151. Sacroiliac Joint Pain: Diagnosis and Management of the SIJ

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In this episode of PTs Snacks podcast, we cover the often misunderstood sacroiliac (SI) joint, explaining its anatomy and function. Listeners will learn about the causes of SI joint pain and the risk factors associated with it. We also discuss methods for diagnosing SI joint pain and effective treatments.

00:00 Introduction to PTs Snacks Podcast
00:58 Overview of the Sacroiliac (SI) Joint
01:28 Anatomy and Function of the SI Joint
02:59 Causes and Risk Factors of SI Joint Pain
04:13 Symptoms and Differential Diagnosis
06:48 Provocative Tests for SI Joint Pain
09:31 Imaging and Injections for Diagnosis
10:43 Treatment Options for SI Joint Pain
11:32 Conclusion and Additional Resources

Resources:

Nejati P, et al. Effectiveness of exercise therapy and manipulation on sacroiliac joint dysfunction: a randomized controlled trial. Pain Physician. 2019;22(1):53-61.

Trager R, et al. Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials. Musculoskelet Sci Pract. 2024;67:102815.

Doğan N, et al. Effects of mobilization treatment on sacroiliac joint dysfunction syndrome. Pain Res Manag. 2021;2021:6613629.

Javadov A, et al. The efficiency of manual therapy and sacroiliac and lumbar exercises in patients with sacroiliac joint dysfunction syndrome. Turk J Phys Med Rehabil. 2021;67(2):129-36.

Cerasoli T, et al. Injective therapies for managing sacroiliac joint pain in spondyloarthropathy: a systematic review and meta-analysis. 2025.

Gartenberg A, et al. Sacroiliac joint dysfunction: pathophysiology, diagnosis, and treatment. Curr Rev Musculoskelet Med. 2021;14(6):414-21.

Liu Y, et al. Comparative efficacy of clinical interventions for sacroiliac joint pain: systematic review and network meta-analysis with preliminary desi

