What is SI joint pain?

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 are common causes of SI joint pain?

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.

Where does it hurt?

In most cases of SI Joint pain, the patient will report low back pain. To be specific, they will point directly to the PSIS on the pelvis on the painful side. Normally only one side will be painful. Sometimes they will have associated glute pain and hip problems too. But, even your low back can cause glute pain. Because of this, it’s possible to feel the pain in other parts of your body. This is called referred pain. Understanding the root cause of your pain is fundamental to treating your pain in the long run & will decrease your dependence on painkillers or treatment that only addresses the symptoms.

What are common symptoms of SI joint pain?

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.

Can SI joint pain be treated?

Yes, SI Joint pain can be treated and with great results. Even better, many times it can be treated conservatively without needing injections, pain medications, or surgeries if you can address it early enough. The key to treatment is to solve the root cause of your pain so you can get the best results and a long-term outcome.

Some root causes of SI Joint pain can be:

• A decreased mid back range of motion
• Poor posture in sitting
• Lack of hip range of motion
• Postpartum or falls
• Weak hip and glute muscles
• Poor lifting biomechanics
• Overloading low back area
• Repeated bending forward at work
• Tight low back and hip joints
• Asymmetries across the pelvis
• Too much sitting
• Developing fear of pain and movement

If you have failed multiple treatment approaches already, your clinician missed the real root cause of your pain and was just chasing the symptoms. The pain or symptom is the effect, not the cause. What do I mean by this? Say your fire alarm goes off in your house. Its purpose is to protect you and make you aware that something is wrong, i.e., that there is a fire in your house. The “alarm” is like your pain (your body’s way of telling you something is wrong) and the “fire” is the root cause. When the fire alarm goes off, you don’t run upstairs and just turn it off, right? You run through the house with the fire extinguisher, trying to find the room where the fire is at. You try to find out what caused the alarm to go off so you can put it out. Once the fire is out, then the fire alarm can go off. Solve the “root” cause of your pain, and then the pain (“the effect”) eventually goes away.

Additionally, there is a common root cause which many clinicians misdiagnose. They treat the low back pain with a cookie cutter approach, hoping it will work and treat it as a simple muscle problem. They tend to rely on stretching, ultrasound, massage, and focus treatment directly on the low back area. However, often the root cause is missed and the symptoms return. So many healthcare clinicians treat pain like this and thus show poor treatment outcomes which results in the pain coming back. Why? They missed the root cause of your SI Joint pain. This is also the case when patients turn to injections, nerve blocks and other surgeries which are still not effective because the actual problem still is not solved, their treatment was just chasing the pain.

The first step in treatment is to identify the root cause of your pain. A specific and individualized treatment approach for your type of pain can lead to a successful outcome for you and resolve your symptoms for the long term. This is why you can’t rely on a standard cookie cutter approach; you need a customized and individualized treatment approach specifically for your type of chronic SI Joint pain.

“Dr. Miller’s diagnosis was ischial-gluteal tendinopathy, stemming from trauma to the sciatic nerve and my SI joint during my biking accident. Three years of scarring was fixed […] just in time for me to run my first half marathon, and I beat my ideal time by almost twenty-five minutes! He is an expert at his profession, and honestly cares about his patients.“

Jerilyn T.
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What happens if it goes untreated?

Minor case – If it is a minor case of SI Joint pain, research shows that many acute cases of pain may spontaneously go away in 4-8 weeks. The SI Joint is tough at first because you need to solve whether the pain is coming from the low back, SI Joint, or hip. Once this is figured out then you will get the results you want. But, you still need to solve the root cause of your specific pain. But who wants to wait 8 weeks to get pain free? Let’s try to solve the root cause of your pain in 2-3 weeks and address all of the risk factors present (so it never returns!) and get you back to your favorite activities faster! We still recommend that you get it checked out by a one of our board-certified physical therapists to ensure that it is just a minor case, to solve all risk factors, and to get the optimal outcome in the fewest visits needed. Most minor cases resolve on their own in time, or get better with some stretching and strengthening. But, the sooner you take action, the sooner you are pain free. (And research supports this!)

