The Sacroiliac Joint Is Not a Diagnosis of Exclusion

The Sacroiliac Joint Is Not a Diagnosis of Exclusion
Written by James Demetrious, DC, DABCO
Board Certified Chiropractic Orthopedist

A review in Skeletal Radiology (Waldman et al., 2024), co-authored by a Palmer College radiology faculty member, reminds us that 15-30% of axial low back pain may originate from the sacroiliac joint. Yet SIJ dysfunction remains under-recognized because its pain overlaps with lumbar, hip, and radicular presentations.

What this means for your next SIJ patient:

Cluster your tests. Individual provocation tests lack specificity. In one study, FABER plus thigh thrust together gave the best predictive value (72% sensitivity, 66% specificity), and another tied the diagnosis to at least three positive provocation tests.
Think asymmetry. Leg length discrepancy, transitional vertebrae, prior lumbar fusion, pregnancy, and repetitive asymmetric sport loading all show up repeatedly in SIJD.
Don’t wait for the image to confirm it. Imaging can be completely normal, and edema-like signal and structural changes also appear in asymptomatic people. Variant anatomy is found in 32-57% of asymptomatic individuals. Imaging is there to rule out other pain generators, not to make the diagnosis.
Conservative care has a real role. The authors note that manual therapy and exercise can reduce SIJD pain and disability, and that for patients who fail conservative management, image-guided blocks help identify candidates for further intervention.

That last point is an opportunity for us. Chiropractors are often the first clinicians to see these patients. When you can recognize the pattern, test with confidence, and know when to co-manage or refer, you give patients clarity much sooner.

Join us for our upcoming SIJ coursework to sharpen your clinical reasoning, from exam and imaging interpretation to evidence-based conservative care and referral decisions.

Reference: Waldman LE, Maluli I, Moon CN, Skalski M, Matcuk GR. Sacroiliac joint dysfunction: anatomy, pathophysiology, differential diagnosis, and treatment approaches. Skeletal Radiol. 2024. https://doi.org/10.1007/s00256-024-04831-z

PostGradDC offers advanced post-graduate chiropractic continuing education. Our founder, Dr. James Demetrious, is a distinguished board-certified chiropractic orthopedist, educator, author, and editor.

© 2026 – James Demetrious, DC, DABCO. Open Access. Unrestricted use, distribution, and reproduction are allowed in any medium, provided you give appropriate credit by citing the original author and source: Demetrious J. The Sacroiliac Joint Is Not a Diagnosis of Exclusion. PostGradDC.com; 2026.