What is the best way to treat a painful Sacroiliac Joint?

So in my earlier post here I talked about what is the best way to assess if the Sacroiliac Joint (SIJ) is a source of pain, and that using palpation tests to determine if a SIJ is painful or dysfunctional have clearly been shown to be unreliable and of no use. This created a flood, well ok, a little ripple of comments and discussions with some claiming that they can feel the SIJ move and that palpation does give them some useful information in which to direct their treatment.

From this article, one or two people have asked how do I treat a painful SIJ if I do come across one, so this is the subject of this post. Now again I’m sure this will create some discussion and some controversy, so please feel free to comment and give me your experiences and insights but please keep it personable, for some reason the SIJ seems to get therapists fired up more than any other area, I’m not sure why???

Ok let’s go…

So the first thing to say here is that I haven’t treated that many painful SIJs, I am not claiming to be a SIJ expert, far from it as I can confidently say I could count on the fingers of one hand (ok maybe both) how many SIJ problems I have ‘treated’ in my career due to there rarity!

I do however get lots of patients telling me that they have been told they have an SIJ problem by another therapist, some have even been told that their SIJ is out or alignment or unstable, which is complete an utter rubbish, and really annoys me that a so called healthcare professional uses these inaccurate and fear inducing terms.

Normally a quick assessment using the pain provocation tests I mentioned in my other post very quickly rules out the SIJ as a source of pain for nearly everyone I see. In my experience it is normally something in the lower back generating pain to be felt around the posterior pelvis, and often there is no firm or conclusive source of the pain, whats call ‘non specific low back pain’ and this can be frustrating for both the patient wanting a diagnosis to explain why it hurts, and also for the therapist wanting to give something technical as a diagnosis, and to treat, and this is why I think the SIJ gets labelled and blamed way too often! Therapists love a big impressive sounding technical diagnosis, it makes them feel they’re using their training and skills to detect something complex and complicated, but unfortunately it’s just not!

A recent study by Cohen et al 2013 states that the SIJ accounts for between 15-30% of all low back pain! I argue, because I like to, that it is much less prevalent, this maybe due to my ‘normal’ clientele being slightly different from that in Cohen’s study.

Ok! So what do I do if I have found a rare SIJ causing pain?

Well simply, I get them all doing exercises, great thanks for reading….

WHAT… WAIT is that it??? I don’t I poke, prod or manipulate them, don’t I give an anterior innominate rotation thrust or a posterior torsion mob here or there….

Well, no I don’t, I cannot remember the last SIJ manual treatment I gave, if I do decide to do any manual therapy, its NOT to correct or attempt to change or alter its position and its definatley not to ‘loosen’ or free it up, let me explain why.

Firstly if we look at the anatomy of the SIJ closely, as in this paper by Vleeming et al 2012 does very well, we can see that the congruity of the bony surfaces, combined with the many strong ligaments that cross it, make the SIJ a very, very stable joint, it has to be, it transfers a lot of force and load from the legs to the trunk and visa versa, this is termed the SIJs form closure ie its shape and structure.

However, the joint also requires the contraction of muscles around it to help control the small amount of movement that is available to allow the effective transfer of stresses across it, this is what’s called force closure, read more in this paper from Wingerden et al 2004 on that.

So in summary the SIJ wants to be stiff and stable but it also needs to move a teeny tiny little bit occasionally.

Now the two main reasons why the SIJ is thought to cause pain is either due to excessive movement causing shearing forces between the joints articular surfaces, and I use the word ‘excessive’ here with caution, as the SIJ doesn’t move much at all, on average about 2-3 degrees, thats about 3-5 millimetres of movement, but it is still thought to be enough to create irritation.

The other reason its thought to cause pain is that the SIJ becomes too stiff, stuck or jammed and the little bit of movement that it is supposed to have isn’t available and so creates pain.

But are these theories correct!

Now, Greg Lehman an excellent physio, chiropractor and an ex researcher, has shown me that we can’t say excessive shearing or extra movement at the SIJ causes pain. (Follow Greg here on twitter, and go visit his excellent site here)

For example this paper here by Damen et al shows that SIJ laxity, which is common during and after pregnancy, isn’t correlated with SIJ pain, they found pregnant women with severe pelvic pain had the same amount of laxity as those no pain, so proving we can’t just blame SIJ laxity for the pain!

Next, the strength need to produce force closure by the muscles around the SIJ are not very much at all, and so cast big doubts on the theory that muscle weakness can leave it vulnerable to laxity and shearing forces. Actually most muscles around the trunk when they activate even gently create enough force to close the SIJ as shown by this study here by Richardson et al showing that if they can stand up they can produce more than enough force to stabilise the a SIJ!

So if not laxity, shearing forces or weak muscles causing the SIJ pain, what about it being stiff, getting stuck or not moving enough?

Well I question how is this is even possible, and if it is, how do we know its stuck? I have already discussed in my other SIJ article that there is no way of palpating or feeling a SIJ move or not move so we can never tell if its stuck, and a too stiff SIJ just doesn’t make sense to me, the SIJ wants to be stiff and rigid, if its too stiff why would that cause pain? And how on earth does it become stuck as some claim, does something get inbetween the joint, highly unlikely in my opinion.

So if not due to excessive movement and not due to it being stuck then why does then SIJ cause pain? Well simply I think its due to plain overload and excessive forces across the joint that it can’t handle, so nociceptive nerve endings around it complain, it’s as simple and straight forward as that, no excessive this, no stuck or stiff that.

So how do we treat it?

Simple, as I said earlier, exercises, to build up the SIJs resitance to take an increased load by increasing the soft tissues capacity in and around it. Which muscles you choose to do will be based on individual severity and irritability and their pain provocation patterns, skill levels and goals but in a nut shell I dont think it matters too much, as we know from that earlier Richardson study all the trunk muscles have a role in producing SIJ force closure. But usually in my experience the muscles of the posterior oblique sling are the ones lacking, most people I meet are weak in the posterior chain and so these are the ones to focus on more, such as the Latissmus Dorsi, Hamstrings, Glutes and of course the large powerful Erector Spinae muscles all of which act on the thoracolumbar fascia.


