Sediment is the most commonly identified pollutant associated with macroinvertebrate community impairments in freshwater streams nationwide. Management of this physical stressor is complicated by the multiple measures of sediment available (e.g., suspended, dissolved, bedded) and the variability in natural "healthy" sediment loadings across ecoregions. Here we examine the relative importance of 9 sediment parameters on macroinvertebrate community health as measured by the Virginia Stream Condition Index (VSCI) across 5 ecoregions. In combination, sediment parameters explained 27.4% of variance in the VSCI in a multiregion data set and from 20.2% to 76.4% of variance for individual ecoregions. Bedded sediment parameters had a stronger influence on VSCI than did dissolved or suspended parameters in the multiregion assessment. However, assessments of individual ecoregions revealed conductivity had a key influence on VSCI in the Central Appalachian, Northern Piedmont and Piedmont ecoregions. In no case was a single sediment parameter sufficient to predict VSCI scores or individual biological metrics. Given the identification of embeddedness and conductivity as key parameters for predicting biological condition, we developed family-level sensitivity thresholds for these parameters, based on extirpation. Resulting thresholds for embeddedness were 68% for combined ecoregions, 65% for the Mountain bioregion (composed of Central Appalachian, Ridge and Valley, and Blue Ridge ecoregions), and 88% for the Piedmont bioregion (composed of Northern Piedmont and Piedmont ecoregions). Thresholds for conductivity were 366 μS/cm for combined ecoregions, 391 μS/cm for the Mountain bioregion, and 136 μS/cm for the Piedmont bioregion. These thresholds may help water quality professionals identify impaired and at-risk waters designated to support aquatic life and develop regional strategies to manage sediment-impaired streams. Inclusion of embeddedness as a restoration endpoint may be warranted; this could be facilitated by application of more quantitative, less time-intensive measurement approaches. We encourage refinement of thresholds as additional data and genus-based metrics become available. Integr Environ Assess Manag 2018;00:000-000. Published 2018. This article has been contributed to by US Government employees and their work is in the public domain in the USA.