Sacroiliac (SI) Joint Injections

At Modal Pain Management in Midtown Manhattan, Dr. Alex Movshis performs image-guided sacroiliac (SI) joint injections as a diagnostic test and a treatment for one of the most commonly missed causes of chronic low back pain. 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). Imaging can’t reliably show whether the joint hurts, and the pain overlaps with lumbar disc, facet, and hip pain, so the diagnosis is often delayed. An image-guided injection of local anesthetic into the joint is the current reference-standard test. It is imperfect, because anesthetic can leak out of the joint and numb nearby structures, but it is the best test available (McCormick 2025). The same injection can deliver corticosteroid into the joint. At 369 Lexington Avenue, Floor 25, in NYC 10017, we follow the technique recommended in the 2025 multisociety SI joint guideline, developed under the American Academy of Pain Medicine and the American Society of Regional Anesthesia and Pain Medicine: image guidance, with fluoroscopy and contrast as the preferred method, and a small injection volume.

What the Sacroiliac Joint Is — and Why It Hurts

The sacroiliac (SI) joint is the junction between the sacrum (the triangular bone at the base of the spine, formed by the fusion of the lower five vertebrae) and the ilium (the wide, flat bone that forms the upper part of the pelvis). There is one SI joint on each side. The joint is small, powerful, and designed primarily for load transfer: it transmits force between the spine and the lower limbs and absorbs the shock of standing, walking, and running. The joint surfaces are irregular and interlocking, stabilized by one of the densest networks of ligaments in the body (the anterior sacroiliac, interosseous, dorsal sacroiliac, sacrotuberous, and sacrospinous ligaments). 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). These are the nerves radiofrequency ablation targets. They do not supply the whole joint, which is one reason ablation does not help everyone.

SI joint pain arises from three overlapping pathophysiologies. Mechanical pain from the joint or its ligaments is linked to pregnancy, trauma (a fall on the buttock, a motor vehicle accident, a heavy lift with rotation), leg length difference, and prior lumbar fusion (Cohen 2013). 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 — true inflammation of the SI joint driven by an underlying systemic inflammatory arthritis such as ankylosing spondylitis, psoriatic arthritis, or inflammatory bowel disease-associated spondyloarthritis — is less common but clinically important to recognize because it changes the entire treatment plan (patients need disease-modifying systemic therapy, not just local injections). Pain after lumbar or lumbosacral fusion is a third pattern. Fusion shifts load onto the SI joint, bone-graft harvesting from the pelvis can damage its ligaments, and some SI joint pain was missed before surgery (McCormick 2025). 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 cases (DePalma 2011). Image-guided SI joint injection is appropriate for all three patterns, though the long-term strategy differs.

The clinical picture has a typical shape, but no single feature proves the diagnosis (McCormick 2025). SI joint pain is usually one-sided and sits low in the back and buttock, often near the posterior superior iliac spine (the bony bump at the top of the buttock). It can spread into the thigh and, less often, past the knee. In 50 patients with injection-confirmed SI joint pain, 94% had buttock pain, 72% lower lumbar 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, though it calls for a careful look for a pinched lumbar nerve. Patients often report pain with prolonged sitting, standing up from a chair or car, rolling over in bed, stairs, or standing on one leg.

Clinical Evaluation — How We Confirm the SI Joint Before Injecting

At the consultation visit, Dr. Movshis performs a structured clinical evaluation designed to determine whether the SI joint is the dominant pain source, or whether the lumbar spine, the hip, or another structure is the primary driver. The evaluation uses provocation tests, maneuvers that stress the joint to see whether they reproduce your familiar pain. The best-known set is the Laslett cluster, six tests that Mark Laslett and colleagues compared against diagnostic injections (Laslett 2005). Later studies did not always match its accuracy (McCormick 2025). The tests are:

The thigh thrust test (also called the femoral shear test) — with the patient supine and the hip flexed to 90°, a downward force is applied through the long axis of the femur, loading the SI joint through the femoral head.

The distraction test — with the patient supine, posteriorly directed force is applied to the anterior superior iliac spines bilaterally, stressing the anterior sacroiliac ligaments.

The compression test — with the patient in side-lying position, a downward force is applied to the iliac crest, stressing the dorsal sacroiliac and interosseous ligaments.

The sacral thrust test — with the patient prone, a downward force is applied to the center of the sacrum, stressing the joint bilaterally.