Image courtesy of saveyourself.ca

How you go about this is up to you, it is obviously guided by the levels of pain the patient is in, if really sore, then non weight bearing strengthening of these muscles can be used to start with until the irritation settles combined with other pain relieving modalities (which I will come onto in a second).

If they’re not too painful then progress them into weight bearing exercises, progressing them until you can get them exercising under extra load and resitance, in different planes of movement and variable speeds dependant on what that patients goals and tasks are, I not going to be giving all the exercises possible or we will be here all day, but exercises like bridges, deadlifts, kettlebell swings, lat pull downs are all great moves.

But what about manual treatment?

Well I’m going to throw in a controversial bomb here and say that although you can apply manual therapy treatments, it really doesn’t matter in my opinion WHAT manual treatment you do for a painful SIJ!!! (I await the backlash)

Yes you can apply an anterior or posterior innominate rotational mobilisation or a scaral thrust or two, even give some ASIS distractions or compressions it doesn’t matter as there is NO physical way you are going to make any structural difference to this emmensly strong and stable joint with your hands, steam roller yes, hands no! Even if you do affect the SIJ a tiny bit, as soon as the patient moves to get up off the treatment couch and stand up it will go back to where it wants to and started off in the first place.

Now before you go of your rocker with rage as I’ve just ridiculed your training and skill, I’m not implying manual treatment of the SIJ is a waste of time, far from it, it does seem to reduce the level of pain felt for a grumbling SIJ, a little bit, for a short while.

But what I do argue with is those that feel they can assess which method or direction of manual therapy is best based on physical assessment and palpation tests,

Simply put it doesn’t make any difference what or which way you bounce, rub, push, poke or pull on an SIJ, its not the physical effects to the joint that matter, its the descending neural pain inhibition effects that do!

But surely there is some role for the direction of pushing or poking or even the exercises we give depending on what you feel and observe the persons posture or degree of pelvic tilt/rotation to be?

Again I’ll say it NO, it doesn’t matter, even if you think you’ve found someone standing with an anterior rotated innominate or a posterior rotated one, or one higher than the other etc etc, as using these bony landmarks to guide your reasoning in deciding on an SIJs position is unreliable and is no more than palpation fantasy as neatly demonstrated by this paper by Preece et al 2008 who found wide normal anatomical variation in the angles of the ASIS and PSIS.

So what do I do, well if I decide on a rare occasion to give some manual therapy on an SIJ, I simply pull and poke it with no real clear idea or direction in mind, I do it on trial and error basis, push a bit this way, get them up and moving a bit, ask if it feels any better, no, ok get them back down, push the other way etc etc.

Now some say that I use this method due to my lack of skill or experience or that I haven’t got the expert super duper ‘feely’ hands or the extra sensory perseption skills that other therapists have! I say nope that’s aload of crap, it’s just me being realistic and honest in realising that no-one and I mean no-one, can assess clinically and tell which way a SIJ needs to go or which way is going to help! So I say why limit yourself and possibly miss helping someone just because of some delusion of skill, some rubbish tests and personal pride, I say push that bugger in all directions until something feels better for the patient, it’s that simple!!!

So in summary I’d argue the only way to treat a true and rare painful SIJ is with exercises. The exercises you choose I don’t believe make much difference but should be chosen depending on the level of your patients pain, irritability and skill. They want to be progressed into loaded, multi directional and varying speeds, dependant on your patients goals, tasks and activity.

Manual therapy can be used to relive a painful SIJ but not on the pretence that you are affecting the physical properties of the SIJ or that you can only try it in one direction after an assessment as you can sense or feel the dysfunction.

Finally does assessing the posture of the SIJ pelvis and lumbar spine of an individual really help us, or does it just place confusion and doubt into the patients mind for no reason when there is scarce evidence to say that any type of posture is of greater risk or worse than any other?

Food for thought I hope???

Once again thanks for reading

Happy exercising





  1. Whilst postural asymmetry is normal and natural, i frequently see movement strategies and postures, (altered weight bearing, a limp, slouching, etc ) that occur in response to multidimensional factors such as nociception, pain, mood, ergonomics, cognitions such as fear of movement etc etc…
    I believe poor posture and altered movement place a person under greater physiology stress and load. Pain often represents a ‘tipping point’ in which a person is unable to deal with resulting physiological stress. Treatment involves identifying antecedent factors, building patient awareness and formulating a multidimensional treatment plan.
    This approach can often receive great criticism due to lack of evidence that a factor taken in isolation (posture) relates to pain or that any single form of intervention (segmental manipulation) consistently achieves changes in pain. I would argue that a reductionist model of research often struggles to evaluate a humanistic patient centred bio psychosocial model of treatment. I apologise if this rant is not directly related to the SIJ.
    In direct respone to your article I would argue:
    To say the only way to treat sij pain is through strengthening exercise, however elegant and well designed is limiting and frankly untrue. Mobilisation, cryotherapy, etc etc
    Size does not always equate to importance, just because something is small does not make it insignificant (plenty of rude jokes springing to mind)
    There is no normal posture but there is ‘more normal’ for that person
    Whilst symmetry is unattainable, less asymmetry is desirable, as is greater mobility. greater asymmetry frequently creates greater physiology stress
    Question: By your own stringent criteria, is there evidence that strengthening impacts on SIJ pain or will accelerate recovery? would appreciate a look if there is. I personally use strengthening exercise but combine with manipulative therapy, education, lifestyle advice etc

    • Hi James
      Once again thanks for your very insightful and intelligent comments.
      I’m sorry if this post comes across as me stating that strengthening exercises are the ONLY way to treat all painful SIJs that’s not what I was hoping to achieve, although i guess my wording at the beginning does imply that.
      I totally agree with you that a multi modal treatment strategy for all areas in therapy is essential, but the postural structural model is grossly flawed and we do need to move away from this in my opinion, again not says that one position or posture is better than other. I agree that pain can alter position and movement but this is a response not a cause.
      With regards to the SIJ i do believe manual treatments combined with strengthening are the best and I do find that using manual techs to reduce pain are a valuable adjunct to treatment, and I do use them myself, BUT as I said in the post the rubbish that surrounds these techniques in terms of theorised physical effects and explanations used and the descriptions that some therapists give to patients to explain what we are doing is what I strongly disagree and argue with.
      The many manual treatments we do work on reducing pain through multiple modes but predominantly via descending neural inhibition, not re adjusting joints, loosening ligaments or changing soft tissue
      With regards to size and importance haha I leave that be, way to many innuendos here, but I get what you’re saying.
      Thanks again

