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Physical Therapist's Guide to Sacroiliac Joint Dysfunction

Sacroiliac joint (SIJ) dysfunction is a lower back/pelvic condition that can result from joint stiffness (hypomobility) or slackness (hypermobility) at the sacroiliac joints in the pelvis. The condition can affect both men and women of all ages, but is more common in females. Symptoms typically are present on 1 side of the back, and affect 10% to 25% of patients with complaints of low back pain. Physical therapists design individualized treatment programs to address SIJ dysfunction based on the specific cause of each person's condition, and treatment goals.

What is Sacroiliac Joint Dysfunction?

The sacroiliac joint is a joint between the sacrum and the ilium, or pelvic bone. The 2 sides of the sacroiliac joint normally work together. If 1 side becomes stiff, they will not move together and this causes pain or muscle stiffness in the area. Pain is often made worse with walking and bending activities. It is also possible that 1 side may become too loose (lax) as well, resulting in SIJ dysfunction. This may occur during the menstrual cycle or pregnancy due to hormonal changes that cause the ligaments to become more lax. SIJ dysfunction can occur with injury, such as when a person falls and lands on 1 side of the body and alters the position of the joint, or when an athlete overtrains. Muscle imbalances and hip problems, such as hypermobility or dysplasia, may also lead to SIJ dysfunction. Sacroiliac pain is also related to some types of arthritis, such as ankylosingspondylitis, an inflammatory process most often affecting the lower back, which may cause the vertebrae to fuse.

How Does it Feel?

People with SIJ dysfunction may experience:

  • Pain that may be sharp, stabbing or dull, localized to 1 side of the pelvis/low back, groin, or tailbone.
  • Pain that may radiate down to the knee.
  • Pain with movements, such as standing up from a sitting position, turning in bed, or bending/twisting.
  • Muscle tightness and tenderness in the hip/buttock region.
  • Pain with walking, standing, and prolonged sitting.
  • Pain that is worse when standing and walking, and eases when sitting or lying down.

How Is It Diagnosed?

When you see your physical therapist, the therapist will ask you questions about your current condition, such as:

  • When did the pain start?
  • What happened to cause the pain to start?
  • Did you experience a fall or injury?
  • Have you experienced similar symptoms in the past?
  • Where is the pain located?
  • What specific movements/activities cause your pain?
  • Are you pregnant, or have you recently given birth?

Your physical therapist will then conduct a physical evaluation. Your therapist may examine the position of your spine, conduct strength tests of the hip, pelvic, and lower extremity muscles, and gently perform movement tests to assess your mobility and flexibility. Specialized tests will be performed to rule out any problems that may require other medical intervention. If further medical intervention is required, your physical therapist may refer you to a physician who specializes in SIJ dysfunction or other conditions that may be causing your symptoms.

Once SIJ dysfunction has been confirmed, your physical therapist will work with you to determine your personalized treatment program.

How Can a Physical Therapist Help?

Your physical therapist will design a targeted treatment program based on your evaluation and your goals for a safe return to sport or daily activities. Treatment may include:

  • Manual therapy. Often, manual therapy for SIJ dysfunction includes soft tissue release or massage for tight and sore muscle groups. Manual therapy and muscle energy techniques (MET) are used to correct pelvic/SIJ alignment. MET uses your own muscle contractions to realign the position of the pelvis, and can be a source of pain relief. Joint mobilizations/manual therapy uses gentle movements to improve mobility of the hip, SIJ, and low back.
  • Flexibility exercises. Stretching exercises may be prescribed to improve the flexibility of tight muscles. They may also help to improve movement in the spine and lower extremities, and help decrease stress at the sacroiliac joint during daily activities.
  • Strengthening exercises. Strengthening helps to improve the stability of the sacroiliac and spinal joints, which helps to reduce ligament strain and pain.These exercises are focused on weak muscles, including the lower abdominal, pelvic floor, and buttocks muscles.
  • Body mechanics. How you move and use your body for daily work and other activities can contribute to your SIJ dysfunction and pain. Your physical therapist will teach you how to improve your movements or body mechanics based on your specific daily activities. The physical therapist may also make recommendations to improve activities, such as sitting, or lifting and carrying objects.
  • Modalities. Hot and cold treatments are often prescribed to loosen up tight muscles prior to treatment, or to alleviate pain following exercise. Electrical stimulation uses electricity to target nerve fibers that send pain signals to the brain, and may also be used in conjunction with ice to provide pain relief.
  • Braces. Your physical therapist may also recommend wearing a sacroiliac belt, designed to provide support to the sacroiliac joints. It is used to provide stability during daily activities as your strength returns, and flexibility improves. This modality is especially helpful for pregnant women.

All treatments prescribed by the physical therapist will be based on your specific case.

Can this Injury or Condition be Prevented?

