Following this incident, I was occasionally plagued with recurring bouts of pain over the general area of my left lower back. I CONTINUED TO SEEK HELP AND OVER A PERIOD OF A COUPLE OF YEARS I consulted chiropractors and massage therapists in search of a cure for what I now know as sacroiliac (SI) pain. The pain was not finally resolved until I began to take particular care with my pelvic alignment during yoga poses, especially in twists and forward bends. That care and attention was the final piece that helped me understand the puzzle of my sacroiliac joint. Continuing to unravel this puzzle has helped me to live and practice yoga pain-free today.
 
LOWER BACK PAIN HAS BEEN AROUND AS LONG AS MEN AND WOMEN HAVE BEEN WALKING UPRIGHT. IN FACT, APPROXIMATELY 80% OF PEOPLE WILL EXPERIENCE SOME FORM OF LOWER BACK PAIN, INCLUDING SACROILIAC PAIN, IN THEIR LIFE. BUT THERE ARE NO DEFINITIVE STATISTICS ON HOW MANY OF US EXPERIENCE SACROILIAC PAIN SPECIFICALLY. PART OF THE DIFFICULTY IN STUDYING THIS PROBLEM IS THAT THERE IS NO WAY TO OBJECTIVELY MEASURE THE DEGREE TO WHICH THE JOINT IS 'OUT'. IN FACT, THERE ARE SOME HEALTH PROFESSIONALS WHO WILL DEBATE WHETHER THE SACROILIAC JOINT CONTRIBUTES SIGNIFICANTLY TO LOWER BACK PAIN AT ALL. HOWEVER, MY EXPERIENCE, AS WELL AS THE EXPERIENCE OF NUMEROUS YOGA STUDENTS, CONTRADICTS THIS BELIEF. 
 

ADDITIONALLY, IT IS MY EXPERIENCE THAT YOGA STUDENTS EXPERIENCE SACROILIAC PAIN IN HIGHER PERCENTAGES THAN THE GENERAL POPULATION BECAUSE OF THE UNUSUAL AND CONSISTENT STRESSES WE PUT ON THE SUPPORTING LIGAMENTS AROUND THIS JOINT DURING ASANA PRACTICE. UNLIKE MANY OTHER JOINTS THAT YOGA STUDENTS STRETCH, THE SACROILIAC JOINT REMAINS HEALTHIER IF IT IS NOT STRETCHED VERY MUCH. IN FACT, FOCUSING ON CREATING STABILITY IS THE KEY TO PREVENTING OVER-STRETCHING AND THUS REMAINING PAIN FREE IN THE SACROILIAC JOINT.

THUS THE BEST "CURE" FOR SACROILIAC PAIN IS TO PRACTICE POSES, ESPECIALLY TWISTS AND ASYMMETRICAL FORWARD BENDS, IN SUCH A WAY AS TO DIMINISH THE TORQUE THROUGH THIS JOINT. KEEPING THE AREA AROUND THE SACROILIAC JOINT STRONG CAN BE ACCOMPLISHED BY PRACTICING STANDING POSES AND SIMPLE BACKBENDS.

SACROILIAC PAIN can be caused by ONE or A combination of factors BUT The SINGULARLY most predictive variable of WHO WILL SUFFER sacroiliac pain is gender. Women suffer about eight out of ten times more often than men, due ESPECIALLY to the structural AND hormonal differences between the sexes. THIS IS ESPECIALLY IMPORTANT TO REMEMBER WHEN YOU ARE TEACHING OR TAKING A YOGA CLASS BECAUSE THE MAJORITY OF YOGA STUDENTS IN THE US ARE WOMEN.
 

The sacroiliac joint is formed by the union of the ilium bone of the pelvis and the curved sacrum at the end of the vertebral column. While there is a small amount of movement allowed at the S-I joint, its major function is one of stability. This stability is necessary to transfer the downward weight of standing and walking into the lower extremities. Held together by strong yet pliable ligaments, the joint is designed to be self-locking when one is standing. This occurs because during standing the sacrum bone is wedged down into the matched pelvic joints due to the incumbent weight of the trunk. The tightly nestled sacrum and pelvic connection thus creates a firm base for the entire spinal column. This stability is lost during sitting when the sacrum no longer is wedged into the pelvis. Suffers of S-I joint pain often prefer standing.

Significantly, women's anatomy allows one less sacral segment to lock together in this process with the pelvis, thus contributing to instability. Additionally, the hormonal changes of menstruation, pregnancy, and lactation can effect the integrity of the ligamentous support AROUND the S-I joint. Because of these hormonal changes, female suffers of S-I pain often find the few days right before their period is the time when their pain is the worse. 

