Two Steps Forward, One Back

Unwilling to compromise the hiking and biking that we had planned for our summer in the Italian Dolomites, I committed to learning coping strategies for an “active healing program” for my irritated left sacroiliac (SI) joint.  As my pain level shot up, I indeed learned more and more.

What not to do: tipping forward increases the load on both the back & SI joints.
Posture, Especially When Hiking
Improving one’s posture is always excellent advice and being more pristine about my spinal alignment when hiking reduced my SI pain. The steep grades we hike sometimes have ball-bearing-like surfaces and those conditions, plus the strain caused by my 12-14 lb day pack, invite bending forward at the waist and neck. Cranking myself up a few more degrees towards vertical helped, as did tipping my head at the neck  better see the immediate trail rather than bending my neck with my head moving forward. Keeping my head more over my hips minimized the strain on my spine and SI by keeping the excess load down--think leverage here.

My goal is to be upright with a bit of lumbar curve (slightly swayback), which is the most sturdy position for the spine, when I hike. I now always wear my SI belt when hiking to help stabilize my pelvic joints as well. 

We began hiking with lightweight, overly long poles in February and I’m suspicious that doing so is helping my SI joint. I keep my poles well forward of me and pull, rather than push, with them. The pulling motion with the long poles definitely helps me maintain better posture and takes some load off of my back and knees. Years ago we each hiked with a single pole and I now think that would be detrimental to my SI joint because of the inevitable asymmetry it entails.

I still won’t fully accept how bad I suspect cycling is for my SI, but raising the handlebars was a winning strategy. I have drop handlebars on my touring bike, which invites a very bent-forward position. Being more upright was better for my SI.

Wearing my SI belt when biking helped, but it sure didn’t stay in place for long. But I wore it on every ride and knew that it would be out of position much of the time. Whenever we stopped, I’d reposition it for more support.  

I’m convinced: sitting is nasty for those of us with SI joint pain. I assumed that my SI belt would solve my discomfort problems when sitting but it doesn’t do the trick for me. The better solution for me is to minimize sitting.

Sitting is my first impulse when I am in pain and I still struggle to resist that impulse. Recently, I had an uptick in pain when hiking and when we paused for a water break, I immediately looked for a place to sit to relieve my discomfort. Fortunately, I remembered that sitting was a loser so instead, I removed my pack and found something to lean against to change the stresses.

Standing more and sitting less has been a challenging lifestyle change for me to implement. The constant SI discomfort is a good motivator to comply, but I often resort to pulling recent medical research from my mental archives to add weight to the argument when my grumpy mind would rather have me sit. Improving one’s overall health by supporting DNA repair by standing instead of sitting quickly comes to mind. Standing workstations and sitting for no more than 20 minutes at a time are the common interventions to promote DNA repair, so I rally with that knowledge and stand up when I know I should for my SI joint.

More recently, I read a new study suggesting that being sedentary increases your risk for developing Type 2 diabetes and that periodic 'un-sitting’ reduces glucose and insulin levels after eating. The study documented that interrupting every 30 minutes of sitting with 3 minutes of moderate walking was enough to improve the subject’s metabolic profile. So now I have 3 arguments with which to confront myself when I’m wanting to sit or sit too long: increased SI joint irritation, compromised DNA repair, and increased diabetes risk.

And if you’ve been sitting while reading this, stand up for at least a moment.

Bridge pose: the wedge position attained by lifting th pelvis.

Bridge Pose
A yoga-teacher friend shared her success with using a bridge pose variation that was recommended by her PT for her SI issues. It was a sterling success for me as well.

To give this bridge variation a try, lie on the floor on your back with your knees bent and your feet flat on the floor and under your knees. Place the intermediate width of a yoga block, or something similar, between your knees and position your feet slightly toe-in to protect your SI. Contract your ab’s to take the natural curve out of your low back—this will bring your waist to the floor and will create a pelvic tilt. Begin pressing both knees into the block. Hold that pelvic tilt and slowly lift your hips to your limit, forming a wedge-shape with your torso. Continuously press both knees into the block and keep the buttock muscles engaged. Hold the position at the top, re-affirm the contraction of the buttock muscles, then slowly lower down, not releasing the pelvic tilt or the pressure on the block until your hips are anchored on the floor. Repeat this movement cycle a dozen or so times.

I rarely do bridge pose because it has always registered as a non-event in my body but this more dynamic variation was magic for me. For years, I’ve had an odd shifting of muscle engagement between the left and right buttock muscles when I lift and lower in a standing forward bend. I knew that the back-and-forward pattern of contraction shouldn't be occurring but I couldn’t smooth it out. The first time I performed this bridge variation, I could tell that it was going to re-pattern my buttock muscle activation.

To speed the therapeutic process, I performed the movement very slowly, using a 30 second count going up and 30 seconds going down.  Doing this corrective exercise so slowly seemingly fixed my erratic muscle firing problem after the 3rd day. It was easy to believe that it would also help my SI pain. 

To add interest and challenge while doing the tedious 30 second counts, I alternated emphasizing pushing with my right knee and resisting with my left and then pushing with the left and resisting with the right. It should have had the same effect as pressing evenly with both knees but I could feel a difference in the muscle activation by shifting my intention. To feel more balanced, I finished each set with a few repetitions in which I pressed both knees into the block with equal force. And once I felt I was in “maintenance mode” I switched to a 5-10 count motion with even pressure.