Severe case – If it’s more of a severe and chronic case of SI Joint pain, your pain will probably start to worsen and increase because the root cause of the pain is not being treated. These cases do take 1-3 months to resolve Many people turn to pain medication and injections at this time but this only blocks the pain for short term. You may not feel the pain when taking pain medications, but the underlying problem is still there. Many people say after the pain medication is stopped, then usually the pain returns and sometimes it returns even worse. This is when you may experience chronic low back muscle pain, radiating pain into your buttock region, groin, and hip. Sitting, bending forward, lifting, getting in/out of a car, and driving all increase your pain now and cause the pain to radiate into your butt and hip. If the SI Joint pain continues to worsen, you may start experiencing more radicular symptoms into your leg just like sciatica. You may have sharp groin and hip pain starting too. Identifying risk factors and the direction of the rotation is crucial for treatment. Even though in many cases, it’s more chronic now, we can still help. Once the root cause is addressed, then we can start decreasing your pain, regardless of how chronic and severe the pain is. This is the crucial first step. It just may take more time to recover from a chronic case. Usually with chronic and severe cases, the longer you have your pain and injury, the longer it takes to resolve.

What outcome can you expect from treatment?

As we’ve discussed, the first step is to solve the root cause of your SI Joint pain. This is the most essential step to plan a treatment specialized for you and your unique type of pain. Your root cause will guide your treatment and dictate what is the best way to treat your pain. This, along with identifying risk factors that may be predisposing you to have your pain and injury, will allow you to start getting pain free again. The next step is to start decreasing pain, modifying activities, and start addressing all of the impairments causing your pain which we discovered during your evaluation. With each session, pain should start to decrease and you should start to regain range of motion with less pain and symptoms. Any radicular and referred pain should resolve fast as well. At this point, we begin light and basic strengthening only if it does not increase pain. Treatment will consist of  a lot of manual therapy and light exercises.

The next step is to achieve full range of motion, (which should correlate to being pain free) and now we can start progressive strengthening. Strengthening the muscles is crucial and research shows that this gives you the best long-term outcome! As you start to get stronger and maintain your mobility, your pain will continue to decrease if it is not already gone. Your increased strength will allow you to perform more activities and prevent flare ups. This usually does take up to 4 weeks. As you clear our goals, then we can start easing you back into sport, golf, running, and whatever your favorite activities are. This is when we start winding down treatments and getting you back into functional strengthening, sport specific training, return to run programs, golfing, and whatever your goals are. At the end, we reassess everything, making sure we achieved all of our goals, your goals, that all risk factors are gone, and finalize your long term home exercise program. There are many factors which can influence your outcome, but 85-90% of our patients respond well to our treatment approach and achieve a successful outcome when completing their plan of care.

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.

Do you need an X-ray and MRI imaging for SI Joint pain?

For most common orthopedic cases, imaging is not needed and the diagnosis can be made with a simple physical therapy evaluation. No need to waste thousands of dollars on unwarranted diagnostic imaging. We also have clinical tests which we can perform to help rule in and rule out pathologies that correlate to MRI findings (which is WAY cheaper than an MRI!). An expensive MRI may just tell us what we already know. Also, often times the positive findings found on x-rays, MRIs, and EMGs may not actually be the root cause of your pain. What does that mean? Many positive findings on an MRI are also found in asymptomatic (pain-free) individuals, so diagnostic imaging may not be able to tell us what is actually causing your pain. For example: many people have a herniated disc in their low back but do not have any low back pain. So if herniated discs can cause no pain, just because someone with low back pain has a herniated disc does not mean that is what’s causing their pain. The key is to find out if your clinical evaluation findings during your evaluation at Pursuit match the MRI findings. If so, then we can decide what is the best way to treat it.

How can a Physical Therapist treat it?

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.

“After at least three years of doctor-hopping […] looking for someone to alleviate my constant dizziness and neck pain, I finally found Dr. Miller. I have more energy and less pain, and have halved my dependence on painkillers. He shouldn’t be the last stop on your road to recovery, he should be the first.”

Lisa B.
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How long does it take for recovery?