Finally, women generally have hip joints which are set wider apart than men, even IF ONE comparES skeletonS of the same HEIGHT. This increased width can effect the stability of the S-I joint during such activities as walking. This occurs because in walking the hip joints are alternately moved forward and backward of one another, causing increased torque across the S-I joint with each step. This particular structural difference in men and women can have a profound effect because unlike the hour a day spent practicing yoga, women often walk hours every day, year after year while performing normal life activities.

THE CAUSE OF SACROILIAC PAIN IS SIMPLE; IT IS 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. SOME SPORTS, ESPECIALLY GOLF AND TENNIS, ARE ASYMMETRICAL AND CREATE REPEATED ROTATORY STRESS ACROSS THE JOINT IN THE SAME DIRECTION. BUT MORE OFTEN FOR YOGA STUDENTS, THIS SEPARATION CAN BE  CAUSED DURING ASANA PRACTICE  BY STRETCHES WHICH MOVE THE PELVIS AND THE SACRUM IN OPPOSITE DIRECTIONS. 

PARADOXICALLY, MY ASANA PRACTICE BOTH CREATED MY PAIN AND WAS THE TOOL I USED TO CURE IT. I CREATED SACROILIAC DYSFUNCTION IN LARGE PART BY THE WAY I WAS PRACTICING SEATED TWISTS. I WAS METICULOUS TO KEEP MY PELVIS FIRM 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". BY FOCUSING ON ALLOWING MY PELVIS TO MOVE WITH MY SPINE IN ALL POSES, I "CURED" MY SACROILIAC. THIS CURE WAS ACTUALLY JUST PREVENTING THE SEPARATION OF  MY PELVIS AND SACROILIAC JOINT.

I FIRST APPLIED THIS UNDERSTANDING TO THE NEGATIVE EFFECT CREATED BY THIS SACRUM-PELVIC SEPARATION IN MY OWN PRACTICE, AND THEN QUICKLY TOOK IT "TO THE MAT" FOR STUDENTS IN MY CLASSES. AGAIN AND AGAIN IT WORKED LIKE MAGIC TO REDUCE PAIN, ESPECIALLY FOR WOMEN, IN TWISTS AND FORWARD BENDS. I REMEMBER ONE SPECIFIC WOMAN WHO SIMPLY COULD NOT PRACTICE ANY ASYMMETRICAL FORWARD BEND WITHOUT A NAGGING PAIN WHICH LASTED FOR DAYS AFTER EACH CLASS. THE SIMPLE SUGGESTION THAT SHE LET HER PELVIS AND HER SPINE MOVE TOGETHER NOT ONLY RELIEVED HER PAIN BUT ALSO ALLOWED HER TO FALL IN LOVE WITH HER YOGA PRACTICE ONCE AGAIN.
 

What are the symptoms of S-I dysfunction? Absent a confirmed diagnosis from a health professional, there are some signs which will help you decide if your S-I joint is "out". First, the most common sign is pain which exists in an area about the size of a quarter over the S-I joint. This pain is most COMMONLY felt only on one side. Importantly, the pain is not necessarily on the side of the dysfunction. 

This dysfunction can either be the sacrum slipping forward or back in relationship to the ilium, or the opposite, which is technically called ilio-sacral dysfunction. In this case, the ilium has rotated in relationship to the sacrum. Sometimes the pain is felt on the left and the actual problem is on the opposite side. Because pain is not an accurate indicator of dysfunction, I suggest you have a health professional confirm your intuition about exactly which side and which way the dysfunction is manifesting. Then you can choose wisely which yoga poses will help.

Other signs of S-I dysfunction are pain radiating into the hip socket, or down the outside of the leg, or pain deep inside the belly, over the anterior surface of the S-I joint. (If you have chronic pain, it is always safest to consult a health care giver to rule out serious problems.) Another test which may help you guess if you have S-I dysfunction is to observe what happens when you move from sitting to standing and back to sitting. 

There is a movement which occurs between the sacrum and the lumbar spine (lower back) when one moves from sitting to standing and vice versa. As was mentioned before, when you are standing, the sacrum is wedged down into the pelvis; it is in a diagonal line (to the horizon) and the lumbar spine is in its natural inward curve (lordosis). When you begin to sit down, the lumbar spine starts to move into flexion thus reversing its curve, and the top of the sacrum tilts backward or posteriorly. When you are sitting, the sacrum is "unlocked" a bit from the pelvis and stays in this less stable position of tipping backward while you remain sitting. As you reverse the process and stand up, the sacrum tips forward at the top again to find its diagonal place of stability against the pelvis and the lumbar spine regains its arch.  This is the "lumbo-sacral rhythm". 

