SI Joint Pain (Sacroiliac Joint Dysfunction)

The sacroiliac (SI) joint is one of the most commonly missed causes of low back, buttock, and one-sided pelvic pain in adults, and one of the most rewarding to treat when the diagnosis is right. Modal Pain Management, at 369 Lexington Avenue in Midtown Manhattan and led by Dr. Alex Movshis, diagnoses and treats SI joint dysfunction and sacroiliitis with image guidance. We follow the 2025 multisociety SI joint guideline for the exam, the image-guided injection technique, and the treatment ladder, in a single-physician practice where the doctor who diagnoses you is the doctor who performs your procedure. If your pain has been called “low back pain” for months or years and conventional treatment has not worked, the SI joint is one of the first things we will rule in or rule out at your consultation.

SI Joint Pain Is Not Lumbar Pain: The Modern Paradigm

For most of the twentieth century, pain in the lower back and buttock was assumed to come from the lumbar spine: discs, nerve roots, and facet joints. The sacroiliac joints were dismissed as essentially immobile and incapable of generating significant pain. That view did not hold up.

The SI joint does move, though only a little. In a radiostereometric study of 25 patients, rotation averaged 2.5 degrees and translation 0.7 mm (Sturesson 1989). The back of the joint and its ligaments get their nerve supply from the lateral branches of the S1, S2, and S3 dorsal rami in over 90% of people, and from branches of the L5 dorsal ramus and S4 in more than half (McCormick 2025). Those nerves can carry pain when the joint capsule is stretched, the ligaments are strained, or the joint is inflamed.

The SI joint is the source of an estimated 15–30% of chronic low back pain felt mainly below the lowest lumbar vertebra (McCormick 2025). The early block studies set that range. A single anesthetic injection relieved 13 of 43 patients (30%) in one study (Schwarzer 1995), while two separate blocks confirmed only 10 of 54 (18.5%) in another (Maigne 1996). After lumbar fusion, the joint takes on more load. In one series of patients with persistent pain after fusion, the SI joint was the most common source found on diagnostic blocks, in 12 of 28 (DePalma 2011). History, exam, and imaging cannot diagnose SI joint pain on their own (Cohen 2005), and lumbar MRI says little about whether the SI joint hurts, so patients can spend months being treated for the wrong structure.

The Modal Pain Management approach inverts the default. When a new patient arrives with low back, buttock, or one-sided pelvic pain, we test for SI joint dysfunction at the consultation visit using provocation maneuvers (distraction, compression, thigh thrust, sacral thrust, Gaenslen’s test, and FABER), the Fortin finger sign, and a focused neurologic exam to separate SI joint pain from lumbar disc, facet, hip, and piriformis pain. When the picture fits, an image-guided diagnostic injection is scheduled, and its result guides the next step on the ladder.

Why It Hurts There: The Anatomy

The sacroiliac joints are paired, irregularly shaped synovial-amphiarthrodial joints between the auricular surface of the sacrum and the iliac portion of the innominate bone. Each joint is stabilized by a network of ligaments (the anterior sacroiliac ligament, the very strong posterior interosseous ligaments, the long posterior sacroiliac ligament, and the sacrotuberous and sacrospinous ligaments) and is acted upon by the lumbar multifidus, the thoracolumbar fascia, the gluteus maximus and medius, the biceps femoris, the latissimus dorsi (via the posterior oblique sling), and the abdominal obliques (via the anterior oblique sling).

