Roughly 25% of
people with back pain have what is called sacroiliac (SI) joint dysfunction,
and I am one of them. What you’ll find in this article is what the SI joints
are, what their purpose is, what dysfunction is and how it occurs, and how you
can reduce the pain and restore proper function through proper strength
training. What you will not find is about curing SI joint dysfunction with
alternative methods to training like steroid (cortisol) injections,
chiropractic realignment, or surgery.
So what are the SI
joints and what do they do?
There are two SI
joints on either side of the sacrum (bottom of spine/tailbone) that connect to
the iliac bones (hip/pelvis) by fibrous ligaments to support the spine and
hips, and would be considered an immovable joint. The iliac bones connect to
each other in the front of the body by a fibrous joint called the symphysis
pubis. Our spinal column is configured so the weight of our body rests on the
two small SI joints at the juncture of sacrum and ilium (spine and hips),
making the lower back susceptible to injury. The purpose of these small joints
is to functionally participate in converting the pelvis into a resilient,
dynamic, accommodating base that dissipates weight, absorbs shock, and provides
a singular proficiency unique to bipedal locomotion. The SI joints are
subjected to compressive forces when our hips move while either
standing/walking, running, twisting, and extreme forces when landing from a
jump or fall. Our hips are designed to absorb forces before they reach the
spine, and the SI joints play an integral part in this function.
What is SI joint
dysfunction?
SI joint dysfunction
is often described as pain in the low back and hip, and may radiate out to
buttocks, down legs or groin. SI joint dysfunction can have many different
causes. Because the SI joints are linked together by small ligaments,
dysfunction can occur from traumatic dislocation as a result of a hard blow to
the joint itself (ex. car crash), falling flat on your butt, inflammation,
illness, infection, chronic overuse, improper lifting
technique, postural/muscular imbalances or chronic dynamic bending
and twisting (ex. repetitive stress injury from playing sport(s). SI joint
dysfunction can happen in both SI joints, and if it does happen it typically
starts in one side, and due to misalignment and compression the opposite side
can be affected. SI dysfunction is often ignored or misdiagnosed, but is a
legitimate syndrome, separate from disc conditions or sciatica.
What causes SI joint
pain?
SI joint pain is
typically due to subluxation (partial dislocation) of the joint.
Basically it means that the joint temporarily slips out of place, and without
external assistance, like a doctor jamming it back in for you, it goes back
into place on its own.
How does a
subluxation happen in the first place?
Each case is
specific to its own but some of the more common things that could be happening
are:
1. Ligaments
are weakened or stretched which will promote an anterior rotation of the iliac
bone (hip bone you can feel on the front side of your body). The hip bone
(iliac) will be lower, in some cases very noticeably, on the affected side
which overstretches ligaments further and results in severe pain in the buttock
and legs, making it difficult to differentiate from other types of back pain.
2. The
symphysis pubis ligaments (front side of the body in the groin area) can tear
and cause SI slippage/subluxation. This is especially common for females as
these ligaments are stressed big time to allow for child birth. If this happens
in either males or females pain can resemble a groin strain. Men will notice
the pain coming from the testicles.
When the SI joint is
knocked out of place for whatever reason it can affect the structural integrity
of the entire spine. When tissues become inflamed and spasm, they pull on the
pelvis (hip bones) and further rotate them out of place.
The pain felt from
SI joint dysfunction can be very severe and mimics that of sciatica. Pressure,
from swelling in and around the joint, may cause pain impulses from spinal
nerves in the area. Nerves leave the spine and travel outward to the leg and
hip muscles. If the nerves are compressed, pain is felt and function is
limited, therefore performance affected. It is unknown whether the pain comes
from the joint surfaces or the ligaments since the area is so rich in nerve
endings that any inflammation or injury in the area results in pain. The pain
may radiate the same nerves that travel through the joint and continue out to
the legs and hips, and some people even feel pain in the abdomen.
Factors that may
increase pain on the affected side are:
1. Movement –
yes I know this is a very vague description, but SI joint pain can be that bad
that any movement at all may increase pain
2. Load bearing
– basically weight lifting or supporting a weight/load that places pressure on
the spinal column
3. Sneezing –
sudden uncontrollable movements like sneezing can be very painful as they can
affect the alignment of the spine
4. Coughing –
like sneezing, coughing can aggravate pain the in SI joint(s)
5. Switching
positions while sleeping and/or moving while laying down
6. Inflammation
can cause pain and more inflammation, creating a very unpleasant cycle.
All of these factors
alone can make everyday life very difficult to say the least. Lower back pain
can very well be a sign of SI involvement as well. In the most severe cases,
functional limitations and weakness may result due to nerve involvement.
How do you know if
the pain is due to SI joint dysfunction?
It is important to
identify that the pain being felt in the lower back is from sacroiliac joint
dysfunction and not a herniated disc for example. Herniated discs may not even
cause pain and therefore attempting to treat the pain as if it were a herniated
disc, like having surgery, would not solve the problem. The range of movement
in the SI joint is small and therefore clinical exams are needed. There are
various clinical exams to determine whether or not the back pain a person is
dealing with is from SI joint dysfunction, and some of the more popular ones
are:
1. Gillet’s
Test
2. Faber’s Test
3. Gaenslen’s
Test
The two sides are
compared for symmetry with the painful side considered the abnormal one.
