Sacroiliac joint pain: when low back pain comes from the pelvic joint

By Charbel Kortbawi DO, MSc.

Pain on one side, in the buttock or the low back, that can show up when getting up from a chair, and sometimes also during a long spell of sitting or standing. It sometimes runs down into the thigh, or further, which can lead to it being mistaken for sciatica. In some cases, the source is the sacroiliac joint, which connects the sacrum to the iliac bone of the pelvis.

Here is what current medical literature says about this pain, and the place osteopathy can take in its care.

What is sacroiliac joint pain?

The two sacroiliac joints connect the sacrum to the iliac bones. They move very little, in the order of 2 degrees in each of the three planes according to a review of the literature. According to the model this review describes, their stability relies on the shape of the joint surfaces, on very strong ligaments and on the tension of the surrounding muscles and fascia.

These ligaments appear able to transmit pain: an anatomical study of five human cadavers with no history of sacroiliac joint pain found nerve fibres containing pain-related neuropeptides (CGRP and substance P) in the anterior sacroiliac ligament and the interosseous ligament. The 2025 international consensus speaks of sacroiliac joint complex pain, joint and ligaments included. It estimates that this explains about 15 to 30% of chronic non-radicular low back pain located mainly below L5, in well-selected patients.

Three expressions are in use: sacroiliac dysfunction, a "locked" sacroiliac joint, and sacroiliitis. The first two refer, in everyday language, to so-called mechanical pain, related to movement and load, without the precise mechanism being established: "locked" is in fact an image that measurements do not confirm (see below). Sacroiliitis means inflammation of the joint, which can accompany an inflammatory rheumatic disease: it is a different situation, covered below.

A "locked" joint or a "shifted" pelvis: what the research shows

The idea of a shifted pelvis or a locked sacroiliac joint is widespread, but the available data cannot confirm it. For most mobility tests performed by palpation, agreement between examiners is slight to fair, with wide confidence intervals (2020 systematic review, 3 of 12 studies of sufficient quality). A 1998 study in 10 patients, with radiological measurement before and after, showed that manipulation normalised clinical tests of the sacroiliac joint without changing the position of the sacrum relative to the iliac bone, which the 2008 European guidelines recall. Its authors state that their results neither prove nor rule out a clinical benefit, and suggest studying the response of soft tissues instead.

These data therefore do not support the idea that manipulation puts a bone back in place: clinical trials instead assess its effect on pain and function.

What are the symptoms?

Pain is most often felt in the buttock, then in the low back, and sometimes in the groin: in a retrospective series of 50 patients relieved by a sacroiliac joint injection, 94% felt it in the buttock, 72% in the low back and 14% in the groin. Half (25 of 50 patients) also had leg pain, including 14 patients (28% of the total) below the knee. This can look like sciatica (see our differential diagnosis of sciatica).

In another study, in 81 patients referred for chronic low back pain, injection-confirmed sacroiliac joint pain was associated with one-sided pain, pain when rising from sitting (a sign also linked to disc-related pain) and at least three positive provocation tests. Being able to point with one finger to a precise spot near the posterior superior iliac spine, the bony prominence at the back of the pelvis, also points towards the sacroiliac joint. None of these signs is enough on its own to make the diagnosis.

What causes it?

No single cause is established, and most of the data are observational.

• Pregnancy and the postpartum period. About 20% of pregnant women have pelvic girdle pain, which includes the sacroiliac joint and the pubic symphysis (2008 European guidelines). In a Danish cohort of women with daily pelvic pain confirmed on examination (sacroiliac, pelvic girdle or pubic symphysis syndromes), 62.5% were pain-free within a month of delivery and 8.6% still had pain two years later. The outlook was worse when pain involved all three pelvic joints (21% still in pain at two years). See our page on osteopathy during pregnancy.
• Trauma and overload. In a series of 54 patients whose sacroiliac joint pain was confirmed by injection, 44% reported trauma (road accident, fall onto the buttocks), 21% a cumulative strain and 35% no trigger. In athletes, repetitive and asymmetric loading is often suggested, a link that is proposed rather than demonstrated.
• Lumbar surgery. After a lumbar fusion, the sacroiliac joint is a possible source of persistent pain: a systematic review of 12 observational studies, of low to moderate quality and highly heterogeneous, reports a pooled incidence of 15.8%, higher when the fusion reaches the sacrum. These figures do not prove that surgery is the cause.

