Episode 64 - SI Joint Pain: A Pain in the Butt?

In this episode of Three Questions, I dive into the research, myths, and missing questions surrounding SI joint dysfunction.  I chat about why treating the SI joint in isolation often leads to frustration, and how sensory feedback, brain mapping, and movement patterns may be playing a much bigger role than you think.

I also share my own experience with SI joint pain, challenge some common assumptions about stability and mobility, and explain why the answer might not be at the SI joint at all.

In This Episode You’ll Hear:

• Why SI joint pain is considered multifactorial and what that actually means
• How poor sensory awareness can cause the SI joint to do jobs other joints should be doing
• Why improving hip function, proprioception, and whole-body organization may matter more than “fixing” the SI joint

If there's one thing I hope you take away from this episode, it's that pain is rarely as simple as the location where the person is feeling it. Sometimes the most meaningful changes happen when we stop chasing symptoms and start asking better questions about the whole system.

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Transcript

Meghann Koppele Duffy: Welcome to Three Questions, where critical thinking is king, and my opinion and research are only here to support your learning and deeper understanding. Hey, I'm your host Meghann, and I'm so honored you clicked on Three Questions today so we can talk about the SI joint or sacroiliac joint. Now, if you're not a movement professional, well, hang on, I'm gonna make this episode super exciting, so don't just turn me off yet.

So the SI joint, if we think of like our pelvis, so you've got these two pelvic halves. So if everybody s- if everybody puts their hands on their hips, you know, we're told, we're told to do that as kids, where you put your hands is actually the top of your pelvis. Now, your pelvis kind of comes around the back, and then there's this tailbone at the bottom.

So we all know the tailbone. So everybody reach back. It's your tailbone. Touch it right now and slide your hand up, and you're gonna feel this kind of bone above the tailbone, and that if you keep going up, it's gonna turn into your spine. Okay? So how our body looks, we've got this spine, we've got our cervical, our neck, our thoracic, our mid back, and then our lumbar.

So we got that little curve in. Then we got kind of our booty. But at the end of our spine is what's called our sacrum. It almost looks like a triangular bone, and then our tailbone's at the bottom, and our sacrum attaches to our ilium, so our pelvic, parts of our pelvis, at what's called the SI joint. Now, this joint can be a bit problematic, and I see, um...

It's, uh, very interesting to me. It's a big problem in the dance and Pilates community, and we'll talk about that later. Now, let's talk about our upper body for a sec. So I want everybody to think of their shoulder blade. Okay? And move your arm up and down right now. So the cool thing about the shoulder blade is when our arm moves up, our shoulder blade actually upwardly rotates on our spine.

That's why we can, like, really do a lot of stuff with our arm. Now, take dancers or fle- hyperflexible people aside, we can't do this, as much motion i- with moving our leg via our hip joint as we can with our arm because of the SI joint. So what if you imagine between your two shoulder blades, say there's was this little bone or this really thick bone that went across and attached the shoulder blades.

Okay? So say if it's a bone, well, there's gonna be a joint between the shoulder blade and that bone, and at that little place, there's gonna be a little bit of mobility, okay? 'Cause there's mobility at all joints. Some very little, some a lot. So imagine right now, think if your shoulder blades couldn't upwardly rotate, so, like, tie a string between them.

Your arm movement is going to be limited. So take that idea and bring it down. So we've got our leg bones, we've got our pelvis, and then we've got this bone in between the sides of the pelvis, which bring our right and left leg together. So if you wanna reach down, you can kind of feel the divot on either side of your sacrum.

Okay? Now, when people go, "Oh, I got back pain," and they reach down and almost grab a little bit of the top of their buttocks... Did I just say buttocks? Their butt. That often can be SI joint pain and actually not lumbar pain. Now to make things more annoying, in our brain, so we've got a sensory and a motor map.

Those joints are next to each other in the brain map, so a lot of times people think they're moving their lumbar spine, their lower back. They're actually moving their SI joint. And if you come around to the front of your pelvis, touch your crotch, you'll feel your pubic bone, and that joint is called your pubic symphysis.

