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Protecting the Sacroiliac Joint in Yoga

Protecting the Sacroiliac Joint in Yoga. Copyright. Ginger Garner.

Part 1 in a 2 Part Series

What would if feel like to not have pain anymore in your sacroiliac joint during yoga practice? That’s the question I asked myself for years before having an “Aha!” moment. This series will help you protect the sacroiliac joint in yoga so you can practice with a happy sacroiliac joint too. 

An Introduction to the Sacroiliac Joint: Telling My Story

The first time I had sacroiliac joint pain, I was practicing a yoga posture. Specifically, a backbend. It wasn’t a crazy extreme backbend. It was just plain old two foot posture, a pose that is a prerequisite for half upward facing bow pose (see pictures below). For those of you not familiar with yoga postures, that’s just a kind of bridge with a little extra spine extension and shoulder movement thrown in. 

Protecting the Sacroiliac Joint in Yoga. Copyright. Ginger Garner.
Bridge Pose. Bridge is the simplest trunk lift off that can be done. It does not require articulation or flexion of the spine, and the weight is borne in the shoulders and feet. ©2016. Garner, G. All rights reserved.
Protecting the Sacroiliac Joint in Yoga. Copyright. Ginger Garner.
Supported Two Foot Posture. This pose usually requires a blanket to perform safely in order to protect the cervical spine, and is done by segmentally lifting the back from the floor. It is more advanced than Bridge Pose. ©2016. Garner, G. All rights reserved.
Protecting the Sacroiliac Joint in Yoga. Copyright. Ginger Garner.
Supported Half Upward Facing Bow Pose – This pose is a progression of the previous two postures, and is where sacroiliac joint issue can be made worse if the pose isn’t carefully scaffolded. In this particular pose I am performing it with the support of a quarter-fold blanket, a block, and a strap. ©2016. Garner, G. All rights reserved.

But that’s only part of the story. There are actually two important parts to this story about the sacroiliac joint. 

The first is – practicing yoga postures as a young 20 something hurt me (that was before I became a physical therapist and athletic trainer). I didn’t know how to protect my sacroiliac joint. Heck I didn’t even know my sacroiliac joint needed protecting. 

The second part to the story is yoga postures aren’t therapeutic in and of themselves, nor or all yoga postures safe or even necessary. 

To understand this, you have to go back in history a bit. Yoga postures, contrary to what most people believe, are a modern phenomenon. Mark Singleton first coined the term “modern postural yoga,” which refers to yoga posture’s young roots. The practice of “asana” as we know it supposedly began at the turn of the 19th century, in the late 1800’s to early 1900’s. Before that, yoga postures were thought to be a moral contradiction to “true spiritual yoga practice.” 

What’s more important is this historical fact – Postures were created by men for men and young boys with a certain body type. So really, yoga postures were never really intended for women. 

That fact bears repeating: Yoga postures were never intended for women. But what does yoga history have to do with the sacroiliac joint? 

Yoga history has everything to do with the sacroiliac joint because these not so ancient yoga postures were designed for men and boys, not women and anyone with a sacroiliac joint susceptible to stability issues. 

Women tend to suffer the most from sacroiliac joint issues, in large part because of our pelvic bony design. The female pelvis is built for childbirth, which makes the pelvic outlet wider and its connecting point, the sacroiliac joint, vulnerable to issues because of its higher degree of movement.

Protecting the Sacroiliac Joint in Yoga. Copyright. Ginger Garner.
Female & Male Pelvis – The female pelvic outlet is much larger than the male pelvic outlet. ©2019. Garner, G. All rights reserved.

Movement in the sacroiliac joint is highly variable, which means there are no universally agreed upon standards for sacroiliac joint range of motion. However, because of female anatomy, it is generally accepted that women biologically have a need for increased sacroiliac joint range of motion. 

Historically, the sacroiliac joint was thought to be an immovable, fixed, even fused, joint. This could still be true for some men; however, it is not true for a large number of people. Just ask anyone who has ever had that deep, lower than low achy back pain. That location is the “aha” point for classic sacroiliac joint pain. 

