Keeping Your Sacrum and SI Joints Happy and Healthy

by Shari

Keeping His Sacrum Happy and Healthy

Now that I’ve described how the sacrum moves (see Yoga and the Sacrum), let’s look at how the sacrum and sacroiliac joints work in some of the typical yoga poses we encounter in a class, and how to keep your SI joint healthy and happy while you do them. Hopefully this will provide help for people who are already suffering from sacroiliac joint problems as well as for people who would like to avoid developing problems.

Note that if you think you might be having sacroiliac join problems but are not sure, I would recommend that you should not try to diagnose yourself. Instead, please try to consult a health care professional for a diagnosis. And although this injury is more common in women, it definitely occurs in men as well, so you guys should also get yourself checked out. Finally, for any of you pregnant yoga practitioners or teachers who teach pregnant women, all of these suggestions that follow are beneficial for pregnant women.

Now let’s get started at the beginning of a typical class. Warm ups are often asymmetrical because we work first with one leg and then the other. A typical warm-up series might include hip openers, reclined leg stretches (Supta Padangusthasana), Figure Four pose, and so on. Any type of hip opener that is asymmetrical will put different stresses on your SI joints. So for our Figure Four pose, when we stretch the piriformis on the right, the sacrum will be turned to the side that is being stretched, the right side. And conversely the sacrum will be turned to the left when we stretch the left piriformis. That’s all well and good, except if you have a piriformis that is already in spasm. Stretching it more only inflames that poor little muscle, so avoid this asymmetrical position if it hurts (or if starts to hurt while you’re in the pose, come out).

Leg stretches are also poses you may need to approach with care. If you are really tight, when you stretch your hamstrings, the hamstrings pull on your ischial tuberosities ( the sitting bones of the ilia), which flattens your lumbar spine and pulls your sacrum into a flexed position. This may cause you pain because as your sacrum is pulled down into the ilia, the two sides may not be moving equally (one side will be moving more than the other side).

When you take your leg out to the side and are stretching your adductors, try not to roll onto the SI joint of the raised leg and have the opposite side of the pelvis roll forward. Learn to move from your hip joint and limit the stress through your sacrum. If one side is tighter than the other, this may also create an asymmetry in the sacrum that will cause pain. In this case, less stretch is better (use a wall to stop the stretch on the raised leg, or use a block, chair, or bolster to limit the stretch).

For standing poses, if you are having SI problems, focus on symmetrical poses and using props. Also, be kind to yourself—think I am going to do 50% not 125%. Standing poses which are done with wide legs and an asymmetrical pelvis position may strain the ligaments holding the sacrum in place, which can then cause subsequent pain. Try firmly contracting the back leg to give some stability to the sides of the sacrum. Although Wide Legged Standing Forward Bend (Prasarita Padottanasana) is a symmetrical pose, how deep you go into the pose and what position your spine is in will all contribute different problems to the sacrum. So, when in doubt, try to keep your spinal curves in neutral and use a chair to take the torso’s weight and do less stretch than more.

In seated poses, spinal position is paramount. You want to keep your spinal curves in neutral and have enough height under your ischial tuberosities (sitting bones) to encourage your ilium to rotate over the femoral heads (hip joints). And never use your arms to pull yourself into pose, but instead rely on your abdominal muscles and spinal stabilizers. This applies to all practitioners, as both a preventative approach for those of you with no current problems as well as a therapeutic approach for those of your with SI problems. As Baxter mentioned, you want your sacrum to move with the ilia, not to be “held back.” If you are currently having symptoms, I would avoid revolved seated poses for quite a while until the symptoms are gone and you understand your vulnerabilities.

Backbends will either feel great or terrible, depending on your issues. Backbends and forward bends position the sacrum into very different positions. In forward bends the sacrum is less stable. In backbends the sacrum is more stable. But stability doesn’t mean it is going to feel good if the inherent alignment of the bones is not congruent.

If backbends feel good, pay attention to symmetry in how you go into and out of a pose. And be careful not to tuck the bottom of your spine—you lumbar spine needs to be in lordosis (curved) when you do backbends, which then puts the sacrum into a more optimum position. And less is better than more as you are healing.

However, if backbends feel terrible, don’t do them. Rather than putting a block under your sacrum in an easy Bridge pose, try an active Bridge pose and slowly evaluate how you feel afterwards. Less lifting is also crucial.

I hope this advice is helps you keep your sacrum happy and healthy!

