Is The Pain in Your Butt from Your SI Joint?

Lower back or buttock pain can sometimes stem from a joint in your pelvis called the SI joint (sacroiliac joint). In fact, between 15-30% of people with chronic, non-radicular pain (no leg pain) are thought to have pain from the SI joint.^[1]Cohen, S. P., Chen, Y., & Neufeld, N. J. (2013). Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother, 13(1), 99-116. doi:10.1586/ern.12.148

The SI joint is where the pelvis and sacrum meet. It’s a sturdy, stable joint with a heavy, strong ligament structure (notice the multiple angles of the ligaments).

SI Joint – source: Wikipedia

This makes sense when you think about it. If the joint was less stable, weaker, then a lot of movements would bother you.

Because the SI joint is so stable, there isn’t much movement available. About 3 degrees total.^[2]Goode A, Hegedus EJ, Sizer P, Brismee JM, Linberg A, Cook CE. Three-dimensional movements of the sacroiliac joint: a systematic review of the literature and assessment of clinical utility. J Man … Continue reading

Whatever movement is there is more of an engagement-disengagement than anything else. The joint surfaces kind of click together with weight bearing, lifting, pushing, pulling or other kinds of physical exertion. By doing so, it creates a more stable platform for the rest of your body.

As you age, the SI joint loses motion. Eventually, it fuses itself.

So, how can you hurt a joint that barely moves?

There are three ways: overuse, high-energy transfer injury, and from child birth.

Case #1

I opened the waiting room door to greet my new client.

She was in her mid-twenties, about 5’5” tall and maybe weighed 110 pounds.

Myra* (when you see *, it means the name is a pseudonym) had been referred to me by her obstetrician for the treatment of lower back pain.

She had given birth about 3 months prior to a healthy baby boy of about 10 pounds.

Right. He was a big baby.

Since the delivery of her child, Myra had unrelenting lower back pain. She hurt with almost every movement, getting in and out bed and just lying down was difficult and, at times, impossible to do.

Case #2

While competing for a spot as a pole vaulter on the US Olympic team, Nick* sped down the runway, planted the 16-foot pole and began to launch himself skyward to clear a crossbar 17 feet in the air.

But midway in the jump, the pole snapped and Nick plummeted to the ground landing directly on his nearly straight left leg.

He ruptured the ligaments that connect the front part of the pelvis – the pubic symphysis – and severely sprained his SI joint ligaments. You could see the malalignment of the pubic symphysis on x-ray. One side was almost an inch higher than the other.

Case #3

After working an entire weekend in her yard, Jules* noticed lower back pain and pain in what she called her right “hip” – which was actually her buttock.

She spent several hours on a Saturday and Sunday raking, shoveling, wheeling wheelbarrows of dirt, yanking weeds, digging. She was determined to get the yard in top shape for a realtor who would be visiting her and her husband the following week to discuss selling their home.

Jules rarely exercised though. At 40 years of age, she told me she “hated” to exercise and the only reason she did all the yard work is that she desperately wanted to sell their home.

Case #1 was an example of childbirth, #2 was high-energy transfer trauma and #3 was overuse.

Most of the time, you’ll know what happened. SI joint pain doesn’t sneak up on you. There’s some inciting event – a fall, lifting something way too heavy, or even just doing way more physical work than you’re used to.

The good news is that the human body has a kind of “operating system” which makes figuring out what to do for things like an SI joint injury a little easier.

Ligaments serve a purpose – to control or restrain joint movement. It doesn’t matter where you find ligaments in the body, they all do the same thing. Some more so than others. Like the SI joint is very strong, stable and so is the joint between your skull and your neck.

And when you injure a ligament, it tends to have a common way of letting you know. An SI ligament sprain would behave like any other sprained ligament behaves – tender to touch, might refer pain to other body areas, you would probably feel better not moving than moving and it doesn’t like to be stretched.

But, the back and the SI joint have developed a more mysterious quality to them. Back pain, SI joint pain seems more difficult and obscure to solve and treat. It’s as if they don’t follow the rules as other joints do.

So let’s jump to a different body area where the treatment is clearer like the ankle joint.

What do you do after you sprain your ankle (and despite what sports commentators say, “walking it off” is not it)?

Initially, you avoid doing things that aggravate the joint, protect the joint, control swelling, and in some cases use partial weight bearing to avoid overloading healing tissue.

You might brace the ankle or wrap it. You wouldn’t stretch the joint that’s for sure. And you probably wouldn’t jiggle it around much either since applying tension to the injured structures would feel bad and interfere with healing.

You would gradually start putting some weight on your foot and then exercising muscles that would have shut down from the injury – like the muscles in the foot, lower leg, and hip – with the aim of increasing the overall physical capacity and strength of the body.

Why wouldn’t we apply the same principles to an SI joint sprain?

One of the things that makes doing this more difficult is that with an ankle sprain, you can use a crutch to assist the foot during weight bearing, you can sit down and remove weight from the foot, you can easily elevate the foot to help control swelling.

You could use crutches for an SI joint sprain but most people, when I suggest it, look at me like I’m the Wicked Witch of the West. If you sit down, you increase the load on the joint and in terms of controlling swelling, well, you can lie down on an inversion mattress like a Bodyslant but it’s a more complicated thing to do (it works well though).

There are some good bracing options (I usually start with something called an SI Belt) but bracing with back / SI joint pain can sometimes be met with resistance. I’ve had some doctors tell me that they don’t want the patient to “get used to it” although they never say that using an ankle or knee brace. In fact, they’ll send athletes back into a game with an ankle or knee brace on.

Certain types of manual therapy can sometimes help reduce pain but keep in mind what’s going on around the joint and avoid anything that provokes symptoms.

Ligaments heal slowly due to a lower metabolic rate than, for example, muscle. And the new ligament fiber will align itself along the lines of stress so you do want to load it as close to the way the body normally moves but with a force that doesn’t hurt.

Biologics – in particular, Platelet Rich Plasma (PRP) injections – can boost the healing response.

PRP has growth factors from your blood that wake up stem cells and help repair the injured tissue. The benefit of PRP isn’t that it speeds up your recovery but it makes the recovery process better.

Injured tissues move through a defined process of repair -> adaptation -> remodeling. PRP helps the repair phase. The adaptation and remodeling come from what you choose to do following the procedure.

How long does it take? That depends on the degree of injury. For Case #1, applying an SI belt gave Myra immediate pain relief but it took about 6 months for her to function normally without it.

For my pole vaulter, the whole process took about a year and for Jules, after three months she was much better but not better enough so she told me she was going to see a chiropractor a friend recommended. I don’t know what happened.

For ligament injuries, you have to be patient and let the body lead. The goal is to assist the body in achieving an enhanced level of physical capacity. You can use certain things, like the SI belt or certain manual techniques to reduce or eliminate pain. But the absence of pain does not always equate to full recovery.

Thanks for reading.

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