The Gaenslen’s test — with the patient supine near the edge of the exam table, one hip is fully flexed and the other is passively extended off the table, stressing both SI joints in opposite directions. Laslett tested it on each side and counted each side as a separate test, which makes six.

The FABER (Patrick) test — with the patient supine, the hip is Flexed, ABducted, and Externally Rotated in a figure-four position, with downward pressure on the flexed knee. FABER is not one of Laslett’s six. It was part of the five-test cluster studied by van der Wurff 2006.

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, and when all six were negative the SI joint could be ruled out (Laslett 2005). In 60 patients checked against two diagnostic blocks, three or more positive tests out of five had a sensitivity of 85% and a specificity of 79% (van der Wurff 2006). 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). A normal lumbar MRI, a hip MRI that rules out intra-articular hip pathology, and the absence of true below-the-knee radicular symptoms strengthen the clinical picture.

Imaging is also reviewed. Plain pelvic X-rays and CT evaluate for sacroiliitis (erosions, sclerosis, joint space narrowing — seen in ankylosing spondylitis and other inflammatory arthropathies), pelvic asymmetry, and prior lumbosacral fusion. MRI of the SI joints with STIR sequences can reveal active inflammation (subchondral bone marrow edema) in inflammatory sacroiliitis. Laboratory workup — including HLA-B27, ESR, and CRP — is indicated when inflammatory arthropathy is suspected.

How the Procedure Works

The image-guided SI joint injection is performed in our in-office procedure suite under sterile conditions. The patient is positioned prone (face down) with a small pillow under the pelvis to flatten the lumbar spine and improve access to the SI joint. The skin over the posterior superior iliac spine and the lower SI joint is cleaned with chlorhexidine or povidone-iodine, and the surrounding skin is draped. A small amount of lidocaine is injected into the skin and subcutaneous tissue over the planned needle entry point — this initial numbing is the only meaningful sting most patients feel.

Under live fluoroscopic guidance — the gold-standard image-guidance technique for intra-articular SI joint injection — a small-gauge procedural needle (typically 22 gauge, 3.5 inches) is advanced through the posterior approach toward the lower part of the SI joint. The lower part is the synovial joint, with a true joint space. The upper part is held together mostly by thick ligament, which is why the lower entry point is the traditional target (McCormick 2025). Once the needle tip is positioned at the joint edge, a small amount of iodinated contrast (0.5–1 mL) is injected under live fluoroscopy. Confirmation of intra-articular spread — the characteristic arthrogram that outlines the curved, irregular contour of the SI joint space — is the critical safety check that confirms correct placement before the therapeutic injectate is delivered. Without imaging, the joint is usually missed. In Rosenberg 2000, CT showed that the injection reached the joint in only 8 of 37 patients (22%) without image guidance, and 24% spread into the spinal canal. The 2025 multisociety guideline recommends against intra-articular SI joint injections without image guidance, at its highest grade (McCormick 2025).

Once intra-articular placement is confirmed, the injectate (0.5% bupivacaine, a long-acting local anesthetic, mixed with 40 mg of triamcinolone or an equivalent long-acting corticosteroid) is slowly injected. We keep the total volume in the joint, contrast included, at no more than 2.4 mL, inside the 2.5 mL limit the 2025 guideline recommends to avoid rupturing the capsule and spreading anesthetic to nearby nerves (McCormick 2025). The local anesthetic provides the diagnostic signal, measured as pain relief during the hours it works. The corticosteroid provides the slower, longer-lasting therapeutic effect.

Ultrasound-guided SI joint injection is an alternative in selected cases, particularly for periarticular injections that target the dorsal sacroiliac and interosseous ligaments rather than the joint space. Ultrasound avoids radiation, which matters in pregnancy, and the 2025 guideline suggests it when radiation or contrast is a problem (McCormick 2025). It is less precise for getting inside the joint. In a randomized trial of 120 patients, ultrasound-guided injections reached the joint 87% of the time versus 98% under fluoroscopy, though pain relief at 2 and 12 weeks was similar (Jee 2014). Ultrasound accuracy also improves with the operator’s experience (Pekkafahli 2003). Modal Pain selects the imaging modality based on the clinical target, the patient’s anatomy, and the published evidence for each specific indication.

