From Research to Practice: A Tricky Case of SIJ Pain

My pelvis feels out of place.

That was how Maria opened our first consultation.

Maria was a 34-year-old financial advisor, mother of a three-year-old daughter, and recreational athlete who had recently become obsessed with HYROX. Between client meetings, daycare pickups, and training sessions involving sled pushes, wall balls, running intervals, and heavy carries, she had built a lifestyle that demanded a lot from her body.

For the previous four months, she had been experiencing pain around her right posterior pelvis. She pointed with one finger just medially to the posterior superior iliac spine and confidently told me she had “SI joint instability.” The diagnosis hadn’t come from a healthcare professional. It came from social media.

She had watched videos explaining how postpartum women often develop pelvic instability, weak cores, and sacroiliac dysfunction. The more she listened, the more convinced she became that her pelvis was somehow misaligned.

What followed was a great reminder that sometimes our most important clinical intervention isn’t a specific exercise. It’s changing the narrative. This blog outlines how I approached Maria’s rehabilitation, and how Physio Network Research Reviews helped shape my clinical reasoning.

Initial assessment

Maria described a gradual onset of symptoms during preparation for her first HYROX competition. Her pain was aggravated by:

• Running intervals
• Single-leg loading activities
• Long periods of standing
• Heavy farmer carries
• Getting out of the car after long drives

Her symptoms eased with:

• Walking
• General movement
• Reducing training volume

Pain intensity fluctuated between 2/10 and 7/10. Importantly, there were no red flags. She denied night pain, unexplained weight loss, systemic symptoms, neurological changes, bowel or bladder dysfunction, or traumatic onset.

Her primary goal was simple:

I want to train hard again without constantly worrying that I’m damaging my pelvis.

That final statement would prove important.

Objective assessment

Lumbar active range of motion was largely unremarkable, although repeated extension reproduced mild discomfort around the right sacroiliac region. Neurological examination was normal.

Hip range of motion was symmetrical and pain-free. Because positive SIJ provocation tests can occur in individuals with a variety of lumbopelvic pain presentations, I wanted to ensure that other plausible contributors had been adequately explored. Lumbar referred pain, hip-related symptoms, training-load errors, and broader psychosocial factors all remained on the differential list throughout the assessment process.

The cluster of sacroiliac provocation tests reproduced Maria’s familiar symptoms. The thigh thrust, sacral thrust, compression test, and Gaenslen’s test were all positive. Several years ago, I might have felt quite confident concluding that the SIJ was the primary source of her pain. However, this Research Review ‘Diagnostic Accuracy of Provocation Tests for SIJ Pain’ challenged that assumption.

The Review highlighted that although clusters of SIJ provocation tests are commonly used in clinical practice, their diagnostic accuracy is more nuanced than many of us were taught. The Review reminded me that positive SIJ provocation tests should increase curiosity rather than certainty. A negative cluster may help us move away from the SIJ as a meaningful contributor, but a positive cluster does not automatically provide a diagnosis.

This changed how I interpreted Maria’s examination. Rather than viewing the positive tests as confirmation of a diagnosis, I treated them as one piece of the puzzle. They suggested that the region was sensitive, but they didn’t tell me exactly which structure was responsible or whether the SIJ itself was the primary driver of her symptoms.

As a result, I placed greater emphasis on the broader clinical picture: her history, symptom behaviour, training loads, aggravating factors, movement assessment, and response to loading.

This ultimately prevented me from falling into the common trap of diagnosing the SIJ solely because the SIJ tests were positive.

The Review that changed my clinical narrative

One of the most useful ideas from this Physio Network Review by Robin Kerr was the reminder that pain around the SIJ does not automatically mean the pelvis is unstable or mechanically faulty. This Review suggests that people often change the way they move when they are in pain, and those changes can become amplified by worry, hypervigilance, or fear of movement.

That made me reconsider not only what exercises I prescribed, but also how I explained Maria’s symptoms. Rather than telling her that her pelvis was “out” or “unstable,” I explained that the area appeared to be sensitive and that sensitivity can be influenced by many factors, including recent training loads, movement behaviours, stress, and the way we interpret pain.

The Review argued that movement-based SIJ dysfunction models are poorly supported by current evidence and that clinicians should be cautious about reinforcing pathoanatomical narratives that may increase fear and perceived fragility.