      • Adam, on a second note, if the mechanisms for pain reduction through manipulation were mainly due to descending neural inhibition, wouldnt you think that TNS and electro treatments would have been or could be efficient on tretment back or sij or other kinds of pain? just wondering about your opinion, as I do think that there are mechanica
        Changes , be it muscle, soft tossue or whatever. Cheers, Claudio

  2. Hello Adam!
    Nice post, I like your sense of humour, honestly!
    Now, onto the serious subject of the SIJ and its treatment. I believe that strengthening you can really solve SIJ problems. I am one of those, however, that still apply manual techniques and this goes for one reason: instant pain relief.
    I have a different kind of population of patients. Although there might be sportsmen, most of them are not, and many are totally sedentary. I agree with you that SIJ diagnosis are very few when considering all back pain patients.
    Usually the lumbar roll manipulation works fine, as the hip extension – thrust in the superior/posterior aspect of the ilium. Another thing that works even better, IMHO, is MWM with the patient standing. That way you put the patient in the painful situation (ex: one leg standing, simulating the stance phase of gait) and apply the technique. We could discuss specific techniques another time.
    I like to follow those with strengthening exercises. We could discuss the reasons (stability maybe, maybe better sensory feedback to the cns to control the area, etc,etc). There should be a correct progression to those.
    Just my thoughts.

    • Hi Claudio
      Thanks for your insightful comments, I agree that some manual techniques are useful and i do use them myself, if they give ‘immediate pain relief’ then that’s great but this is IMO due to the neural effects rather than physical as you say maybe the effects on the CNS
      Glad to hear you do strengthening exs and the one u describe sound great, as I say each case is individual and down the the patients level of pain, irritability and skill and or fears
      Thanks again

      • Hi Adam,
        this topic on “where do the effects come from?” in mobilization/manipulation could go a long way. We both are aware of the articles where they mobilized ramdom and specific low back vertebras for the same effect and similar articles. These are really leading to the idea that you wrote. Though there are many others.
        On the other hand I still think that the mechanical effects are there, meaning for example that, when you manipulate/mobilize you get more free motion, less restriction and that is if not the main, one of the reasons for the pain reduction. The descending factor is being well established in literature (as long as I know) but I don’t think that the mechanical effect has been well researched. Actually, I think that there were researches involving x-rays but that would not access the level of freedom of movement.
        Hopefully one day the answers will be more clearly seen.

    • Hello Zach,
      I think we would mostly benefit if we all could freely share our ideas and approaches to the problems we face in day to day therapy work. I think we all are trying to find the safest/quickest way to solve (for real) our patients problems.

  3. Adam,
    Great job here dispelling several myths regarding treatment of patients with SIJ or pelvic girdle pain particularly when it comes to manual therapy.
    What are your thoughts on this:
    “Pelvic girdle pain disorders may be associated with ‘excessive’
    as well as ‘insufficient’ motor activation of
    the lumbopelvic and surrounding musculature.”
    This quote comes from Peter O’Sullivan’s Masterclass Paper on Pelvic Girdle Pain Disorders in Manual Therapy 2007
    In other words there may be a subgroup of patients who, for a variety of reasons, tend to excessively recruit the muscles around the pelvic girdle. Perhaps these patients are fearful/anxious or have been told that they should consciously contract their ‘core’ muscles to support their ‘unstable’ SIJ?

    • Hi Bill
      Thanks for your kind words
      Yes I agree with some of Pete’s work and do agree that there are those with Lx +/- SIJ pain that do ‘over brace’ or ‘splint’ due to fear and anxiety, and again getting into these pts minds and Rx both physically and psychologically is a must by helping them overcome fear and apprehension in a safe and controlled environment show them how to move and dispel these fears etc is a must, rather than bouncing up and down on them for 30mins on a couch
      However I don’t think it is ever possible to put all LBP into sub groups that I know Pete is trying to do, just way to complex but i do like his simple down to earth and evidenced based approach, right up my street
      Cheers again Bill

  4. Adam, I really like your way of thinking, its solid and clear!
    I agree with a lot of what you said, specially in this new version of the text.
    There’s a topic that invites discussion for me, because there’s a lot of evidence suggesting that descending neural pathways are an important factor in pain treatment. I do not disagree. But to me its far from being the only one. Call me an structuralist or something like it, but we don’t have very solid evidence refuting the mechanical theory that something is stuck or in bad position.
    Actually, we have some good evidence concerning (refuting) the “subluxation/positional fault/osteopathic lesion” hypothesis, meaning that its not some bone that is misaligned or badly positioned that is the source of pain. But we don’t have evidence that the movement might be more limited or resisted, or the tone of the muscles is elevated or diminished.
    We have articles showing that a dysfunction on (inhibition of) the multifidi muscles is related to pain. We have articles showing that HVLA to low back reestablishes proper function on the multifidi and that there’s also a change (for the better) in symptoms. Whats going on, is the lack of proprioception (muscle inhibited sends less proprioceptive info than when active) the cuase of pain? Compensatory hypertony from erector spinae, with pain coming from the elevated tone stimulating free nerve endings or noci nerve endings? Or the hypertony makes the movement difficult to do, limiting one side, maybe favoring hypermobility on another (painful) segment? Or just the fact that those hipertonic muscles are with non-variable pattern of activation (not going on too deeply, but intermuscular coordination could be diminished by an stereotypical/non varied fiber activation).
    I mean, we could start talking about everything that is around pain, like proprioception, the gate system, descending pathways, muscle tone, muscle function (correct me if i am wrong, but you consider muscle function in a mechanical way when talking about the shoulder – why not consider it with the same emphasis on the low back? I know that the subject is SIJ, but I am still on the emphasis f the descending pathways), intramuscular coordination, pain and cocontraction and lack of movement variety, improving muscle coordination. Why are we leaving the mechanical behind. I am not disconsidering the text you suggested from Liederman, but I think there’s a lot that has not been shown yet, and IMO we cant totally discard a mechanical hypothesis). I mean it is still, IMHO, too early to discard completely a mechanical mechanism. Not discarding the other mechanisms, they go along with the mechanic.
    Working with MWMs (Mulligan) you dont have many directions, its usually one direction that you use that really produces the effects. Its different from HVLA (I tried both direction of HVLA a case of SIJ I treated, both worked, one added to the other). Though not that different, as both have evidence suggesting an widespread effect on other areas, but its a technique that you need to be specific regarding to pain.
    Hope to hear from you!