Fall prevention, the use of proper body mechanics (such as correcting your posture), and maintaining healthy activity levels are all ways that SIJ dysfunction may be prevented. Adhering to appropriate strength and flexibility programs can maintain muscle mobility and strength to keep the area stable when joint hypermobility is present. Your physical therapist can work with you to strengthen and stretch your joints and muscles to prevent conditions like SIJ dysfunction from occurring.

To prevent a recurrence of SIJ dysfunction after physical therapy treatment is completed, you will need to continue performing your home-exercise program. It is imperative that you do this to maintain your strength and flexibility. Improving and maintaining muscle strength will continue to provide stability for the sacroiliac joint and low-back ligaments after an injury.

Real Life Experiences

Jessica is a 29-year-old marathon runner who began experiencing low back pain a few months ago when training for a marathon. However, once she finished the training and the race, her pain subsided.

She is now 30 weeks pregnant, and her low back pain has returned. Jessica does not recall a particular instance that started the pain, but remembers waking up one morning feeling stiff after a 3-mile run the day before. She has now stopped running because of the pain.

She presents with complaints of a sharp pain in her right low back, which is worsened with sitting for greater than 10 minutes as well as standing after sitting.  She is not able to run because of her pain, and she has difficulty walking for more than 20 minutes. She also reports pain with any rotating movements, such as when rolling over in bed. Her inability to sit is limiting her job tolerance as a sales manager, and she is frustrated that she is not able to exercise as she would like to. She is not sleeping through the night, as she wakes every time she rolls over.

After listening to Jessica's history, her physical therapist performs a thorough evaluation. She assesses her posture and notices the right SIJ is rotated forward, causing the right leg to be slightly longer than the left. He asks Jessica to bend forward, backwards, and rotate her spine. She reports a lot of stiffness with the movements, and her pain increases with bending and twisting. She also feels tightness in her lower back, gluteal muscles, and right hip. Strength testing shows that Jessica is experiencing muscle weakness of her abdominal, pelvic floor, and buttocks muscles.

Her physical therapist performs some special tests for the sacroiliac joints. The tests reproduce her symptoms indicating SIJ dysfunction.

Jessica receives physical therapy treatment over the next 5 weeks. Treatment includes education for positioning and body mechanics to help with her sleeping, sitting, and driving positions to minimize her low back pain. Her physical therapist performs soft-tissue massage to improve Jessica's flexibility and movement and provide pain relief, as well as METs to correct her pelvic alignment. She designs a home-exercise program for her to build up her weak muscles and gently stretch her tight muscles, including heat and ice treatments before and after she exercises.

After 5 weeks of therapy, Jessica can sit through work meetings and serve customers with improved ease. She is also sleeping better at night, and is no longer waking up during the night due to back pain. She has not yet returned to running; however, she is able to walk for exercise now without any pain. She is happy with this ability, and has decided to return to running after her delivery.

Jessica returns to the clinic 2 months after giving birth for a reassessment, as she is ready to resume running and wants to prevent reinjury. She has continued to do strengthening exercises that focus on the lower abdominals as well as the gluteals, to maintain the strength she gained from physical therapy. She also has incorporated stretching for the legs and low back. Her strength and flexibility are normal. At this time, she was issued a return to run program. The program she was issued was a combination of a walk/run, which gradually decreased the walk time and increased the run time. She was educated to run every other day, allowing enough time for her body to recover in between each session. She was instructed to call with any questions or concerns as she progressed through the program.

She calls her physical therapist after the 4 weeks have been completed to report she has safely returned to pain-free running. Jessica has met all of her set goals, and is pain-free with all activity.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat SIJ dysfunction. However, you may want to consider:

  • A physical therapist who is experienced in treating patients with SIJ dysfunction. Some physical therapists have a practice with an SIJ dysfunction focus.
  • A physical therapist who is a board-certified clinical specialist or certified manual therapist, or has completed a residency or fellowship in Women’s Health or Orthopedic physical therapy. This person has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you are looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people who have SIJ dysfunction.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of sacroiliac joint dysfunction. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Foley BS, Buschbacher RM. Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment. Am J Phys Med Rehabil. 2006;85:997–1006. Article Summary on PubMed.

Bronlinson PJ, Kozar AJ, Cibor G. Sacroiliac joint dysfunction in athletes. Curr Sports Med Rep. 2003;2:47–56. Article Summary on PubMed.

Hansen HC, Helm S Jr. Sacroiliac joint pain and dysfunction. Pain Physician. 2003;6:179–189. Free Article.

Harrison DE, Harrison DD, Troyanovich SJ. The sacroiliac joint: a review of anatomy and biomechanics with clinical implications. J Manipulative Physiol Ther. 1997;20:607–617. Article Summary on PubMed.

Cibulka MT. The treatment of the sacroiliac joint component to low back pain: a case report. Phys Ther.1992;72:917–922. Free Article.

Ankylosing spondylitis. Mayo Clinic website. Accessed April 21, 2014.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Kristin Dryden, PT, DPT, OCS .  Reviewed by the editorial board.

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