SI Joint Pain: Understanding Diagnosis and Treatment
The sacroiliac (SI) joints connect the spine to the pelvis and help transfer forces between the upper body and legs. When pain develops in this region, simple activities such as walking, climbing stairs, getting out of a chair, or turning in bed can become surprisingly difficult.
But pain felt near the SI joint does not always come from the joint itself. The lumbar spine, hips, muscles, ligaments, and other structures can produce similar symptoms, making careful assessment essential.
This article explores how the SI joint functions, what may cause pain in this region, how clinicians distinguish it from other conditions, and how manual therapy, progressive exercise, and practical self-management may support recovery.
The Good News
SI joint-related pain can be persistent, but it does not mean the pelvis is permanently “out of alignment” or damaged. Once serious conditions and competing sources of pain have been considered, an individualized plan can help reduce symptoms, rebuild movement confidence, and restore function.
Article Index
Signs and Symptoms
SI joint-related pain is often felt on one side, near the small depression just below the beltline where the spine meets the pelvis. It may spread into the buttock, outer hip, groin, or thigh. Some people can point to the painful area with one finger, but location alone cannot confirm that the SI joint is the source.
Common symptoms include:
Pain near one side of the posterior pelvis
Buttock, hip, groin, or upper-thigh discomfort
Pain when rising from a chair or getting out of a vehicle
Difficulty climbing stairs or standing on one leg
Discomfort when walking, running, or taking longer strides
Pain when turning in bed or lying on the affected side
Symptoms after prolonged sitting or standing
The pain may feel sharp, aching, or deep and can vary with movement, position, and load. Numbness, tingling, marked weakness, or pain extending well below the knee may suggest nerve involvement or another source and requires further assessment.
Because the lumbar spine, hip, muscles, and other pelvic structures can produce similar symptoms, diagnosing SI joint-related pain requires more than identifying where it hurts.
Anatomy and Biomechanics of the SI Joint
The two sacroiliac joints form a bridge between the spine and the legs. Each connects the sacrum, the triangular bone at the base of the spine, with one side of the pelvis. Their primary role is to transfer forces while allowing a small amount of movement.
The front portion of the SI joint has features of a synovial joint, while the stronger rear portion is supported by dense connective tissue and powerful ligaments. These include the anterior, posterior, and interosseous sacroiliac ligaments, along with the sacrotuberous and sacrospinous ligaments.
Stability comes from two complementary mechanisms:
Structural stability: The joint’s irregular surfaces and ligaments resist excessive movement.
Muscular stability: The gluteal, abdominal, spinal, pelvic-floor, and other surrounding muscles help control forces across the pelvis.
Because the SI joint moves only slightly, pain cannot reliably be explained by whether it is simply “stuck,” rotated, or out of alignment. Symptoms may arise from the joint itself or from nearby ligaments, muscles, and other lumbopelvic structures. Understanding how the entire region manages load is therefore more useful than focusing on joint position alone.
Beyond the SI Joint: The Kinetic Chain
Walking, climbing stairs, lifting, and turning require coordinated movement across the feet, legs, hips, pelvis, and spine. The SI joint sits within this kinetic chain, transferring forces rather than working in isolation.
Muscles such as the gluteals, deep hip rotators, abdominals, spinal extensors, and pelvic-floor muscles help control the pelvis during movement. If strength, mobility, or coordination changes elsewhere in the chain, the way forces pass through the lumbopelvic region may also change.
Fascia contributes to this regional connection. The thoracolumbar fascia links muscles of the back, abdomen, pelvis, and hips, while strong ligaments, including the iliolumbar and sacroiliac ligaments, provide structural support. These tissues may contribute to pain, but their involvement must be considered alongside the joints, muscles, nervous system, and movement pattern.
For this reason, assessment should extend beyond the painful spot. Treatment may include manual therapy for relevant joint or soft-tissue restrictions, combined with exercises that improve strength, movement control, and tolerance for meaningful activities. The objective is not to correct a supposedly misaligned pelvis, but to help the entire system manage load more effectively.
Diagnosis: Building the Clinical Picture
Diagnosing SI joint-related pain can be challenging because symptoms often overlap with conditions affecting the lumbar spine, hips, nerves, and surrounding soft tissues. No single symptom, physical test, or postural finding can confirm that the SI joint is the source.