Pain arises through several distinct mechanisms. Mechanical pain from the joint or its ligaments is linked to pregnancy, trauma (a fall on the buttock, a car accident, a heavy lift with rotation), leg-length difference, and prior lumbar fusion (Cohen 2013). A misstep that produces an unexpected single-leg load, or repetitive twisting in golf, tennis, hockey, and other rotational sports, can set it off. Ligamentous strain develops when the dorsal sacroiliac and interosseous ligaments are overloaded by leg-length difference, pelvic obliquity, or post-traumatic asymmetry. Pain from the ligaments outside the joint may be at least as common as pain from inside it, though the evidence is weak (McCormick 2025). Inflammatory sacroiliitis is an immune-mediated process driven by ankylosing spondylitis, psoriatic arthritis, IBD-associated arthritis, or reactive arthritis, and involves joint inflammation, bone marrow edema on MRI, and, over time, fusion of the joint. Septic sacroiliitis is rare but is a true emergency. It presents with fever, severe one-sided buttock pain, and raised inflammatory markers, and is seen most often in people who inject drugs, people with weakened immunity, and after childbirth. Pain after lumbar fusion develops as fusion shifts load onto the SI joint. Bone-graft harvesting from the pelvis can also damage its ligaments, and some SI joint pain was simply missed before surgery (McCormick 2025).

Pain from the SI joint spreads more widely than most people expect, which is one reason it is misdiagnosed. In 50 patients with injection-confirmed SI joint pain, 94% had buttock pain, 72% lower back pain, 50% leg pain, 28% pain below the knee, and 14% groin pain, and a few had foot pain (Slipman 2000). Pain below the knee does not rule out the SI joint, but it calls for a careful neurologic exam to look for a pinched lumbar nerve.

SI Joint Pain vs. Other Causes of Low Back, Buttock, and Groin Pain

The most clinically valuable thing a pain specialist can do at the first visit is identify which structure is producing the pain. The differential diagnosis for one-sided lower-back-and-buttock pain is broad, and the wrong-structure mistake is common.

Lumbar disc herniation and radiculopathy produce pain that follows a dermatomal pattern, often radiates below the knee into the calf or foot, and comes with numbness, tingling, weakness, or reflex changes. Pain typically worsens with sitting and improves with walking. The straight-leg raise test is positive. SI joint pain rarely produces true neurologic deficits.

Lumbar facet joint pain localizes beside the midline at the L4–L5 and L5–S1 levels and is reproduced by extension and rotation. It does not typically refer below the gluteal fold. A diagnostic medial branch block makes facet pain likely when it relieves enough of the familiar pain, by the threshold your insurance plan uses. If both lumbar facet and SI joint pain are present, sequential diagnostic blocks are used to sort out the contribution of each.

Hip osteoarthritis and femoroacetabular impingement (FAI) present with front-of-groin pain, a limp with a shortened stance on the painful side, restricted internal rotation, and a positive FADIR (flexion, adduction, internal rotation) test. SI joint pain can also refer into the groin, but hip pathology is reproduced by hip range-of-motion testing and shows on hip X-rays. When both are present, an intra-articular hip injection clarifies the relative contribution.

Piriformis syndrome presents with deep buttock pain that worsens with sitting and can produce sciatic-pattern leg pain, with a positive FAIR test (flexion, adduction, internal rotation of the hip while seated). The pain is typically deeper in the buttock than SI joint pain and is reproduced by pressing midway between the sacrum and the greater trochanter rather than over the joint itself.

Inflammatory sacroiliitis (ankylosing spondylitis, psoriatic arthritis, IBD-associated arthritis, reactive arthritis) presents with morning stiffness that improves with movement, alternating buttock pain, onset before age 45, a family history of spondyloarthritis, and often a raised CRP. Most people with ankylosing spondylitis carry the HLA-B27 gene marker, but so do many people without the disease, so the test supports the diagnosis rather than making it. MRI can show bone marrow edema next to one or both joints. Rheumatology referral and disease-modifying therapy are the foundation of care.

Hip labral tear produces deep groin pain and mechanical clicking or catching, and is reproduced by the FADIR test. MR arthrography is the most sensitive imaging study. Some patients have both labral and SI joint problems.

Greater trochanteric pain syndrome / hip bursitis presents with lateral hip pain over the greater trochanter, pain when lying on the affected side, and tenderness with single-leg stance. It sits in a different place than SI joint pain, but the two can coexist, and gluteal weakness feeds both.