The first time I had sacroiliac joint pain, yes, yoga postures were the culprit. 

I had been practicing Ashtanga, Iyengar, and Viniyoga-based yoga, and it was slowly killing my low back and sacroiliac joint. I just didn’t know it until I learned more about the human body and my own body. 

Yoga instructors I had taken classes or worked with at conferences or privately pushed me hard, sometimes harder, and never once discussed safety or even alignment of this (or really any) area. Mind you this was the early 1990’s when there was little supervision or oversight of safety or ethics in yoga or yoga leadership at any level. The point is, I trusted them, and it hurt me. 

I had taken various classes with high profile instructors and “gurus” at giant and small conferences across the US. And yes, I even had a class with Pattabhis Jois and other “celebrity” teachers. At the time, I was a fledgling pre-med student looking to relieve stress and feel better from hours of hunching over a desk trying to keep a 4.0 GPA. I could care less about guru worship and attending the hippest studio. But still, I got hurt. 

And in hindsight, after studying and becoming licensed in athletic training and physical therapy, I knew that there wasn’t a shred of solid anatomy or physiology being taught in any of the yoga I had taken. Ever. 

As a young student I knew it seemed fishy and felt a little wrong sometimes, mostly because as a woman I can spot egotistical swagger and patriarchal posturing from a mile away. And that was what a lot of teachers did. They stood at the front of the class or on stage and barked out postures and demanded that mine and all the other attendees bodies fit a certain shape or look. But even though I felt hesitation, the embarrassment or my own ego issues of not looking like everyone else, or of coming across as being a defiant student, shamed me into doing the poses anyway.

But then the old proverb, know better, do better, kicked in hard, in the form of pain.  

By the late 1990’s I had earned my physical therapy and athletic training licenses, and I knew better. I had also attended yoga teacher and therapist trainings, and instead of learning, I spent a LOT of time treating yoga teachers’ sacroiliac joint (and other) pain (for free) and counseling people on quietly backing out of asana that wasn’t right for them. Then I knew it was more than just me knowing better, I had to do better for others too.

I shook off any notion of identifying with lineages. I secretly considered them ridiculous cults that sold snake oil. I was angry because I knew the industry wasn’t safe for consumers when it came to asana. But I knew better than to speak up. And honestly, I didn’t know how to speak up. In the very loud and theatrical world of the yoga industry, calling the guru’s bluff would have been career suicide. So I kept quiet. 

Instead, I put my head down and started working. 

I got busy writing continuing education to help folks practice yoga safely, and to help other healthcare providers use yoga in an effective way. I started a private practice that helped people in my community access yoga in a safe, best evidence way. I made sure that everyone could attend by offering sliding scale fees, taking payment plans, and even bartering. And I studied the research. I read, took continuing education courses in every aspect of spine and pelvic health that I could, and went back to school and earned my doctorate. Doing all of this has kept me busy for the last 20 years, and as hard as it has been (pushback is incredible when you are trying to change the status quo) it was the right thing to do – and, it brings me to my point of this post. 

The point of this post that I want to help you avoid injury and pain caused by unsafe yoga practice. I hurt my sacroiliac joint while doing yoga postures the way I was told to do them, instead of how my body needed them to be done. And I don’t want you to make that same mistake. 

Once I began to honor the tenets I am about to share with you, and recalibrated yoga postures to fit my female body and its needs, my sacroiliac joint pain vanished. 

To do that I had to dive deep into trunk, hip, and pelvic physiology and pathophysiology. I became a pelvic health physical therapist. I took courses in manual therapy, myofascial work, pain, biomechanics, and the spine. I had to figure out what muscles in the trunk and pelvic area should be used, how often, how much, and in what pattern to create a stable, pain-free sacroiliac joint. 

More than 25 years later, I know a lot more than I did. I am proud of myself for walking away from guru-based “lineages” in order to pursue simple, evidence-informed yoga. That wasn’t easy, and it still gets me into hot water with those who feel like gurus are gods and know everything about the human mind and body possible. 

