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19 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol

Proper upfront diagnosis and a simple mechanical treatment plan may prevent unnecessary procedures in this patient population. The authors share their clinical experience with a four-step exercise protocol.
Pages 38-41

Low back pain is one of the most common complaints seen in medical practice. Although often associated with degenerative disc disease, sacroiliac joint dysfunction can be overlooked as a possible cause of low back, pelvic, and leg pain. In some cases, misdiagnosis may lead to unnecessary invasive procedures, including surgery. Herein, the authors review the differential diagnosis of sacroiliac (SI) joint dysfunction and share their success with a four-step exercise protocol for pain relief.

Editor's Note: As of October 2020, this SI joint dysfunction protocol is now being taught in orthopedic classes on how to diagnose sacroiliac joint pain and dysfunction. See a protocol update at end of article.


Sacroiliac Joint Dysfunction Diagnosis

SI joint dysfunction may be diagnosed easily with the Prone Press Up Test, which is widely known to physical therapists, chiropractors, and physicians specializing in musculoskeletal conditions.1 The patient is placed in prone position and asked to press up into lumbar extension. The practitioner places their thumbs over the bilateral SI joints. If one thumb does not translate as far inferiorly, then it is considered a positive Prone Press Up Test on that side.

Then, the clinician can perform the Quadrant Test.2 The Quadrant Test is another common test to confirm SI joint dysfunction. For the Quadrant Test, the patient is in the standing position and asked to perform lumbar extension with side bending to each side. Reproduction in symptoms is considered a positive test to the painful side.

Finally, the clinician may perform an SI joint Compression Technique with Quadrant Test (see Figure 1). In standing position, the patient is asked to perform a Quadrant Test. The practitioner places the palm of their hand on the anterior superior iliac spine (ASIS) of the patient and applies a medial force to the ASIS creating an in-flare of the pelvis on the painful side and then asking the patient to perform a Quadrant Test concurrently. If the patient reports relief of symptoms with this technique, an out-flare of the SI joint may be present. All three tests are done to rule in/out the SI joint diagnosis stemming from an upslip and/or out-flare of the innominate. These tests may be performed in any order.

Sacroiliac Joint Dysfunction Exercise Protocol

The senior author, Whelton, has appeared to have identified the root cause of SI joint dysfunction as an upslip and/or out-flare of the innominate on the side of pain in 12 patients using the aforementioned tests. Most of the patients had failed several forms of conservative and invasive treatments and some were recommended to have SI joint fusion surgery by their surgeons.

The 12 patients were able to achieve full range of motion and total elimination of symptoms immediately by performing an inferior Grade 4 or 5 mobilization and/or an SI joint compression technique. The patients were then put on a four-step exercise protocol (see below) to correct these mechanical dysfunctions with the result that all 12 had negative Quadrant Tests and negative Prone Press Up Tests. They all reported no pain and achieved full range of motion in 5 weeks and all returned to prior level of function. They were instructed to perform the 4-exercise protocol once a day after discharge for a period of 5 weeks. These exercises, shown in Figures 2-5, included:

  • Lower trunk rotation 3 x 30 seconds, bilaterally, 2 to 3 times a day at home
  • Supine piriformis stretch 3 x 30 seconds bilaterally, 2 to 3 times a day at home
  • Side-lying hip abduction 30 reps, bilaterally, 2 to 3 times a day at home
  • Side-lying hip adduction 30 reps, bilaterally, 2 to 3 times a day at home.

SI Joint Exercise Protocol Results

Each of the patients was followed up within several weeks to months after their 5-week treatment course. Ten out of 12 patients reported still having no SI joint pain; one reported exacerbation of symptoms twice, however, when he started doing the exercises again at home, the pain was eliminated again. One patient stated experiencing occasional SI joint “discomfort but not pain” that resolved when performing the exercise protocol. Table I outlines each patient’s initial pain score on the VAS and outcome.