Okay? And then we have another joint, which is our ball and socket hip. So all those joints are pretty close together. So a lot of people, when they think they're moving their leg, like kick that leg up. If your pelvis moved on the side of the leg that's in the air- Or the pelvis move based off the standing leg, there is a lot of mobility in other joints.

Okay? So one of my students asked me, shout out Claudia, asked me to do an episode on the SI joint, and I said, "Would love to." Now, when we think about the SI joint, what do we think about? Well, I've seen trainings on how to mobilize the SI joint, stabilize it, all these things. But what's interesting to me, and what I wanna ask you, question one, what's the deal with the SI joint and why do we treat it as if it exists in isolation?

Number one, based off what I just told you about brain mapping, could it be possible that you think you are treating the SI joint, but you are treating other nearby joints? Okay? Could be. Also, when we look at the research, a big research, um... Now, it wasn't kind of a regular peer review study. They basically looked at a bunch of different research, and the conclusion was that SI joint pain is multifactorial.

I was like, "Duh." So it means it's not purely structural, not purely biomechanical, not purely neuro. It's multifactorial. There's a lot of factors, and SI joint pain could be different for each person, okay? So knowing what all the research and a bunch of experts got together, broke down all the research, and this is their conclusion.

That doesn't mean that it's gospel. I always say research doesn't give us a destination, it asks us more questions, okay? But if we know it's multifactorial, just looking at purely treating the SI joint can al- often only give temporary relief. Now, I work with SI joint pain. I also had a major SI joint pain problem.

Now, I fractured my sacrum. I don't remember how old I was Had to be like 27, 'cause it was before I met Brian. Anyway, I was at a bar looking very cute, very cute outfit, very high heels. I put my foot on a bar stool and it slipped, and when I went to sit down, I sat on the floor. I did not know I b- fractured my sacrum because I was in my 20s and I was at a bar.

We'll leave it at that. Woke up the next morning, I remember going to my sister's apartment in Hoboken, and I said, "I think I broke my butt. Doesn't this feel weird?" And you could literally feel... My sister's like, "Um, I'm pretty sure... I don't know anything about the body, but I feel like the bone is supposed to be this way, and it's that way."

Long story short, went, got an X-ray, had a fracture through my sacrum. So again, that was an acute injury. Yes, and. However, I know I've always had poor hip mobility. Always did. I remember being a kid stretching, like, you know, to warm up for, like, softball or whatever, and I'd be like to the coach, "Um, my back hurts."

And he's like, "What are you, 85?" And I'm like, "No, but my back still hurts." Because when I would try to mobilize my hips, I would over-mobilize my lumbar spine. Okay? Now, if you see how I'm built, makes sense. Always, as my mom said, I always had a tight little tushy. It's not so little anymore. But that actually inhibited hip movement, so it was kind of easier and more effe- effective or efficient as a kid to just move my lower back.

Okay? It didn't hurt unless it hurt. So when a client comes in with SI joint pain, I want you to ask yourself, "How can I best support this joint?" Now, I'm gonna go right into question two because I feel like question one and two kind of piggyback We know we cannot work in an isolation, but would you micromanage another joint that moves that little?

Okay? So if I told you that the SI joint moves about under two degrees... Now, keep in mind, our sacrum, it moves in three different planes, and the biggest movements that it does when we're talking about the sacrum in relation to the iliums is nutation and counternutation. So kind of a little bit of tipping forward and tipping back.

Okay? Now, also the iliums can move on the, uh, sacrum. There, there's a lot of small, tiny movements of the SI joint and the, um, um, in relation to the iliums and hips. Okay? One degrees, under two degrees. Now, the, uh, different studies measured this differently. There were a lot of studies that I found that were done on cadavers.