Pelvic floor dysfunction can produce posterior pelvic and SI-region pain, especially after childbirth, and is assessed with an internal pelvic floor examination, usually by a pelvic floor physical therapist.

How SI Joint Pain Is Diagnosed

No single test confirms SI joint pain, and imaging alone is not diagnostic. The SI joint can be the pain generator in patients with normal MRI scans, and degenerative changes on imaging are common in adults without pain. Diagnosis comes from a careful history, a focused physical examination, and, when indicated, an image-guided diagnostic block.

The Fortin finger sign is a simple bedside clue. The patient points with one finger to the spot that hurts most. When the patient consistently points just below and inside the PSIS, the SI joint becomes more likely. It supports the diagnosis but does not settle it.

The provocation tests stress the joint to see whether they reproduce the familiar pain: distraction, compression, thigh thrust, sacral thrust, Gaenslen’s test on each side, and FABER (Patrick’s test). In Laslett’s study of 48 patients, three or more positive tests out of six had a sensitivity of 94% and a specificity of 78% against a diagnostic injection (Laslett 2005). In 60 patients checked against two diagnostic blocks, three or more positive tests out of a five-test set that included FABER had a sensitivity of 85% and a specificity of 79% (van der Wurff 2006). Those figures work out to a positive likelihood ratio of about 4. Other studies found lower specificity, and the 2025 guideline concluded that a negative cluster is better at ruling the SI joint out than a positive one is at ruling it in (McCormick 2025). When fewer than three tests are positive, the SI joint is unlikely to be the main source and other structures move up the list.

A focused neurologic exam excludes lumbar radiculopathy: straight-leg raise, dermatomal sensation, motor strength of L4 (tibialis anterior), L5 (extensor hallucis longus), and S1 (gastrocnemius and FHB), and reflexes (patellar at L4, Achilles at S1).

Imaging is used to exclude other diagnoses and to screen for inflammatory sacroiliitis. A pelvic X-ray and lumbar MRI are typical first studies. Dedicated SI joint MRI with coronal-oblique STIR sequences is the study of choice when inflammatory sacroiliitis is suspected, because it can show bone marrow edema before structural changes appear. CT is reserved for evaluating fusion, erosion, or post-traumatic anatomy.

The diagnostic image-guided SI joint injection is the reference-standard test when the clinical picture is uncertain or when interventional treatment is being considered. It is imperfect, because numbing medicine can leak out of the joint and numb nearby structures, but it is the best test available (McCormick 2025). A small dose of numbing medicine is placed into the joint under X-ray or ultrasound guidance. If your usual pain drops substantially while the medicine is working, the SI joint is a likely pain source. How much relief counts as positive follows your insurance plan’s policy, from at least 50% in the 2025 guideline to 75% or more in some insurers’ policies (McCormick 2025). One positive block can mislead: a systematic review put the false-positive rate of single uncontrolled SI joint blocks at about 20% (Simopoulos 2012).

The Image-Guided Treatment Ladder

SI joint pain responds best to a stepwise approach. The right step depends on how long the pain has lasted, whether it is mechanical or inflammatory, and how it has responded to prior treatment. At Modal Pain Management, we walk through this ladder with each patient at the consultation visit and set the order based on the diagnostic findings.

Step 1 — Structured physical therapy and load management. Many cases of recent-onset mechanical SI joint pain (after pregnancy, an injury, or overuse) settle with a 6–12 week course of targeted physical therapy. The evidence for physical therapy in SI joint pain is mostly indirect, borrowed from general low back pain research (McCormick 2025), but the approach is low-risk and addresses the drivers. The usual components are pelvic alignment work (Mulligan techniques and muscle energy techniques), gluteus medius and maximus strengthening (single-leg bridges, side planks, monster walks), lumbar multifidus activation, deep hip external-rotator strengthening, oblique sling activation, and postural and ergonomic correction. Sleep position changes (a pillow between the knees when lying on your side), avoiding prolonged single-leg standing and asymmetric loading, and a graded return to activity matter too. An SI belt can ease symptoms in pregnancy-related and acute post-injury SI joint pain. We coordinate care with Modal’s in-house physical therapists, on the same floor.