As I listened to Maria describe her fear of damaging her pelvis, I realized that my rehabilitation plan would need to address more than physical capacity. It would also need to address her beliefs.

Early rehabilitation: Building confidence before capacity

A big part of the first few sessions was helping Maria make sense of her pain. We talked about the difference between sensitivity and damage, explored how training stress and fear can both influence symptoms, and focused on rebuilding confidence rather than trying to “fix” a supposedly unstable pelvis.

We discussed:

• How pain does not always equal tissue damage
• Why postpartum does not automatically mean instability years later
• The robustness of the pelvis and SIJ
• How training loads can temporarily exceed tissue tolerance
• Why pain can become influenced by factors beyond local tissue structures

Importantly, I avoided language such as:

• “Your pelvis is out.”
• “Your SIJ is unstable.”
• “You have a weak core.”

These messages may seem harmless, but can unintentionally reinforce fragility.

Exercise prescription initially focused on maintaining movement while reducing symptom irritability:

• Walking program
• Split squat isometrics
• Hip hinge variations
• Modified carries
• Trunk strengthening exercises selected for confidence-building rather than “pelvic stabilization”

Training volume was reduced by approximately 30%. After three weeks, her pain intensity had reduced from 7/10 peaks to around 4/10. More importantly, her fear was beginning to change.

Mid-stage rehab: Expanding capacity

By week four, symptoms were less reactive.

This phase focused on progressively exposing Maria to the activities she valued. Strength work included:

• Bulgarian split squats
• Romanian deadlifts
• Step-down variations
• Single-leg RDLs
• Loaded carries
• Rotational medicine ball exercises

Rather than chasing perfect movement patterns, we focused on adaptability. This was another practical application of the narrative proposed in Robin Kerr’s Review.

If SIJ pain is not necessarily driven by subtle positional faults or movement dysfunctions, then rehabilitation should not become an endless search for ideal alignment. Instead, we can help patients become stronger, more confident, and more resilient across a variety of movement options.

During this period, we also addressed some important training behaviours. Maria had developed a tendency to constantly monitor her pelvis during exercise. She frequently checked whether her hips felt level. She worried whenever symptoms appeared.

Part of rehabilitation involved gradually reducing this hypervigilance. We shifted attention away from the pelvis and toward performance metrics:

• Running pace
• Training consistency
• Recovery quality
• Strength progression

The goal was simple: Move from protection toward performance.

Return to HYROX

By week eight, Maria was completing:

• Running intervals
• Sled pushes
• Sled pulls
• Wall balls
• Farmer carries

Pain occasionally appeared during high-volume sessions but was no longer interpreted as a sign of injury. Instead, it became useful information about training load.

At week twelve, she completed a HYROX simulation session at approximately 90% race intensity. By week fourteen, she successfully returned to competition.

Interestingly, her occasional symptoms had not disappeared entirely. But her confidence had returned. And in many ways, that was the more meaningful outcome.

Wrapping up

Reflecting on this case reminded me how easy it is to overinterpret findings around the SIJ. Had I relied solely on positive provocation tests, I could have confidently diagnosed “SIJ dysfunction” and built a treatment plan around correcting a biomechanical problem.

Instead, the Physio Network Research Reviews encouraged me to think differently, reminding me to be cautious about diagnostic certainty of provocation test clusters and challenging me to reconsider how I communicate findings and reinforce narratives.

As clinicians, we are often under pressure to provide a precise structural explanation for pain. Patients frequently expect one. But sometimes the most evidence-based answer is also the most honest:

This area is sensitive right now, but that doesn’t mean it’s damaged, unstable, or incapable of getting stronger.

Maria’s recovery wasn’t driven by finding the perfect exercise or identifying a hidden biomechanical fault. It was driven by a combination of reassurance, progressive loading, capacity building, and a narrative that supported confidence rather than fear.

And that’s a lesson I’ll continue to carry into future cases involving pain around the sacroiliac joint area.

Enjoy evidence that changes your clinical practice? Cases like Maria’s remind us that research doesn’t just help us choose exercises; it helps us think differently.

If you want clinically relevant research distilled into practical takeaways that can immediately influence your assessment, communication, and rehabilitation strategies, subscribe to Physio Network’s Research Reviews and stay connected to the evidence shaping modern physiotherapy practice.