Assessment commonly includes:
A detailed history of symptom location, onset, aggravating activities, trauma, pregnancy, and inflammatory features
Examination of the lumbar spine, hips, gait, strength, and movement
A cluster of SI joint pain-provocation tests, such as thigh thrust, distraction, compression, sacral thrust, and Gaenslen’s test
Neurological and vascular screening when leg symptoms or the clinical history make these relevant
Several provocation tests reproducing the person’s familiar pain increase suspicion of SI joint involvement. A negative cluster makes the SI joint less likely to be the primary source. These findings must still be interpreted within the complete clinical picture.
The following practitioner-focused videos demonstrate components of this broader assessment.
Click Image to Watch Video
Low Back Examination
This video demonstrates orthopedic procedures used to examine common sources of low back and pelvic pain. The findings help determine whether symptoms are more consistent with the SI joint, lumbar spine, hip, or surrounding tissues. No single orthopedic test establishes the diagnosis.
Lower Limb Neuro Examination
This video demonstrates the assessment of lower-limb strength, sensation, and reflexes. Neurological findings may point toward nerve-root involvement, peripheral neuropathy, or another condition rather than isolated SI joint pain.
Peripheral Vascular Examination
This video reviews procedures used to assess lower-limb circulation. A vascular examination is not required for every patient with SI-region pain, but it becomes important when symptoms, medical history, skin changes, or walking limitations raise concern about impaired blood flow.
These videos are intended for practitioner education and do not replace an individualized clinical assessment.
Imaging: What It Can and Cannot Tell Us
Most people with suspected SI joint-related pain do not require immediate imaging. Diagnosis begins with the history and physical examination. Imaging becomes more important when trauma, inflammatory disease, infection, fracture, malignancy, or another structural condition is suspected.
Imaging findings must be interpreted cautiously. Degenerative changes may appear in people without pain, while someone with significant SI-region pain may have relatively unremarkable images.
X-rays
X-rays provide a basic view of the pelvis, hips, and lower spine. They may help identify:
Advanced degenerative changes
Some fractures or significant bony abnormalities
Features suggesting inflammatory sacroiliitis
Hip or lumbar conditions that may contribute to the symptoms
X-rays cannot reliably show subtle SI joint movement or confirm that the pelvis is “out of alignment.”
Magnetic Resonance Imaging
MRI provides detailed images of bone marrow and soft tissues. It is particularly useful when investigating:
Active inflammatory sacroiliitis
Occult stress fractures
Infection or tumour
Lumbar disc, nerve-root, or other soft-tissue pathology
MRI findings still need to correspond with the patient’s history and examination.
Computed Tomography
CT provides excellent detail of bony anatomy and may help identify:
Subtle or complex fractures
Bony erosions or sclerosis
Advanced degenerative changes
Structural abnormalities requiring further investigation
When the diagnosis remains uncertain, an image-guided local anaesthetic injection into the SI joint may provide additional information in selected cases. Even this procedure is not a perfect diagnostic test and should be interpreted alongside the broader clinical findings.
Differential Diagnosis: What Else Can Feel Like SI Joint Pain?
Sometimes pain located directly over the SI joint is exactly what it appears to be: pain arising from the joint or its supporting ligaments. Common presentations are common, and the clinical examination should begin with the most likely explanation.
At the same time, nearby structures can produce similar symptoms. These include:
Lumbar Disc or Nerve-Root Disorders: Disc herniation, spinal stenosis, or nerve-root irritation may cause back and buttock pain, often accompanied by pain below the knee, numbness, tingling, weakness, or altered reflexes.
Lumbar Facet Joint Pain: Facet joint irritation can refer pain into the lower back, buttock, or upper thigh. Lumbar movement and local examination may help distinguish it from SI joint-related pain.
Hip Disorders: Osteoarthritis, labral pathology, femoroacetabular impingement, and greater trochanteric pain syndrome can produce groin, lateral-hip, buttock, or thigh symptoms. Hip and SI joint problems may also coexist.
Deep Gluteal and Soft-Tissue Pain: Muscles, tendons, and nerves within the buttock can produce pain close to the SI region. Possible sources include the gluteal tendons, proximal hamstring tendon, deep hip rotators, and sciatic nerve.
Inflammatory Sacroiliitis: Axial spondyloarthritis and related inflammatory conditions can affect one or both SI joints. Suspicion increases with prolonged morning stiffness, night pain, alternating buttock pain, other inflamed joints, psoriasis, inflammatory bowel disease, or uveitis.
Sacral or Pelvic Fracture: Stress or insufficiency fractures should be considered following trauma or when pain develops in someone with osteoporosis, prolonged corticosteroid use, or increased training load. MRI or CT may be required.