Step 2 — Image-guided SI joint injection. When pain has lasted longer than 6–8 weeks, interferes with sleep or work, or has not improved enough with physical therapy, an image-guided SI joint injection is the next step. It is done under fluoroscopic or ultrasound guidance because the joint is deep and its opening is narrow and oblique. Without imaging, CT showed the injection reached the joint in only 8 of 37 patients (22%) (Rosenberg 2000). In a randomized trial, injections reached the joint 98% of the time under fluoroscopy and 87% under ultrasound (Jee 2014), and ultrasound accuracy improves with the operator’s experience (Pekkafahli 2003). A long-acting corticosteroid is combined with a small volume of local anesthetic. The procedure takes 15–25 minutes, and there are no activity restrictions afterward. The evidence for the steroid’s effect is real but limited. Systematic reviews rate it as limited or poor (Hansen 2012), and the 2025 multisociety guideline found low-certainty evidence of relief for at least a month (McCormick 2025). In an uncontrolled series of 39 patients, two-thirds had relief beyond 6 weeks, averaging 37 weeks (Liliang 2009). The numbing phase doubles as the diagnostic test. A positive joint injection points to the SI joint, but it does not reliably predict how well ablation will work. Before ablation, blocks of the small nerves behind the joint are often used, because they numb the same nerves the ablation treats (McCormick 2025).

Step 3 — Radiofrequency ablation (RFA) of the lateral branches. If injection relief keeps fading, SI joint radiofrequency ablation of the L5 dorsal ramus and the lateral branches of the S1, S2, and S3 dorsal rami is the next step, usually after diagnostic blocks of those nerves. The self-pay price is a flat $1,500 per session. Insurance coverage varies by plan and is decided case by case, so our office checks your plan’s policy before scheduling. The procedure quiets the nerves that supply the back of the joint and its ligaments while leaving leg strength intact. Because the sacral nerves vary in position from person to person, technique matters. Cooled RFA and bipolar strip lesioning both make large lesions that can catch the variable sacral nerves, and the 2025 guideline favors large-lesion techniques (McCormick 2025). Cooled RFA has the most randomized trials (Cohen 2008, Patel 2012, Cohen 2024). No trial has compared it head to head with conventional RFA. In the first sham-controlled trial, 79%, 64%, and 57% of treated patients had at least 50% relief at 1, 3, and 6 months, versus 14% with sham at 1 month (Cohen 2008). In people who respond, relief commonly lasts about 6 months to a year. The evidence is not one-sided. A large pragmatic trial without a sham procedure found a benefit of 0.71 points on a 10-point scale at 3 months, below its own threshold for a meaningful difference (Juch 2017), and a 2026 meta-analysis found only small effects against sham, with low certainty (Truong 2026). The procedure is done under fluoroscopic guidance with local anesthetic, usually without sedation. Patients who want sedation have it at a surgical center. Normal daily activity resumes within 24–48 hours, and a temporary flare of soreness in the first one to two weeks is common. The treated nerves slowly grow back, so relief usually fades within months to about a year (Cohen 2008). The procedure can be repeated. In one clinic’s records, a repeat treatment gave relief at least as long as the first (Kurklinsky 2020).

Step 4 — Minimally invasive SI joint fusion referral. For severe, refractory SI joint pain, minimally invasive SI joint fusion uses implants placed through a small incision to stop motion between the sacrum and the ilium. The 2025 guideline rates the evidence as weak: two pragmatic randomized trials of the minimally invasive lateral approach were positive, but a sham-controlled trial was not. It reserves fusion for carefully selected patients with at least 6 months of pain, at least 12 weeks of failed conservative care, at least 3 of 6 positive provocation tests, other pain sources ruled out, and a positive response to two low-volume diagnostic injections into the joint (McCormick 2025). Risks include infection, implant problems, and nerve pain in the leg, and the procedure cannot be undone. We coordinate this referral with minimally invasive spine surgeons in New York City when the indication is clear.

