The sacroiliac joints (SIJs) are the body’s structural meeting place. Here, the spine meets the pelvis, the upper body meets the lower body, the axial meets the appendicular skeleton, and the left and right sides meet the center. These deep, complex, and large articulations play a key role in bending, sitting, stepping, walking, and many other daily activities.
What is more, when there is SIJ pain, it can seem to affect the very core of our subjective experience, giving a sense of instability and disruption that, for many people, is reflected in their mood and outlook, as well as in their objective physical functioning (Image 1). Work with the SIJs is indicated when clients experience:
• Low-back pain, especially when unilateral (discussed below).
• Sciatic pain, both axial and appendicular (see Massage & Bodywork, July/August 2011, “Assessing Sciatic Pain,” page 110).
• Pain or sensitivity in the SIJs themselves, such as in sacroiliitis (inflamed joints) or sacroiliac dysfunction syndrome (too much or too little movement, also discussed below).
Sacroiliac (SI) mobility and balance are also important to address whenever working with issues such as scoliosis, leg-length differences, asymmetrical activities and habits (such as throwing sports or crossing one’s legs), and other structural or functional patterns that demand extra accommodation at the sacral meeting place.
In this article, I’ll describe two gentle but effective SIJ techniques from Advanced-Trainings.com’s Advanced Myofascial Techniques seminars. In addition to being useful in addressing the symptoms listed above, these two examples of SIJ techniques are also effective ways to:
•
Begin a session, since they tend to evoke a palliative parasympathetic response (the sacrum is one of the body’s two locations for parasympathetic nerves).
•
End a session, both because of their calming and quieting effect, and because ensuring sacral adaptability after working elsewhere is thought to aid in integration and help prevent postsession discomfort. (Ida Rolf, the originator of Rolfing Structural Integration, used sacral work as part of the closing ritual in most, if not all, of her sessions.)
SI Anterior/Posterior Release
When SI motion is excessive, such as after an injury, the joints can become irritated. However, in walking and bending, there is a surprising amount of movement in healthy SIJs—they twist, glide, shear, and gap to a palpable degree. These motions are crucial for shock absorption, structural adaptability, and kinetic loading.
Since the planes of the SIJs are oblique, anterior to posterior movement of the sacrum in relationship to the ilia will slightly distract (open) the SIJ (Image 2). We can use this principle to assess and release mobility restrictions at the SIJs.
With your client supine, locate the posterior superior iliac spine (PSIS) on one side (Images 4 and 5). Move your fingertips just medial to the PSIS, but stay lateral to the body’s midline. You’ll be in position to lift the sacrum anteriorly on that side. Slowly, but firmly, lift with your fingertips. Keep some flexion at each finger joint, leaving your wrist and arm as relaxed as possible to protect your forearm from any strain. Feel through the sacral multifidi and erectors to sense the bony feel of the sacrum itself. Lift firmly and steadily, but gently.
Rest your other hand lightly on the same side’s anterior superior iliac spine (ASIS) in order to encourage that ilium to drop posteriorly. This anterior hand is much gentler and more receptive than the directive touch of the posterior hand. Since the pelvic girdle is built to transmit the force of gravity from spine to legs, it will respond to overt force from your hands by stiffening and stabilizing. Proceed slowly and lightly enough that you don’t evoke this stabilizing response. Although it may feel like you are using too little pressure to have an effect, if you are patient enough, the client’s experience can be dramatic.
Use both hands to sense a slight posterior yielding of the ilium, and/or an anterior drifting of the sacrum. Although the exact amount of movement here is a subject of ongoing debate, computed tomography scans have shown 4–8 millimeters of PSIS motion here, even in the elderly.1 So even though it is likely to be small, this movement will be quite tangible to both you and your client. Imagine pushing a large boat away from a dock—at first there appears to be nothing happening, but then slight movement becomes apparent after a few moments (Image 3). The key is to wait for the release—often it takes 3–6 breaths to feel the drift happen—and then believe it when you feel it. Clients report sensations such as warmth spreading down their limb, an overall softening of the pelvis, or an easing of the low back. If clients report pain, it is likely a sign of joint irritation; in this case, back off to their level of comfortable tolerance.
This technique is both an assessment and a release, so you can use it to compare and balance left and right SIJs. SI stiffness is highly variable between individuals, but is more even side-to-side in asymptomatic individuals.2 If one side of the sacrum is particularly stiff or slow to respond, you can
use the SI Wedge Technique to get a more specific release.
SI Wedge Technique
Like the previous technique, the SI Wedge Technique can help reestablish normal mobility in a restricted SIJ. Try this variation when you find a restriction that doesn’t respond to the SI Anterior/Posterior Release Technique, or whenever you want a more specific release right at the SIJ.
Use the PSIS as a starting place, but instead of moving medially onto the sacrum, curl your fingers around the medial aspect of the PSIS. Like the last technique, this one involves lifting with the fingertips from underneath; but instead of lifting on the sacrum itself, stay close to the ilia, and lift into the SIJ space in a laterally oblique direction (Images 6 and 7).
As the name suggests, your fingertips will form a wedge right at the SIJ. This puts pressure into the spinal erectors, sacral multifidi, and posterior SI ligaments (all possible sources of SIJ pain). When you’re in position, wait there; once the outer layers release, your client’s pelvic structure will open and settle around your fingers. This opening is the result of a response in the strong interosseous SIJs.
