Sacroiliac Joint Dysfunction: Causes, Symptoms, and How We Can Help

All information in this blog is supported by peer-reviewed research, including a December 2025 international multispecialty consensus guideline. There is currently no dedicated NICE guideline for this condition, so current evidence is used throughout. Reference numbers appear throughout, with the full list at the bottom of the page.

What Is Sacroiliac Joint Dysfunction?

The sacroiliac joints (SIJ) connect the base of the spine to the pelvis on either side, and dysfunction here is a genuinely significant and often under-recognised cause of lower back and buttock pain. SIJ complex pain affects between 15% and 30% of patients with chronic mechanical low back pain below the L5 level, making it a meaningfully common, if frequently overlooked, contributor to persistent back pain. ¹

Pathophysiology involves disruption of the ligamentous support around the joint, altered load transfer through the pelvis, and pain signalling activated within the joint capsule and surrounding structures. ²

Common Signs and Symptoms

Sacroiliac joint dysfunction has a genuinely varied clinical presentation, frequently mimicking lumbar discogenic pain, intra-articular hip pathology, or a wide number of other musculoskeletal pain syndromes of the posterior pelvis. ¹ This makes it one of the more diagnostically challenging conditions in musculoskeletal practice, and one of the most commonly misattributed.

Pain is typically localised to the buttock region and may be accompanied by numbness, tingling, weakness, pelvic pain, leg instability, or groin pain. ² Patients frequently indicate the area between the gluteal folds and posterior iliac crests as the primary site of discomfort, and the pain can range from a dull ache to a sharp, stabbing quality in more acute presentations. ²

Common features include:

• Localised pain over the posterior pelvis, typically just below the waistline on one side

• Pain worsened by activities that load the pelvis asymmetrically, such as standing on one leg, climbing stairs, rolling over in bed, or rising from sitting

• Pain that is typically worse with prolonged or sustained positions, including sitting, standing, and lying ³

• Bending forward, stair climbing, hill climbing, and rising from a seated position can all provoke symptoms ³

• An inability to sleep on the affected side ²

• In women, symptoms may worsen during menstruation ²

• A feeling of leg instability or buckling in some cases ³

• Urinary frequency, reported in a proportion of cases ³

Where Does SIJ Pain Refer To?

This is one of the most clinically important aspects of SIJ dysfunction to understand, because pain is rarely felt only over the joint itself. The referral pattern is genuinely wide and variable, which is exactly why SIJ dysfunction is so frequently mistaken for disc herniation, sciatica, hip pathology, or a hip flexor problem.

Research mapping referred pain patterns from the SIJ has identified the following areas, broadly in order of frequency: ² ⁴

• Buttock, the most consistent and common referral site, present in the vast majority of cases

• Lower lumbar region, just below the waistline on the affected side

• Groin and anterior thigh, a recognised but often underappreciated referral pattern, present in around 44% of confirmed SIJ cases ⁵

• Posterior thigh, the most common lower limb referral site, occurring in approximately 50% of patients ²

• Lower leg, less common but documented

• Knee and occasionally foot, present in a smaller proportion of cases

  
  

A particularly useful clinical detail is that when the lower lumbar region and buttock are painful together, SIJ dysfunction becomes a more likely source than lumbar spine pathology alone. Conversely, pain below the knee, whilst possible, is considerably less common with SIJ dysfunction than with true sciatica from disc herniation or nerve root compression, helping to distinguish between the two. ²

Groin and anterior thigh referral deserves specific mention, since it is one of the most commonly missed features of SIJ dysfunction and one of the most important clinically. Research has found that 44% of patients with confirmed SIJ dysfunction reported groin pain, which improved following a diagnostic injection directly into the SIJ, confirming the joint as the source. ⁵ Pain from the SIJ can genuinely be felt at the front of the thigh, and sometimes even around the knee, which is exactly why it is so easily confused with a hip flexor problem, hip joint pathology, or upper lumbar nerve root referral from L2, L3, or L4. ⁶

It is genuinely important to know that the SIJ is actually a relatively rare primary pain generator, accounting for only 3 to 6% of patients complaining of significant pain in the SIJ region, with the lumbar spine accounting for 88 to 90% of cases presenting with this pattern. ⁵ This reinforces why a structured, systematic assessment working through the lumbar spine, SIJ, and hip joint in order, using appropriate provocation tests for each, is the only reliable way to identify the true source of symptoms in a complex presentation.

