Efficacy and safety of manual therapy for sacroiliac joint dysfunction: a systematic review and meta-analysis

Background Manual therapy is widely used for sacroiliac joint dysfunction, but its benefits and safety remain uncertain. Methods We searched nine databases from inception through December 31, 2025, for controlled studies comparing manual therapy with nonmanual interventions. Two reviewers independently selected studies, extracted data, assessed risk of bias using RoB 2, and rated certainty using GRADE. Random-effects meta-analyses were conducted when clinically appropriate. The review was registered in PROSPERO (CRD420251267640). Results Twenty-six studies involving 1,923 analyzed participants were included. Manual therapy reduced pain (14 studies; standardized mean difference (SMD), −1.33; 95% confidence interval [CI], −1.72–−0.95; I 2 = 84%) and improved study-defined clinical response (17 studies; risk ratio (RR), 1.27; 95% CI, 1.16–1.39; I 2 = 76%), Oswestry Disability Index scores after conversion to a common 0–100 scale (6 studies; mean difference (MD), −12.46; 95% CI, −21.68–−3.24; I 2 = 98%), and Japanese Orthopaedic Association scores (4 studies; mean difference (MD), 4.40; 95% CI, 2.89–5.92; I 2 = 77%). Certainty was very low for all outcomes. Two studies reported trial-specific harm results and no events: Kamali 2018 described visit-level monitoring, whereas Soomro 2024 provided a dedicated harms statement. Two additional studies made only a general statement that no adverse reactions occurred, and 22 studies provided no trial-specific safety result. Conclusions Manual therapy may provide short-term pain relief and functional improvement for sacroiliac joint dysfunction, but the evidence is very uncertain because of risk of bias, substantial heterogeneity, possible small-study effects, and sparse safety reporting. The findings therefore require cautious interpretation. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251267640 , PROSPERO: CRD420251267640.