Transcript

0:31

Hey everyone. Welcome to PTs Snacks podcast. This is Kasey your host, and if you're tuning in for the very first time, what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in bitesize segments of time. Now today we're gonna cover a topic that I can't believe I haven't talked about yet, and that is the S sacroiliac joint or SI joint. It gets a whole lot of love or hate from social media, from patients, from PTs, but we're gonna talk about what truly is SI joint pain and maybe some other things to consider before we do. If you've listened to the show for at least three times and you found it to be helpful. If you wouldn't mind just leaving a review wherever you listen to this, that would mean the world to me. And if you already have done so, thank you so much. You have no idea how much those really help the show. Now diving in today's topic though. We're gonna further define the sacroiliac joint Review. A little bit of anatomy'cause why not? And we're gonna talk about what this looks like, how we test for it, and then briefly on the treatment that has been found to be the most effective for sacred iliac pain. And just for the sake of brevity, I'm going to call it SI joint. Just from here on out so that it flows off the tongue a little better. But diving in, what is this joint? Essentially this joint is between the sacrum and ileum bones of the pelvic ring. So technically it's a di arthrosis amfi arthrosis joint. Say that five times fast. The superior and dorsal portion is an amfi arthrosis joint, which means it has a, a little fiber cartilage that fills up the joint space, and in the inferior and ventral portion is a di arthrosis with Hyland cartilage that covers the joint surfaces. And then it has a synovial cavity. This joint is the largest axial joint in the body. Its surface area is huge. Like we're talking 17.5 centimeters, so it doesn't really move very much, but it does help to disperse forces, from the lower body, from the upper body as a shock absorber. It is in innervated anteriorly from the ventral rami of L five to S two nerve roots and posteriorly from the lateral branches of the dorsal rami of S one to S four nerve roots and there's two on either side of the sacrum, again, I can't stress this enough. Motion is pretty minimal. We're talking about two to four millimeters in any direction. Sometimes I've heard descriptions of the SI joint as if it just kind of wiggles around loosely. And our sacrum is just holding on for dear life. But this is not a joint that is prone to move a whole lot. So in terms of who gets this? Well, it's kinda hard to say. This is a really hard. Diagnosis to diagnose. But it is estimated currently in the research to be the source of 15 to 30% of low back pain. I would call that a pretty high number. It's very common after a lumbar and lumbosacral fusion surgeries, which makes sense to me. If you're going to fixate a portion above or below a region, the surrounding regions may have to operate a little bit differently from a biomechanical perspective, but. Si. Joint pain can be traumatic and a traumatic, so trauma traumatic, think motor vehicle accidents, falls lifting and twisting injuries, whereas a traumatic can be infections. Cumulative injury over time. Pregnancy is often listened as a potential source of a reason for this to happen. And inflammatory arthropathies. So risk factors that are associated with getting this would be gait abnormalities, prior lumbar fusion, obesity, lumbar spinal stenosis, pregnancy, a leg length discrepancy, and scoliosis. Now with the SI joint. There are a lot of surrounding tissues that can all refer pain into this region. So I think to really do a good job of actually ruling in or ruling out SI joint pain, you need to be sure that you understand everything that could possibly refer pain in that area. So beyond the SI joint, some sort of discogenic pain radi, osteopathic symptoms, facet pain from the lower lumbar segments. If they are showing signs of ankylosing spondylitis, sacral stress fractures, posterior femoral acetabular pathologies, or even if it's lower down proximal hamstring insertional pain, there's. Probably more that I could have listed, but things to keep in mind, you need to be very good at being able to understand with these what would prove your hypothesis versus disprove it. So let's say this patient is walking into our clinic and they have pain. Why do we know what this is? So when we are talking to them, they may complain about unilateral pain with things like laying on that side, climbing stairs. But keep in mind their pain could be bilateral too. They may also have pain with prolonged sitting, bending forward transfers, prolonged walking. It could be a lot of repetitive activities like vacuuming, sweeping, mopping, pulling weeds. Thornton's finger test is a very big test for this. So basically if a patient points to pain that is inferior and medial to the PSIS, that is called the forton finger test, which. You can use as a sign for you to keep investigating and maybe consider the SI joint. But keep in mind with SI joint pain, it may be localized, but not always. It could refer to other places like posterior lateral thigh. Now, objectively. We wanna make sure we're ruling out several differentials. So looking at the surrounding regions, if we're ruling out things that are coming from the back, we should probably test for things that could be coming from the back, like if we're suspicious of facet joint referral or they have something neurological going on. Are we testing the nerves? Are we testing muscles, tendons, anything that seems applicable. So beyond the. Range of motion strength testing, things that are applicable for what this patient is going through. The tests that are highlighted specifically for provocative pain tests for the SI joint region would be FABERs gains, lenss distraction, thigh thrust, lateral compression, and sacral thrust. Thrust Pavers is basically already describing the testing position. The patient is supine and they're. Going into a figure four position, you're pushing down on their knee and assessing for if they are having pain recreated in the SI joint. Now this test is also used for hip pathologies. So if they're reproducing hip or groin pain, that tells you something, but it doesn't necessarily tell you this SI joint right gains lens. I would compare similar to modified Thomas test, but you're testing for if they have pain in their SI joint region with that position. Distraction there. The patient is supine and you're adding an outward rotary stressy stress on the a SIS. And while this is not a comfortable position for most patients, you're looking for discomfort in the SI joint region, in case you weren't sure by thrust. They're in supine and you're bringing, you're standing on the opposite side that you're testing. You're gonna bring their leg across their body and. Basically add a shearing stress to this region through the thigh, which is why it's called a thigh thrust. You're adding a posterior force lateral compression. The patient is in side lying and you are trying to compress their SI joint and then sacral thrust, you are there in prone and you are pushing down on their sacrum. So a lot of these names are pretty self-explanatory. Now, if they have one test, you're not gonna be like, yeah, this is positive. This is it. Because if you are considering, for instance, like a lumbar facet pathology, there may be some of these tests that may aggravate, let's say a unilateral L five facet joint or a zygopotheses joint. So ideally at least three provocative tests are positive to consider the SI joint as a possible point of pain. And of the three, ideally it's gonna be thigh thrust or a compression test. We find in our research that three or more pain provocation tests have a 91% sensitivity and a 78% specificity. So if they're not positive, pretty good likelihood they don't have it. And 78 percent's not too bad for. So with those odds, the collection of information that you're gathering is more important than an isolated test. Imaging can also rule out other sources of potential pain in that area. Like for instance, let's say they have some sort of trauma and there was a fracture in that region, somewhere in the pelvic realm or lower lumbar. Or maybe imaging can also rule out other things like let's say they have a tumor in that area. Now in several studies that I have seen, they listed injections as the gold standard for diagnosis and more specifically on fluroscopic or ultra side guided. That way we actually know we're in the area.'cause there was a study where they basically did not allow physicians to use any imaging equipment. Really just palpation. And about 12% of them got it right. Ideally there is some sort of imaging to help guide their injections to make sure if we are trying to diagnose SI joint or just give our patients pain relief, we're actually in the right spot. Now in terms of treatment, let's say we've rolled out the other pathologies that we've been concerned about, and from there we just determine they have SI joint pain. So what are we gonna do about it? The first line of defense is typically ideally going to be physical therapy. Whether it's with modalities and exercise. I've seen a combination of exer of studies. Comparing manual versus exercise versus both, and the most consistent beneficial response for patients has been a combination of manual and exercise. What that exercise is specifically, well, that, uh, varies a little bit in the research, but in terms of manual, that can be very helpful for the short term. We need exercise for the long term, like 12 plus weeks where people can maintain their benefit. So manual for pain relief, exercise for resilience. Right. Okay. So yes, there's a lot more things that I could say about the SI joint region and the main takeaway is. Yes, people can have si joint pain. But we also need to make sure that we're doing a good job of determining if it is or if it's something else in that region that looks like it. And from many of these tests that we currently have, if you're a physical therapist, treating clinic, using a combination of tests can help you to put together the best clinical picture. If you have any questions, feel free to reach me at PTs Snacks podcast@gmail.com. Or there is a feature in the show notes where you can just send a brief little text and whether you have questions about the topic or if you have. Requests for future episodes. I'm all ears. Right now I'm just going on making sure I'm covering the basics of what I can. But if anyone has special requests, I would love to hear that. Now, before I get too carried away, if you are in need of CEUs and or maybe you're studying for a specialty exam prep. Med Bridge is actually offering listeners over a hundred dollars off their year subscription, which is great'cause they have a ton of courses, webinars. Practice exams, study guides, all that kind of stuff. I use them for my OCS and I've used their features for a patient home exercise program where you can basically put together pictures of what you wanna give your patients and type in how many reps and sets, and you can either print it off for your patient'cause sometimes people like paper or you can give'em a QR code just sign it to them in an app and they can just literally go and watch videos of the exercise instead of trying to decipher what that. Picture is doing. So check out the show notes if you're interested. And if you're a student, there's an even better deal for you. So definitely make sure to check that out. And then other than that, I hope you guys have a great rest of your day.