Chapter 5

Basics of the SI Joint Exam

Painful SI joints are identified by taking a thorough history, physical exam, and performing a diagnostic sacroiliac joint injection, under fluoroscopic guidance. 

Sacroiliac joint pain syndrome can mimic other spine-related conditions such as radicular pain syndrome, facetogenic pain syndrome and Piriformis syndrome.

SI joint pain syndrome has several common symptoms. These include: lumbosacral pain, buttock pain, pain referring to the groin, hip girdle, thigh and leg pain, poor sleep habits, sitting problems, and unilateral leg instability. 

A symptomatic SI joint can refer symptoms distally in a somatic distribution such as transient numbness, prickling or tingling, urinary frequency, iliac crest pain, increased pain with menstruation, sexual intercourse, stair climbing or with sustained positions.

A patient history should include asking about the onset of pain, the mechanism of pain, the duration of pain, exacerbating factors, relieving factors, and prior history. Other things to check for in the history include whether or not patient is suffering from fever, chills, night sweats, bowel or bladder incontinence.

Prior history would include any recent physical rehabilitation or physical therapy, any manual medicine, any chiropractic treatment, any acupuncture, any recent history of non-steroidal anti-inflammatory use or muscle relaxers, any history of recent epidural steroid injections or any spinal intervention.

Location is extremely important in the diagnosis of SI joint pain.  Typically patients presenting with SI joint pain typically present with paramedian pain below the level of the L-5 or in the buttock region.

Key tests that should be performed during the physical exam would be the following: pointing to the site of pain while standing, evaluating patients while they're in a seated position to see if they're actually sitting on the painful side, do they have tenderness over the sacroiliac joint, do they have tenderness over the sacral sulcus. 

The five provocative tests used in clinical practice to diagnose sacroiliac joint pain would be the following: Gaenslen's, Thigh Thrust, Distraction Test, Compression Test, and Faber's maneuver. 

If three out of those five provocative maneuvers are positive then consider the diagnosis of sacroiliac joint pain syndrome being highly probable.

A diagnostic sacroiliac joint injection is used for diagnostic purposes.  In this particular type of injection a local anesthetic such as lidocaine or bupivacaine is used where the medication is actually injected into the sacroiliac joint under fluoroscopic guidance.


Dr. Patel is a paid consultant of SI-BONE Inc.

The iFuse Implant System is intended for sacroiliac fusion for conditions including sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and degenerative sacroiliitis. This includes conditions whose symptoms began during pregnancy or in the peripartum period and have persisted postpartum for more than 6 months. There are potential risks associated with the iFuse Implant System. It may not be appropriate for all patients and all patients may not benefit. For information about the risks, visit: www.si-bone.com/risks

"In my practice the prevalence of sacroiliac joint pain is quite high.  In patients presenting with the chief complaint of low back pain I’ve seen patients as high as 30% presenting with sacroiliac joint pain syndrome.  

Painful SI joints are identified by taking a thorough history, physical exam, and performing a diagnostic sacroiliac joint injection, under fluoroscopic guidance.  

Sacroiliac joint pain syndrome can mimic other spine-related conditions such as radicular pain syndrome, facetogenic pain syndrome and Piriformis syndrome. 
SI joint pain syndrome has several common symptoms.
These include: lumbosacral pain, buttock pain, pain referring to the groin, hip girdle, thigh and leg pain, poor sleep habits, sitting problems, and unilateral leg instability.  

A symptomatic SI joint can refer symptoms distally in a somatic distribution such as transient numbness, prickling or tingling, urinary frequency, iliac crest pain, increased pain with menstruation, sexual intercourse, stair climbing or with sustained positions.

A patient history should include asking about the onset of pain, the mechanism of pain, the duration of pain, exacerbating factors, relieving factors, and prior history.

Other things to check for in the history include whether or not patient is suffering from fever, chills, night sweats, bowel or bladder incontinence.
Prior history would include any recent physical rehabilitation or physical therapy, any manual medicine, any chiropractic treatment, any acupuncture, any recent history of non-steroidal anti-inflammatory use or muscle relaxers, any history of recent epidural steroid injections or any spinal intervention.

Location is extremely important in the diagnosis of SI joint pain.  Typically patients presenting with SI joint pain typically present with paramedian pain below the level of the L-5 or in the buttock region.
Key tests that should be performed during the physical exam would be the following: pointing to the site of pain while standing, 

evaluating patients while they’re in a seated position to see if they’re actually sitting on the painful side, 

do they have tenderness over the sacroiliac joint, do they have tenderness over the sacral sulcus.  

The five provocative tests that I use in clinical practice to diagnose sacroiliac joint pain would be the following: 
Gaenslen’s, 
Thigh Thrust, 
Distraction Test, 
Compression Test 
and Faber’s maneuver.  
If I see three out of those five provocative maneuvers being positive then I would consider the diagnosis of sacroiliac joint pain syndrome being highly probable.


A diagnostic sacroiliac joint injection is used for diagnostic purposes.  In this particular type of injection a local anesthetic such as lidocaine or bupivacaine is used where the medication is actually injected into the sacroiliac joint under fluoroscopic guidance.
When we look at therapeutic sacroiliac joint injections a corticosteroid mixture is used which is utilized to treat the inflammation within the sacroiliac joint."