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Yoga and the Sacrum

by Shari

Nina asked me to expand a bit on Baxter’s previous post on sacroiliac challenges with asana practice (see Friday Q&A: Sacroiliac (SI) Joint Injuries). I wanted to start by giving a little more background on sacroilac anatomy. As Baxter previously stated, the sacrum is nestled in between the two ilia bones that comprise the pelvis. The front of the pelvis is the symphysis pubis and the back is where the sacrum is located.

The sacrum is affected by many different forces. Along with the pelvis, it forms the bridge between your head, spine, torso and arms with your legs and feet. All forces from the top of your body pass through your sacrum and out to your lower limbs, and at least sixty muscles directly or indirectly affect the sacrum.

However, the sacrum does not move on its own but moves only because of the connections it has to the two ilia bones as well as the muscles that either directly insert onto it or cross over it. This means that the sacrum can only be passively moved. The sacrum’s passive motions caused by muscle action directly onto the pelvis and coccyx (think pelvic floor muscles also) include pivoting (forward and backwards motion) and rocking (spinning on a certain axis).

When you go into a yoga pose, how you set your legs and pelvis up is going to directly affect forces on your sacrum. So if you are turning your pelvis to the right, unless your legs are in the same direction as your pelvis, your sacrum will get conflicting forces through it. There are too many muscles to go into in here, but it’s important to understand that the leg muscles that cross from your pelvis to your femur and the abdominal muscles that attach to your pelvis will have a profound affect on the position of your sacrum. The spine also has a direct effect of moving the sacrum, especially L5 (the lowest of the five lumbar vertebrae) as well as the two ilia bones.

Why the sacrum is so important for yoga students is that we put undue strain on the ligaments that are firmly holding the sacrum in place with the two ilia and on the ligaments that hold the sacrum to the L5 vertebra, particularly when doing asymmetrical poses. And one of the main muscles that has a direct affect on the sacrum is the pesky piriformis. Now why, of all the 66 muscles, am I singling out the piriformis? Well it is one muscle that many yoga students have heard about, and it is one of the main muscles that we stretch when we do Thread the Needle or Figure Four pose. The following figure shows the muscle in red (and you can see how it connects the sacrum and to the leg):

That's it for now! Tomorrow, we'll look at how the sacrum and sacroiliac joints work in some typical yoga poses (see Keeping Your Sacrum and SI Joints Happy and Healthy). Hopefully this will provide help for people who are already suffering from sacroiliac joint problems as well as for people who would like to avoid developing problems.

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Friday Q&A: Sacroiliac (SI) Joint Injuries

Q: I have been having problems with low back pain caused by my sacroiliac joint (SI joint) going out of alignment. It seems like something I'm doing in my yoga practice is making it worse. I’m looking for both techniques to snap the sacrum and pelvis back into place and alignment, and advice on how to prevent this from happening. I would appreciate any help with this. I want to keep practicing!

A: I asked Baxter to answer this question because he’s the back care expert (and MD), but since I’ve had this problem myself, I know a little something about it. And maybe even have slightly different advice than Baxter. So Baxter asked me to preface his answer with my own.

First of all, this is a common injury for dancers and yoga practitioners, though not for the general population. In general, forward bends and twists take the sacroiliac (SI) joints out of alignment. Janu Sirsasana seems particularly bad. Backbends can put the joints back into proper alignment. So for now, I'll just suggest that at the end of a practice that includes forward bends and twists (even standing versions of these) that you include some kind of supported backbend before Savasana. Stay in the pose for at least three minutes. You want to restore the curve in your lower back. For example, Bridge pose with a block under the sacrum or even Legs Up the Wall pose with a bolster, where your lower back is arched over the bolster, can help restore the curve. (I’m recommending supported backbends because active backbends—which Baxter recommends below—at the end of a forward bend practice reverse the quieting effect of the practice. This is not really an issue for twisting practices. Regardless, you might try both as everyone is different.)

I also recommend that you read articles on the topic by Roger Cole on the Yoga Journal web site (see Protect the Sacroiliac Joints and Practice Tips for the SI Joints). I’ve learned a lot from him over the years, and have taken his workshop on the SI joint.

Finally, as wonderful as yoga is, it isn't necessarily the answer to everything, so you may need to take time off from certain poses or your asana practice entirely to heal before resuming practice. I, myself, as well as other yoga friends, have had good results from going to a chiropractor who realigns the sacrum manually. My chiropractor is also a yoga teacher—that's the perfect combination if you can find one. 

Now for Baxter’s reply.