Imaging does not explain the pain on its own: among 373 pelvic CT scans of people with no history of low back or pelvic pain, 65.1% showed sacroiliac joint degeneration (substantial in 30.5%), and up to 91% in the oldest people.

How is it diagnosed?

There is no single test. The diagnosis rests on the history of the pain, a battery of provocation tests (distraction, compression, thigh thrust, Gaenslen's test, sacral thrust) and a search for other causes. No single one of these tests is informative both when positive and when negative (2023 systematic review): they are therefore combined, most often requiring at least three positive tests. With an assumed prevalence of 20%, the probability of sacroiliac joint pain rises to about 35% if the battery is positive and falls to about 8% if it is negative (2021 meta-analysis of 5 studies, certainty of evidence judged very low). These tests are therefore mainly useful to rule the sacroiliac joint out: a positive battery is not enough to confirm it.

A controlled anaesthetic injection into the joint (two successive blocks) remains the reference, but a single block is imperfect. In a series of 54 pre-selected patients, 19 responded to a first block and only 10 were confirmed by a second, and a 2012 systematic review puts the false-positive rate of a single block at about 20%. The examination therefore relies on the whole picture and seeks to tell the sacroiliac joint apart from a disc herniation with sciatica, lumbar facet joint pain, hip disease or piriformis syndrome. The medical diagnosis is a matter for the doctor: the osteopath carries out a clinical assessment to decide whether to treat and refers you to a doctor if needed, who will judge the value of a specialist opinion or imaging.

Mechanical pain or inflammatory sacroiliitis: do not confuse them

Sacroiliitis is inflammation of the joint, which can accompany axial spondyloarthritis and is a matter for a rheumatologist. Axial spondyloarthritis affects about 1 to 5% of people consulting for chronic back pain (over 3 months): from 0.7% to 5.3% depending on the criteria in a British general practice study, about 5% according to a 2020 review.

An inflammatory origin is suggested by onset before age 40, gradual onset, night pain, improvement with exercise and no improvement with rest. These five criteria were validated in patients with chronic back pain seen by rheumatologists: having at least four matched the rheumatologist's judgement (inflammatory-type back pain) with a sensitivity of 80% and a specificity of 72% in a cohort of 648 patients. They point towards a rheumatology opinion; they cannot establish a diagnosis, and not meeting four criteria does not rule out an inflammatory origin: if in doubt, talk to your doctor. The British NICE guidelines advise this opinion when back pain started before age 45 and has lasted more than 3 months, with at least 4 criteria from a list of 9 (for example waking in the second half of the night or improvement within 48 hours of anti-inflammatories).

MRI is not decisive on its own: in one study, 23% of healthy volunteers and 4 of 7 women with postpartum back pain had MRI findings that define sacroiliitis according to ASAS (the Assessment of SpondyloArthritis international Society).

The role of manual therapy and osteopathy

For sacroiliac joint pain, the specialist guidelines generally place non-invasive care before injections, radiofrequency or surgery, without being unanimous that this step is mandatory. The 2025 international consensus specifies that the evidence for this care is limited and mostly indirect, extrapolated from low back pain. The American Society of Pain and Neuroscience (2024) asks that conservative care be properly carried out before any injection or surgery.

For back pain in general, the French Haute Autorité de Santé (2019) makes physical activity the main treatment. It ranks manual techniques (manipulation, mobilisation) among the "possible" options (grade B, second line), provided they are part of a combination of treatments that includes supervised exercise; its recommendations are addressed to all professionals who care for low back pain, osteopaths included, without evaluating osteopathy as a discipline. The American College of Physicians (2017) lists spinal manipulation among the non-drug treatments to choose first (low-quality evidence for it). The WHO (2023) states that it may be offered in chronic primary low back pain, by trained and credentialled professionals (conditional recommendation, very low-quality evidence). The British NICE suggests considering it alongside exercise. These texts concern low back pain in general, not the sacroiliac joint.