Muscle spasm in the groin and front of the thigh is also a genuine and recognised feature of SIJ dysfunction, and one worth understanding properly. Multiple muscles have direct anatomical relationships with the ligaments of the SIJ, including the rectus femoris (the large muscle running down the front of the thigh), the iliopsoas (the hip flexor running from the lumbar spine and pelvis to the front of the hip and thigh), and the iliac muscle specifically. ⁷ Irritation of the SIJ can cause any of these muscles to go into spasm as part of a protective response. Research has specifically identified spasm of the iliac muscle as a mechanism producing groin pain and tenderness in SIJ dysfunction, with symptoms relieving following a diagnostic SIJ injection confirming the joint as the source. ⁸ So if you are experiencing spasm or tightness in the front of your thigh or hip alongside lower back and buttock symptoms, this may well be part of your SIJ presentation rather than a separate hip flexor problem.

What else refers to the groin and anterior thigh? Given how widely this pattern is shared across several different conditions, it is worth knowing the most important other sources. The upper and mid lumbar nerve roots (L2, L3, and L4) specifically supply the anterior thigh and groin, meaning disc herniation or foraminal narrowing at these levels can produce pain felt entirely at the front of the hip and thigh rather than in the lower back itself. ⁶ Hip joint pathology, including osteoarthritis, labral tears, and femoroacetabular impingement, are also primary referral sources for groin and anterior thigh pain. ⁹ Adductor-related, inguinal-related, and iliopsoas-related groin pain are also recognised causes in their own right. ⁹ This breadth of differential diagnosis is exactly why a thorough, structured assessment is so essential, and why pain location alone cannot confirm or exclude SIJ dysfunction as the source.

Risk Factors

• Female sex, a consistently identified risk factor ²

• Pregnancy, related to hormonal ligament laxity and altered pelvic load ²

• Trauma, including falls or direct impact to the pelvis ²

• Repetitive microtrauma, from occupational or athletic overuse ²

• Degenerative changes, affecting the joint over time ²

• Previous lumbar spine fusion surgery, a notable risk factor, with research finding measurable rates of new-onset SIJ pain developing after spinal surgery ² ³

• Obesity ²

• Inflammatory arthropathies, underlying inflammatory joint conditions can also affect the SIJ ²

What to Look Out For

Please seek medical assessment if you experience:

• Fever or feeling generally unwell alongside SIJ pain (possible infection)

• Loss of bladder or bowel control

• Numbness in the groin or saddle area

• Significant, unexplained weight loss alongside persistent pain

• Pain following major trauma

How Is It Diagnosed?

A thorough history should be taken, consistent with the diagnostic features of SIJ dysfunction, alongside consideration of the recognised risk factors, which should heighten clinical suspicion that the SIJ may be the source of someone's lower back pain. ⁴ Diagnosis relies on a cluster of hands-on provocation tests rather than any single test alone, the presence of three or more positive provocation tests meaningfully increases diagnostic specificity, though fewer than three positive tests does not entirely rule the SIJ out as a source of pain. ⁴ Imaging is generally used to rule out other potential causes, such as fracture or inflammatory spinal disease, rather than to confirm SIJ dysfunction itself. ⁴

How We Can Help

Conservative management forms the recommended first-line approach for SIJ pain. ¹

Osteopathic manual techniques and manual therapy: hands-on treatment to address restriction and asymmetry around the pelvis and surrounding joints, supporting better load distribution through the SIJ.