    • Hi Claudio
      Thanks again for your comments, I’m not refuting the mechanical possibilities as a source of pain from the SIJ, but instead the clinicians ability to diagnose said mechanical dysfunction.
      The SIJ is such a difficult joint to Ax that there is (in my opinion) no way of ever knowing if there is a mechanical issue here, instead a method of treating the SIJ with manual treatments to push it this way or that, can and should be attempted IF the SIJ has been found to cause pain with the collection of provocation tests as described by Laslett but these are rare occurrences, if the SIJ is painful then a CS injection should be given and once pain reduced then exercise therapy can begin.
      However, it is the SIJ resilience to load and stress that is the main issue to address in my opinion and this should always be the main stay of all painful SIJ with manual Rx being a small adjunct

  5. Hi Adam, very insightful post thank you for that, very well rounded although like you said you may have shot yourself in the foot by giving your opinion
    Then again that’s why we do what we do, yes we say that it’s evidence based but if your patient gets better then that too is evidence, the how just brings another question…
    I agree with your approach I too use manual therapy only too affect the nociceptic irritation during the early stages or during an acute reactive phase if the issue is long standing, for greater affect I also use kinesiology taping
    But all this is to decrease or ‘change’ the stimulus thereby offering me a platform with which to work and develop an aggregated loading strategy for the individual
    On the whole I find that weakness and or some kind of associated movement compensation are the greatest causes of any SIJ pain syndrome and associated with this is the inappropriate approach to training and exercise whether it be highly repetitive or to aggressive both don’t allow for adaptation and development of necessary function
    Look forwards to your next post
    Mike Carolan

  6. Sorry if im late to the party. Id be divorced if I wrote this stuff out weekly! Nice post and I enjoyed reading it. Having worked in Crewe many moons ago where folk frequently crash into trees off of motorbikes requiring their pelvis to be pinned back together, they never woke saying they had SIJ pain. Ive always struggled with SIJ assessments and rarely perform an examination of the area using palpation only tests. I generally use the same tests in Lasletts evidence as provocation tests. If positive then tape/belt/and lots of force closure exs……..or remove the aggs! However, I have found positional analysis helpful for treating backs. Acute backs using the chicago is quite legend as a technique. Other than rudimentary Lx manip, not convinced it cavitates or shifts the SIJ. METs? Great for muscle activation but even these i think are more likely to serve as a means of muscle activation/inhibition with the resultant outcome being a mobilisation of the pelvic girdle, reducing load on the Lx or dis-inhibition (such a word?) of dysfunctional force closure muscles.
    It is often frustrating when folk are told their pelvis keeps “coming out”. Indeed, it may be mal aligned but this is a reflection of pain and muscle tonus. Although a crude clinical analysis it does serve perhpas to provide a laymans interpretation or therapists for a difficult problem. That said the pelvis is a pretty large structure so motion analysis, while carrying little in the way of empirical rigor, may assist in helping create a clinical approach and some form of movement diagnosis (dare I say) IF it is the strucutre causing pain. But, then we delve into the rhelms of physio ‘art’ in practice (sometimes it is) where evidence is lacking. Still, some physios/chiros/osteos do it well and folk get better – provided they are not going back three times a week for a year. Good posts again fella! Like the angry posts on twitter too. Controversial and just what the physio, therapy and medical world needs.

  7. Such a great article dispelling the myth about SIJ dysfunction. I think it unfortunate that our profession tends to follow the lattest fads without really examining the logic or research behind it.
    It’s unfortunate that you feel your article or opinions are controversial because they shouldn’t be. This is sound clinical reasoning and I wish more people used it. It is really not about having the perfect answer and I am sure we will learn much more about the SIJ as times goes on but good, logical clinical reasoning should always underpin our treatments.
    I too tend to use Laslett’s tests and look at the distribution of pain to rule the SIJ in or out as a potential cause of symptoms. And as you said – it is not that common. Soft tissue work or manual therapy can certainly help with pain relief but is also often a patient expectation and as such I don’t think there is any harm in providing it. But exercise is the way to go!
    Thank you for a great article!

  8. I am no trained expert, but I have a twisted SI joint. Was the result of having my knee locked on the brake on impact during a MVA. I agree with you on some points you have made, but not on all.
    I agree that manual manipulation is only temporary if it does any good at all, it hurts to get shoved back in and it’s only a matter of time before I get twisted up again. Not to say that I haven’t had my good streaks where I don’t fully twist up again, but eventually it just falls apart.
    I realize you feel that a twisted or damaged SI joint isn’t really possible however, right where your diagrams indicate the location of my SI joint is the site of the pain and its significatly indented compared to the other side. I felt the beginning of another slip about a week ago, I’ve slowly been twisting and twisting to the point it feels like there is a stabbing knife in my lower back and I’ve felt one side slowly become more and more indented over the last week.
    You Seem to be stating there is no actual remedy. What can correct the twisting so that one can move enough to exercise and strengthen? I would love to be working out right now and strengthening. Please correct me if i am wrong, but this feels like a chicken before the egg question.

