and interventional treatment.39,40 Physical performance measures (PPMs) are increasingly popular as some believe they demonstrate causal relationships between physical performance post injury and calculation of fall risk.15

Laboratory studies

Routine laboratory studies are not necessary unless suspicion is raised for malignancy or systemic inflammatory disease. If suspicions are high for systemic disease then consider ordering a complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), antinuclear antibody profile (ANA), human leukocyte antigen status (HLAB27), and rheumatoid factor.16

Malignancy screening should include prostate specific antigen (PSA), calcium levels, serum protein electrophoresis/urine protein electrophoresis (SPEP/UPEP), and other age appropriate cancer screening tests.17


Imaging work up typically begins with plain anteroposterior pelvis/lumbar spine radiographs. Another imaging technique called the Ferguson View (20 degrees caudocephalic anteroposterior X-ray) was considered superior by some clinicians but this has been challenged recently with studies suggesting no clear superiority present for the Ferguson View versus typical plain films.18 Computed tomography (CT) and magnetic resonance imaging (MRI) exhibit appropriate sensitivity, specificity, and predictive values when utilized for structural and inflammatory sacroiliitis.19,20 MRI may be used to further evaluate additional surrounding tissue structures as well as the lumbar spine for signs of spinal stenosis or nerve impingement. Bone scans may be helpful if malignancy or occult fractures are suspected causes of pain. As with other causes of back pain, imaging studies typically are a poor predictor of SI joint pain.

Supplemental assessment tools

Performing diagnostic injections (local anesthetic with or without steroid) with appropriate relief of pain (greater than/equal to 75%) twice helps to localize pain to the SI peri- or intra-articular region. This can be performed in preparation for further local blocks or more definitive treatment with lateral branch neurotomy or SIJ fusion surgery.

Pain symptoms should be monitored utilizing one of the commonly accepted validated pain scales such as the Dallas Pain Questionnaire (DPQ), McGill Pain Questionnaire (MPQ), Oswestry Disability Index, Roland-Morris Back Pain Questionnaire, or the Visual Analog Scale (VAS). Chronic pain patients may also have signs of depression or post-traumatic stress disorder so assessing symptoms using the Patient Health Questionnaire (PHQ-9) or Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).21,22,23

Early predictions of outcomes

Factors associated with improved outcomes in musculoskeletal pain include: less anxiety, stronger belief in personal control, less belief in consequences, less pain, less fatigue, higher level of education, and male gender. Psychiatric comorbid conditions are also associated with decreased therapeutic efficacy after interventional pain techniques.24,25


Lower back pain is commonly associated with poor ergonomics and work place related exposures, particularly physical work. Lifting heavy objects and carrying at an awkward position are strongly associated with lower back pain. Additional work place factors include: work place psychosocial stressors, such as time pressure, conflicts with co-workers and superiors, and general irritability and strain related to work activities. Poor diet, minimal exercise, resultant obesity, lower socioeconomic status, and generally unfavorable attitude toward health status are associated with higher pain levels and rate of disability.26

Social role and social support system

A sense of social and emotional support is reported to have a relevant interaction with participation in activities of daily living. Depression is also common among patients with lower back pain and is associated with worse outcomes. Higher level of overall functional social support is associated with recovery from depression and less depressive symptoms. Patient self-reporting also indicates that tangible support is rated as “helpful”, particularly when provided by family members and physical therapists.27,28

Professional Issues

Lower back pain, particularly in the chronic setting, is often associated with motor vehicle accidents, work place injuries, disability compensation, and various other medicolegal concerns. Appropriately assessing pain pathophysiology, setting realistic outcome goals, and addressing patients’ social and emotional concerns related to the functional status of their pain are effective techniques to ethically treat non-radicular, non-malignant lower back pain.29,30


Available or current treatment guidelines

American College of Physicians guidelines for acute or subacute low back pain begin with non-pharmacologic treatment such as: superficial heat, massage, acupuncture, or spinal manipulation. Medications include NSAIDs or muscle relaxants. For chronic low back pain, exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, electromyography feedback, cognitive behavioral therapy, or spinal manipulation are first line. If no response then one may proceed to NSAIDs, duloxetine, or tramadol for medication therapy. Opioids are generally not recommended.31

The Spine Intervention Society Appropriate Use Criteria Committee recently performed a multi-disciplinary committee evaluation about SI joint injection criteria. SI joint interventions were deemed appropriate in those with one or two positive provocative tests on physical examination and the usage of both local anesthetic and corticosteroid upon initial injection. Maximal pain above the L5 vertebra was negatively correlated with recommendation for injection and imaging findings were neutral regarding guidelines to pursue injections. Injections were deemed an appropriate first intervention when pain was present >1 month, intensity was >4/10, and there were patient reported functional limitations. Further injections were considered warranted if the patient received > 50% relief from the initial injection. Lateral branch blocks were deemed appropriate following diagnostic injection providing >75% pain relief. Duration of pain >2-3 months and diagnostic injection pain relief >50% provided sufficient justification to proceed to lateral branch radiofrequency neurotomy. Repeat neurotomy was indicated if the patient experienced >50% relief for >3 months duration.32