Most SI-region pain is musculoskeletal and can be assessed without alarm. Further medical investigation is reserved for cases in which the history, examination, or progression of symptoms suggests something outside the usual pattern.
Treatment: Reducing Pain and Rebuilding Capacity
When the history and examination support SI joint-related pain, treatment should address both the sensitive region and the activities that matter to the patient. The aim is not to push the pelvis back into place. It is to reduce pain, improve movement, and rebuild the body’s ability to manage load.
Care may include:
Education and Activity Modification: Temporarily adjusting provocative movements while maintaining as much comfortable activity as possible.
Manual Therapy: MSR joint and soft-tissue procedures may be used to address painful or restricted movement in the lumbar spine, pelvis, hips, and related kinetic chain.
Progressive Exercise: Mobility, strength, balance, and movement-control exercises help improve tolerance for walking, lifting, climbing stairs, and other daily activities.
Reassessment: Functional progress guides whether treatment is continued, modified, or referred for further investigation.
Manual therapy can provide a useful window for movement, but lasting progress usually depends on gradually restoring confidence, strength, and functional capacity.
Treatment Demonstration Videos
SI Joint Pain - Unravelling the Mystery
In this video, Dr. Brian Abelson, DC, and Miki Burton, RMT and MSR Instructor, demonstrate examination concepts, manual procedures, and functional exercises that may be incorporated into an individualized approach to SI joint-related pain.
Chiropractic Adjustments
This practitioner-focused video demonstrates joint-manipulation procedures that may be used when examination identifies relevant pain or restricted movement in the lumbopelvic region. Adjustments are not intended to correct a permanently displaced SI joint. Their clinical purpose is to reduce pain and improve movement so the patient can participate more comfortably in rehabilitation.
Fascial Expansion: MSR Low Back Pain Protocol
This video features Dr. Brian Abelson demonstrating MSR fascial-expansion procedures used within the broader lumbopelvic kinetic chain. The approach draws on clinical anatomy, fascial relationships, and selected principles from acupuncture and traditional Chinese medicine.
These procedures may be considered when soft-tissue sensitivity or restricted movement contributes to the clinical presentation. They should be integrated with exercise and reassessment rather than presented as a stand-alone solution.
These videos are intended for practitioner education. The procedures require appropriate professional training and should not be attempted as self-treatment.
Exercise: Rebuilding Strength and Movement Confidence
Exercise helps the body regain the strength, coordination, and load tolerance needed for everyday movement. There is no single exercise program for SI joint-related pain. The starting point should reflect the person’s symptoms, abilities, and goals.
A well-rounded program may include:
Mobility
Mobility exercises can reduce stiffness in the hips and lumbar spine when limited movement is contributing to the presentation. Options may include:
Gentle hip-rotation movements
Posterior hip or gluteal stretches
Pain-tolerant lumbar rotations
Hip-flexor mobility
Stretching should feel controlled rather than forceful. If a movement repeatedly increases familiar pain, its range, duration, or selection should be modified.
Strength and Movement Control
Progressive strengthening improves the ability of the trunk, pelvis, and legs to manage load. Exercises may include:
Bridges
Clamshells or other hip-abductor exercises
Modified planks and trunk-endurance exercises
Sit-to-stands, squats, and step-ups
Gradually progressed lifting and carrying tasks
The objective is not to hold the pelvis rigid. It is to develop adaptable control during real movement.
Balance and Functional Training
Balance and proprioceptive exercises can improve confidence and control during walking and single-leg activities. These may include:
Supported single-leg standing
Tandem walking
Controlled step-ups and step-downs
Lateral stepping
More challenging balance exercises when appropriate
Progress should be measured by meaningful improvements, such as getting out of a chair more comfortably, climbing stairs, walking farther, or returning to work and recreation.
Exercise Demonstration Video
SI Joint Pain - Unravelling the Mystery
Beginning at 09:40, Miki Burton, RMT and MSR Instructor, demonstrates exercises commonly used for SI joint-related pain. These movements provide a starting point and should be adapted to the individual rather than followed as a universal prescription.
Exercise may produce mild, temporary discomfort, but it should not cause progressively worsening pain, neurological symptoms, or a sustained loss of function.
What Guides Our Approach to SI Joint Pain
SI-region pain can involve the joint itself, its supporting ligaments, nearby soft tissues, or another part of the lumbar, pelvic, or hip region. Our approach begins by determining which explanation best fits the complete clinical picture.