    • Hi Cait
      I’m sorry first of all that you are in pain, but I will state again your SIJ cannot be twisted unless there is significant trauma to it, I’m talking about broken bones not a jarring or knock, its just physically impossible to twist it.
      I’m not questioning your pain maybe coming from the SIJ or the surrounding tissues which are highly sensitive, the effects of manipulation here are not physical but neural hence the temp relief you get.
      Doing exercises even very light simple movements are the way forward for long term relief, they will work not only to desensitise the neural element of your pain but also increase the SIJ capacity for daily stresses and strains so I would suggest you see a good Physio who can start you off on some simple light exercises
      All the best

      • Adam,
        Thanks for the reply, exercise does help once I get back into place.
        I had a host of medical support for years including my GP, neurologist, physio, kinesiologists and an independent medical evaluation. All of of which were in agreement with my diagnosis. They used not only what they found hands on, but it was also backed by 2 MRIs and a CAT scan. The final conclusion was that its most likely going to continue to go out of place if I did anything high impact. So far they have been right, this last outage was brought on by ziplinning.
        This has been going on for years, and what I have been referring to is not nerve pain, I know what that feels like as I’ve also suffered from it for years.
        It isn’t possible to exercise when I totally fall out of place, my body tenses right up and it’s beyond painful to have muscles contracted against a joint that is incorrectly placed. The only treatment I’ve found is heat and massage combined with gently manipulating myself back into place, it takes a few days to work.

  9. I am a semi-athlete in my 6th month of pregnancy. Mid pregnancy, I started to feel significant pain in a localized spot of my gluteal area, which I thought was a muscle issue. However, I have been told that this is actually posterior pelvic pain associated with the physiological changes of pregnancy, and specifically, a flare-up in the sacroiliac joint. Does this sound plausible to you? If so, does this also mean that I need to cut our all high-impact exercise until after delivery? What other options do I have for challenging exercise (other than swimming)? Thanks very much!

    • Hi
      Yes this does seem a plausible diagnosis, the SIJ and it’s ligaments do undergo increased stress and strain and so change during pregnancy, with regards with what you can and cannot do I’m afraid I can’t help as I have no experience in this area, sorry
      All the best

  10. Hi Adam,
    My partner ‘pulled’ his back about 2 years ago, it hurt for a couple of weeks then it went away.
    Approximately 10 months ago he started to have some real problems with his lower back. After going to the doctors and taking the prescribed anti inflammatory’s for 2 weeks we went back to the doctors ! As the NHS waiting list is quite substantial we sought out a private physio.
    He has been to see her every 7-10 days for getting on for 9 months. He has had periods where it has eased off slightly but has never fully gone away.
    It started out as a pain in his lower back. He has continued exercising, when it’s been very bad he’s just taken lots of small walks that seemed to help. He uses ice packs to reduce inflammation, and heat.
    3 weeks ago it became very severe !
    He has been in excruciating pain. He’s taking stronger anti-inflammatory tablets, and pain killers. We’ve been to the doctors again !! He’s been back to his physio !!
    They are all saying he needs an MRI, his doctor is saying he has sciatica now, because he has pain radiating down his leg when he walks. His physio is saying she thinks it’s swelling in his SI joint ??
    I know you are probably very busy but I am struggling so much to help him.
    He is never off work sick, he’s generally very healthy. He has no other symptoms. He is miserable !
    I’m not sure what I expect you to tell me. Yours is the first blog I’ve read that seems practical ! I suppose I’m just frustrated and looking for answers. Would you be recommending and MRI at this point ?
    Many thanks

    • Hi Nicole
      First of all I’m sorry to hear of your husbands predicament, unfortunately it is not right or ethical for me to give specific advice online without seeing and assessing your husband to ensure that there is no immediate concerns that he needs onward referral.
      All I can say is that most (95%) of back pain, even the severe painful ones are nothing to be concerned about and they do settle down given time
      It would be wise that he seek medial advice to get whats call the red flags checked to ensure nothing underlying, then an MRI maybe needed, however again these can be inconclusive and misleading.
      My general advice is to keep moving as able, use pain killers heat or cold and regular change of positions to reduce pain as able
      Sorry I know this probably doesn’t help much
      All the best

      • Hello again Adam,
        I just wanted to say thank you for responding.
        I have learnt over these last few weeks that it can be extremely difficult to diagnose a cause for back pain, the MRI will be our next attempt to find a ‘reason’ for it, but whatever it shows (or does not show) I will continue to push him to exercise and find a way to manage it as best he can himself.
        Thank you again for the reply, it’s very much appreciated when it does feel sometimes like back pain is not taken seriously by some professionals.
        Kindest regards

  11. Hi Adam,
    I compete in long course triathlons (full and half ironmans) and considor myself to be a very fit 48 year old.
    App 7 weeks ago I had an accident where my right leg slipped sideways in front of my left leg- there was no pain in my back at the time of the incident, but a few days later lower back and pelvic pain radiating down my right leg increased to the point that I ended up in ED at my local hospital. An MRI diagnosed Sacral and adjacent iliac bone marrow contusion and I was sent home with strong pain relief. A few weeks later the pain had not improved and so I had a bone scan to eliminate the presence of any stress fractures, and a pelvic plus upper femoral MRI to eliminate any soft tissue pathology. Both were NAD- and so the diagnosis of sacroiliac dysfunction was made by yet another specialist who suggested prolotherapy of the SIJ to help stabilize the joint and provide pain relief.
    What is your opinion of this form of therapy in the treatment of SIJ dysfunction ?
    I have read about PRP injections into joints, and as wondering whether or not this would be benificial.
    Although I obviously miss my training and racing, I now just want to regain some quality of life where I am am not in constant pain and regularily requiring analgesia just to survive.
    Many thanks for your advice,

    • Hi Lisa
      Thank you for your message and I’m sorry to hear of your accident, I have seen prolo therapy injections used for ‘SIJ’ issues with mixed results so I’m afraid I cannot give you any clear advice and as I haven’t met you or assessed you it would be even more amiss of me to do so, all I’d advice is seek as many opinions as you can and read around as much as you can, as I’m guessing you are doing reading my piece here
      I wish u all the best

  12. Adam did you know that the incidence of SI joint pain increases tremendously in people have Lumbar spine fusions or congenital anomalies that limit normal motion in the lumbar spine. I treat dozens a month in my practice and some do not get better unless they are “poked” as you say or injected with a steroid, but most get better with NSAIDS, stretching (and I mean mainly the Piriformis, Hamstrings, and Iliopsoas muscles) to substitute for the lack or normal lumbar ROM which places additional force on the joint. And if I was wrong as you say, then why d I have a great success rate. My Healthgrades rating by my patients is 5/5.

