Dr. Emily Warren, DPT — a McKenzie-certified physical therapist with over 14 years of practice in Salt Lake City — sees this regularly at Mindful Movement Physical Therapies.
Your SI joint pain got worse after the chiropractor “adjusted” you — now you can’t even get out of bed without that catch
Dr. Emily Warren, DPT — McKenzie-certified, dry needling specialist who actually assesses what’s driving your SI dysfunction instead of cracking you three times a week. One-on-one in Salt Lake City — no referral needed.
Quick Answer: SI joint pain responds to physical therapy that addresses the underlying instability, muscle imbalances, or directional preference — not generic stretches or repeated manipulations. Most patients I treat see measurable improvement in 4-6 sessions when we identify the actual mechanical driver, whether that’s poor motor control at the joint, lumbar referred pain masquerading as SI dysfunction, or true ligamentous laxity.
You’ve Been Doing the Piriformis Stretch for Three Months and Your Butt Still Hurts
I see this weekly in my Holladay and Salt Lake City clinics: someone’s been diagnosed with “SI joint dysfunction” after a 90-second exam, handed a printout of generic stretches, and told to stretch their piriformis. Three months later they’re still limping around the Bonneville Shoreline Trail wondering why their butt and low back hurt worse when they hike downhill.
Here’s what most providers won’t tell you: the SI joint is one of the most over-diagnosed and simultaneously misunderstood pain generators in the pelvis. I had a 52-year-old marathon runner from Millcreek last year who’d been getting SI joint “adjustments” twice a week for eight months. Her pain was constant. When I did a McKenzie assessment — which actually loads the spine in different directions to see what changes the symptoms — her pain centralized completely with lumbar extension. It wasn’t her SI joint at all. It was a directional preference from her L5-S1 disc referring into the exact distribution she’d been calling “SI pain.”
That’s not to say SI joint pain isn’t real. It absolutely is. But the SI joint doesn’t exist in isolation. It’s part of a kinetic chain that includes your lumbar spine, hip, pelvic floor, and the entire posterior chain that gets hammered when you’re skiing moguls at Alta or climbing Mount Olympus every weekend. When I assess SI joint pain, I’m not just poking the dimples on your low back and declaring victory. I’m figuring out whether the joint itself is the problem, or if it’s screaming because something else in the system is broken.
The clinical challenge is that true SI joint pain and lumbar referred pain can look almost identical: one-sided low back pain, pain with rolling over in bed, difficulty standing from sitting, pain with single-leg stance. A 2018 study in PM&R found that even experienced clinicians have poor diagnostic accuracy when relying on individual provocative tests for SI dysfunction — which is exactly why I use a cluster of tests, movement pattern assessment, and trial treatment to figure out what’s actually wrong.
What Actually Causes SI Joint Pain (And Why “Alignment” Is Usually Nonsense)
Ligamentous Laxity and True Instability
This is real SI joint pathology: the ligaments that hold the sacrum to the ilium get lax — often from pregnancy, trauma, or hypermobility disorders like Ehlers-Danlos. The joint moves excessively because the passive restraints aren’t doing their job. You feel a deep, achy pain right at the PSIS (those dimples), worse with asymmetric loading like carrying a toddler on one hip or standing on one leg to put pants on.
What helps here isn’t more manipulation — you’re already too mobile. You need motor control retraining and stabilization. I teach patients how to recruit their deep hip rotators, pelvic floor, and transversus abdominis to create dynamic stability the ligaments can’t provide anymore. A 2019 systematic review in the European Spine Journal found that motor control exercise significantly reduced pain and improved function in patients with SI joint pain, especially when combined with manual therapy directed at the lumbar spine and hips — not just repeated SI “adjustments.”
Lumbar Spine Referred Pain (The Most Common Impostor)
Most people I see with “SI joint pain” actually have lumbar pathology — usually L5-S1 or L4-L5 — referring into the buttock and posterior pelvis. The pain distribution overlaps perfectly with true SI pain, but the driver is discogenic or facet-mediated. This is where the McKenzie assessment I’m certified in becomes critical: I load your spine in flexion, extension, side-bending, and rotation to see if the symptoms centralize (move toward the midline) or peripheralize (spread further down the leg).
If your “SI pain” centralizes with repeated lumbar extension, you don’t have an SI problem. You have a directional preference at the lumbar spine, and treating the SI joint is a waste of time. I had a 44-year-old software engineer from downtown Salt Lake City last year with right-sided “SI pain” that three providers had manipulated. Her pain abolished completely after five reps of prone press-ups. The SI joint was innocent.
Hip Pathology Creating Compensatory Pelvic Pain
Femoral acetabular impingement (FAI), labral tears, and hip osteoarthritis all change how you load your pelvis. When your hip doesn’t move well, your SI joint and lumbar spine compensate, and eventually they start complaining. I see this constantly in the 40-60 age range: someone’s hip is stiff from years of running on Wasatch trails, they start hiking differently, and suddenly their SI joint is angry.
