Out of Joint
Years ago I was in the middle of my yoga practice, legs wide apart, bending deeply down over my right leg in Upavistha Konasana (Open Angle Pose) when I heard it—a popping sound in my left lower back, like a wine bottle being opened. Alarmed, I came up but only noticed a dull ache over my sacrum. I shrugged it off and finished my session relatively unfazed.
But it didn't go away. In fact, I was plagued with recurring bouts of pain. At the time I was in physical therapy school and had easy access to an orthopedist. His examination revealed little, and when I demonstrated the pose at his request, he smiled and expressed skepticism that I had lower back pain at all. Needless to say I felt somewhat hopeless about understanding what was causing this nagging pain. I continued to seek medical help over the next few years and even consulted with chiropractors and massage therapists. My chiropractor finally diagnosed my pain as being caused by my sacroiliac joint, but he had little success in treating it.
To my surprise, the pain was finally resolved at the place where it first occurred: my yoga mat. I noticed that when I began to take particular care with my pelvic alignment during yoga poses, especially in twists and forward bends, the pain and discomfort went away. That extra care and attention were the final piece that helped me understand the puzzle of my sacroiliac joint. Although my practice caused my sacroiliac pain, it was also the best medicine when it came to not only healing it but also preventing any future problems.
Casing the Joint
Lower back pain has been around as long as men and women have walked upright. In fact, approximately 80 percent of people experience some form of lower back pain, including sacroiliac pain, during their lifetime—although there are no definitive statistics on how many experience sacroiliac pain specifically. Part of the difficulty is there is no way to objectively measure the degree to which the sacroiliac joint is "out." In fact, there are some health professionals—like my orthopedist—who debate whether the S-I joint contributes significantly to lower back pain at all.
The sacroiliac is one of the joints in the pelvis, formed by two bones, the sacrum and the ilium. While there is a small amount of movement allowed at the S-I joint, its major function is stability, which is necessary to transfer the downward weight of standing and walking into the lower extremities. Held together by strong yet pliable ligaments, it is designed to lock in place when you stand; the sacrum bone wedges down into the pelvic joints due to the weight of the trunk—similar to the way a padlock closes. This tight sacrum-pelvis connection creates a firm base for the entire spinal column. However, when you sit, this stability is lost because the sacrum is no longer wedged into the pelvis—which is why S-I joint pain sufferers often prefer to stand.
Sacroiliac pain is a result of stress at the joint created by moving the pelvis and the sacrum in opposite directions. This can be caused by an accident or sudden movements, as well as poor standing, sitting, and sleeping habits. However, it has been my observation during 30 years of teaching and practicing that yoga students—particularly women—experience sacroiliac pain in higher percentages than the general population. This is mainly due to the unusual and consistent stresses put on the supporting ligaments around the S-I joint during asana practice, as well as poses that move the pelvis and sacrum in opposite directions.
Women are eight to 10 times more likely to suffer from sacroiliac pain than men, mostly because of structural and hormonal differences between the sexes. A woman's anatomy allows one less sacral segment to lock with the pelvis. It may sound minor, but this has a big influence on instability. Also, the hormonal changes of menstruation, pregnancy, and lactation can affect the integrity of the ligament support around the S-I joint, which is why women often find the days leading up to their period are when the pain is at its worst. Finally, women's wider hips influence stability during everyday activities; in walking, for example, as each hip joint alternately moves forward and backward with each step, every increase in hip width causes an increased torque across the S-I joint. Add the fact that women also make up two-thirds of exercise walkers, and it's easy to see why sacroiliac pain is found so much more commonly in women than it is in men.
Before turning to the mat for help, you first have to determine whether your lower back pain is in fact due to S-I dysfunction. There are a few telltale signs. The most common is pain that exists in an area about the size of a quarter over the S-I joint. This pain can be caused by the sacrum either slipping forward or backward in relationship to the ilium. It is commonly felt only on one side—and sometimes not on the side of the actual dysfunction. Another simple way to test whether your S-I joint is causing your pain is to observe your symptoms as you slowly stand and sit.
Other signs include pain radiating into the hip socket, or down the outside of the leg, or deep inside the belly over the anterior surface of the S-I joint. But pain is not an accurate indicator; there are other situations that mimic S-I dysfunction. It's important to have a health-care professional confirm your intuition—especially about which side and which way the dysfunction has manifested. Once you have been diagnosed, you can use yoga by practicing specific poses in a certain way. Remember, though, that while yoga can help strengthen around the joint, as well as provide the awareness necessary to help you prevent future problems, asanas in and of themselves may not be sufficient to cure all sufferers.