    • Thank you for your comments, I’m not fully up to date of the evidence of post surgical lumbar fusions so can’t fully comment, but the mechanical approach u take has to also be implemented with the neuro psycho social side and remember that confirmation bias can effect ones view and anecdotal data doesn’t equal evidence either I’m afraid
      Thanks again
      Regards Adam

  13. I suffered sacro iliac pain for 5 years until my doctor ordered full rest on diazepam. No pain at all for the last 16-17 years.

    • can you explain how long and of how much strength did you take… diazepam is never considered as solution but you case seems different kindly explain your experience

  14. Hi, as a person that has a lot of trouble with my SI Joint, I would really appreciate some exercises to help me. Does anyone have the time to post some? Or know of a site I can visit? Thanks Jess, ‘sufferer’.

    • Hi Jess
      My best advice is go and see someone in person, getting advice and guidance online and in articles is all well and good, but for best results go an see a good physio for specific assessment and guidance

    • John, the chances of pain in the region of the SIJ being as a result of Ankylosing spondylitis are low, but that’s one of the reasons that a full assessment by someone with a practical and realistic approach is required. It’s very easy to get lost in the opinions of many people and to become distrusting, but usually if someone is honest enough to say that manual therapy is likely to offer temporary relief and exercise is the best long term strategy it’s a good starting point.
      Thanks for another great post Adam.

  15. I have been suffering from S I joint pain( left side) for 8 years now, since having severe s p d with my son and having it also 2 years previous with my daughter’s birth and with a miscarriage in between them. Am now in the process of being diagnosed with hyper mobility syndrome. I can’t and have never been able to stand for long periods of time comfortably without leaning into one leg more than the other and I can’t sit comfortably I either lean forward on my elbows or lean back in soft chairs and twist into my right side. I can only lay on my back at night with pillows under my knees and feet, the pain is excruciating and have had manual manipulation and sometimes it helps and holds for a bit and sometimes it goes back to normal within a matter of hours.I’ve done clam exercises, pilates and started in the gym which includes doing a front lift with buttock clench. The si has just ended up going into spasm well the muscles and ligaments around it and manipulation helped a bit but the pain never fully goes away and now it’s popped and put itself back out again giving me pain, pins and needles and a swollen feeling in the leg and numbness in the base of my back again! Nothing has worked the only thing I can think of is to wear a pelvic belt again! Am so tired of the pain and so disheartened that people think it doesn’t exist, it does and it hurts like hell! The pain itself stops me from being able to hold my back up in a better posture as it makes the joint hurt more! Is there any answer to it? Have seen an osteopath, pilates teacher, doctor, back doctor, rheumatologist, done exercise, taken pain killers had mri scans, and yes my pelvis is rotated (right side forward, left back) and my right leg is a lot shorter than my left and I feel this does affect it’s function- any help please Adam?

    • Hi Lucy, I’m sorry to hear of your troubles and this sounds like a complex history and that you have had many suggestions and treatments already, in these cases there usually isn’t just one simple answer and its usually not just the biomechanical structures that needs to be addressed and treated, instead a full biopsychosocial approach is best and this cannot be done online, I would recommend seeing a therapist who practices this and go from there, hope this helps

  16. Lucy, did anyone suggest a right heel lift to maintain the correction as the pelvis is likely to be anteriorising on right and/or posteriorising on left to compensate for the shorter right leg and this is the cause of continued relapse. I am assuming that you have had the pelvic aligment corrected with suitable joint manipulations and also some form of pubic symphysis release already and that it does not sustain, Peter

    • Hi Peter
      I’m not sure if you’ve read my post but what you are advocating here is EXCATLY what is wrong with SIJ Ax and Rx in this industry
      Firstly how can you tell reliably that the pelvis is ‘anteriorising’ or any other ‘ising’ when I’ve just shown that there is NO way to palpate accurately for this!
      Secondly how do you correct a pelvis with manipulations? This structural and mechanalistic thinking just doesn’t stand up to evidence or scrutiny, the forces need to ‘adjust’ a pelvis are astronomical and just won’t happen, the effects of hands on manual therapy are through neuromodulation not correcting alignments or other such nonsense
      Leg length differences are perfectly normal in all of us and most of us adapt to them as we grow and develop and so don’t need correcting, read more on that here http://thesportsphysio.wordpress.com/2014/01/11/the-long-and-short-of-leg-length-differences/
      Lucy, please do go and see a therapist have some gently manual therapy and pulling massage stretching and exercises to see if they help, but don’t listen Peters or anyone else’s advise who tells you that your pelvis is this way or that, or that it needs ‘adjusting’ or releasing, as this is all nonsense that no therapist can ever say they can feel or see reliably or accurately

  17. Please don’t discount laxity. As a person with ehlers-danlos syndrome who is a 9/9, I can tell you, there are people who have SIJ problems actually proven on X-ray and scans. I have severe arthritis and malalignment showing on imaging studies.
    It can happen. Don’t discredit hypermobilty and laxity. It can cause a vast array of problems, including in the SIJ.

    • Hi Heidi
      I don’t discount SIJ laxity I just discount it being as common as thought by most in this industry and if there is laxity I discount therapists being able to feel it
      This study here http://m.bjsm.bmj.com/content/47/10/e3.28.short shows SIJ laxity does indeed occur, BUT 85% will have a history of trauma, 9% after child birth and only 7% of unknown causes such as hypermobility,
      And therapists can NOT feel laxity of the SIJ the only way is via CT or SPEC scans not with them using their fingers as I discuss in this post, I also work with hyper mobility patients and have done a blog on it a few years ago if u want to read it look through my contents page
      All the best

  18. Excellent post and bang on the money in my opinion. A radiologist friend once said “oh yeah, your SIJ will move; in a car crash or a fall from a high building or ladder”.

