PONOS CLINIC · SPINAL AND PELVIC PAIN
Chronic sacroiliac pain
Identify the source of pain, distinguish its causes and choose a targeted pathway: from clinical assessment to treatment for persistent symptoms.
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“Sacroiliac pain is an almost daily presence in my clinical practice.”
Dr Evangelos Panagiotakos
Pain near the buttock or the base of the spine deserves a focused examination: recognising a sacroiliac contribution can change the treatment pathway.
What is sacroiliac pain?
The sacroiliac joints connect the sacrum to the pelvic bones and help transfer loads between the trunk and lower limbs. Pain may arise from the joint, capsule or posterior ligaments: this is why the term sacroiliac joint complex is also used.
Persistent or recurrent pain can limit walking, sleep and daily activities. Its location suggests a possibility but does not confirm it: the lumbar spine, hip and muscles can produce similar symptoms.
Symptoms that may guide assessment
Where it is felt
Pain in the lower back, close to the back of the pelvis, often more noticeable on one side. It may spread to the buttock, groin or thigh.
When it interferes
Prolonged sitting or standing, climbing stairs, rising from a chair or turning in bed may provoke pain. None of these symptoms is specific on its own.
Pain extending down the leg, tingling or weakness also warrants neurological assessment: these symptoms should not automatically be attributed to the sacroiliac joint.
Sacroiliac pain and sacroiliitis are not synonymous
Sacroiliitis means inflammation of the sacroiliac joint. Pain in the region may instead relate to mechanical loading, degenerative changes or surrounding structures, without inflammatory sacroiliitis.
Relevant contexts include previous trauma, pregnancy and the postnatal period, changes in loading and previous lumbar surgery. These factors guide assessment but do not establish the source of pain on their own.
Prolonged morning stiffness, night pain, improvement with movement and a history of psoriasis, uveitis or inflammatory bowel disease may suggest an inflammatory condition requiring investigation. Radiofrequency does not treat the underlying inflammatory disease.
Women, men and pelvic biomechanics
The female pelvis has anatomical and biomechanical differences also associated with pregnancy and childbirth. Joint mobility, loading and ligament laxity may contribute to pelvic girdle pain; hormonal changes are one of the factors involved, particularly during pregnancy.
This does not mean that every woman has sacroiliac instability or that pain in women is necessarily inflammatory. Greater mobility does not automatically mean pain, and rheumatological conditions must be distinguished from mechanical problems.
In Dr Panagiotakos’s clinical experience, some women experience substantial benefit from injections, while some men with persistent pain respond well to radiofrequency after diagnostic selection. This is an observation from his own practice, not validated comparative response rates or a rule for choosing treatment: both options may be appropriate for women and men.
Is the pain always neuropathic?
No. Persistent pain does not establish nerve damage. Burning, electric shock sensations, altered sensation or radiating pain require differential diagnosis; joint, muscular and neural components may coexist.
Diagnosis: examination, clinical tests and targeted imaging
- Pain history: location, duration, provoking movements, previous treatments and impact on activities.
- Physical examination: assessment of the spine, pelvis, hip and neurological function.
- Provocation tests: several concordant manoeuvres may support suspicion; one positive test does not confirm the diagnosis.
- Investigations when indicated: X-rays, MRI or CT address specific questions, including inflammation or other pathology.
A degenerative finding does not prove that the structure is painful. Conversely, imaging without obvious abnormalities does not exclude all forms of sacroiliac pain. Findings are interpreted alongside symptoms.
Specialist assessment is particularly helpful when pain persists despite appropriate care, recurs frequently or is not explained by the known lumbar condition.
The first consultation: comparing pain before and after a block
When assessment, clinical indication and safety conditions allow, Dr Panagiotakos may perform an initial ultrasound-guided injection with low-concentration local anaesthetic during the first consultation.
Before: define the symptom
Pain intensity is recorded and a task that reproduces it is identified: getting up from the examination couch, walking or performing an agreed movement.
After: repeat the same task
Once it is safe to stand, reported pain and movement are reassessed in the first few minutes. The patient describes how the symptom has changed; the clinician observes any functional improvement.
The patient’s account is a central clinical finding. Rapid improvement consistent with the local anaesthetic’s effect provides useful diagnostic information, which should also be documented over the following hours. Relief within one minute is not a requirement: onset and duration depend on the anaesthetic and the clinical context.
Pain is a subjective experience; comparing function adds observable information. However, anaesthetic spread to nearby structures may relieve pain without establishing the joint as the sole cause. Ultrasound guides the procedure but does not, by itself, confirm intra-articular spread.