—Nina

A: It might be helpful to our readers to define what we mean by “sacroiliac dysfunction.” Typically, the joint between your sacrum bone and the two halves of the pelvic bones meet at the right and left side of the posterior pelvic area and form a fairly firm, barely moveable joint called the sacro-iliac joint, or SI joint for short. 

The only exception to the “barely moveable” concept is for women about to give birth. In order for the safe delivery of the baby’s head and body, the joints of the pelvis, including the pubic symphysis in front, have to be able to move. The pregnant woman’s body produces a hormone, relaxin, which allows the ligaments around the joints to loosen and permit more movement than normal. Once the baby is safely delivered and breast feeding is concluded, the production and release of relaxin slows and disappears and the SI joint regains its previous firmness.

As Nina pointed out, seems there are a few groups of folks more likely to loosen one side of the joint. These include gymnasts, dancers and yoga practitioners. And indeed forward folds combined with twists seem to be regular culprits. These poses create a torquing action through the pelvis that can overstretch the ligaments and result in more mobility on one side. It is unusual, in my experience, to have someone with both SI joints hypermobile, but I have seen it at least once before.

And indeed, Roger Cole has written some very good articles on this topic, and leads workshops on the topic around the country, which I have attended and can highly recommend. In addition, Judith Lasater has an article in the Yoga Journal archives on her bout with SI joint dysfunction, how yoga brought it on, and how yoga helped her heal it (see Out of Joint).  She also has some discussion in her book, “Yoga Body” on the particulars as well, if you want to dive a little deeper. After reviewing the chapter in her book on the pelvis, I found a 1991 review of all the research to that date on intra-pelvic joint movement, including SI joint movement.  It seems there is some evidence for minor but distinct amounts of normal healthy movement at the SI joints, but a decent amount of confusion still existed at the time of that study.

As for asana recommendations, I like active backbends, especially Locust, but doing a variation Roger Cole teaches where you have the legs parallel, you strap the ankles and push out against the strap as you lift the legs up. He also recommends doing some asymmetric propping with sandbags, but I have found the symmetric version effective for some students.  And I’d put a block between the knees for active bridge and also consider strapping the thighs without a block and push out against the strap as you go up. I believe the theory is that you are creating some lateral space so that the SI joint that is misaligned can pop/slide back into place. These are only two of a whole slew of pose variations that Roger shares in his workshops, so look for the chance to study with him down the road.

And don’t discount the benefit of working with a good physical therapist, as I have had students who were taught some effective simple adjustments they could do to get the SI back in good alignment. And as Nina has mentioned, I have had some students work with chiropractors and osteopathic physicians who got adjustments that resulted in SI re-alignment.  Ideally, you would not need to do this very frequently.

This is certainly a hot topic, so keep your eyes and ears open for new developments on the issue of SI joint dysfunction.  Thanks for your question!

—Baxter

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Friday Q&A: Squarers Beware!

Triangle Pose (Trikonasana) from Yoga: The Poetry of the Body

Q: Here’s a kind of fussy Iyengar question…and your response need not be Iyengar-based! What about that back-leg hip and leg rotation in Triangle pose? Many years ago I learned that, like the front leg, the back leg has an external rotation in triangle and that the hips should be squared up to face toward the front of the room. But I’ve also had teachers instruct to let the back-leg hip roll forward a bit. Does this represent an evolution in the understanding of the pose? Is there an Iyengar orthodoxy that may not be the best way for all of us to practice? What do you all think? How do you teach or practice triangle?

A: When I read your question, I heard my teacher, Donald Moyer, saying, "Squarers beware!" Yes, there definitely has been an evolution in the understanding of the positioning of the back leg in Triangle pose, as well as other related standing poses (Warrior 2, Extended Side Angle) in the Iyengar world. I asked Baxter to elaborate. —Nina

A: As you adjust your feet, turning your right foot out 90 degrees, and kicking your back heel back about an inch or two, your hips will naturally turn a bit toward the front leg. Let this happen! This position keeps the top back of your sacrum wide and relaxed, unlike what happens when you strongly externally rotate your back thigh bone or try to square your hips with the long edge of your mat.