What you can do to
help fix the problem
Here are some
training tips to help restore a normal relationship between the sacrum and
ilium:
1. Ilium
positioning exercise – there is an exercise you can do at home to temporarily
realign your SI joint. To do this exercise all you need is a door frame. Basically
you stand in between the door frame with your back flat against one side of the
frame. Place your unaffected foot about halfway through the frame to allow your
lower back to press tightly against the frame. Lift your affected leg as high
as you can and press into the opposite side of the frame with your heel, as if
you were doing an isometric single leg press. This should help temporarily push
the iliac bone backwards, back into place.
2. A more
conservative and permanent treatment would be to strengthen and/or lengthen the
surrounding muscles, depending on what muscle(s) is/are affecting the SI joint,
to keep the joint stable which will enhance the shock absorbing properties of
the tissues. Stronger muscles, tendons and ligaments hold a joint together and
prevent subluxation. If you recall from
my mobility/stability article, the hips (hip flexors) need
to be mobile so the lower back can provide stability. If the hip flexors are
tight, the joint above, being the lower back (SI joint), becomes compromised.
Creating a structurally balanced physique is the most effective solution to
curing SI joint dysfunction without a physical therapist. If you have SI joint
dysfunction, chances are your structural issues are related to having tight hip
flexors (possibly from sitting all day at work), which mechanically inhibits
your glutes from activating when needed. You’ll notice if you flex your glutes
that your lower back naturally aligns itself to properly absorb any sort of
shock that it may need to, and you may even immediately feel less tension in
the lower back. The problem is that no one really clenches their glutes all day
to provide the lower back with the stability it needs, and when the hips flex
or tighten, pressure falls onto the lower back (SI joint). Other muscles that
may be weak due to tight hip flexors and weak or inhibited glutes are the
hamstrings and abs. Strengthening the glutes, hamstrings and abs, along with
improving the flexibility of the hip flexors, will help with stabilizing the SI
joint and preventing dysfunction.
3. It is
important to warm up the muscles surrounding the hip prior to
activity (load bearing, high-impact sports) to ensure optimal shock absorption.
An exercise that I use on people that have SI issues is a variation of a glute
bridge that I simply call “Glute Activation”. To do this exercise you need a
partner. You lay on your back on a mat or the floor with feet roughly shoulder
width apart and knees bent at 90 degrees as if you were going to do a sit-up.
Your partner stands over you, trying to push your legs together. As you resist,
and activate the external rotators of the hip (glute med), press your pelvis up
off the ground as high as you can while pushing through your heels, to activate
the extensor muscles of the hip (glute max). Do as many reps as needed, usually
5-10 are suffice. Then have your partner place their hands on the inner part of
the knee and try to push your legs apart from each other. As you resist, and
activate the adductors, press your pelvis up off the ground as high as you can,
just as you did while pushing outwards. Do as many reps as needed, once again
5-10 should be suffice. This exercise activates all the major muscles around
the hip so they can take on more stress while load bearing. There is no rule
that says you can’t do this exercise prior to every set if you want. Sometimes
I’ll have clients do it before every set, and other times only at the beginning
of the workout. Its purpose is to simply activate the glutes and increasing the
firing rate to that muscle so use it as needed.
In my experience,
I’ve noticed that the exercises that require the hip extensors (glutes,
hamstrings, erectors) in some way (squats, deadlifts barbell rows) are the ones
that are the most negatively affected by a sacroiliac joint dysfunction. Fixing
this issue with proper training is something that will take a lot of time, as
it took quite some time for the condition to develop in the first place.
Some other tips to
help deal with SI joint dysfunction are:
1. Don’t rely
on rest for recovery as ligaments will further slacken from disuse.
2. Sit-ups,
bending at the waist with the knees straight and also bringing the knees into
the chest (lower ab exercises like a reverse crunch) will displace the SI
joints
3. Don’t place
heat on the lower back if it is sore as heat expands ligaments contributing to
instability
4. Put ice on
the lower back if you need relief as it reduces inflammation and relaxes
muscles
If the SI joint
remains in an abnormal position the pain will ultimately come back. Even spinal
misalignments during sleep can aggravate SI syndrome so try and pay close
attention to how your body rests while you sleep.
Sacroiliac joint
dysfunction can be very painful and ultimately set you back from doing things
you want to because of it. Alternative methods such as chiropractic realignment
have also helped in my own experience, but are more of a temporary fix. The
tips I’ve outlined in this article are what I have found to be the most
effective long term solution.
If you have any
questions about sacroiliac joint dysfunction, feel free to contact me at ben@paramounttraining.ca. I'm available for online consulting and personalized program design,
as well as one on one training if you are located in the Greater Toronto Area (GTA).
You say do not do situp type exercises. Then how does one stretch their hamstrings? steve smith
ReplyDeleteMy response to that would be, 'why do you want to stretch the hamstrings in the first place?'
ReplyDeleteYou're likely response is that they are tight. To which I'd say, it's not likely that they are tight, but that the hips are out of kilter, which would also happen to negatively affect the SI joints. If anything, focus should be on lengthening the hip flexors, and restoring alignment in the hips before putting extra emphasis on stretching the hamstrings.
If you have any further questions or comments Steve, feel free to email me directly to discuss, or if it relates to this article, feel free to submit another comment. Thanks
Thanks!
ReplyDeleteAmazing post
ReplyDelete