Navigating the New Guidelines for Sacroiliac Joint Complex Pain

A multispecialty international working group convened by AAPM and ASRA‑PM has issued consensus guidelines that make the evaluation and management of sacroiliac joint (SIJ) complex pain more structured.

Clear diagnostic criteria and a staged treatment pathway are intended to reduce misdiagnosis and premature interventions. The guidance links focused examination, image‑guided diagnostic injections, and stepwise treatment decisions—changes that will affect outpatient assessment and escalation patterns.

The guideline moves practice away from ad hoc testing and early escalation toward a reproducible diagnostic pathway and a stepped management model that favors conservative care first. Clinicians are asked to document focused exam findings and time‑limited trials of therapy before escalating interventions; this framing sets the stage for the diagnostic details that follow.

Focused clinical examination now takes primacy: the guideline recommends documenting provocative maneuvers such as FABER (flexion–abduction–external rotation), the thigh‑thrust test, compression, Gaenslen’s test, and sacral thrust in the diagnostic workup. In parallel, the group supports image‑guided intra‑articular or periarticular injections to confirm the SIJ as the pain generator. While many clinicians may use a practical cutoff of ≥50% short‑term pain relief during the expected anesthetic window to interpret diagnostic sacroiliac injections, the guideline emphasizes clinical concordance over a single fixed numeric threshold.

First‑line therapy prioritizes noninvasive, individualized care: focused physical therapy for lumbopelvic stabilization, activity modification, nonopioid analgesics, and multimodal rehabilitation that includes behavioral strategies. Typical conservative trials are pragmatic—commonly 6–12 weeks with objective functional goals—before declaring treatment failure. Apply protocolized conservative management and consider escalation only after an adequate trial has not restored function or meaningfully reduced pain.

Escalation to interventional procedures requires objective indicators: persistent, function‑limiting pain after an adequate conservative trial; concordant diagnostic confirmation via targeted injection; and careful consideration of patient preference and comorbidities. The guideline suggests image‑guided SIJ injections for diagnostic and therapeutic effect and considers radiofrequency ablation for suspected posterior ligamentous nociceptive sources while acknowledging variable durability and limited high‑certainty evidence. Refer for surgical evaluation when structural indications are clear. Shared decision‑making should guide procedural selection, balancing expected benefit, durability, and patient goals.

Key Takeaways:

• The working group mandates a structured pathway—focused exam plus image‑guided confirmation—before intervention, improving diagnostic specificity and reducing premature escalation. Implement this pathway at initial outpatient assessment.
• Primary care, physiatrists, pain specialists, and surgeons who evaluate low back and pelvic pain should adopt the exam checklist and stepwise care plan to standardize referrals and interventions. Standardize documentation and referral triggers in your clinic.
• Start 6–12 week protocolized conservative trials, use image‑guided diagnostic injections when exam findings localize to the SIJ, and escalate to radiofrequency or surgical pathways only after confirmed diagnosis and failed conservative care—apply shared decision‑making at each step.