Proceed With Caution
The sacroiliac joint remains healthier if it is not stretched too much. In fact, focusing on creating stability is the key to preventing overstretching and thus remaining pain free in the sacroiliac joint. I have found that the best poses for sacroiliac pain are twists and asymmetrical forward bends, both of which help to diminish the torque through the joint. And strengthening the muscles around the S-I joint so as to prevent future problems can be accomplished by practicing simple backbends and standing poses. But while these poses can be beneficial, doing them incorrectly can put further stress on the area and end up causing more harm than good. If your sacroiliac is already out, then twists and forward bends can be especially problematic.
When it comes to twists, the only way to prevent further injury and discomfort is to meticulously move the pelvis and sacrum together. I learned this the hard way. I ignited my sacroiliac pain in large part by the way I was practicing seated twists. I was meticulous to keep my pelvis firmly on the floor when I twisted. This had the effect of stressing my sacroiliac joint as my spine was twisted strongly in one direction, while my pelvis "stayed behind." Yet I was able to use these asanas to my advantage. By focusing on allowing my pelvis to move with my spine in all poses—preventing the separation of my pelvis and sacroiliac joint—I "cured" my sacroiliac.
Another popular method of teaching and practicing twists is to hold the pelvis still and then use the arms as a force "against" the spine. This can be a lightening rod for sacroiliac pain. The popular pose Marichyasana III (Marichi's Pose) is an example of this, where practitioners often use the arm to create the torque necessary for the twist instead of twisting from the pelvis. It's better to create as much of the twist as you can before using your arm—this will decrease the possibility of separation and strain at the S-I joint.
Popular forward bending poses—such as Janu Sirsasana (Head-to-Knee Pose), Baddha Konasana (Bound Angle Pose), and Upavistha Konasana (Open Angle Pose)—also can be tricky. Remember that sitting in and of itself "unlocks" the sacrum and the ilium. If additional stress is then placed on the joint, discomfort and/or injury could occur. To avoid this, you need to be mindful of a few minor details while doing the poses. For example, in Janu Sirsasana, the critical side of the asana is the one with the bent knee. As you begin to bend forward, the spine moves while the pelvis and sacrum tend to remain behind, especially on the side with the knee drawn back. This kind of separation is, by definition, sacroiliac dysfunction.
When you practice Janu Sirsasana, be sure the pelvis moves forward with the spine. If you strongly bring the bent-knee side of the pelvis forward, it will help to unite the joint and heal the problem. During a therapeutic period, you may want to practice the pose with the foot touching the opposite knee instead of the inner thigh to further reduce the torque .
Both Baddha Konasana and Upavistha Konasana unlock the sacroiliac joint and potentially strain the transverse ligaments of the sacrum, particularly if you bend forward. If you have S-I problems, it's wise to skip these poses during acute flare-ups of pain. At other times, place a firm, rolled blanket under the outer thighs in Baddha Konasana, especially if you are supple. The blanket reduces the stress that the weight of the thighs places on the S-I joint. Supporting the outer thighs is also good practice for restorative or relaxation poses. Holding these poses for long periods can aggravate already stretched-out ligaments and worsen S-I pain. And under no circumstances should you push down on your knees or place extra weight on them in order to increase the stretch.
When you sit in Upavistha Konasana, there is little to support and/or stabilize the sacroiliac joint, and bending forward only adds to this instability. If you suffer from sacroiliac pain, bring the legs closer together than usual and rest the arms and forehead on a chair in order to prevent further discomfort. Also, certain rotator muscle stretches—such as Eka Pada Rajakapotasana (One-Legged King Pigeon Pose), which many students use to warm up before class—should be avoided during acute sacroiliac pain. The piriformis muscles, strong external rotators of the thigh, attach to the sacrum and the femur. Stretching them can increase S-I joint instability.
Healing the sacroiliac joint takes constant vigilance. The most powerful healer is simply not to create the torque of sacrum and ilium moving apart. But strengthening the area can be useful too, and one of the best ways to do this is with simple backbends, such as Dhanurasana (Bow Pose), in which the pelvis moves forward and contracts the posterior muscles. This helps move the sacroiliac into place and also strengthens the muscles of the lower back and hip, which can then help to hold it there.
Standing poses can help strengthen the area around the sacroiliac joint. Focus on Trikonasana (Triangle Pose) and Utthita Parsvakonasana (Extended Side Angle Pose), as these poses strengthen the rotator and gluteal muscles that help to stabilize the area of the S-I joint. In standing poses be careful of any asymmetrical position that could cause the pelvis and sacrum to move in different directions. Remember that you want the area to be strong and supported by contraction of the powerful muscle groups of the pelvis and hip, like the gluteals and rotators.
Also, avoid twisting standing poses during flare-ups because they can torque one side of the joint. Keep in mind, though, that the best cure for sacroiliac dysfunction is prevention. Understanding the importance of keeping the sacrum and pelvis together in twisting and sitting movements—in your yoga practice and everyday life—is the key to remaining pain free.