I am smart enough and know enough to say this – I don’t know everything.  However, I do know this much about the sacroiliac joint:

  1. Much more will be learned and discovered and researched about the sacroiliac joint.
  2. I’ve treated hundreds of folks with sacroiliac joint dysfunction in my career as a physical therapist and athletic trainer, and each one is unique. 
  3. The basic biomechanics of the sacroiliac joint will not change. 
  4. The basics of safety in sacroiliac joint alignment in yoga postures will not change. 
  5. The number of variations in a pose is only limited but your creative mind, so never think a yoga pose isn’t for you. Any pose can be adapted to create success for you. 

I’ll teach you what I have learned and practiced over the years to work through my almost decade struggle with sacroiliac joint pain as a young yogini. I’ll show you what it takes to be your own healing guide, and hopefully get you back on track to practicing yoga without sacroiliac joint pain. Please know that this blog and all my blogs are never a substitute for medical care and do not constitute a patient/provider relationship. Please always consult your doctor or physical therapist before starting this or any other exercise or movement. 

Let’s Talk Research on Anatomy & Physiology 

What kind of potential issues can be expected if you have sacroiliac joint dysfunction? For starters, the pain patterns can vary. However, most pain will situate itself below your belt line, in the “lower low back” area, below your actual low back and above your tailbone. However, some people will have tailbone pain and pelvic pain, or pain inside the pelvic bowl area. 

Potential Issues with Sacroiliac Joint

Protecting the Sacroiliac Joint in Yoga. Copyright. Ginger Garner.
©2019. Garner, G. All rights reserved.
  • Low back pain
  • Neck pain
  • Myofascial pain
  • Pelvic pain
  • Continence issue
  • Sexual dysfunction (dyspareunia) 
  • Nonrelaxing pelvic floor 
  • Fatigue from unresolved chronic pain
  • Psychoemotional issues from unresolved chronic pain, like depressive feelings, anxiety, impatience, lack of motivation, feelings of helplessness, loss of feelings of control over health and body

Who gets Sacroiliac Joint Issues?

As I mentioned earlier, statistically, women have more sacroiliac joint pain than men because of pregnancy being one of the main risk factors. However the other two major groups who have sacroiliac joint tend to be young athletes and the elderly. 

Protecting the Sacroiliac Joint in Yoga. Copyright. Ginger Garner.
Bony Landmarks of the Sacrum ©2019. Garner, G. All rights reserved.

The sacroiliac joint is “an under-appreciated source of mechanical low back pain, affecting between 15 and 30% of individuals with chronic, non-radicular pain. Predisposing factors for sacroiliac joint pain include true and apparent leg length discrepancy, older age, inflammatory arthritis, previous spine surgery, pregnancy and trauma. Compared with facet-mediated and discogenic low back pain, individuals with sacroiliac joint pain are more likely to report a specific inciting event, and experience unilateral pain below L5. Owing in part to its size and heterogeneity, the pain referral patterns of the sacroiliac joint are extremely variable. Although no single physical examination or historical feature can reliably identify a painful sacroiliac joint, studies suggest that a battery of three or more provocation tests can predict response to diagnostic blocks”1 

Sacroiliac Joint Movement: How Much Does It Move? 

“The sacroiliac is a true diarthrodial joint, consisting of two surfaces held together by fibrous capsule and enjoined with synovial fluid. The average surface area has been estimated to be approximately 17.5 cm2, although there is significant variability between individuals regarding the shape and size.”1,2,3 “The sacral and ilial surfaces of the joint are covered with hyaline and fibrocartilage, respectively, and have rough and coarse textures believed to be due to physiological adaptation to stress.”1,3

The sacroiliac joint bears quite a load; it is a critical connecting point, along with the hip, between the upper and lower body. It must attenuate force during walking and running; and it has a network of ligamentous support that softens and offers less support for women during menstruation, pregnancy, labor and delivery, and during breastfeeding. The ligaments include the anterior and posterior sacroiliac ligaments, the sacrospinous and sacrotuberous ligaments, and the interosseus ligaments (see below).  