If your S-I joint is out of place, the transition from sitting to standing can be uncomfortable, especially at the halfway up point. The first part of standing up and the last few inches may feel fine; it is that mid-range of the process of standing up which will be difficult. This is the part in the rhythm when the sacrum is "attempting" to lock itself into the pelvis and if there is a misalignment, the rhythm is interfered with and strain is experienced. Once you are standing, other muscles can help to create the stability that may be lacking from the S-I joint.
 

If you have one or more of these symptoms, I suggest that you check with your health professional; there are other things which can mimic S-I dysfunction. TO CURE YOUR PAIN, YOUR CHIROPRACTOR OR PHYSICAL THERAPIST MAY PERFORM GENTLE MANIPULATIONS ON YOUR SACROILIAC JOINT; YOU MAY ALSO FIND THAT MESSAGE OR BODYWORK HELPS. Once you have a specific diagnosis, then you can USE YOGA BY practicING the poses in the way they are presented BELOW to avoid future problems. WHILE YOGA CAN HELP YOU STRENGTHEN AROUND THE JOINT AS WELL AS PROVIDE THE AWARENESS NECESSARY TO HELP YOU PREVENT FUTURE PROBLEMS, YOGA ASANAS IN AND OF THEMSELVES MAY NOT BE SUFFICIENT TO CURE ALL SUFFERERS.
 
 

(Note: for sake of this article, suggestions for practice will be made as if the student were suffering from the ilium being stuck a little back or posterior on the left. This is ilio-sacral dysfunction and is fairly common, in part, I think, from driving positions in which the right pelvis is repeatedly pushed forward as one presses on the gas and brake. Practice suggestions can be reversed if necessary for the other conditions.) 

Once you have ascertained exactly what is going on with your S-I joint, then the first thing to do is to begin to pay attention to three things: how you stand, how you sit, and how you sleep. Whenever you are standing, pay attention to keeping the pelvis level; in other words, avoid standing with one hip socket forward of the other and avoid one-legged standing as well. If you think back to your teenage years, you may remember a time when you stood habitually on one leg. This uneveness places a torque across the joint and can increase the strain on the ligaments which hold the joint securely together.

Sitting well is even more important. Most of us sit with our pelvis in an uneven position, as when we cross one knee over the other. We may sit by rolling the pelvis back, thus collapsing the rest of the spine in a typically slumped position. Sometimes we sit in an asymmetrical way, even in lotus or half-lotus, or in chairs rotating repeatedly to one side at our desk or when we drive. The singularly most important thing you can do while sitting to avoid exacerbating sacro-iliac pain is to keep the pelvis and sacrum moving together in the same direction.

 For example, when you sit in a chair with one leg up and continually turn to one side you are turning the spine away from the pelvis; this creates strain. Try instead to move pelvis and sacrum together. It also helps to sit just the way we know we should: with the spine in all its normal curves, the shoulder blades vertical and the head directly over the body. Sitting as if for meditation with the spine in alignment and the pelvis level and even reduces the strain from an unstable sacro-iliac joint. Be sure to pay special attention to the lower back. In our culture, most people have flattened lumbar spines. Our chairs promote this flexed position of the lower back, and as we have seen previously, this contributes to S-I pain. Keep that lumbar curved inward !

It is important to pay attention to your sleeping positions AS WELL. Make sure that you do not sleep in an asymmetrical position which torques your pelvis and your spine in opposite directions. Instead, think of the pelvis as a "vertebral". Keep the whole spine, including the pelvis, in one alignment. A common sidelying sleeping position is one in which the top leg rotates over the bottom one. This definitely can torque the sacro-iliac joint. Instead, sleep on your side with the knees even, perhaps using a pillow between them for comfort. A little lumbar flexion when sleeping is not as dramatic for the S-I joint because one is not in a weight bearing position and strain is greatly lessened. But keep the pelvis and spine together, not torqued apart.

If you have S-I dysfunction, twists will usually make them worse. The only way to prevent further injury and discomfort is to meticulously move the pelvis and sacrum together. A good twist to do this in is Bharadvajasana. In this twist the pelvis and spine move together. Try to create the twisting motion at the top of the thighs which is the hip joint, instead of through the lower back.  In fact, this is a useful philosophy for all twists. Focus on moving through the hip joints.