A parallel track for inflammatory sacroiliitis. When the clinical picture, lab work (HLA-B27, CRP, ESR), and MRI suggest inflammatory sacroiliitis (ankylosing spondylitis, psoriatic arthritis, IBD-associated arthritis), the foundation of care is rheumatology co-management with disease-modifying therapy, such as TNF-alpha inhibitors or IL-17 inhibitors. An image-guided steroid injection can still help a flare. In a small double-blind trial in spondyloarthritis, 5 of 6 steroid-injected joints had more than 70% relief at one month, versus 0 of 7 placebo joints (Maugars 1996). The underlying immune disease must still be treated systemically. We refer to and co-manage with rheumatologists in the Midtown and Upper East Side area.

Physical Therapy and Self-Care

The most important thing a patient with SI joint pain can do is build and maintain pelvic stability through targeted exercise. The exercises that matter most activate the gluteus medius and maximus (which control single-leg stance and pelvic drop), the lumbar multifidus (which provides segmental spinal stability), and the deep hip external rotators (which control the position of the femur in the socket). A typical program builds from isometric activation to strengthening to functional, sport-specific loading over 8–12 weeks.

Specific home strategies include: sleeping on your side with a pillow between the knees to keep the pelvis neutral, avoiding prolonged single-leg standing (no “hip-hanging” while waiting in line), avoiding sitting cross-legged for long periods, using a wedge cushion or a sit-stand desk to break up prolonged sitting, addressing a leg-length difference with a heel lift if the exam confirms one, and using an SI belt during pregnancy or for the first weeks of an acute flare.

Heat is generally more useful than ice for chronic SI pain because it relaxes the surrounding back and gluteal muscles. Ice is more useful in the first 48 hours after a clear acute injury. NSAIDs can help for short courses but should not become a long-term strategy because of the stomach, kidney, and cardiovascular risks of chronic use.

When SI Joint Pain Is an Emergency

Most SI joint pain is not dangerous, but several presentations need same-day or emergency evaluation:

• Fever with severe one-sided sacroiliac pain: concerning for septic sacroiliitis, particularly in people who inject drugs, people with weakened immunity, after childbirth, or after a recent invasive procedure. Inflammatory markers (CRP, ESR), blood cultures, and dedicated SI joint MRI are urgent.
• New bowel or bladder dysfunction or saddle (perianal) numbness: concerning for cauda equina syndrome. Call 911 or go to the nearest emergency room.
• Unexplained weight loss with night pain that does not change with position: concerning for cancer. Urgent imaging and workup.
• Pain with inflammatory eye symptoms (uveitis), psoriasis, IBD, or a family history of ankylosing spondylitis: suggestive of inflammatory spondyloarthritis. Same-week rheumatology evaluation.
• Severe, sudden pelvic pain after trauma: a pelvic fracture must be excluded, particularly in people with osteoporosis. Emergency pelvic imaging.

Why Modal Pain Management for SI Joint Pain in NYC

We do three things deliberately. First, we examine for the SI joint in every patient who presents with low back, buttock, or one-sided pelvic pain. The provocation tests, the Fortin finger sign, and the focused neurologic exam are completed at the consultation visit, so the likely pain generator is identified before any procedure is offered. Second, we use image guidance for every SI joint injection, fluoroscopic or ultrasound, because without it an injection reached the joint in fewer than 1 in 4 patients in a CT study (Rosenberg 2000). Third, the doctor who diagnoses you is the doctor who performs your procedure. In a single-physician practice, there is no handoff to a fellow or a rotating proceduralist. Dr. Movshis personally performs every consultation, every injection, and every radiofrequency ablation.

Same-week consultation appointments are typically available at 369 Lexington Avenue in Midtown Manhattan. Image-guided injection, when indicated, is scheduled at the same office once insurance authorization is in place. Most commercial PPO plans are accepted, and benefits verification is free and done before your visit.

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