Intra-articular block
This assesses a possible contribution from the joint. Interpretation depends on accurate placement and the spread of local anaesthetic.
Blocks before radiofrequency
Denervation of the posterior complex may require prognostic blocks of the relevant nerve branches. A joint injection and a lateral branch block are different tests.
A favourable response supports target selection but does not guarantee benefit from subsequent treatment. The response threshold and need for further blocks are determined in relation to the planned procedure.
Treatment matched to the diagnosis
Rehabilitation and conservative care
The pathway may include therapeutic exercise, gradual load management and individualised medication. The aim is to improve function and tolerance of activity, avoiding repeated ineffective treatment without reassessment.
Image-guided injections
Injections may have a diagnostic or therapeutic purpose. In PONOS practice, ultrasound is used to identify landmarks and guide the needle in real time under sterile conditions. When intra-articular placement needs confirmation, fluoroscopic guidance with contrast or CT may be indicated, depending on the clinical question and contraindications.
The procedure is generally outpatient and often does not require sedation. Preparation, medication and return to activity are individualised. Relief may be temporary and does not mean that the underlying cause has been cured.
Immediately: the anaesthetic effect
Initial pain reduction is interpreted in relation to the target, the provoking task and the expected duration of the medication.
Over the following days: the anti-inflammatory aim
When adding a corticosteroid is indicated, the aim is to reduce the inflammatory component and prolong benefit. The effect may develop over the following days, with variable magnitude and duration.
An injection combining local anaesthetic and corticosteroid therefore also has a therapeutic purpose. It is not equivalent to a purely diagnostic block: adding corticosteroid does not increase diagnostic specificity, and the two effects should be assessed separately.
Are three injections always necessary?
No: the response guides the pathway, not a predetermined number. After each treatment, the extent and duration of benefit, function regained and adverse effects are considered. Sufficient benefit may make further injections unnecessary; a modest or absent response after the first or second treatment prompts reassessment of the diagnosis and target.
Lack of response does not automatically establish a mechanical cause, just as benefit from corticosteroid alone does not prove inflammatory disease. Three injections cannot be guaranteed to eliminate pain.
Radiofrequency in selected cases
When pain from the posterior complex persists despite conservative treatment and diagnostic selection is favourable, radiofrequency treatment of the nerve branches carrying pain signals may be considered. The technique, expected benefits and risks are discussed during a dedicated consultation.
If lumbar facet joint pain coexists, it also requires its own assessment and specific blocks: treatment is not automatically extended to surrounding joints.
The procedure does not reconstruct the joint and is not automatically indicated for every case of pelvic pain. Benefit may be partial, temporary or absent; the response is reassessed at follow-up.
Before assessment and after treatment
Bring available images and reports, a medication list and a summary of previous treatment, including how long any benefit lasted. Before a procedure, report allergies, infections, possible pregnancy and anticoagulant or antiplatelet treatment; do not stop medication independently.
Follow-up considers pain, sleep, walking and activities regained. The outcome guides the next steps: continuing rehabilitation, reconsidering the diagnosis or discussing other options.
Fever with severe pain, significant trauma, new or progressive weakness, loss of sensation in the perineal area or new bladder or bowel dysfunction require urgent assessment.
Frequently asked questions
Does sacroiliitis always show on an X-ray?
No. Imaging is chosen according to the clinical suspicion; MRI may be useful in early inflammatory disease. No scan replaces clinical assessment.
Does buttock pain always indicate a sacroiliac problem?
No. It may also arise from the lumbar spine, hip, muscles or nerves. Pain distribution is only one part of the diagnosis.
Does a positive injection mean I need radiofrequency?
No. The clinician considers which structure was tested, how much the symptom improved and whether the proposed procedure matches the target.
Can I return to activities immediately?
This depends on the treatment and your individual response. Follow the instructions provided about activity, driving and follow-up.
References and further reading
- Damen et al., 2001 — Asymmetric sacroiliac joint laxity and pelvic pain in pregnancy.
- Cohort study of factors associated with response to sacroiliac radiofrequency.
- ASPN, 2024 — Guideline for the treatment of sacroiliac disorders.
- International consensus, 2025 — Diagnosis and treatment of sacroiliac joint complex pain.
- Guy’s and St Thomas’ NHS — Sacroiliac joint injections.
Spinal pain · Chronic low back pain
Educational information: this does not replace a consultation or individual advice.