The sacroiliac (SI) joint connects the spine’s sacrum to the pelvis’s ilium, acting as a load-transferring shock absorber between the upper body and the legs. Pain from this joint is a common cause of lower back, hip, and buttock discomfort, affecting 15% to 30% of patients with chronic low back pain. The deep, complex nature of the joint and overlapping pain patterns with conditions like sciatica make accurate diagnosis challenging. Managing SI joint pain requires a coordinated, multidisciplinary approach involving several specialists to identify the source of discomfort and provide effective treatment.
The Starting Point: Primary Care and Initial Screening
The journey for most patients begins with a Primary Care Physician (PCP), such as a Family Medicine or Internal Medicine doctor. Their initial role is to conduct a thorough history and physical examination to distinguish SI joint pain from other causes of low back pain. The PCP often performs specific physical maneuvers, known as provocation tests, to reproduce pain in the SI joint, helping create a presumptive diagnosis. After initiating conservative management, such as a brief course of nonsteroidal anti-inflammatory drugs (NSAIDs), the PCP provides the appropriate referral to a specialist for definitive diagnosis and comprehensive treatment.
Non-Surgical Specialists for Comprehensive Management
Once other causes of back pain are ruled out, patients are often referred to non-surgical specialists who manage the bulk of conservative SI joint care.
Physiatrists (PM&R)
Physiatrists, or doctors of Physical Medicine and Rehabilitation (PM&R), specialize in restoring function and are experts in musculoskeletal and nerve-related disorders. A physiatrist provides an in-depth, non-surgical diagnosis and prescribes a comprehensive rehabilitation plan, sometimes including prescription medications or bracing.
Physical Therapists (PTs)
Physical Therapists (PTs) are fundamental to conservative management, focusing on correcting biomechanical issues that contribute to SI joint stress. Their treatment involves targeted exercises designed to stabilize the joint by strengthening surrounding muscles, particularly the core and gluteal muscles. They also use manual therapy techniques to improve joint mobility and correct movement patterns that may be causing excessive shear forces across the joint.
Chiropractors
Some patients also benefit from the expertise of Chiropractors, who use manual adjustments or manipulations to address alignment issues in the spine and pelvis. This care is often used in conjunction with physical therapy to ensure the SI joint and surrounding structures are moving optimally. The goal of these non-surgical professionals is to provide long-term pain reduction by improving the mechanical stability and function of the joint complex.
Advanced Pain Management and Interventional Procedures
When conservative methods fail, the next step involves specialists focused on interventional procedures, such as Pain Management Specialists or Interventional Radiologists. These physicians utilize image-guided techniques to confirm the diagnosis and deliver prolonged pain relief. The gold standard for definitive diagnosis is a diagnostic injection, where a local anesthetic is precisely injected into the joint under fluoroscopic or CT guidance.
A significant reduction in pain following this injection confirms the SI joint as the primary pain source. Therapeutic injections, combining a corticosteroid with a local anesthetic, are performed to reduce inflammation within the joint. For patients with recurring pain after temporary relief from injections, Radiofrequency Ablation (RFA) may be performed. RFA uses heat to lesion the small nerves that transmit pain signals from the joint, offering relief that can last for six months or longer.
Surgical Options and the Role of Surgeons
Surgery is reserved as a treatment of last resort, considered only after all conservative and interventional therapies have failed to provide lasting relief. The surgical specialists involved are typically Orthopedic Spine Surgeons or Neurosurgeons, who specialize in procedures that stabilize the connection between the spine and the pelvis.
The primary surgical intervention for chronic SI joint pain is Sacroiliac Joint Fusion (SIJF). This procedure involves placing implants across the joint, often minimally invasively, to encourage bone growth and permanently stabilize the joint. Criteria for fusion include a confirmed diagnosis via a positive response to a diagnostic injection and documented failure of at least six months of comprehensive non-surgical management. Surgical stabilization aims to eliminate painful motion within the joint, providing a definitive solution.