The FADIR and FABER tests during my eval tell me if the hip is part of the problem. If your groin hurts when I flex and internally rotate your hip, or if you can’t externally rotate and abduct without pain, we’re treating your hip mobility and motor control alongside anything we do for the pelvis. A 2020 study in the Journal of Orthopaedic & Sports Physical Therapy found that patients with chronic low back and pelvic pain often had concurrent hip impingements that went unrecognized — and treating the hip improved the back pain.
Pelvic Floor Dysfunction and Myofascial Pain
Your pelvic floor muscles attach directly to the sacrum and coccyx. When they’re hypertonic (too tight) or have trigger points, they create deep pelvic and buttock pain that patients swear is their SI joint. I had a 38-year-old trail runner from Park City last year with right buttock pain she was convinced was SI dysfunction. Her Gaenslen’s and thigh thrust tests were negative. When I palpated her obturator internus and piriformis, she nearly came off the table. We did dry needling to the deep hip rotators and pelvic floor relaxation exercises, and her pain dropped 70% in three sessions.
This is where being a Professional Yoga Therapist in addition to a PT changes my clinical approach — I’m not uncomfortable talking about pelvic floor function, and I know how to assess it without referring you out for six more appointments.
Post-Pregnancy Biomechanical Changes
Relaxin loosens every ligament in your pelvis during pregnancy, and some women never fully restabilize afterward. Add in a 30-pound toddler you carry on one hip while hiking Little Cottonwood Canyon, and you’ve got a recipe for chronic SI irritation. The ligaments are lax, the motor control never got retrained, and the joint is moving too much with every step.
I’ve treated dozens of postpartum women in Salt Lake City who were told their SI pain was “just part of having kids.” It’s not. You can retrain the system — but it takes specific motor control work, load management, and often dry needling to the muscles that are chronically overworking to compensate.
What My Assessment Actually Looks For
When you come in for an evaluation — which is 90 minutes, one-on-one, no aides or techs — I’m not just doing three SI provocation tests and calling it a day. Here’s what I’m actually assessing:
- Thigh thrust, Gaenslen’s, and FABER tests: These load the SI joint in different directions. If three out of five provocative tests are positive, you might have true SI pathology — but I’m still not done. I need to know if it’s the primary driver or a red herring.
- Active straight leg raise (ASLR): You lift one leg while lying down. If it’s hard or painful on one side, and gets easier when I compress your pelvis manually, that tells me you have a force closure problem — your muscles aren’t stabilizing the pelvis properly.
- McKenzie repeated movement testing: I load your lumbar spine in all directions to see if your pain centralizes or peripheralizes. This is the single most valuable part of my assessment for differentiating lumbar referred pain from true SI pain. If your symptoms centralize, we’re treating your spine, not your SI joint.
- FADIR and FABER for the hip: I need to know if your hip is contributing. If you’re impinging at the hip, your pelvis is compensating, and we’re treating both.
- Single-leg stance and step-down: I watch how you load the pelvis and whether you have a Trendelenburg sign (hip drop). If your glute medius isn’t firing or your deep hip rotators are weak, your SI joint is getting hammered with every step.
- Palpation of deep hip rotators, pelvic floor, and lumbar multifidi: Trigger points in the piriformis, obturator internus, or pelvic floor can mimic SI pain perfectly. If I press on your piriformis and reproduce your exact pain, we’re needling it, not manipulating your SI joint.
By the end of the eval, I know whether you have true SI instability, lumbar referred pain, hip pathology, myofascial pain, or some combination. That’s what determines the treatment plan — not a generic protocol I hand to everyone with butt pain.
What Treatment Actually Involves
If you have true SI instability — ligamentous laxity with poor motor control — I’m teaching you how to create dynamic stability through muscle activation. That means specific cueing for transversus abdominis, pelvic floor, deep hip rotators, and glute medius. I use real-time ultrasound sometimes so you can see your transversus firing (or not firing). We progress from basic stabilization in hooklying to loaded positions like single-leg stance, step-downs, and eventually return to trail running or skiing.
If your pain is lumbar-referred, we’re doing McKenzie-based directional preference loading. If you centralize with extension, you’re doing repeated press-ups, prone lying, and eventually loaded extension under my supervision. The SI joint isn’t the target — your lumbar disc is.
If you have hip impingement or labral pathology contributing, we’re mobilizing the hip, improving your internal rotation, and teaching you how to hinge properly so you stop compensating through your back and pelvis.
If you have myofascial pain from overactive hip rotators or pelvic floor dysfunction, I’m dry needling the trigger points — piriformis, obturator internus, sometimes even the pelvic floor muscles if they’re accessible and hypertonic. A 2017 study in the Journal of Orthopaedic & Sports Physical Therapy found that dry needling combined with manual therapy and exercise significantly reduced pain and improved function in patients with chronic pelvic and buttock pain.