Excuse me. All right. First of all, when you're doing it on a cadaver, there's not a brain attached. So often if you move my leg passively, and me when I'm dead passively, it's gonna be two different things. When I am alive, based off previous experience and current sensory input, my brain is going to go yellow light, red light fast.

Okay? So if you move my leg, I'm gonna move based off what is available and the sensory feedback. When you are working with a cadaver, this is why I encourage everybody to go and do a cadaver lab, but acting as if taking cadaver labs is going to make you a better movement teacher is simply not accurate.

Okay? Cadavers don't have brains attached, so we can understand the fascia and manipulate the body however we want. That works if you're working with puppets. Now, please understand, I think everybody should do a cadaver lab and see what things actually look like. However, when there is a brain attached, we have a nervous system that is going to respond differently.

It's not just... You cannot look at things through a purely biomechanical lens. I wish we could. That's my background. That's why I left biomechanics. I studied biomechanics, loved it, it was helpful, but it only takes one piece of the picture, gives you one part of the picture. I screw up sayings all the time.

You know what I meant. Okay? Now, let's talk about the pubic symphysis. That also moves about one degree. Lumbar spine. Your lumbar spine moves approximately, like, 50 to 60 degrees in a single plane. Okay? Now, we can also move our lumbar spine in multiple planes, but think of just single plane. Now, let's talk about your hip.

Depending on the movement you're doing or the plane, it can move from 40 to 120 degrees. So the hip joint has a lot more movement than the SI joint. We can all agree. This is fact. Now, let me bring it back to the upper body. So people still think, and I see teachers teaching people how to mobilize and move based off their SI joint.

Would you do the same with their sternoclavicular joint? So I'm gonna ask you to touch. So you've got a sternum in the middle, then you've got your clavicle. So there's this little notch. Touch it right there. Now, I'm not saying we ignore this joint, but your sternoclavicular joint is about 40, has 40 degrees of movement when the arm moves over our head.

Do you micromanage and teach movement of the sternoclavicular joint? No. We might bring attention, we might do a release, we might do something, we might bring sensory feedback there. So I just want you to think logically about how you're approaching the SI joint. Okay? So if we should be really micromanaging joints, we should be fixing bigger problems first.

And let me tell you, I have people, clients from all over the world on Zoom, in person, anytime a Pilates teacher moves their hips, especially when they're doing footwork on the reformer, nine out of 10 of them mobilize their SI joint before they mobilize their hip How do I know? Because I'm palpating it while they're doing it.

Is it wrong to move your SI joint before your hip? Well, it depends on what you're doing. But shouldn't we focus and get the maximum movement out of our hip before we micromanage the SI joint? Let me tell you, every single Pilates teacher I've worked with SI joint dysfunction has no sensory feedback back there.

They have no idea they're moving their SI joint when they are, and when they need to, it's not really moving. So if we can change that sensory and motor map with actual comparison, and what I call it is we have to improve, augment the error. Okay? If you wanna try this, what I'm gonna ask everybody to do, stand up, put your hand down your pants, and kinda grab your butt meat on the right side.

Think your pinky is gonna kind of touch your SI joint. So kind of go and find your sacrum, find where it indents a little bit, make sure your pinky's there, and just kinda grab your butt. What I want you to do is lift your right leg up. Did the skin or your body under your pinky move a lot, a little, or not at all?

Just notice. Now, put that foot down. Lift your opposite leg. Don't move your hand. Keep your hand exactly where it is. When you lift your left leg, what happens? Do you feel rotation? Does the tissue move in your hand? I want you to not be an expert at what you are feeling. I just want you to do it, okay? Now, this might be the first time you've done that.

That's okay. You're not gonna be an expert at knowing what your SI joint does, okay? We're gonna talk about touch-based cues a little bit later. Touch-based assessments, I mean. So what I was looking for there is when we do hip flexion or when our hip needs to stabilize, and our SI joint needs to stabilize when we move the other side, what is actually happening?