The MSR framework includes:
Careful Assessment: History, movement examination, SI joint pain-provocation tests, and neurological, hip, or vascular screening when indicated help identify the most likely pain source and competing diagnoses.
Kinetic-Chain Reasoning: The SI joint is considered in relation to the lumbar spine, hips, pelvis, and lower extremities rather than treated as an isolated or misaligned structure.
Individualized Manual Therapy: Joint and soft-tissue procedures may be used when they are relevant to the examination findings and produce a meaningful improvement in pain or movement.
Progressive Rehabilitation: Exercise develops mobility, strength, balance, coordination, and tolerance for the activities that matter to the patient.
Reassessment and Collaboration: Progress is measured through changes in function, not treatment frequency alone. When improvement stalls or findings suggest another condition, the plan is reconsidered and referral or interdisciplinary care may be appropriate.
The objective is not to promise a cure or correct a supposedly displaced pelvis. It is to help each person understand the problem, regain confidence in movement, and build the capacity needed for daily life.
References
Cohen, S. P. (2005). Sacroiliac joint pain: A comprehensive review of anatomy, diagnosis, and treatment. Anesthesia & Analgesia, 101(5), 1440–1453.
Fortin, J. D., & Falco, F. J. (1997). The Fortin finger test: An indicator of sacroiliac pain. American Journal of Orthopedics, 26(7), 477–480.
Laslett, M. (2008). Evidence-based diagnosis and treatment of the painful sacroiliac joint. Journal of Manual & Manipulative Therapy, 16(3), 142–152.
Maigne, J. Y., Aivaliklis, A., & Pfefer, F. (1996). Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine, 21(16), 1889–1892.
Newman, D. P., Soto, A. T., & Opitz, J. L. (2022). Sacroiliac joint dysfunction: Diagnosis and treatment. American Family Physician, 105(3), 239–245.
Saueressig, T., Owen, P. J., Diemer, F., Zebisch, J., & Belavy, D. L. (2021). Diagnostic accuracy of clusters of pain provocation tests for detecting sacroiliac joint pain: Systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 51(9), 422–431.
Sembrano, J. N., & Polly, D. W. (2009). How often is low back pain not coming from the back? Spine, 34(1), E27–E32.
Slipman, C. W., Jackson, H. B., Lipetz, J. S., Chan, K. T., Lenrow, D., & Vresilovic, E. J. (2000). Sacroiliac joint pain referral zones. Archives of Physical Medicine and Rehabilitation, 81(3), 334–338.
Szadek, K. M., van der Wurff, P., van Tulder, M. W., Zuurmond, W. W., & Perez, R. S. G. M. (2009). Diagnostic validity of criteria for sacroiliac joint pain: A systematic review. The Journal of Pain, 10(4), 354–368.
Trager, R. J., Baumann, A. N., Rogers, H., Tidd, J., Orellana, K., Preston, G., et al. (2024). Efficacy of manual therapy for sacroiliac joint pain syndrome: A systematic review and meta-analysis of randomized controlled trials. Journal of Manual & Manipulative Therapy, 32(6), 561–572.
Tsoi, C., Griffith, J. F., Lee, R. K. L., Wong, P. C. H., & Tam, L. S. (2019). Imaging of sacroiliitis: Current status, limitations and pitfalls. Quantitative Imaging in Medicine and Surgery, 9(2), 318–335.
Vleeming, A., Schuenke, M. D., Masi, A. T., Carreiro, J. E., Danneels, L., & Willard, F. H. (2012). The sacroiliac joint: An overview of its anatomy, function, and potential clinical implications. Journal of Anatomy, 221(6), 537–567.
Disclaimer:
The articles and embedded videos on the MSR website are provided for educational and informational purposes only. They are not a substitute for individualized assessment, diagnosis, or treatment by an appropriately qualified healthcare professional.
Some videos demonstrate clinical examination and manual therapy procedures intended for licensed or regulated healthcare professionals with appropriate training. These procedures should be performed only within the practitioner’s legal scope of practice and should not be attempted as self-treatment.
Viewing or using this content does not establish a practitioner-patient relationship. If you have questions about a medical condition or symptoms that are new, severe, or worsening, consult an appropriately qualified healthcare provider.
MSR is not responsible for decisions made or actions taken solely on the basis of this educational content. For complete information about website use, third-party links, privacy, and legal terms, please review the MSR Terms of Use, Privacy Policy, and full website disclaimer.
DR. BRIAN ABELSON, DC. - The Author
Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.
He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
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