Sacroiliac (SI) joint pain originates from the joints connecting the spine’s base, the sacrum, to the pelvis’s large hip bones, the ilia. This condition typically presents as discomfort in the lower back and buttocks, sometimes radiating down to the hip, groin, or upper thigh. Because the symptoms can mimic other common ailments like a herniated disc or hip arthritis, accurately identifying the SI joint as the source of pain is often challenging. Effective treatment requires consulting different specialists, each offering a distinct approach to managing the condition.
Primary Care and Initial Diagnosis
The initial step in addressing lower back and buttock pain often begins with a primary care physician. Their primary function is to serve as the triage point, performing a preliminary evaluation of the patient’s symptoms and medical history. The provider will use physical manipulation tests, known as provocative maneuvers, to stress the SI joint and determine if it is a likely source of the pain.
These doctors are also responsible for ruling out other common causes of lower back pain, such as issues originating from the lumbar spine or hip joints. They may order initial diagnostic imaging, like X-rays of the pelvis, to check for structural changes or arthritis. Once they suspect SI joint dysfunction, their main role shifts to coordinating care and providing a referral to a specialist who can offer more targeted management.
Conservative Management Specialists
When SI joint pain is suspected, the next phase of treatment focuses on conservative, non-invasive methods, often led by specialists in rehabilitation. Physical Therapists (PTs) are at the forefront of this care, designing tailored exercise programs to address the underlying mechanical dysfunction of the joint. Physical therapy aims to stabilize the joint by strengthening the core and gluteal muscles.
Rehabilitation Medicine Physicians, also called Physiatrists, often oversee this conservative treatment plan, focusing on restoring function and reducing pain through non-surgical means. They utilize their expertise to manage pain medications and direct the PT’s efforts, especially in complex cases. Some patients may also seek care from Chiropractors, who use manual adjustments and mobilization techniques to address stiffness in the SI joint. Successful conservative treatment, which may include the use of a supportive pelvic belt, is a first-line approach and can resolve symptoms for many individuals.
Interventional Pain Management Providers
If conservative management, including physical therapy and medication, fails to provide lasting relief, the patient is typically referred to interventional pain management providers. These specialists, often Anesthesiologists or Physiatrists with fellowship training in pain, focus on minimally invasive procedures for both diagnosis and therapy. The gold standard for confirming SI joint pain is a diagnostic injection, where a local anesthetic is injected directly into the joint under image guidance. If the pain is temporarily relieved by the anesthetic, the SI joint is confirmed as the pain source.
Once the diagnosis is confirmed, therapeutic procedures can be pursued, including injecting corticosteroids alongside the anesthetic to reduce inflammation. For chronic pain that returns after injections, Radiofrequency Ablation (RFA) is an option, where specialized needles heat the sensory nerves that transmit pain signals from the joint. This procedure intentionally disrupts the nerve’s ability to send pain messages, potentially offering relief that can last six months to over a year. These interventional techniques are procedural in nature, distinguishing them from the exercise-based focus of conservative therapy.
Surgical Treatment Specialists
For a small percentage of patients whose chronic SI joint pain has failed to respond to conservative and interventional management, surgical treatment becomes the final consideration. The specialists who perform these procedures are typically Orthopedic Surgeons or Neurosurgeons with expertise in spinal and pelvic surgery. The standard surgical intervention is Sacroiliac (SI) joint fusion, also known as arthrodesis.
The goal of SI joint fusion is to eliminate the painful motion within the joint by permanently joining the sacrum and ilium bones together. This procedure is increasingly performed using minimally invasive techniques, which involve small incisions to insert metal implants across the joint to stabilize it. While this represents the end of the treatment pathway, fusion surgery is generally reserved for patients who have demonstrated significant, though temporary, pain relief from the diagnostic injection, confirming the joint as the primary pain generator.