The old school instructions tend to cause narrowing and bunching of the muscles and soft tissues of the left sacroiliac joint, in our present example, which over time I believe can contribute the sacroiliac joint dysfunction and lower back pain.  So, again, let your hips rotate a bit to the right. Once you tip your hips and spine out over the right leg, simply firm the inner edge of your back leg (adductors) toward the outer edge of your back leg (ileo-tibial band), and you will have a nice strong feeling in your back leg to assist in grounding of your back foot.  Maintain the rightward rotation of your pelvis, even as you rotate your upper belly and chest up toward your top arm. On more occasions than I can count, when I have taught this version of Triangle pose, the old schoolers comment on how much better the pose feels in the pelvis and lower back. See what you think! —Baxter

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Interview with Steve Cropley: Relief from Sciatic Pain

Baxter: When we spoke recently, you reminded me of an event that happened to you while attending a week-long retreat lead by JJ Gormley and me.  What was going on with your body that week?

Steve: I suffered low back problems from my high school years on. I routinely jumped off of gas tanker trucks onto concrete in leather-soled moccasins. Today they call that sort of thing “Parcorp”; in the 60s it was called “working for Dad.” My back problems got worse over the years. Years of downhill skiing, running, and working added to the problems. Chiropractors were my only saviors until sciatic pain.

In the spring of 2000, I developed sciatic pain. No relief from chiropractors, acupuncture, massage or physical therapy. I was suffering a pain that generally isn’t felt at its source. In my case, I did feel it from its source in the low back, through the hip and knee, through the ankle, top of my foot, toes and the sole of the foot. I couldn’t sit stand or lie down without constant shooting pains. Thinking that yoga might be part of the problem, I stopped my practice except for Viparita Karani (Legs Up the Wall or Waterfall pose). This pose was the one reliable way to fall asleep; I would plop down anywhere when I needed a break from the pain. I had months of agony before the pain began to recede. I returned to my yoga practice with the occasional recurrence of the sciatic pain, none as severe as the first. 

Baxter: You learned a valuable way of working with lower back pain from JJ that you now share with your students. Can you share it with us here?

Steve: It’s July 2004. I am in a weeklong yoga workshop at the Feathered Pipe Ranch with JJ Gormley and Baxter Bell. This particular afternoon, Baxter is teaching and JJ is assisting students. I can feel the tell tale bite of sciatic pain and I am moving in every direction, except the ones that Baxter is guiding us into, trying to find relief. JJ spots me and I tell her my sciatica was acting up. “Which side?” she asks. JJ shows me how to bring the hip points together with a yoga strap. JJ has me to do symmetrical poses. I did easy down dogs, cat backs, child poses and on my back, knees to chest and easy hip raises. Within a few minutes, the pain was gone. JJ answered the question on my face. “I figured this out on myself. “ She too had fought sciatic pain.

I am 60 now and in my life I have hurt all the major joints, broken fingers and toes, ribs, my jaw and my skull. On occasion, I wake up with low back pain. The difference today: I know that within a few minutes of rising, I will have figured out what it takes to make the pain disappear and get on with my day.

I have taught JJ’s belt trick to a lot of people in the last few years. Building extra press boxes at the 2006 Super Bowl, I found one of our electricians moaning and rolling around on the concrete. This guy had been self medicating, using alcohol to help him cope with his sciatic pain for years. Our 12-hour days and 7-day weeks were taking their toll on him. I taught him JJ’s belt trick, and some simple asana. Within a few minutes, he was able to find relief and go back to work.

This August a student came to class with sciatic bite, my term for that mild or beginning pinch that one gets as sciatica acts up. I taught her JJ’s belt method and she continued class pain free. As class continues, I forget about her earlier sciatic bite and guide her into a twist. She has an immediate reaction as her sciatic bite returns. We go back to JJ’s method, belt and symmetric poses. Pain stops. I haven’t seen this student since Thanksgiving, but I know she has JJ’s belt method in her toolbox, another tool to ease the body and calm the mind.

Here is JJ’s sciatic belt trick/method/remedy. Put the belt around the hips with the buckle on the hip point of the affected body side. Hold the buckle in place as you draw the belt tight. The action is to draw the hip points together.

Baxter, I don’t know why this works. Dr. Patty Tobi and I were talking about this yesterday. Does the pull of the strap or compression from the strap make others nerves fire and make the mind reset the brain’s reading of the enflamed nerves? Patty wonders if the strap puts pressure on a meridian.

Baxter: The belt trick is one I have used for stabilizing the pelvis and opening the sacroiliac joints so they can reset. Sacroiliac joint pain can cause sciatic-like pain patterns. It is hard to say what the belting is doing anatomically, but it very impressive in its effect on stopping back pain.