The total procedure time is 15–25 minutes from skin prep to injection completion. After the injection, the patient is observed for 15–20 minutes in the recovery area, given a structured pain diary, and discharged home with post-procedure instructions.

The Evidence Base

Research on SI joint injections goes back three decades, and much of it is small. The early prevalence studies used diagnostic injections as the test. Schwarzer et al. 1995 gave a single anesthetic injection to 43 patients with chronic low back pain centered below L5-S1, and 13 (30%) got substantial relief. Maigne et al. 1996 used two separate blocks: 19 of 54 patients responded to the first, but only 10 (18.5%) were confirmed by the second. That gap shows how often a single block gives a false positive. A systematic review put the false-positive rate of single uncontrolled SI joint blocks at about 20% (Simopoulos 2012). The 2025 multisociety guideline puts the prevalence at 15–30% of chronic low back pain felt mainly below L5 (McCormick 2025).

The evidence that steroid injections relieve SI joint pain is real but limited. Systematic reviews rate it as limited or poor: “poor” in Hansen 2012, “limited” in the 2013 ASIPP guidelines, and Level III to IV in the Simopoulos 2015 systematic review. The best controlled data come from inflammatory sacroiliitis: in a small double-blind trial, 5 of 6 steroid-injected joints had more than 70% relief at one month, versus 0 of 7 placebo joints (Maugars 1996). In an uncontrolled series of 39 patients with block-confirmed SI joint pain without spondyloarthritis, two-thirds had relief beyond 6 weeks, averaging 37 weeks (Liliang 2009). In a randomized trial of 51 patients with SI joint-related leg pain, the injection succeeded in 50% at 6–12 weeks, versus 72% for manual therapy (Visser 2013). The 2025 multisociety guideline, the most recent evidence review, found low-certainty evidence that steroid injections into or around the joint relieve pain for at least a month in patients diagnosed by history and exam, with slightly stronger evidence for injections around the joint (McCormick 2025). Cohen 2005, a review in Anesthesia & Analgesia, noted that history, exam, and imaging cannot diagnose SI joint pain on their own, which is why the injection doubles as a test.

Image guidance matters for accuracy. Without it, only 22% of injections reached the joint on CT (Rosenberg 2000). Its effect on results is smaller: in a randomized trial of 125 patients, fluoroscopic and landmark-guided injections gave similar relief at one month, but fluoroscopy did better at three months, by about one point on a 10-point scale (Cohen 2019). In spondyloarthritis, CT-guided steroid injection into inflamed SI joints reduced both pain and the inflammation seen on MRI, with relief lasting about 9 to 10 months on average (Bollow 1996, Braun 1996). The 2025 multisociety guideline recommends image guidance for every intra-articular SI joint injection, with contrast to confirm placement under fluoroscopy (McCormick 2025).

For patients whose injection relief keeps running short, lateral branch radiofrequency ablation of the L5 dorsal ramus and the S1–S3 lateral branches is the next option. In a placebo-controlled trial of 28 patients, 79%, 64%, and 57% of treated patients had at least 50% relief at 1, 3, and 6 months, versus 14% of placebo patients at 1 month, but only 2 of 14 still had relief at one year (Cohen 2008). In a sham-controlled trial of 51 patients using cooled RF, 47% of treated patients versus 12% of sham patients met the success criteria at 3 months (Patel 2012). Hansen 2012 rated the evidence for cooled RF as fair. The large pragmatic MINT trial found a smaller benefit, 0.71 points on a 10-point scale at 3 months, below the 2-point difference its authors set as clinically important (Juch 2017). The 2025 guideline found that RFA helps for at least 3 months, and at least 6 months with techniques that reliably reach the nerves (McCormick 2025). Several major insurers classify SI joint RFA as unproven, so we check your plan’s policy before scheduling. The self-pay price is $1,500.

Who Is a Good Candidate — and Who Isn’t

Image-guided SI joint injection is the right procedure for several specific clinical scenarios and the wrong procedure for others. The consultation visit produces a clear yes/no/with-modifications answer for each patient.

