Sacroiliac Joint Dysfunction - Common Cause Of Lower Back Pain And How You Can Minimize It

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).