Alternatively, use two hands to assess and address both SIJs simultaneously (Image 8). Watch your body use, as this position can be more challenging than the one-sided version, though it does allow precise side-to-side comparison and a sense of side-to-side balance for your client. Having both sides worked in this way can be particularly relieving when the SIJs are irritated, perhaps because the bilateral pressure simulates the pressure of sacral multifidi contraction (which has been observed to be diminished in some cases of low-back pain).
SIJ Pain
SIJ pain is frequently the result of an injury, such as a fall or auto accident. One peer-reviewed study showed that about three in five cases of SIJ pain can be traced to a traumatic injury.3 Hormonal changes and pregnancy can bring on SIJ pain, as can arthritis and inflammatory bowel diseases. A limp or gait impairment, for example from a knee or ankle issue, can also irritate the SIJ, usually on the opposite side. Asymmetrical forces on the sacrum, such as imbalanced sacrotuberous ligaments, iliacus, or rotators, can cause pain and irritation as well.
SIJ pain is often felt by the sufferer to be directly in or superficial to the SIJ, though, because the joints are deep and large, pain related to the SIJs can be hard to locate precisely. SI pain can refer to the buttock, groin, hip, leg, or low back. In research involving blocking SI sensation with an anesthetic, the SIJs have been shown to be directly responsible for 15–21 percent of generalized low-back pain.4 It is likely that SIJs are indirectly responsible for an even greater percentage of back pain, since they play such an important role in spinal alignment and mobility.
When there is pain or irritation felt at the SIJ, it is usually unilateral or asymmetrical, that is, worse on one side. As mentioned, SIJs can be problematic by being either immobile or hypermobile. Pain, sensitivity, and irritation can be felt on either the immobile or hypermobile side, though more severe and ongoing irritation is more commonly felt on the hypermobile side. Even though hands-on work is generally better at loosening than tightening tissue, we can still help hypermobile SIJs in a number of ways. Here are some considerations:
1. If the less mobile side is more painful, work to loosen that same side, using the techniques discussed here, or others. This usually provides immediate relief, and when incorporated into ongoing work and complementary activities, such as stretching and habit modification, will give lasting results.
2. If the more mobile side is also more painful, release the less mobile side, but do much less work (if any) on the hypermobile, painful joint. Work any soreness in gluteals and hip muscles on the hypermobile side (since they’re likely working to compensate for the lack of ligament stability), but don’t work directly on the hypermobile joint, at least at this stage. Ask your client to track any changes in his discomfort in the days after the session. If there is less pain, you’re on track and have probably relieved the strain on the hypermobile side by spreading the demands of adaptability across both joints, and/or by hydrating irritated joint tissues. Continue working in this way until the irritation subsides.
3. If your hypermobile client reports no change or a worsening of symptoms after working on just the less mobile, less painful side, you may want to discuss the option of working with the hypermobile side directly. Although conventional wisdom says that working directly with inflamed tissues can further aggravate them, I (and many others) have observed marked improvements in SIJ comfort after working directly with a hypermobile, painful joint. Occasionally, there can be a worsening of symptoms in the day or two after the session and, more rarely, for several days. Even in these cases, once the immediate aggravation has settled, there is almost always less pain and aggravation. This higher-risk, higher-reward approach is appropriate only if both you and your client are informed and comfortable with its implications. Consider factors such as your level of experience, access to supervision, and referral practitioners, as well as your client’s history, stability, and the potential impact on her life or livelihood. If you, or your client, are uncomfortable with the prospect of the symptoms perhaps worsening afterward, take the cautious route of direct work only on the asymptomatic side, and lighter, indirect work on the symptomatic side.
4. If SI pain persists, referral to a complementary specialist is indicated. Success in dealing with SI pain has been reported by users of physical therapy, Rolfing and structural integration, osteopathy, chiropractic, rehab and functional medicine, and prolotherapy or sclerotherapy (tightening of loose ligaments by therapeutic scarring), as well as fluoroscopic injections and fusion surgery. If you have your client’s permission, ask her other practitioners about how your work can support and complement their goals. This is a great way to educate yourself and further help your client.
Keep in mind that a worsening of SI symptoms after using the techniques described here is quite rare. Performed properly, these techniques are nonintrusive and have been successfully used by the thousands of practitioners who have trained with us. Whether you use these techniques to begin a session, address SI pain, or close and integrate, your clients will appreciate your gentle, precise work with their SIJs.
Notes
1. G.L. Smidt et al., “Sacroiliac Motion for Extreme Hip Positions. A Fresh Cadaver Study,” Spine 22, no. 18 (1997): 2,073–82. In addition to 4–8 millimeters of posterior superior iliac spine translation, this and other studies cite up to 17 degrees of angular motion at the sacroiliac joints.
2. L. Damen et al., “The Prognostic Value of Asymmetric Laxity of the Sacroiliac Joints in Pregnancy-Related Pelvic Pain,” Spine 27, no. 24 (2002): 2,820–24.
3. T.N. Bernard et al., “Recognizing Specific Characteristics of Nonspecific Low Back Pain,” Clinical Orthopaedics and Related Research 217 (1987): 266–280.
4. Diane Lee, The Pelvic Girdle (Philadelphia: Churchill Livingstone, 2004).
Til Luchau is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout the United States and abroad. He is also a Certified Advanced Rolfer and has taught for the Rolf Institute of Structural Integration for 22 years. Contact him via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page.