The strongest candidates have chronic SI joint pain that has lasted 6–12 weeks or longer despite conservative care (physical therapy, anti-inflammatories, activity changes, an SI belt), with a picture that fits: one-sided pain low in the back and buttock, a positive provocation cluster, no signs of a pinched nerve, and a lumbar MRI that doesn’t explain the pain. Three groups deserve a mention. Pain that began during or after pregnancy is more likely to come from the ligaments around the joint (Cohen 2005), so a periarticular injection plus pelvic and gluteal physical therapy may fit better than an injection into the joint. Pain after lumbar fusion often comes from the SI joint (DePalma 2011), but steroid injections failed more often and wore off sooner in patients with a prior fusion (Liliang 2009). In inflammatory sacroiliitis, the injection can control symptoms while systemic disease-modifying therapy is adjusted.

The procedure is not the right first-line treatment for:

• Acute low back pain in the first 6 weeks. Conservative care comes first.
• Pain mainly below the knee in a nerve-root pattern, with numbness or tingling. A pinched lumbar nerve is more likely, and a lumbar epidural steroid injection is usually the better option.
• Pain with red-flag features: fever, weight loss, progressive weakness, numbness in the groin, or bladder or bowel changes. These need urgent workup, not an injection.
• Suspected infection of the SI joint, which is a medical emergency.
• Skin infection over the injection site.
• Blood thinning that is not under control.

Comparison vs. Other Low-Back Pain Treatments

Patients evaluating their options for chronic low back and buttock pain frequently want a side-by-side comparison of where SI joint injection fits on the broader treatment ladder.

Compared to lumbar epidural steroid injection: the two procedures target fundamentally different pain sources — lumbar ESI treats nerve-root pain from disc herniation, spinal stenosis, or lumbar radiculitis, while SI joint injection treats joint capsule and ligamentous pain from SI joint dysfunction. Patients with below-the-knee radicular symptoms, a positive straight-leg raise, and lumbar MRI showing nerve-root compression are lumbar ESI candidates. Patients with unilateral posterior superior iliac spine pain, a positive Laslett cluster, and unremarkable lumbar MRI are SI joint injection candidates. A significant number of patients have both — mixed lumbar and SI joint contributions — and a structured diagnostic workup (selective injections to each potential source) is the most reliable way to sort it out.

Compared to lumbar facet (medial branch) block: both target posterior-element low-back pain, but the anatomic targets are different. Lumbar medial branch blocks target the facet joints of the lumbar spine — typically L3–L4, L4–L5, and L5–S1 — and the pain pattern is usually midline or paramedian, worse with extension and rotation. SI joint pain is one-sided, centered over the posterior superior iliac spine and upper buttock, and worse with sitting and transitional movement (standing up from a chair). Patients with mixed facet and SI joint pain often benefit from sequential workup of each.

Compared to lateral branch radiofrequency ablation of the SI joint: the injection tests the joint and treats it for weeks to months. RFA aims for longer relief, at least 3 to 6 months in the 2025 guideline’s review (McCormick 2025), and is chosen for patients whose pain has been traced to the nerves behind the joint, usually with lateral branch blocks. The two procedures are sequential phases of the same treatment ladder, not competitors.

Compared to surgical SI joint fusion: surgical SI joint fusion, minimally invasive or open, uses implants 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 (McCormick 2025). 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. Risks include infection, hematoma, implant problems, and nerve pain in the leg (McCormick 2025), and the procedure can’t be undone. When fusion becomes a reasonable option, Modal Pain Management refers to orthopedic and neurosurgical spine surgeons in New York City.

Compared to physical therapy alone: structured physical therapy targeting the gluteus medius, the core, the pelvic floor, and the hip abductors is the foundation of SI joint management and should be ongoing regardless of what interventional procedures are performed. Injection and PT work together. The injection can bring pain down enough for productive PT, and PT works on the strength and movement problems that keep the joint irritated. The evidence for PT in SI joint pain is mostly indirect, borrowed from general low back pain research (McCormick 2025). In one small randomized trial of SI joint-related leg pain, manual therapy succeeded in 72% of patients, versus 50% for an injection and 20% for general physiotherapy (Visser 2013). The 2025 guideline rates the evidence for physical therapy and structured exercise as indirect and low certainty (McCormick 2025).

What to Expect: The Patient Pathway

The full pathway from initial consultation to therapeutic SI joint injection at Modal Pain Management typically runs 2 to 4 weeks for a new patient.

Initial consultation visit (45 to 60 minutes, and it may include an ultrasound exam). Dr. Movshis reviews your back and buttock pain history, prior imaging, prior treatments and responses, and overall medical context. A structured physical examination — including the full Laslett cluster, a lumbar spine exam, a hip exam, and a neurologic exam — sorts out the dominant pain generator and rules out referred pain. Imaging is reviewed. The diagnostic plan, the indications for SI joint injection, the expected response rates, the alternatives, and the cost and insurance picture are discussed in plain language. Most patients leave the consultation with a clear written plan.