Steve Cropley is Head Custodian, Santosha Yoga, Sheridan WY, CYT 300 RYT 200. Steve read Light on Yoga in 1971 and determined he was already practicing yoga. He found a teacher and began formally studying yoga in the mid 90’s. Steve began studying with Baxter Bell in 2003, and Baxter introduced Steve to JJ Gormley. Steve graduated from JJ’s Special Ed Yoga program, which he practices to this day. Steve has led impromptu yoga classes in Beijing and Inchon Airport in Seoul. You can find Santosha Yoga at the Santosh Yoga web site.

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Friday Q&A: Is Loren Fishman's Osteoporosis Sequence Safe?

Q: You say that people should not do the same poses all the time. What about programs like Dr. Fishman's osteoporosis study, which has participants doing the same sequence of poses every single day?

A: Thanks for this question. Indeed, if a person does the same sequence day in and day out, you could run the risk of a repetitive strain injury. The fact that Dr. Fishman's sequence is only supposed to take 10 minutes a day to do means that the practitioners are not holding the poses terribly long, which would reduce this risk considerably. However, a review of the poses taught (see here) reveals several poses that I feel could be potentially injurious to the wrists, neck and lower back, these being Upward Bow pose and the deep seated forward bends. I would consider other poses if I were to design such a practice, but Dr. Fishman does mention tailoring the sequence to students individual needs. I would suspect that this had to be done quite a bit.

Recall that the number of patients that started the study was much larger than those that completed the study. (117 vs 11). Interestingly, there is no discussion as to what caused so many to drop out  and why they were unable to do a 10 minute practice everyday. One factor could have been boredom, which is why I often suggest that students alternate practices from day to day to help maintain better focus and follow through. And it is possible that some found the sequence too advanced, despite the individual adjustments offered. The bottom line, in real life, when you can vary your practice, I highly recommend you do so.

—Baxter

A: With Baxter's blessing I'm going to tell you why I wouldn't want to do this sequence on a daily basis. I'll start by telling you that the three yoga injuries I've sustained have all been repetitive strain injuries. I was a pretty enthusiastic practitioner for a number of years, and did a lot of standing poses and sun salutations. And the injuries I had were: sacroiliac joint injury (common among dancers and yoga practitioners, but not the general public), tennis elbow (possibly from sun salutations), and housemaid's knee (from kneeling too much on the bare floor).

Now let's look at the sequence:

1. Triangle Pose (Trikonasana)
2. Downward-Facing Dog Pose (Adho Mukha Svanasana)
3. Upward-Facing Dog Pose (Urdva Mukha Svanasana)
4. Bridge Pose (Setu Bandhasana)
5. Upward Bow Pose/Rainbow Pose (Urdva Dhanurasana), without or with a chair
6. One-Legged Forward Bend (Janu Sirsasana)
7. Two-Legged Forward Bend (Paschimottansana)
8. Boat Pose (Navasana)
9. Reclined Leg Stretch (Supta Padangusthasana)
10. Marichyasana 1 twist
11. Lord of Fishes twist (Matsyendrasana)
12. Reclined Twist (Jathara Parivarthasana)

After I got over the shock of trying to imagine doing all those poses in 10 minutes, without any warm-ups, I examined the poses in detail. First, two of the poses in the sequence are known for causing sacroiliac joint injuries, Triangle pose (Trikonasana) and One-Legged Forward Bend (Janu Sirsasana), with One-Legged Forward Bend a particularly guilty party. For me, personally, I've concluded it's just not good to do either of those poses every single day. Then, as Baxter mentioned, there is a very deep backbend in the sequence, Upward Bow, and doing this every day could put a lot of strain on the wrists and elbows, but of just as much concern to me is that it is followed immediately by a deep forward bend, taking the lower back into such extreme movements with no rest between. In particular, the Two-Legged Forward Bend is known for causing lower back strain. The combination of the deep backbend followed by the deep forward bend could cause a lot of back strain (personally, I would have moved the forward bends to the end of the sequence). The sequence ends with three twists, asymmetrical poses that are also hard on the sacroiliac joint, with no symmetrical counter pose to finish the sequence. (On the bright side, no danger of housemaid's knee here.)

I understand some of the thinking behind this sequence, which tries to engage all the different muscles of the body to strengthen as many bones as possible, within a short sequence, and uses the twists to "release" the back after the strain of the backbends and forward bends. However, if I were to design an osteoporosis practice, for safety's sake, I would develop five or more different sequences that the practitioner could alternate between on different days, rather than trying to cram everything into one single practice. There are so many wonderful poses in the yoga tradition, why would you limit yourself to just 12?

—Nina

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