Protecting the Sacroiliac Joint in Yoga. Copyright. Handspring Publishing.
Hip “Rotator Cuff” & surrounding local stabilizers. ©2016. Garner, G. Medical Therapeutic Yoga. Handspring Publishing Ltd. Edinburgh, UK. All rights reserved.

They provide stability to the joint by holding the joint together when load is being transferred, say when walking, rolling over in bed, lifting a child, or getting out of a car. The ligaments do not act alone, however. The local muscles and fascia (see below) also provide support and stability, as well as allow for mobility. These muscles include the “hip rotator cuff” (see below), the pelvic floor (see below) and the superficial muscles, including the gluteus maximus, medius, minimus, and latissimus dorsi. The hip flexors can also be involved (see below), especially when there is a deficiency or injury at the hip.

Protecting the Sacroiliac Joint in Yoga. Copyright. Handspring Publishing.
Female Pelvic Floor Fascia. Notice the connections between the pelvic floor (tendinous arch of the levator ani) and the obturator internus. This is a common problem in pelvic pain, hip pain, hip labral injury, and sacroiliac joint pain. ©2016. Garner, G. Medical Therapeutic Yoga. Handspring Publishing Ltd. Edinburgh, UK.
Protecting the Sacroiliac Joint in Yoga. Copyright. Handspring Publishing.
Female Pelvic Floor. ©2016. Garner, G. Medical Therapeutic Yoga. Handspring Publishing Ltd. Edinburgh, UK.

Studies have reported various limit on sacroiliac joint movement. Harrison et al., reported that motion was most likely limited to 6 degrees of freedom, which means the sacroiliac joint is capable moving in both translational and rotational movements 6 different ways.5  Older reviews reported rotation between 1 and 12 degrees with translation between 3 and 16 mm, but they also acknowledged that available range of motion varied based on the position of the person.6 Other studies report similar findings, but the overall consensus is that three dimensional motion analysis is not a useful clinical measure for predicting or identifying pain in the sacroiliac joint.

Protecting the Sacroiliac Joint in Yoga. Copyright. Pelvic Floor Fascia. Copyright Ginger Garner
Pelvic Floor, Hip, & Trunk Fascia. The interaction of fascia and ligamentous support with the pelvic floor, sacroiliac joint, and the trunk.
©2016. Garner, G. Medical Therapeutic Yoga. Handspring Publishing Ltd. Edinburgh, UK. All rights reserved.

To summarize, the sacroiliac joint does not move much, but it DOES move. And it moves more in the younger and older athletic populations as well as in pregnant and lactating women. 

So what does this mean for yoga posture practice? It means that we need to focus on protection and preservation of the sacroiliac joint as a supporter of spinal stability. And in high risk populations, we need to take more care in using typical “hot spot” or commonly problematic yoga postures/asana. 

A Review of Sacroiliac Joint Movement 

To give you an overview of the rotational and translational components of the sacroiliac joint, let’s refer to the illustrations below. 

The sacrum is capable of: 

  1. Rotation around a vertical axis (left and right rotation) – See the bottom illustration labeled “rotation”
  2. Rotation around a horizontal axis (nutation and counternutation) – See both illustrations below
  3. Shear or translational movements (small movements that are not measurable)
  4. Torsion – (a combination of the two types of rotation) – See the bottom illustration
Protecting the Sacroiliac Joint in Yoga. Copyright. Sacroiliac Joint Movement - Rotation. Copyright Dr. Ginger Garner.
Sacroiliac joint rotation around the horizontal axis.* This rotational movement is known as Nutation and Counternutation. Notice that there are 4 types of required movement that contribute to each of the two rotational movements. Movement is no more than 2-5 degrees of flexion or extension around a horizontal axis. Nutation is considered a “locked” or close-packed (stable) position. Counternutation is considered an “unlocked” or open-packed (less stable) position. This is important because if there is dysfunction in sacroiliac joint movement, for example, one side moves but the other is fused or doesn’t move, doing a yoga pose over the top of this impairment could cause or increase pain.
©2016. Garner, G. Medical Therapeutic Yoga. Handspring Publishing Ltd. Edinburgh, UK. All rights reserved.