Manual therapy shows up in my treatment, but it’s not the star of the show. I’ll mobilize stiff segments in your lumbar spine or hip if they’re limiting your movement, but I’m not “adjusting” your SI joint three times a week. The research is pretty clear that manipulation provides short-term pain relief but doesn’t change long-term outcomes unless you combine it with motor control retraining and load management.
How SI Joint Pain Actually Affects Your Life in Salt Lake City
You can’t ski. Getting off the chairlift at Snowbird — that moment where you shift your weight to one leg and push off — sends a knife through your right buttock. You’ve stopped going because it’s not worth the pain.
You can’t hike downhill. Walking up the Bonneville Shoreline Trail is fine, but coming back down, every step jars your SI joint and by the time you’re back at the trailhead you’re limping. You’ve started avoiding anything with elevation loss, which in Utah basically means you’ve stopped hiking.
You can’t sit through a movie. Sitting in a car for more than 20 minutes makes your butt ache so badly you have to pull over and walk around. Long drives up to Park City or down to Moab are out of the question.
You can’t stand and cook dinner. Ten minutes at the stove and your low back and SI joint are screaming. You’ve started eating more takeout because standing in the kitchen hurts too much.
You can’t pick up your kid without bracing. Lifting your toddler out of the car seat — that asymmetric lift with a twist — makes your SI joint catch. You’ve started asking your partner to do all the lifting, and you feel like your body is failing you at 36.
This is what I treat. Not “back pain” in the abstract. Real limitations that are taking apart your life in specific, measurable ways.
When to Get Imaging (And When It Misleads You)
I don’t order imaging on everyone. If you’re under 50, you don’t have red flags (unexplained weight loss, night pain, fever, trauma, history of cancer), and your symptoms fit a mechanical pattern, imaging won’t change what I do. I’m treating the movement dysfunction and pain pattern, not a picture.
That said, X-rays can be helpful if I suspect significant arthritis, spondylolisthesis, or structural asymmetry in the pelvis (like a leg length discrepancy or old fracture). MRI is useful if I think you have a stress fracture, inflammatory arthritis like ankylosing spondylitis, or if your symptoms aren’t improving after 6-8 weeks of appropriate treatment.
Here’s where imaging misleads you: an MRI will often show “degenerative changes” at the SI joint in people over 40. Those changes are common and often asymptomatic. A 2016 study in the Clinical Journal of Pain found that MRI findings of SI joint degeneration didn’t correlate with pain or functional limitation — plenty of people with terrible-looking SI joints on imaging had zero pain.
So if your doctor shows you an MRI and says, “See, your SI joint is degenerated, that’s why you hurt,” take it with a grain of salt. The imaging might be accurate, but it doesn’t tell me whether that’s the pain generator or an incidental finding. The clinical exam and your response to treatment tell me that.
Red flags I do want imaging for: pain that’s constant and unrelenting regardless of position, pain that wakes you from sleep (not just hurts when you roll over, but wakes you at 2 a.m. and won’t let you go back to sleep), unexplained fever, significant trauma, or neurological symptoms like foot drop or saddle anesthesia.
Why Session Length Changes Everything
I spend 90 minutes with you at the first visit and 60 minutes at every follow-up. It’s one-on-one. I’m not handing you off to an aide to do exercises in a corner while I see three other patients. I’m not billing your insurance for 12 units and giving you 20 minutes of face time.
That structure matters clinically. SI joint pain is diagnostically complex. I need time to do a full McKenzie assessment, test your hip, assess your pelvic floor and deep rotators, watch you move, and figure out what’s actually driving the pain. I can’t do that in a 15-minute insurance mill appointment where I’m expected to see four patients an hour.
When we do treatment, I’m there the whole time. If I’m dry needling your piriformis and obturator internus, I’m managing the needles, monitoring your response, adjusting depth and location based on what I feel and what you report. If we’re working on motor control, I’m cueing you in real time, giving tactile feedback, using ultrasound to show you what’s firing. You’re not doing a generic exercise sheet while I chart on someone else.
I run a cash-based practice because this model doesn’t fit insurance reimbursement. Insurance pays for volume, not time. The incentive structure is to see as many patients as possible per hour, document everything to justify billing, and move people through. I can’t practice evidence-based physical therapy in that environment — not for something as nuanced as SI joint pain.
You don’t need a referral in Utah. You can call (385) 332-4939 or book directly. I’ll spend the time to figure out what’s wrong and what to do about it.
Get Back to Skiing, Hiking, and Living Without That Deep Ache in Your Butt
Mindful Movement Physical Therapy serves Salt Lake City, Holladay, Millcreek, and surrounding Utah communities. No referral needed.
Ready to Get Out of Pain?
Dr. Emily Warren, DPT sees patients one-on-one at Mindful Movement Physical Therapies in Holladay and Salt Lake City. No referral needed in Utah. Most patients see clear improvement in 4–6 visits.
📞 Call: (385) 332-4939
📅 Book Your Evaluation Online →