For manipulation of the sacroiliac joint itself, the guidelines remain reserved: the 2025 consensus judges the evidence for the effectiveness of chiropractic treatment insufficient (grade I), and the 2008 European guidelines on pelvic girdle pain, whose treatment analysis covered pregnancy and the postpartum period, found no controlled trial of manipulation or mobilisation, while accepting that they may be tried over a few sessions to see whether they relieve pain.

The trials, for their part, are favourable but limited. In a small Dutch randomised trial (51 patients with sacroiliac joint pain and leg pain), a favourable result (complete relief or lower average pain than at baseline) was obtained at 6 or 12 weeks in 72% of patients after two sessions of manipulation, against 20% with a guided exercise programme and 50% with a corticosteroid injection (15 to 18 patients per group): better than exercise, with no significant difference from the injection. A 2024 systematic review (16 trials, 11 pooled for pain and 8 for disability, the comparator being almost always an exercise programme) found a significant improvement in disability, but no significant reduction in pain, the confidence interval including zero: the effect on pain remains uncertain. Its authors judge the certainty of evidence low for disability and very low for pain, with high heterogeneity between trials. They consider that manual therapy appears to be a viable conservative option, to be confirmed by higher-quality trials.

In another small Iranian randomised trial (51 patients, no control group), the advantage appears to change over time: at 6 weeks, manipulation gave better results than exercise alone; at 12 weeks, exercise did; at 24 weeks, the three groups (manipulation, exercise, both combined) had all improved with no significant difference between them.

An osteopathic consultation combines an examination that looks for warning signs and refers to a doctor if needed, manual work on the sacroiliac joint, the pelvis, the lumbar region and the gluteal muscles, then activity advice and suitable exercises. As trials specific to the sacroiliac joint are few and short (mean follow-up of 6 weeks), it makes sense to build the manual technique into this overall programme rather than offer it alone. For sacroiliac joint pain, the trials concern manipulations and mobilisations performed by different professionals, and not osteopathy as such; only the studies carried out during and after pregnancy explicitly evaluate osteopathy. These data do not concern so-called visceral or cranial techniques.

During and after pregnancy, a 2017 meta-analysis of 8 trials of osteopathic treatment for low back pain (5 of them unpublished theses) concludes there is a possible benefit on pain, mostly against no treatment or usual care. Its authors judge the evidence moderate in quality during pregnancy (results varying widely between trials) and low in quality after delivery. In the largest trial (400 women), osteopathic treatment and a placebo treatment (an ultrasound device set to emit no waves) both limited the worsening of pain compared with usual care alone, with no significant difference between them.

Exercise, pelvic support belts and practical advice

Exercise has the largest number of trials, especially during pregnancy, with low to moderate-quality evidence: the 2015 Cochrane review, conducted in pregnant women, found that an 8 to 12 week programme reduced the number of women reporting combined low back and pelvic pain (4 pooled trials, results varying widely), with no difference for pelvic pain alone (2 group-exercise trials), and after delivery a trial of 81 women gave better results with supervised stabilising exercises than with physiotherapy without specific exercises. Outside pregnancy, the 2025 consensus judges the evidence indirect (grade C, low certainty).

A pelvic support belt can be tried for short periods to see whether it relieves pain, with no evidence supporting its use as a stand-alone treatment (2008 European guidelines). We found no controlled trial testing a sleeping position or a sitting posture for sacroiliac joint pain: the usual advice comes from clinical experience. It consists of breaking up long spells of sitting, staying active, and looking for the night-time position that reduces pain, for example on the side with a cushion between the knees.

