SI Joint Pain: Why It Comes Back, and What Actually Holds

How to tell it's the SI joint

The classic SI joint pattern is a dime-sized spot of pain just below the belt line on one side — the 'Fortin finger sign,' named after the physician who described it. Clients can typically point to it with one finger. Common aggravators: rolling over in bed, standing on one leg to put on pants, getting in and out of a car, sitting on hard surfaces for extended periods. Referral can go into the back of the thigh but usually does not extend below the knee (if it does, think disc or piriformis).

Compression tests, distraction tests, and provocation maneuvers (FABER, Gaenslen's, thigh thrust) reproduce the pain. A skilled clinician can usually confirm SI involvement in a few minutes of testing.

Why adjustments alone often don't hold

If the joint is being repeatedly pulled out of alignment by an overactive QL, an underactive glute medius, or a chronically shortened hip flexor, resetting the joint without addressing that muscular pattern gives you a few good days — then the pattern reasserts itself and the joint slips back. This is not a failure of the chiropractic profession. It is what happens when you treat the joint in isolation from the tissues that control it.

The soft tissue and the joint are one system. Bodywork that releases the drivers, combined with re-loading of the stabilizers, is what allows an adjustment (or self-mobilization) to actually hold. Many of our clients see a chiropractor and a soft tissue therapist concurrently — the combination often produces results neither would produce alone.

Postpartum and pregnancy SI pain

Relaxin, the hormone that softens ligaments during pregnancy to allow the pelvis to open for delivery, is doing exactly what it's supposed to do — but a side effect is that the SI joint becomes predisposed to instability. Add the extra weight in front, the altered center of gravity, the deconditioned deep core after delivery, and the constant asymmetric loading of carrying a baby, and postpartum SI pain is one of the most common complaints we see in our women's wellness work.

Postpartum SI pain often responds beautifully to a combination of gentle manual work (releasing the guarding, restoring symmetry), PEMF for the inflammatory component, and a graduated return to deep core and glute medius activation over six to twelve weeks. This is best done in coordination with a pelvic floor physical therapist when available — many of our postpartum clients see us and a pelvic PT concurrently.

The male athlete SI pattern

SI joint pain also shows up in male athletes — particularly golfers, runners, and anyone whose sport requires rotational power off one leg. The pattern here is usually chronic asymmetric loading combined with underdeveloped glute medius and deep abdominal control. The same principle applies: release the drivers, restore the stability, adjust the loading pattern.

What we sequence in our practice

For acute SI flare: down-regulate the guarding muscles with slow manual therapy (piriformis, QL, glute medius, deep hip rotators), calm the joint itself with PEMF and heat, then very gentle joint mobilization when the tissue has released enough to allow it. For chronic recurring SI pain: same manual work, plus a graduated re-loading program (glute bridges, dead bugs, bird dogs, side-lying leg raises, single-leg balance) over multiple weeks so the muscular pattern can actually change.

The goal is a joint that does not need constant 'popping back in.' Clients who commit to the loading work are often the ones who go from chronic monthly flares to occasional maintenance visits within a season.

When SI pain needs more than bodywork

Genuine sacroiliitis (inflammatory arthritis of the joint), ankylosing spondylitis, and other systemic inflammatory conditions can present as SI pain. If you have morning stiffness that lasts more than an hour, night pain that wakes you, iritis or uveitis history, psoriasis, IBD, or a family history of any of the above, please see a rheumatologist. Bodywork can be supportive alongside medical management, but it is not the primary treatment for those conditions.