  19. Hi Adam,
    Thanks for a brilliant article. From a personal point of view I would like to back up you statements that exercise does help SI joint problems. I had problems for many years until I discovered light exercises that helped that area, similiar to the ones your mentioned: glute bridges, alternate arm and leg raises etc… I would follow this with ice and try to alternate the exercises each day. As time goes on more and more can be done. I eventually progressed to light dead lifts which I am so impressed that you mentioned, They really helped me towards the end of the recovery, everyone I spoke to said I was nuts!
    The SI joint has gone on me again recently and I am back into light exercise again. I have to start all over as I had forgotten all of the above, I have had to retrace my steps to remember what really worked. For the last six months I have done a lot of classical Pilates on the reformer which has strengthened the abs and pelvic floor but has not really done the muscles on the back of the body at all. It hasn’t really been as good as I thought and as we speak I am just starting to get back into the ones done previously and it’s great to get confirmation from your article that these are the areas one has to concentrate on. Thanks again,

    • By the way, any thoughts on what should be stretched along the way? Another post mentioned piraformis, hamstrings and psoas, all of which seemed to make sense. My psoas and adductors have been super tight over the years.
      Thanks Reg

      • Hi Reg
        I am quite controversial in that not a fan of stretching much at all, especially static stretching, I don’t think it offers much, to maintain flexibility we need to just move. Also strength training has been found to be a far more effective way of maintaining flexibility than static stretching.
        Also we have to ask ourselves what causes the sensations of stiffness and tightness, research is now showing us that actually its a weak and overloaded muscle that sends distress signals to the brain saying its feeling the strain, the brain interpret these signals as stiffness and so get you to stretch, when in fact really what the muscle needs is strengthening to stop the distress signals being sent in the first place.
        So don’t stretch, strengthen more.

  20. Thanks for writing this detailed post on ways to treat a painful Sacroiliac Joint, and the top image also build my basic understanding on joints and other related elements as well.

  21. Hi,
    Just want to say your blog is awesome. I’m just a band 5 with just over a years worth of MSK experience (a few years elsewhere in other physio roles), ergo I know hardly anything about treating the SIJ (I probably know hardly anything about most conditions – it sure takes years and years before you become anywhere near an expert on anything!?). I have (or thought I had) a few SIJ patients on my case load at the moment, so this blog is really interesting. The little I have learned about the SIJ is from my own self directed learning (hence coming across this article) and mostly from supervisors and colleagues. I have found learning from others though, can be frustrating. Some of these physiotherapists, who are undoubtedly experienced in their fields, are very set in their ways and many, despite being advocates of ‘evidenced based practice,’ still do treatments that have little or no evidence to support their treatment choice. Some of the best physiotherapists I’v found in my limited experience are the one’s more ready to admit they do not know what is wrong with the patient. Sadly, there are many, in my opinion, who are arrogant and have a ‘superiority complex’ (thank god I can stay anonymous here!) – a term, a senior physiotherapist with a PHD under his belt, once said to me when voicing similar opinions, whilst I was a band 3 – only now am I realising the truth of this. I thought the last paragraph of your article was definitely food for thought – for example, ‘postural dysfunction’ must be one of the most common diagnoses that physios’ use (if we exclude “mechanical back pain” which must be one of the vaguest), which may well be a true diagnosis (again I’d like to emphaise my lack of expertise in this area), but how many of us have perfect posture? And why, when we do not have this perfect posture, do we not all suffer the same pains and problems others do? (another blog subject maybe?) I’m probably boring the socks off you now if you or anyone else even reads this. I just wanted to say thanks for the awesome blog, physio shouldn’t be monolithic and should be open to controversial debate! Hope this doesn’t all sound too obsequious.
    Thanks again,

    • Hi Rachael
      Thanks very much for your kind comments
      I must admit I had to google obsequious… But no not at all!
      All the best with your career, keep that open inquisitive mind strong, bite your tongue often with fossils that refuse to change and keep asking the difficult questions and you will be fine
      The only certainty is uncertainty and start to get comfortable feeling uncomfortable
      All the best

  22. Adam, what do you make of leg length differences, upto 2 cm between legs, right shorter ostensibly caused by wrongly rotated innominates? Palpation (which you hate) shows left side is anterior, right is posterior. The illiac crest on right is higher and ostensibly the cause of all the issues (LLD). palpation/techniques per the book “malalignment syndrome” show inflare on left, outflare on the right, how would you assess the path forward for such a case? I am the one suffering, because i had some unecessary manual mobilization and all this was the result. I sort of disagree with you that all this does not matter or is placebo, let me explain. before my manual therapy based on MET, my xray showed spine tilting to the right. MET/mobilization changed my pelvis position and now i am tilting to the left. its not in my mind but on xray film. so presumably misbalanced rotation of the two sides of the pelvis can cause issues. your thoughts welcome. since right now, attempts to fix it with MET are going nowhere as i am told a complicating factor may be some sacral torsion and what not.
    your mention of thoracolumbar force closure makes ample sense. actually you are saying the same other folks are saying. their back muscles are perhaps so weak they completely rely on the sacral-muscle-lig complex to achieve this. and hence the end result is improper closure, biomechanics. in your method, you make sure there is enough support to get the job done by getting the entire ecosystem activated.
    however, the question is how does one fix badly aligned pelvis/misaligned rotations etc on either side? also, in your experience is it possible to jam the sacrum in some pattern (left on left torsion etc) or is that plain hyperbole?

  23. Thanks for the info. I have psoriatic spondylitis, All of pain is in my SI joints. I just had a SI joint injection 3 weeks ago and just yesterday my pain is back again. I know i can’t just keep getting injections so I need to try other things for pain relief. Thanks for the tips

  24. i’m glad some of your patients find relief from exercise. However I’ve been damaged by physical therapists who believe that all back and SI joint pain can be cured by exercise. I’ve been suffering SI joint pain for 8 years following pregnancy, I am a practicing scientist with a Ph.D. and I have studied this problem extensively. This is not a joint that is stabilized by muscles. It is held together by ligaments. They can become loosened by injuries, age, or pregnancy. Sprained SI joint ligaments are easy to diagnose – the posterior ligaments are on the surface of the low lower back and you can dig your fingers into them and feel the pain. The ligaments can also swell and squeeze the nerves to the legs and cause referred pain. Exercise makes it worse, not better. This is the case with all ligament injuries. Or tendon injuries. Or muscle injuries. They require a certain amount of rest to heal. Not all back pain and SI joint pain can be cured by exercise. I wish it were true but it isn’t.