Nutation requires 4 movements to occur:

  1. Forward movement (flexion) at the base (top) of the sacrum.
  2. Backwards and downward movement of the ilia (elephant shaped ears of the pelvis that attach to the sacrum).
  3. The sitting bones (ischial tuberosities) to move forward and wider.
  4. The apex (bottom) of the sacrum to move backward (extension).

Counternutation requires 4 movements to occur:

  1. Backward movement (extension) at the base (top) of the sacrum.
  2. Forward and upward movement of the ilia.
  3. The sitting bones move backward and more narrow.
  4. The apex of the sacrum to move forward.
Protecting the Sacroiliac Joint in Yoga. Copyright. PYTI. 2018.
Sacroiliac Joint Multi-Axial Movement – Torsion Types **
Key – PSIS – posterior superior iliac spine SB – sacral base. ILA – inferior lateral angle. LOR – left of right. ROL – right on left
Left of Right Posterior Sacral Torsion – If the left side of the sacral base (PSIS) is close to your fingers (if you were touching the sacrum with your fingertips) and the right PSIS is further away (toward the front of the body), coupled with an ILA and apex that is shallow on the left and deep on the right, then you could have a left on right (LOR) posterior sacral torsion. How would this affect yoga postures? In spinal backbends, this type of torsion would rear its ugly head and could create pain.
Right on Left Anterior Sacral Torsion – If the right side of the PSIS is backwards/closest to your fingers and the left side is further away, coupled with an ILA that is deep on the left and shallow on the right, then you could have a right on left (ROL) anterior sacral torsion. What does this mean for yoga postures? It means that if flexion is painful and these conditions are palpated, yoga postures will need to be adapted to diminish pain and intervene or treat the condition.

*These movements are a part of normal sacroiliac joint movement. Impairment or dysfunction happens when this movement does not occur, occurs asymmetrically, or happens in excess.

**This is not to say that sacral torsion causes pain. I see plenty of patients with no pain and no issues that have noticeable sacroiliac joint malalignment; however, that doesn’t mean you have to treat it. “If it’s not broken, don’t fix it” applies here. Not all sacroiliac joint malalignment is problematic.

Wrapping it Up & Getting Ready for Part 2

Now that I’ve reviewed implications and movements of the sacroiliac joint in yoga, and also shared my personal journey of overcoming sacroiliac joint pain, I’d love for you to join me for Part 2.

Part 2 will put Part 1 into perspective and allow you to see and practice for yourself. In Part 2, I’ll discuss how to encourage safe movement and progression in yoga postures (asana), including identifying common problematic postures.

Sources

  1. Cohen et al. Sacroiliac joint pain: A comprehensive review of epidemiology, diagnosis and treatment. https://www.ncbi.nlm.nih.gov/pubmed/23253394.
  2. Bernard T, Cassidy J. The Sacroiliac Joint Syndrome: Pathophysiology, Diagnosis, and Management. The Adult Spine: Principles and Practice. Raven Press Ltd, New York, NY, USA, 2107–2130 (1991).
  3. Vleeming A, Stoeckart R, Volkers AC, Snijders CJ. Relation between form and function in the sacroiliac joint. Part I: Clinical anatomical aspects. Spine 15(2), 130–132 (1990).
  4. McLauchlan GJ, Gardner DL. Sacral and iliac articular cartilage thickness and cellularity: relationship to subchondral bone end-plate thickness and cancellous bone density. Rheumatology (Oxford)41(4), 375–380 (2002). 
  5. Harrison DE, Harrison DD, Troyanovich SJ. The sacroiliac joint: a review of anatomy and biomechanics with clinical implications. J. Manipulative Physiol. Ther. 20(9), 607–617(1997).
  6. Walker JM. The sacroiliac joint: a critical review. Phys. Ther.72(12), 903–916 (1992).

This and all blog posts related to yoga and/or physical therapy on www.gingergarner.com are not a substitute for medical advice and are not a prescription or program for individualized physical therapy. You must seek the advice of your health care provider and, only after a thorough physical examination and clearance, participate in any movement or exercise program.