I just want you to take note. When I move my right leg without good sensory feedback, I over-mobilize my SI joint to the point that it is painful. But as soon as I can get sensory feedback, whether it's my hand, Kinesio tape, touching my pubic bone and my other leg to bring relationships, my SI joint does not over-mobilize.

It moves the proper amount, and I have zero pain, okay? So don't be mad if you have SI joint pain. Also, I'm gonna say something that might not be popular. I don't care. Not here to be popular. I'm here to ask questions. When you are actively and consciously always pulling in your abs and engaging your TVA...

So right now, take a big inhale through the mouth and, uh, through the nose and exhale through your mouth like you're blowing out birthday candles When we do that, it's changing intraabdominal pressure. You're using your TVA as an additional spinal stabilizer. But when we shift the pressure like that, oftentimes it can affect the sensory feedback, and the brain gets confused where the SI joint is in relation to pubic symphysis, hip, and lower back.

Okay? Now, you can also look at research. People think they're pulling in their pelvic floor, but when there is actual electrodes and biofeedback, they're actually pushing their pelvic floor out. So what I want you to hear is our proprioception, what we feel, is not always reliable. So let's review question one and two.

We now know that the SI joint moves very little, under two degrees. We also know that when it... And what's interesting, some of the research I looked at, they didn't see much movement difference based off people who were asymptomatic or had symptoms. So what it's telling me is the people who didn't have symptoms probably were also over-mobilizing or under-mobilizing their SI joint, but their brain had other options.

It wasn't causing a problem. For someone with pain, it's your brain telling you that pattern is no longer serving us. We need something new. So rather than trying to micromanage that pain pattern, we need to create new patterns, give the brain new. Okay? So I just want you to ask yourself, "How can I best support the SI joint by making sure all the other big joints are moving correctly and not forcing small joints to do big joints' jobs?"

Our glenohumeral, the most mobile joint in the body, the hip joint, ball and socket, second most mobile. Let me tell you, just because you're moving legs and arms doesn't mean you are differentiating and fully using those joints to their full capacity. It is a huge problem. It's something we work in with neuro.

I work with professional athletes. I work on my body every day, and that's what's so cool about the body. Everybody has different sensory gaps, so it's not like one magic exercise. But we- when we can identify those sensory gaps, it's so cool. So knowing that, how can we give feedback to the SI joint, especially if it's moving too much?

Can we use the skin? Can we use pressure? Can we use other tools? I see a lot of people releasing their A- SI joints, releasing the muscles around their SI joints. Those muscles are tight, pelvic floor, gluteal muscles, piriformis, because they are trying to probably stabilize your SI joint. Okay? If you're a dancer, you're probably over-mobilizing your SI joint because you have to.

You're doing these extreme ranges of motion that are beautiful on stage. But when we take and take and take from joints, they're going to lose the stability they need. They're gonna have to get it somewhere. So yeah, I don't really believe in releasing things. I'm not saying that releasing things won't make you feel good in the short term, but it's gonna be a self-fulfilling prophecy.

You are basically disrespecting your brain, your brain saying, "I don't like this movement pattern. I'm gonna tighten shit up. I'm gonna create a pain." I'm not create. I'm gonna... You know, nociception's gonna happen. I'm not gonna go into pain science. You're gonna be in pain. Well, believe it at that Okay? So what do we do?

We say, "Okay, let me release these, let me feel good so then I can reinforce that pattern again." What if we gave our brain something else? What if we said, "Okay, what if we don't move this area and try to move other areas?" I want you to think about that. I want you to think about how I can create an environment when people are supine that doesn't screw up their proprioception.

Everybody, when they lay on their back, they still feel roundness in their body. When you are laying on the floor, you are actually flat in a lot of sections. So supine exercises can screw up our proprioception. That doesn't mean we avoid them. We adjust. That's why you'll always see me have a thin towel along someone's spine, 'cause our spine should never be in the same plane as our back ribs.

Okay? So if we're working something in a specific proprioceptive environment, we can't expect that to translate when we change the entire environment. I know, kinda sucks, but keeps it interesting. And that's gonna lead us to question three. What does the research actually tell us about what we know about SI joint assessments?

