SI Joint Pain

Intro: What is the SI joint?

Stand in front of a mirror and look at your lower back. For many of you, you’ll see 2 little dimples just below the lower back region. This is where your sacroiliac (SI) joints are: one on the left and one on the right.

It’s named after the two bones it connects: the sacrum and the ilium (the upper part of the pelvis). These sit just below the lower back or the lumbar spine. These two bones are connected by strong and thick ligaments and muscles.

In fact, many patients that walked into my PT clinic would complain of lower back pain and after an evaluation by me, it ended up being an SI joint diagnosis. The SI joint is to blame for 15-30% of low back complaints according to this article.

Throughout the remainder of this blog, let’s take a closer look at this joint, the most common injuries to it, the causes of those injuries, how to treat it most of the time, and how to modify the rest of your day and workouts around it.

PS- I personally have suffered from SI joint instability since I was 22 years old, so the methods I share here to treat it are tried and true from my PT experience and my own experience overcoming it.

Symptoms of SI Joint Pain

Pain stemming from the SI joint often feels like a pain in the lower back or pelvis region that can radiate (spread) into the hips or groin. There may be possible numbness/tingling into the gluteal region and possibly down the leg(s). Also, it can be on just one side or both.

Personally, I began having SI joint pain when I was about 22-years-old and running a lot. Hear more about my story here. My shoes were not supportive and there was a lot of repetitive, high impact from my feet up to my SI joints from hitting the pavement. After running one day, I laid down on the ground and my SI joint shifted out of place causing a sharp pain. I couldn’t get up off the ground. I had to stay still and eventually was able to rock my legs side to side. I didn’t have radiating pain, but it was isolated right over the SI joint on the right side. It was super tender to touch and felt like a deep ache.  I was in PT school at the time, so my classmates assessed me and we figured out my R SI joint had shifted into an anterior tilt. We did some manipulations, muscle energy techniques, and then I began following a regular glute strengthening program.

For most of my patients with the same diagnosis, they described it similarly. Some also had some associated tenderness and pain into the glutes and piriformis as those muscles were guarding due to the instability.

However, symptoms will vary based on what’s truly causing the SI joint issue. Let’s talk about that next.

Common Causes of SI Joint Pain

As with any joint in the body, here are the most common causes of pain at the SI joint:

• Degeneration or osteoarthritis (from cartilage wearing down over time)

• Strain (often due to a fall causing significant muscle guarding)

• Inflammation of one or both SI joints called sacroiliitis (or SI joint dysfunction)

• Dislocation or subluxation

• Hypomobility or stiffness

• Instability, displacement, or malalignment (hypermobility from weakness, trauma, or pregnancy)

• Fracture (from a traumatic injury or fall)

• Leg length discrepancy and/or scoliosis (causing abnormal movement and walking)

“The mechanism of SI joint injury has previously been described as a combination of axial loading and abrupt rotation” according to this article.

The top causes of SI joint pain are pregnancy, prolonged vigorous exercise, and degenerative changes. SI joint issues are more common in women because the ligaments around the pelvis become more lax during childbearing. This is due to relaxin being released to widen the pelvis and allow the baby to be born!

Since the SI joint moves in all three planes of motion, it can misalign in all three planes.

Location and Muscles Affected by SI Joint Injuries

A picture may help you better understand where this pain lies, so check out the photo below. 

Photo credit: Aptiva Health

As you can see now, the pelvis is 2 separate parts: left and right. So it’s very common for one side to shift out of place, throwing everything off balance.

You can also see that there are many ligaments and muscles surrounding the SI joint. When the joint itself is injured, those ligaments and muscles either freak out and start guarding or they loosen up and weaken - depending on the injury.

If the joint is unstable, shifted out of place, is misaligned, or really lax then it would be very beneficial to strengthen all these muscles surrounding it: glutes, piriformis, and erector spinae.

Testing for SI Joint Issues

The first step to get a proper diagnosis would be to see your doctor or Physical therapist. Most SI joint issues can be diagnosed with tests in their clinics. However, if there’s a fracture or degenerative changes, those would need to be seen on Xray. 

Below are a few of the most common tests for the SI Joint done by physicians and therapists. However “clinical studies have for the most part demonstrated that neither medical history nor physical examination findings are consistently capable of identifying dysfunctional SI joints as pain generators” according to this article.