Insurance authorization (7–14 business days). Our team submits the prior authorization request with documentation of conservative care, examination findings, and imaging. Coverage rules and relief thresholds vary by plan, and we check your plan’s policy.

Image-guided SI joint injection (15–25 minute procedure). Performed in our Midtown NYC office under live fluoroscopic or ultrasound guidance, usually without sedation. If you want sedation, it is done at a surgical center. You go home after a 15–20 minute observation period and record your pain in the pain diary for six to eight hours and the next morning. Plan for someone to drive you, because the leg on the injected side can be numb or weak for a few hours.

Follow-up visit (15 minutes, 2–3 weeks after the injection). The pain diary is reviewed and the response objectively measured. The diagnostic signal (relief while the anesthetic worked) is interpreted, and the therapeutic response since the injection is assessed. The long-term plan is updated — repeat injection on schedule, progression to lateral branch RFA, or escalation to surgical consultation — based on the clinical picture.

Ongoing management. Most patients transition to a structured gluteal/core physical therapy program after the injection, return for a repeat injection if and when pain recurs, and, if relief from injections keeps running short, move on to lateral branch blocks and RFA.

Recovery, Activity, and Return to Function

Most patients go back to their normal day after the injection. In a study of 191 fluoroscopically guided SI joint injections, 132 had follow-up about two days later. Of those, 12.9% had soreness at the injection site and 5.3% a temporary increase in pain, and side effects in the days afterward were more common in younger patients and after injections on both sides (Plastaras 2012). The leg on the injected side can feel numb or heavy for a few hours, so plan for someone to drive you home. The full aftercare instructions, including the interactive pain diary, leg numbness, why pain can feel worse, blood thinners, and the warning signs that need a call or an emergency room, are on the SI joint injection aftercare page, which also prints as a one-page sheet.

Insurance, Authorization, and Practical Logistics

Many commercial PPO plans cover image-guided sacroiliac joint injections for chronic low back or buttock pain, usually with prior authorization documenting how long the pain has lasted, the conservative care tried, exam findings that point to the SI joint, and a workup of other sources. Requirements, relief thresholds, and repeat limits vary by plan, and our office checks your plan’s policy. We handle the prior authorization on your behalf.

We accept most major commercial PPO plans (United Healthcare, Aetna, Cigna, BlueCross BlueShield, Oxford, Empire BCBS) and do not accept Medicare, Medicaid, HMO plans, or workers’ compensation. Out-of-pocket cost depends on your individual deductible and coinsurance — we verify benefits and provide a written estimate before the procedure. Visit our insurance verification page to check your plan, or call (646) 290-6660 for a benefits check.

For patients without coverage, or who prefer to self-pay, an SI joint injection is $700, listed on our self-pay pricing page.

Why Patients Choose Modal Pain Management for SI Joint Injections

Dr. Alex Movshis is double board-certified by the American Board of Anesthesiology in anesthesiology and pain medicine, and completed his pain medicine fellowship at Mount Sinai. He performs SI joint injections in our office under live fluoroscopic guidance with contrast confirmation, the method the 2025 multisociety SI joint guideline prefers, or under ultrasound when radiation or contrast is a concern. Patients who want sedation have the injection at a surgical center. We treat the SI joint injection as a structured diagnostic and therapeutic tool, not a one-off intervention: every injection is paired with a documented pain diary, a follow-up visit to objectively measure response, and a clear long-term plan that escalates to lateral branch radiofrequency ablation or refers to surgical colleagues when appropriate.

Our Midtown NYC office at 369 Lexington Avenue Floor 25 is one block from Grand Central Terminal, making it accessible from anywhere in the New York metro area. Same-week consultation appointments for new patients are typically available.

If you have chronic low back or buttock pain that has not responded to physical therapy and conservative care, unilateral pain centered over the posterior superior iliac spine, pain that is worse with sitting and standing up from a chair, or pain after pregnancy or lumbar fusion surgery that fits the SI joint pattern — image-guided SI joint injection may be the right next step. Learn more about the underlying condition on our SI joint pain page, or book a consultation to discuss whether you are a candidate.

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