Deep tissue and sports massage: targeted soft tissue work for the muscles surrounding the pelvis and lower back that frequently develop compensatory tension.

Medical acupuncture and cupping: used as part of a broader treatment plan to support pain management.

Pelvic stability advice: practical guidance on activities and positions that load the SIJ asymmetrically, particularly relevant during pregnancy or following recent trauma.

Exercise and Rehabilitation

• Pelvic stability and core strengthening exercises: building control around the pelvis to better support the SIJ during everyday movement.

• Gluteal strengthening: the gluteal muscles play an important supportive role in pelvic stability.

• Graded return to activity: gradually reintroducing activities that load the pelvis asymmetrically, such as single-leg standing tasks or stairs.

• Pregnancy-related modifications: where relevant, adapting exercise and movement advice to support the changing demands placed on the pelvis.

Your practitioner will guide a programme tailored to your specific presentation and contributing risk factors.

What to Expect at Your First Appointment

We will take a thorough history, paying close attention to relevant risk factors such as pregnancy, previous trauma, or spinal surgery, and carry out a hands-on assessment using a cluster of validated provocation tests rather than relying on any single test. We will explain clearly what we find and build an evidence-based treatment plan.

Frequently Asked Questions

Do I need a scan? Not usually for initial assessment. Imaging is generally used to rule out other causes rather than to confirm SIJ dysfunction itself.

Is this related to my pregnancy? It can be, genuinely. Hormonal changes during pregnancy increase ligament laxity around the pelvis, which is a well-recognised contributor to SIJ-related pain.

Will I need an injection? Not necessarily as a first step. Conservative management, including manual therapy and targeted exercise, is the recommended starting point, with injections considered for more persistent cases.

How long will it take to improve? This varies depending on the underlying contributing factors, but many people see meaningful improvement with consistent conservative treatment over several weeks.

Recognise these symptoms? Get in touch using the contact form and we will assess and build the right treatment plan for you.

BOOK YOUR APPOINTMENT HERE

References

1. McCormick ZL, Hurley RW, Cohen SP. Sacroiliac joint complex pain consensus practice guidelines from a multispecialty, international working group: an infographic. Pain Medicine. 2025;26(12):936-937. Available at: https://academic.oup.com/painmedicine/article/26/12/936/8346383

2. Sacroiliac Joint Injury. StatPearls Publishing. Updated September 2025. Available at: https://www.ncbi.nlm.nih.gov/books/NBK557881/

3. Incidence and risk factors of new-onset sacroiliac joint pain after spinal surgery: a systematic review and meta-analysis. PeerJ. 2024. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11439385/

4. ASPN Treatment of Sacroiliac Disorders Clinical Guideline Summary 2024. Guideline Central. Available at: https://www.guidelinecentral.com/guideline/3686380/

5. Sacroiliac Pain: Structural Causes of Pain Referring to the SI Joint Region. DePhillipo NN, Corenman DS, Strauch EL, Zalepa King LA. Clinical Spine Surgery. 2019;32(6):E282-E288. Available at: https://pubmed.ncbi.nlm.nih.gov/30379658/

6. Differences in Gait Characteristics of Patients with Lumbar Spinal Canal Stenosis (L4 Radiculopathy) and Those with Osteoarthritis of the Hip. PMC. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404331/

7. Sacroiliac Joint Dysfunction. Wikipedia. Available at: https://en.wikipedia.org/wiki/Sacroiliac_joint_dysfunction

8. Unexplained lower abdominal pain associated with sacroiliac joint dysfunction: report of 2 cases. PubMed. 2011. Available at: https://pubmed.ncbi.nlm.nih.gov/21869561/

9. Differential Diagnosis of Hip Pain. Dr Alison Grimaldi. Available at: https://dralisongrimaldi.com/differential-diagnosis-of-hip-pain/