Table corrected May 2021



Lack of understanding of common causes of SI joint pain may lead to the misdiagnosis and mistreatment of SI joint dysfunction. Over the past 37 years, Shealy has noted that at least 15% of patients coming to his clinic for various problems have either sacral torsion or shear. This problem of SI dysfunction often seems to be ignored or improperly treated with surgery often involving fusion. Using an SI joint compression technique and/or a Grade 4 or 5 inferior mobilization to the side with the painful SI joint immediately relieved the pain of 12 patients. Whelton has successfully treated more than 1,000 patients with SI joint dysfunction using the protocol outlined in this paper. Proper evaluation and simple mechanical therapy may be effective in all properly diagnosed and treated patients.1,2 This protocol should be considered as a first-line treatment for SI joint dysfunction of any severity. Although not utilized for the patients outlined in this paper, the use of a 3- to 5-pound ankle sand weight may be necessary for the adduction and abduction exercises as tolerated.


Sacroiliac joint dysfunction should be diagnosed and treated before any surgical intervention,3-5 because once the SI joint has been fused in a non-anatomical position, correction is not possible.

SI joint dysfunction is the primary cause of 25% to 50% of significant chronic low back pain3 and should be corrected before considering surgery. SI joint dysfunction was found to be caused by an upslip and/or out-flare of the innominate on the painful side and was immediately relieved using a Grade 4 or 5 inferior mobilization of the innominate on the painful side and/or an SI joint compression technique. Lasting relief was achieved with an exercise protocol consisting of four exercises to address the upslip and/or out-flare.

Author’s Note (July 2021): The author, Whelton, originally published this protocol stating the patient should perform 1 set of 30 reps of adduction and abduction exercises with the use of an ankle sand weight as being optional.  He now recommends that his patients start off at one set of 30 reps for adduction and abduction and then increase as tolerated to 3 to 5 sets with a 3-lb sand ankle weight for women and 5-lb sand ankle weight for men for both the adduction and abduction exercises. The protocol should be done until the symptoms are eliminated and often takes weeks for the patient to start noticing a change in symptoms; in rarer cases, it may take months for total resolution of SI joint dysfunction and symptoms. 

 The author would also like to note that realignment of the SI joint can serve as an immediate and strong indicator as to the etiology of pain as stemming from the SI joint in origin versus pain stemming from pathology of a different structure of the body. The SI joint can refer to low back, buttock, hip, groin, thigh, knee, lateral shin, and lateral ankle and can mimic sciatica-like symptoms. When the upslip is realigned and the SI joint is gapped open (see Figure 1) and immediate relief is experienced by the patient in the aforementioned areas, this serves as an indicator that the etiology of the symptoms is from the SI joint versus another structure. This assessment can aid the practitioner in diagnosing the origin of referred pain immediately.  


Clinician Experience with Using SI Joint Exercise Protocol

Dear Dr. Whelton, ...Just wanted to let you know that I got two results with your SI joint protocol so far. One patient recovered in 4 weeks (to be discharged this week)! As for the second patient, he is pain-free in a little over 2 weeks. Both men were doing the exercises like a religion and never skipped a day. I have another one now at the stage of having good and bad days, an indication that the protocol is working. Prior to this, she used to have to eat breakfast standing for the greater part of the past 6 months...apparently word got out to my other patients and I have been crazy busy! Thanks for sharing this knowledge – on behalf of my patients as well!... –E John (June 2020)

Dear Dr. Whelton, I just wanted to share with you that my first patient has finished your 5-week protocol for SIJ dysfunction. 10 years of chronic and at times very severe low back pain is completely eliminated. Love the way you think and thanks for all the help. –A Chasse (June 2020)

*Comments have been edited for clarity.

See also, Dr. Whelton’s exercise protocol for treating plantar fasciitis pain




Last updated on: September 3, 2021
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Root Cause of Plantar Fasciitis: Three-Step Exercise Protocol
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