Injections, radiofrequency and surgery

When conservative care is not enough, corticosteroid injections, radiofrequency of the joint's nerves or, as a last resort, surgical fusion are considered. Their levels of evidence are uneven and experts disagree. The 2025 consensus considers that corticosteroid injections can relieve pain for at least 4 weeks in well-selected patients, on a small number of trials (grade C, low certainty), and rates the effectiveness of radiofrequency for relief lasting at least 3 months as grade B (moderate to high certainty), whereas the BMJ guidelines (2025), developed for chronic spine pain including the sacroiliac joint, strongly recommend against radiofrequency and joint-targeted injections. For minimally invasive fusion, two open-label trials are favourable, but the only trial with sham surgery (63 patients) shows no superiority; the consensus proposes it only as a last resort. These options are discussed with the doctor proposing them.

When to see a doctor before any manual treatment

The Haute Autorité de Santé reminds practitioners that a medical diagnosis must precede any non-drug management of low back pain, and that screening for warning signs must stay in mind at every stage. For pain that is recent, unusual, worsening or not improving within 4 to 6 weeks, see your doctor. Certain signs also call for a medical opinion, sometimes urgently.

• Severe one-sided lumbo-gluteal pain, with or without fever. Infectious sacroiliitis is rare, but it is often diagnosed late: in a French series of 39 adults, the mean delay was 43 days, and only about 4 patients in 10 had a fever: its absence therefore does not rule out this cause.
• Urinary or bowel problems, loss of sensation in the perineum, leg weakness: go to the emergency department without delay. Cauda equina syndrome is rare (under 0.3% of presentations with low back pain according to a systematic review), but it is a surgical emergency.
• Major trauma, or pain in an older person with osteoporosis, even without a fall. A sacral fracture can occur after a minor knock or with no trauma at all: in a hospital series of 56 patients (mean age 80), 32% had had no trauma, and X-ray detected the fracture in only 2% of cases against 93% for MRI.
• History of cancer, unexplained weight loss, night pain that worsens at rest. A history of cancer is the warning sign that most increases the probability of a spinal tumour: about 7% in primary care and up to 33% in the emergency setting according to a BMJ review. Unexplained weight loss and night pain are not very specific on their own, but as a precaution each of these signs warrants a medical opinion.
• A picture suggesting an inflammatory origin (onset before age 40, night pain, improvement with activity), which calls for a rheumatology opinion.

Key takeaways

• Sacroiliac joint pain is most often described as mechanical (the pelvic joint and its ligaments), to be distinguished from inflammatory sacroiliitis or a rarer cause that call for a medical opinion. It is estimated to explain about 15 to 30% of chronic non-radicular low back pain located mainly below L5, in well-selected patients.
• No single test is enough: the diagnosis combines the history of the pain, a battery of provocation tests and a search for other causes.
• The joint moves very little and nothing shows that manipulation puts it back in place: manual treatment aims at pain and function.
• For the sacroiliac joint, specialist guidelines generally place non-invasive care first, on limited evidence, and the 2025 consensus judges the evidence for the effectiveness of chiropractic treatment insufficient.
• For back pain in general, the HAS ranks manual techniques among the possible options in second line (grade B), only combined with supervised exercise; the American College of Physicians and the WHO list spinal manipulation among many options, on low to very low-quality evidence.
• For the sacroiliac joint, trials of manual therapy are few and short, with an improvement in disability but an uncertain effect on pain: it fits into an overall programme with exercise.
• Urinary or bowel problems, loss of sensation in the perineum or leg weakness: emergency care without delay. Severe pain (with or without fever), major trauma, a history of cancer or an inflammatory picture: a medical opinion before any manual treatment.

Further reading

• Back pain as a whole: chronic low back pain and multimodal treatment of chronic low back pain
• Wider pelvic pain: chronic pelvic pain
• Exercises: back strengthening and back stretches

Frequently asked questions (FAQ)

Note on the sources of this article

This article summarises publications indexed in PubMed and health guidelines (HAS, NICE, WHO, American College of Physicians, international consensus statements on sacroiliac joint pain), listed in the Sources below. For sacroiliac joint pain, they concern manual techniques practised by different professions, and not osteopathy as such. It is intended for general information and does not replace a medical consultation.

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This article offers general information and does not replace a personalised consultation with a healthcare professional.