A common way of teaching and practicing twists is to hold the pelvis still and then use the arms as a force "against" the spine. This approach is a perfect way to create sacro-iliac pain. The popular twist Marichyasana III is a clear example of how holding the pelvis still can increase the torque across the S-I joint and cause problems. 

Here's how it works. Students often holds the pelvis still and uses the arm with force to create the torque necessary for the twist instead of twisting from the base, i.e. the pelvis. If the left pelvis is rotated backward as in the example, then Marichyasana III to the left with the pelvis held stationary moves the spine away from the pelvis. If, on the other hand, the student moves the pelvis AND the spine into the left twist simultaneously there will be less possibility of separation and strain at the S-I joint.  Try to create as much of the twist as you can BEFORE you actually use the arm.

Three popular sitting poses can be especially problematic for the sacroiliac joint. The first is Janushirshasana. Remember that sitting in and of itself "unlocks" the sacrum and the ilium. If stress is then placed on the joint in this less-than-stable position, discomfort and/or injury could occur. In the S-I example given above, the critical side of the asana is the one with the left knee drawn backward.  As the student begins to bend forward with the left knee back, then the spine tends to be pulled forward by the hands while the pelvis/sacrum remain behind. 

It is this separation that is by definition sacro-iliac dysfunction. When you practice janushirshasana be sure that your pelvis is moving forward with the spine, not remaining behind.  If you practice the pose by strongly bringing the left pelvis forward, it will help to unite the joint and heal the problem. During a therapeutic period, you may even want to practice the pose with the foot touching the opposite knee to reduce the torque even more.

Two other sitting poses which can be difficult if you are suffering from sacro-iliac pain are baddha konasana (bound angle pose) and upavistha konasana (seated angle pose). Both of these poses unlock the sacro-iliac joint, and both poses potentially strain the transverse ligaments of the sacrum, especially if you bend forward. If you have S-I problems, try to skip these poses during acute flair ups of pain. At other times, try placing a firm rolled blanket under the outer thighs in baddha konasana, especially if you are supple.  Flexible students do not need the added strain to the sacral ligaments in this pose. The blanket will reduce the stress the leverage the weight of the thighs places on the S-I joint. 

Supporting the outer thighs is also a good practice to do when you are practicing restorative or relaxing poses. Sitting for a long time in this pose as part of a relaxation process can exacerbate the stretch in already stretched out ligaments and worsen S-I pain. Under no circumstances push down on your knees or place sandbags on them to increase the stretch of the pose. This is a recipe for S-I difficulties.

Upavistha Konasana is even more challenging. When you are sitting in     this pose there is very little which is supporting and/or stabilizing the sacro-iliac joint. Bending forward only adds to this instability. If you are suffering from pain, try bringing the legs closer together than usual and just resting the arms and forehead on a chair. This will help to prevent further discomfort. 
 

Healing the sacro-iliac joint takes a period of 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 as well. In the case being discussed here of the pelvis rotating backward on the left, simple backbends in which the pelvis is moved forward are useful. An especially helpful backbend for this posterior rotation of the ilia is the classic Bow pose. This pose strongly moves the pelvis forward and contracts the posterior muscles. Not only does this help to move the sacro-iliac into place it also strengthens the muscles of the lower back and hip which may help to hold it there.

You can also practice a variation of this pose at the wall. Stand about an arm's length from the wall with both palms on the wall, shoulder height. With an exhalation, lift the left leg up and hold onto your ankle with your left hand. Keep breathing. Lift the leg until you feel your left ilium rotate forward; hold that position and then pump upward 6 to 10 times in small movements. Be sure to keep the left pelvis rolling toward the wall and the breath moving. DO NOT repeat on the right. Remember, this is a therapeutic movement to help "teach" the S-I joint how to return to a healthy position. One way of looking at it is to realize that the right pelvis is rolling forward all the time if your left pelvis is stuck backward all the time. 

WHEN YOU HAVE FINISHED THIS MOVEMENT, TAKE A MINUTE TO STAND QUIETLY, THEN WALK A FEW STEPS AROUND AND SEE HOW YOUR BACK FEELS. YOU MAY WANT TO TRY THIS ADJUSTMENT BOTH BEFORE AND AFTER  YOUR REGULAR PRACTICE, AS WELL AS WHENEVER YOU FEEL DISCOMFORT IN YOUR LEFT SACRO-ILIAC JOINT.

IN CONCLUSION, sacro-iliac pain is not uncommon among yoga practitioners, especially women. But understanding the importance of keeping the sacrum and pelvis together in twisting and sitting movements can be the key to the best cure of all --- prevention.

*Please check out the Oct 2001 issue of Yoga Journal for photos of the poses