• Faber test / Patrick sign

• Yeoman’s test

• Gillet test

• ASIS compression and distraction

• Muscle length tests of the piriformis, hip flexors, and hamstrings

Conservative Treatment for SI Joint Pain

Disclaimer: The information provided is not intended to be a substitute for professional medical advice, diagnosis or treatment.  Never disregard professional medical advice, or delay in seeking it, because of something you have read on this website.  Never rely on information on this website in place of seeking professional medical advice.

Most of the time, SI joint issues can be resolved with Physical therapy. However if conservative treatment does not resolve it, the next step is to try an injection (often lidocaine or cortisone) to reduce the pain and/or inflammation. Or a nerve block may be done.

Physical therapy for SI joint pain is hugely successful to help with mobilizing the guarded muscles, strengthening the weakened muscles, and re-stabilizing the SI joint region.

Strengthen those glutes! That’s the best treatment for SI joint pain - seriously.

Treatments for SI Joint Pain (from basic to advanced):

• Reduce the activity that may be aggravating it

• Joint mobilization (level depends on stage of injury; especially of L5/S1

• Muscle energy techniques (like the shotgun technique to use the muscles to realign the SI joint)

• Range of motion exercise (within a pain-free range) 

• Stretching (plus contract-relax technique)

• Strengthening exercise (including isometrics and neuromuscular stimulation) to load the ligaments and muscles progressively

• Cardio (to help vascularization or bring blood flow to the area for healing)

• Functional exercise (form training for unilateral exercises especially)

• Manual/Massage: soft tissue massage (especially of the guarded muscles)

• Modalities: Ice

• SI Joint or Pelvic belt (temporarily used until the muscles and ligaments are strong enough again) see link below

• Possible shoe inserts (if the cause of SI joint issues is a leg length discrepancy)

Below are some Amazon links to SI joint pain related products that may be helpful:

Physical Therapy Exercises for SI Joint Pain

There are lots of exercises you can try. The most important thing is consistency. Building back up strength and stability in the SI joint region takes time, so practice these exercises daily.

I’ve compiled all the best exercises for SI joint pain into the video below. Focus on strengthening the glutes, lower back, hamstrings, and core.

Save it, give it a thumbs up, and follow along daily!

Mission: Mobilize, Modify, Move

It’s my goal to ensure you learn three things with every blog post: how to mobilize your body, how to modify exercise, and how to optimize your movement. 

Above I shared a video for SI joint mobility and stretching. I also shared some great glute strengthening exercises. Strengthening the glutes helps stimulate blood flow to the muscles and tendons and also improves stability around the SI region.

Now, let’s cover some ideas for how to modify exercise if you have SI joint pain:

• Consider adjusting your workout split to focus more on the upper body and core more often - temporarily until your SI feels better.

• Modify lower body exercises by working within a comfortable range of motion, using lighter loads, & slowing things down. For example, if you’re doing a squat try these things:

• Don’t go down as deep

• Do it bodyweight or lighter load than usual

• Go slower so you can really focus on form

• Consider doing it in front of a mirror so you can watch your knee alignment

• Try out different stances: narrow, wide, wider, toes forward, toes more turned outward

• Prioritizing bilateral exercises. Unilateral exercises typically require one side of the pelvis to rotate one way and the other the opposite way. So focus on exercises where the legs are in the same position like a squat, wall sit, leg press, bridge, hip thrust, etc.. Those will likely feel better and cause less flare-ups than unilateral (or single-leg) exercises like a split squat, any lunge, single-leg deadlift, etc..

Finally, let’s talk about how to move better throughout the day without flaring up your SI joint pain. Throughout the day, modify any of the repetitive movements you make as that’s possibly the true cause of the inflammation. Or take more breaks while doing them. For example, if you are going to pick up your baby off the ground, go into a  deep squat with the feet even instead of staggered feet. Or if you’re using the stairs and have discomfort maybe use the escalator or elevator temporarily as that could cause a flare-up.

SI joint pain is very common, so if you’re experiencing any please go see your doctor or Physical therapist for an evaluation and customized treatment plan for you.

But know that there’s hope. Because I strengthen my glutes regularly now, I’m able to reduce my SI flare-ups to about 1-2x/year max and they usually only last a day or two now. Whereas when I was in my 20’s it occurred very frequently and would last a few weeks.

If you stay consistent with your exercises there’s hope. 🙂

Thanks for reading!

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