Treating Sacroiliac Joint (SIJ) Pain: Clinician’s Guide

Sacroiliac joint (SIJ) dysfunction is a famously slippery cause of back pain—sometimes the villain, sometimes a red herring. As clinicians, our job is to identify whether SIJ dysfunction is part of the pain story, and then build a treatment plan that's both practical and patient-centered. Here’s a breakdown of how to approach this, pulling together clinical rules of thumb with a stepwise plan, highlighting who benefits from each option.

How SIJ Pain Presents

Clinically, I stick to a straightforward rule: If the pain is above the belt line, think facet joints or discs. Below? SIJ and hips take the lead. This quick-and-dirty line of thinking isn’t perfect, but it helps orient the workup and narrows the field efficiently, especially with busy or complex cases.

Patients will usually describe a deep ache in the buttock, occasionally sending pain into the posterior thigh or groin, that’s aggravated by motion or weight shifts like standing from a chair. Direct palpation doesn’t always clinch it, so listen closely to functional complaints—instability, inhibition, and “off” movement patterns are all clues.

Stepwise Approach to Treatment

My guiding philosophy: start with the least invasive option, escalate only when earlier steps haven’t panned out, and always tailor interventions to the patient’s symptoms and goals.

1. Physical Therapy and Conservative Care

For most patients, this is the first—and often best—step, especially those with mild to moderate pain or those new to care. Components include:

• Muscle Energy Techniques (MET): Manual maneuvers to reset the joint, best for those with movement restrictions.

• Guided Movement & Motor Pattern Retraining: Addresses lost hip mobility and poor movement habits. Patients who feel “locked up” or weak benefit here.

• Manual Therapy & Taping/Support: Extra support like SIJ belts or shorts for those reporting instability or needing short-term relief to regain confidence.

The main point of conservative care is restoring normal movement and function and putting the muscles in a better position to be recruited, which in turn can take pressure off the SIJ and support recovery.

2. Injections

For patients who haven’t improved with therapy—especially when diagnosis is still murky—SIJ injections offer both clarification and potential relief. Key points:

• Steroid Injections: Target inflammation and pain, often providing major diagnostic info if symptoms ease up significantly post-injection.

• Dual Purpose: Both confirms the SIJ as culprit and buys time for rehab.

This step is best for those with stubborn symptoms or when there’s diagnostic uncertainty, not as primary treatment.

3. Surgery: SIJ Fusion

A rare endpoint, suitable for only a small subset:

• Indicated for severe, disabling SIJ pain (confirmed via prior treatments and diagnostic blocks) after exhausting non-surgical options.

• SIJ Fusion: Stabilizes the joint, intended to restore quality of life only when pain is refractory and truly disabling.

4. Medications

A supporting role, not the star:

• NSAIDs: For inflammation, useful during acute flares.

• Muscle Relaxants or Neuropathic Agents: Helpful for patients with significant spasm or nerve-related pain.

• Medications are rarely curative, but they do help patients engage in active treatments and pursue daily function with less discomfort.

Supporting Patients Beyond the Algorithm

It’s easy to get locked into checklists and protocols, but SIJ dysfunction can wear patients down emotionally and functionally, as nearly everything throughout a day adds to their pain. They need practical tools—but also encouragement that function is more important than finding a “perfect fix.”

The process is collaborative: Each step, from PT through to injections (and rarely surgery), is chosen based on their specific challenges, context, and how they respond as their care unfolds. Use conservative tools like SIJ belts whenever you can to help patients get out of the weakness/spasm cycle of frustration.

Our Takeaway For You

In summary, picking the right treatment for SIJ dysfunction means more than memorizing an algorithm—it’s a sequence of trial, adjustment, and guided partnership, shaped by clinical insight and real-world results for both doctors and patients.

For more insight and practical advice, tune in to episode 34 of It’s Not in Your Head Podcast.