Recovery time for SI Joint pain depends on multiple factors:

• The severity and chronicity of your pain
• Whether your pain is an easy or complex case
• If the root cause of your pain was solved or if it was missed (this is the key to getting a great recovery!)
• How long you have been in pain for and when you need to be pain-free by
• Other therapies and treatments you have tried
• Which medical professional(s) you saw prior to seeing us
• How active you are in trying to resolve your pain
• Which treatment approach is chosen and if it is proven to work for your pain

There are many factors that influence your recovery time and every patient’s recovery time is different. If you do nothing and don’t pursue treatment, it could gradually get better on its own, you could continue to have the same pain persist, or it could continue to get worse. As stated earlier, most acute cases may or may not resolve in 4-8 weeks. If you get expert treatment that solves the root cause of your pain, some cases resolve in 1-3 weeks! Then you can get back to sports, exercise, and your favorite activities without flare-ups and recurrences. Some of our patients are pain-free in 1-3 visits and back to 100% in 2 weeks!

If it is a complex case with chronic pain, your recovery may take longer, but you can still get a good outcome. Some chronic cases can resolve as fast as 2 months but can take as long as 4-6 months. It varies with every patient because every case of SI Joint pain is different. Every patient’s recovery varies depending on the factors listed above. After a thorough evaluation here at Pursuit Physical Therapy, you will know your exact timeline of recovery, your prognosis, and when you should reach your goals.

How much does it cost?

The average cost of care for a case of spine pain in the US is $1800-$6600. This high price is due to many factors: the over-inflated cost of healthcare, the over expensive cost of unwarranted imaging (x-rays, CT scans, and MRIs) that is not needed, over-utilization of care (which increases the number of visits needed to be treated, requiring multiple visits to different doctors and physical therapists for the same diagnosis), and getting billed for unnecessary and unproven treatments that you don’t even need. All of these factors increase cost and this is why healthcare is so expensive. We strive to end that unnecessary, expensive cycle. In fact, we are currently publishing our first-year data with the University of Central Florida that shows the cost-effectiveness of our treatment approach.

This year, the average cost of our care was shown to be $814-$1141. Some of our patients get even as low as $315 for the full treatment! So if you have a deductible of $3,000-$10,000 and you have to pay out of pocket for your treatment, we can save you lots of money.

Remember, every case of pain is different and not all SI Joint pain is the same. It is hard to predict exactly how much your treatment is going to cost you. But after a thorough evaluation, we can tell you exactly what is causing your pain, how long it is going to take, what the best way to treat it will be, and exactly how much it is going to cost. We have no hidden fees, no co-pays, and no miscellaneous bills that you will be surprised by 3 months after you receive treatment. Your pain, your diagnosis, your goals, and what is best for you dictate your treatment and how much it will cost, and while it varies for every patient, treatment at Pursuit is still much more affordable than standard healthcare.

How long are sessions?

Our evaluations are always one-on-one with one of our board-certified specialists and 60-90 minutes long. We like to perform thorough evaluations so we can solve the root cause of your pain, identify all risk factors, and make sure that we do it right. After the evaluation, you will know your diagnosis, the root cause of why you have your pain and symptoms, your prognosis, an expected timeline of when you should see results, what the best way to treat your pain is, how much it will cost, and your expected recovery outcome. We want you to fully understand everything about your pain and injury. What is best for you and will get you the best outcome is what will dictate your care and treatment. There will be plenty of time for you to ask questions so we can make sure you fully understand why you have your pain and what the best way to treat it will be. After the evaluation is completed, all treatment sessions are 60 minutes going forward and still one-on-one with your physical therapist. You and your physical therapist will design a customized treatment plan that works for you and that will achieve your goals.

How can it 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.

What are the next steps?

Getting started is simple. The first step, and the key to getting you pain-free again is to solve the root cause or your case of pain. Remember, not all pain is the same. Your pain is different than someone else’s pain, even though it may be in the same area. If you’re ready to get pain free, give us a call at (407) 494-8835 or fill out the form below. The next step is to schedule your evaluation so we can solve the root cause for you. We’re happy to answer any questions you may have and we would love the opportunity to help you.