So the consensus guideline that I talked about earlier, um, ugh, this... I, I don't like this sentence. It kinda pisses me off. It said, and they were pretty direct about this, "Palpation and positional tests have poor reliability." Hold on a sec. I believe that, yes, and I believe two things. I believe that they are not reliable because the multifactorial issue here.

I also believe they're not reliable because people don't spend time getting good at tactile assessments End of story. People teach, they go, "Okay, do this assessment. See where I'm putting my hands? You do it." And people are like, "No, no, no. What I feel?" That's like when I teach tactile, I say to each student, "What do you feel?

Explain it to me." "I don't know." "Well, tell me what you feel. Do you feel pressure? Do you feel this? What does it feel like when I do it?" And, um, one of my students, Cindy, who does... She teaches the McLaughlin scar tissue technique. One of the most meaningful things, I was, uh, co-teaching with her. I asked her to do it to a student, and then I did the technique kind of poorly, and I said, "What was the difference?

Explain why hers was better." And the student explained it in a way that Cindy was like, "Oh my God, that's exactly what I was trying to do." I said, "Good job. You're really good at this." But it helped the student understand how touch feels different. Now, I know, um, if you look at, um, oh gosh, Movement Rev, her name is Anna Hartman, wonderful practitioner, love her as a person too.

She uses an SI joint assessment, and she fights with people all the time because they're like, "Oh, well, that's not reliable." She's like, "Yeah, it is, 'cause I'm really good at it, because I spend the time, and I figure it out, and I look at how the whole body is." She's not looking for one plus one equals two.

She's saying, "Let's see what we feel when this is happening." She'll... She uses visceral work. Awesome. Whatever she's doing, great. For me, when I'm palpating and seeing how somebody's moving, I'm assessing what is moving too much and what's not. What is it protecting? How can we give the brain other feedback so that intuitively the nervous system, the body, can have that structural support protection, let go of other things.

So I look at from a neuro perspective, which is not the only way to look at it. Visceral, I think they're both super interesting. Do what you like. If you don't like being hands-on with people, don't be hands-on with people. But to say that assessments don't work because you haven't dedicated the time and energy to doing them, I have no patience for that conversation.

Mm, mm, mm. I see it in neuro all the time. We settle for okay. I never settle for okay, and I don't let my students settle for okay Our clients deserve more, and we are not gonna be good at a technique when we first learn it. It has taken me twenty-five years to finally explain my assessments in a way that people are starting to understand.

But let me tell you, these assessments made sense in my brain twenty-five years ago, and everybody would smile and nod at me, so I thought they made sense to them. Then when we started to get into it, I realized I don't think they're actually getting it, not because they're stupid, but it takes time. So if you wanna work with SI joint dysfunction, there is no one-fix-all approach.

And let me tell you, when I cannot isolate my right hip, I will have SI joint pain in whatever I do because I had some fundamental movement issues. Then I had a traumatic injury that has screwed up my brain mapping there. Because of that, I need to constantly keep my right hip active and communicating with my right foot.

Stuff I have to do every day, okay? It's like brushing your teeth. You don't brush your teeth on Monday and expect your breath to be fresh on Tuesday. I can't do my hip exercises on Monday and expect my brain to still pick that as the preferred pattern if I don't do it. Whatever you do the most wins. All right?

So assessments are unreliable if you don't get good at them and ask yourself what you're looking for. As I said, the SI joint doesn't move a lot. If you don't know what you're feeling, look at how the SI joint is moving in relation to other joints. Is it moving more than this? Is it moving less than this?

What happens when I move the lumbar spine? What's happening at the SI joint? Should that be happening? Why is this moving more than that? These are the questions I want you to ask yourself. I want you to put people in positions where their SI joint doesn't hurt, and when they say their SI joint hurts, I want you to put your hand on them when it hurts and when it doesn't hurt.