      • Well that’s a cop out… If you are truly interested in educating people on your theories and dispelling what you consider to be “erroneous beliefs,” then climbing down off your soap box and engage in discourse with people who refute what you are saying. Don’t just run away and hide from other points of view.
        I, for one, support her statements. I am a yoga teacher and therapist, personal trainer, as well as someone who has struggled to manage SI dysfunction for over a decade. Why are we wrong? Or are you merely unable to come up with a response and hiding behind your dismissive comment?

      • Soap box? What soap box??? And what exactly is your question?
        If you are truly interested in debate around why the notion of many assessments and beliefs around the SIJ are flawed, unreliable and inaccurate, you would not start with personal comments and ad hominem!
        I’m not hiding, my views on assessment and treatment of the SIJ are very clearly presented here with supporting evidence and explanations as why I think those who peddle myths to yoga teachers, personal trainers etc are wrong!
        By the way what sort of therapist are you and what teaching in anatomy and physiology have you had?
        Please read the evidence and papers I have presented here then get back to me with a specific question without personal comments, and maybe we can go from there!

    • Thank you for your post. My daughter has been dealing with back pain for 3 months now. She is 15 years old. We did physical therapy, the chiropractor, x-rays, MRI, and finally a pain management clinic. She was diagnosed with an SIJ injury. It makes perfect sense now that I have researched it. She was told she needed to take a break from sports for 6 weeks to allow this injury to heal. Exercise and stretching right now is not recommended. Gradually it will be but the ligaments need time to heal. I appreciated reading your post as this was exactly the information we were given and made sense since PT did not work.

  25. Hi Adam, I have had ongoing issues with my sacroiliac for the past 12 years. I saw a kinesiologist for 5 years and go to a neurology chiropractor now. I have had more success with the neurology chiropractor because he has physical therapists that help you with strength movements. I have also found that stretching exacerbates the problem if done in excess. I have found that strengthening movements from yoga or callistenics have helped the most. I am now doing modified lunges, ballet squats, incline pushups, holding plank position for 50 seconds, doing jumping jacks and situps with a yoga resistance band that all seem to be helping strengthen the muscles to keep me moving with ease and no pain. This has been a recent development in my quest for relief so I just wanted to share what has helped me. I have a computer desk job so I am sitting for most of 7 hours a day. These exercises seem to be helping after that length of sedentary time. I hope this might help others out there that have had setbacks and find that if they do too much they are back to square one. Ease into the routine. Start with 10 reps of each in succession with 3 sets and work up to 5 sets every other day. I am just now after 2 months at a point where I am adding an additional day of 5 sets and so far no setback. If I can continue doing this 4-5 days a week and stay pain free and active, I will be so happy! I also agree that adjustments might help relieve the pain in the moment, but the adjustments are not an ultimate fix. If you don’t work on strengthening the muscles, the adjustment is short lived and you are back for another before a week has gone by. Because everyone is different, it may take some trials to find what works for each person like you said. I started having the pain when I was pregnant and then it recurred about 6 years later when I started perimenopause. I think when you have additional weight and inflammation in your body, it seems to make it worse. That’s my 2 cents worth. Thanks for your professional honesty! -Lisa

  26. Hi Adam,
    Thanks for a great article!
    I’ve been trying to help my SIJ for awhile now. I started going to a chiropractor several months ago for pain in the lower right side, which was determined (by MRI) to be caused by disc herniation in the L4, L5, and S1 vertebrae. I’ve been undergoing several therapies: E-stim, ultrasound, and spinal decompression, which all have helped somewhat.
    However, in the last few weeks of treatment, a very significant (new) pain has developed which I believe to be my SIJ expressing itself. Since the decompression has been at 110 lbs., I’ve asked that I be taken off those. I’m concerned that though the decompression has been good for my disc situation, possibly it is too strong a setting and has “loosened up” or stretched the muscles supporting the SIJ (?). All the clinical signs of a painful SIJ are evident.
    In my internet search, I came across your article, and it makes a lot of sense. I’m going to talk to my chiropractor about stepping away from the decompression and focusing on exercises to help strengthen my posterior oblique muscles. There is a reason my SIJ is crying out in agony.
    Thanks again!

  27. Hi Adam. I just finished reading your article. I have Sacroiliac Joint pain. Two weeks ago I happened to pick up a bag full of clothes…This is a procedure which i do almost everyday. All of a sudden I had extreme pain from my lower back which spread around both side of my pelvis to the front of the pelvis. The pain was terrifying. I felt like I had been electrocuted. I have had Sciatica back problems for well over twenty years…but I have never felt anything in my life like this pain. I could not walk. The pain had crippled me. I am use to pain due to my back problems. Nerve pain in the lower legs…and I know with time and exercise it will get better. But this pain,,,was not like what I was used to with the Sciatica. The pain eventually settled in the right hip. At first I needed a cane just to even get out of bed…as it was just too painful to pull myself up My hip bone was sore…like it had been traumatized…I could not lay on my left leg at night…the good leg, because the pain was so severe from the right leg…in a minute or less I would want to throw up because of the severe pain. At times the pain is still so severe that I feel like I want to throw up. I have never had pain like this. NEVER! This could never be confused with Sciatica. The pain is just too devastating.
    I noticed when I slept on the right leg…the pain would dissipate. I have a Ortho Posture Mattress which I bought because of my bad back. I think this helped. I tried doing all of my back exercises…however as of today…”it’s been two weeks,” and I still cannot even do one exercise of any kind. The pain is getting less…but it is still deep in the back muscle. But I am hopeful…and taking it slow. Thanks for your article.
    Aujunai Charpentiair

  28. Man you talk a lot of crap just give us the helpful information and stop arguing with yourself!

    • Well if I talk a lot of crap… You must read a lot of it to even bother commenting… Why dont you go and do something useful with your time!

  29. HI adam, A really useful evidenced based blog that has hugely helped develop my knowledge of SIJ assessment and treatment. It has saved me a huge amount of time and I feel much more confident know in explaining the SIJ to patients who regularly say their pelvis is unstable and they need to hold it together.

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