At different disease stages

  • New onset/acute – Initial treatment emphasizes education (postural awareness, pelvic/spinal body mechanics, and activity modification), superficial heat, massage, spinal manipulation, ice, electrical stimulation, and topical creams. local pain control with nonsteroidal anti-inflammatory drugs (NSAIDs), topical creams, ice, and electrical stimulation. NSAIDs and muscle relaxants may prove beneficial if previous methods have failed.
  • Subacute (Recovery phase)-The focus of this phase is to increase mobility, flexibility, stability, and to restore healthy gait. Rehabilitation exercises including pelvic and spine stabilization, core strengthening, and postural re-education coupled with manual medicine techniques such as muscle energy, SI joint mobilization, and manipulation should be utilized. This should be followed by a maintenance exercise program and the patient should be educated about self-directed exercise. If residual pain limits function, an SI joint injection may be considered.
  • Chronic/stable (Maintenance phase) – The focus is to restore muscle balance, strengthen appropriate muscles, and initiate functional exercises (standing in multiple planes) with transition to a home program. If pain persists and there have been positive responses to diagnostic and therapeutic SI joint injections on 2 occasions (>50% relief), then radiofrequency neurotomy may be indicated. If radiofrequency neurotomy is not helpful, SI joint fusion surgery may be considered.

Patient & family education

Patient’s and their families must act as an extension of the multi-disciplinary therapeutic team and should continue to practice appropriate postural techniques and stretching exercises. Adherence to activity modification as well as work place hygiene and ergonomics should be stressed to the patient and their family. For patients with chronic pain concerns, the patient and family should be reminded of the need to continue with physical activity despite pain and addressing socioeconomic concerns or sleep hygiene represent effective techniques to battle their pain. Involvement of medical practitioners may be necessary for appropriate considerations to be made at work.33

Emerging/unique Interventions

Prolotherapy, an injection technique that introduces a small amount of an irritant solution to painful joint spaces, ligaments, or tendon insertions, to promote growth of normal cells, has seen increased utilization and review over the past ten years. Some researchers postulate that refractory SI joint dysfunction is related to degeneration of posterior ligaments of the SI joint and that prolotherapy is efficacious in stimulating the production of collagen fibers, thereby stabilizing the joint. Current research has been limited due potentially biased patient selection and small sample sizes; however, some studies suggest non-inferiority of prolotherapy when compared to local anesthetic/corticosteroid injections with regards to pain and disability improvement.34,35 Platelet rich plasma (PRP), a supernatant of growth factors obtained from a cell separating process applied to the patient’s own blood, is an injection technique being utilized for certain musculoskeletal conditions. Like prolotherapy, the current literature is lacking regarding definitive recommendations about PRP injections but some case series and prospective studies have shown long lasting improvement from SI joint PRP injections and some have proposed that PRP provides additional pain relief and functional improvement over corticosteroid injection.41,42

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Patients with back pain should be managed in a multi-modal approach that utilizes exercise and modality based techniques, non-opioid pharmacologic agents, and procedural intervention when warranted. Special consideration should be given to the psychologic, workplace, and socioeconomic factors that influence chronic pain. Adherence to guidelines and avoidance of overly aggressive treatment regimens maintains ethical practice measures.


Cutting edge concepts and practice

The interventional armamentarium has been expanding recently with literature suggesting benefits from peripheral nerve stimulation for therapy-refractory SI joint pain. Surgical studies have exhibited some benefit of minimally invasive sacroiliac joint fusion for the relief of pain and restoration of functional status. Other proponents for injections have suggested an increased utilization of ultrasound guided needle placement to decrease radiation exposure. Further research into the appropriateness of theses techniques is currently needed.36,37,38


Gaps in the evidence-based knowledge

A variety of topics related to pain management need further research to suggest continued utilization of current practices. Prolotherapy, corticosteroid injections, and surgical fixation all have individuals that espouse the benefits of these techniques and further research regarding an appropriate algorithm involving invasive procedures would prove beneficial for practitioners and patients. Further quantification of the role of socioeconomic status, peer support, and psychologic intervention may provide a methodologic approach that may best be utilized for overall pain improvement.


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Original Version of the Topic

Ricardo Nieves, MD. SI Joint Pain. Original Publication date: 12/09/2011

Author Disclosure

Travis Coats, MD
Nothing to Disclose

Xiaoli Dong, MD
Nothing to Disclose