Feel. What's the difference? What are they moving? Where are their v- where-- what are they protecting? I want you to take a step back and ask more questions. I am telling you, this will be the best thing you ever do. And just from experience I got the best PT. They would do visceral work, hands-on stuff, and on the table my SI joint would feel good, and then they'd work on something else.

I'm like, "Oh, no, it's hurting again." "No, no, no, it's fine." No, it's not fine. You created a shift in my body, and then you shifted something else that put me back in there. Shouldn't we explore that? And let me tell you, as soon as I got up and walked, after about a few steps, the pain would be right back. The only thing that really helped me was wearing an SI belt, which was helping bring proprioception to the SI joint so I didn't over-mobilize my right and under-mobilize my left.

I had gotten into this pattern, and when I wore that SI belt, I would do my hip exercises. But the real sauce, guys, my SI joint pain went away when I was able to reorganize my upper quadrant. Yes, you heard me. Everything is connected. The shoulders down crap that had been beaten into me in all movement had created no tensegrity through my lat and my system.

So basically, my upper body was sitting on my lower body like most people. I invite everybody to elevate their shoulder girdle until they feel that what's called tensegrity. Just feel your skin kind of, not tighten, but whoop, feel a little more taut. Then instead of putting your shoulders down, what if we lift from our head so our shoulders are away from our ears?

Stop pulling your shoulders down. I know. If your shoulders go up, there's a reason. That's how your body is creating tensegrity. Work with that. Fix the head, the visual vestibular. Get the hips to activate. Use a multi-human, full human approach to SI joint dysfunction, and I'm telling you, you are going to be shocked with the results.

And to leave you, if you are currently in SI joint pain, stop moving it Or if you put your hand on and it's not moving, I want you to look at the joints above and below it. I want you to go... If that doesn't help, go even further away. Most people, when they start moving their hips, cannot differentiate in the brain the difference between SI joint movement and hip movement.

It's not that they don't understand biomechanics. It is a brain mapping issue. I'll never forget one of my... Ugh, I love her so much. Um, she has been a student for a long time, but I noticed in all the training she would never move. I don't judge 'cause I don't like to move in trainings, I like to listen. And then eventually she's like, "I have really bad SI joint pain."

And I was like, "All right." We were doing supine stuff. I had her ha- hand on her SI joint, and I had her hand in front, like around where her ovary was, and I asked her to create more space there, and then I asked her just to do some hip flexion exercises. And she goes, "Meg, put your hand on my belly. Every time I move my hip, I feel like it drops down right there."

I go, "It does. What if you maintain the space between... Create more space between your ovary and your SI joint." Now, was she on her exact ovary? No, I'm just, "Keep your hand on your belly." SI joint pain went away. Why? Because every time she moved her hip, she was dumping. There was mobility in her SI, uh, in her SI joint and pubic symphysis in relation to her other hip.

She had no idea it was happening, and let me tell you, if you looked at her, you really couldn't see it. You had to feel it. Okay? So that totally negates what all the research says, that touch-based assessments are not reliable. I think they have poor reliability because we don't actually know what we're touching and what we're doing.

We're just doing what people to- taught us. Ask more questions. What does it feel like to you? Does it feel hard? Does it feel soft? Does it feel like it goes forward or back? Okay? Tell people, talk about it. Have more questions. Just stop blaming the SI joint

I'm gonna leave you guys with that. Just stop leaving the l- stop... Oh my God. I had a good closing and I, I screwed it up, but I'm gonna keep going. I'm gonna fix, I'm gonna fix this. I'm gonna fix this. I'm gonna leave you with stop harassing the SI joint. Touch it, be curious, and reach out to me if you need help.

I don't want anybody struggling with SI joint pain. We can fix this. We gotta think outside the box. We gotta support each other. We gotta support the joints. We've gotta check the sensory environment, and we have to be better at what our hand-based assessments are telling us. So hopefully you got a lot out of this episode, and I will see you guys next time.