Locust Pose
Another yoga pose, Salabhasana or Locust, which is done face down on the floor, is also therapeutic for SI joint issues. The teacher that shared her PT’s bridge variation especially likes to do this pose in the low form with lifted straight legs, or arms and legs, like Superman in flight. She recommends slowly moving the legs apart and together several times while they are held up off the floor.  Like in bridge, emphasize contracting the glutes to help stabilize the SI joints while in the pose. 

Adductor Magnus Sacroiliac Dysfunction
For those of you with a good command of anatomy, check-out this video from Eric Beard. All of the muscles that he mentions are muscles that have been agitated with my SI joint dysfunction and my right knee is the loser in the deal. The part of his scenario that doesn’t fit for me is that the knee pain and muscle struggles are on the right side but it is my left SI joint that is chronically irritated. Perhaps there is a compensating step in there that explains the discrepancy in my case.

Engage Those Glutes

The chiropractor that I saw for my SI issues in December 2014 recommended engaging the glutes, the big muscles in your buttocks, when rising from sitting. I found this difficult to do until I anchored the muscle patterning while in a different position.

Success with the glute engagement and pain relief both came from focusing on engaging my glutes in my left buttock when lifting up from a forward bend, not from sitting. The more often I remembered to contract my left buttock muscles when coming up from bending over to wash my toes, picking something off the floor, or accessing a low cabinet, the better my SI felt. I of course contracted the right buttock muscles as well, but since my pain is in the left SI joint, that is the buttock I focused on with my intervention.

Once I had the habit of engaging the glutes in the more extreme bending forward position, it took several weeks to be successful with activating the glute muscles when moving into standing from sitting. 

A poor substitute for sacropelvic blocks for the traveler.
A Glute Trick
While I was gaining proficiency with engaging my glutes when lifting up from a standing forward bend, I found a little trick to ease my way around pain when returning to an upright position. While bent over, I’d lift my left heel as high as  possible and heavily weight the ball of that foot. With my left knee bent, I’d then bring my torso upright, maintaining the lifted heel position. The little sequence seemed to force my glutes to engage on that side, which protected my SI. This ritual was very helpful in getting me through my worst period of pain.

A Substitute for Sacropelvic Blocks
In the prior piece on SI joint pain, I mentioned resting on sacropelvic blocks to sooth my SI joint—blocks similar to those that the chiropractor used to launch my healing journey. Too big to carry with me overseas, especially on my bike, I jury-rigged a substitute when my SI joint pain spiked in early August.

I placed tightly rolled, stretchy exercise bands under Bill’s thick flip-flops to simulate the wedge shape of the blocks. I already knew how to position them, as in which hip has the block-substitute nearest my waist with the flip-flop perpendicular to my spine. The photo is an approximation of the positioning: the rolled bands are actually more towards my mid-line than in the photo—the flips wouldn’t pose properly without more weight on the tips. 

My old ripstop bags contained the hotel's extra bedding for substantial leg supports.
Sleeping Positions
Changing to being a side sleeper with support for the upper leg and maintaining minimum flexion at the hips is challenging for many of us, but it requires little time to know that it is the right thing to do. (Discussed in previous piece.)

I started the transition last winter with one rolled pillow supporting my left leg and then added a bit of support for my right leg. While traveling for 3 months this summer, I managed with the equivalent of only a small pillow between my knees that I successfully kept in place when rolling over. That was sufficient for weeks, then my pain level shot up.

To counter the increased pain at night, I dug out a pair of ripstop nylon bags we’d made 20 years ago for our bike panniers and began stuffing them with all of my fleece clothing and socks to make higher supports for both legs.  When our accommodations provided extra blankets or pillows, I’d stuff them into my purple nylon bags for even firmer support. The bags happened to have draw cords on them, so I tied the ends together to help keep the makeshift pillows on the bed through the night, or at least within easy reach if one fell off. The greater my pain, the higher I wanted the supports. 

Now feeling doomed to be dealing with SI pain for years, I ordered a ‘proper’ pillow designed for good alignment while side sleeping when at home and an inflatable pillow for travel, both from Both were great purchases. The $20 sculpted foam InteVision Knee Pillow indeed stays in place when rolling from side to side and makes me less of a bed-hog than when I was using clothes or blankets in my purple bags for support. 

The "Sea To Summit Aeros Ultralight Pillow, Regular“ made me gasp at $37, but it was worth it. I tried a couple of inflatable pillows 15 years ago for camping and they all quickly leaked. Hoping things had changed, I’d read online reviews for the current crop of inflatables and clearly the widely advertised manufacturers hadn’t learned any new tricks. By chance, I spotted this Sea To Summit product in Italy and decided to wait so as to pay for it in dollars rather than Euros. We already had a few products from the company and knew that their claim to fame was their water tight seals and trusted that, especially given the price, they could reliably make air tight seals as well. 

My post-trip knee pillows: an inflatable for travel; a hefty foam pillow for home.
Note the small travel bag for the red inflatable pillow in the photo. The pillow only weights 2.1 oz or 60 g, which makes it grand for travelers like us on a tight weight/space budget. The online reviewers loved this product and I was smitten the first night, trying it both for a head pillow and a knee pillow for my SI. Like the bulkier foam pillow, it was easy to keep between my thighs and roll with it in place when I shifted from one side to the other.

"Position of Comfort”
Finding a “position of comfort” was a phrase used by a physical therapist I know who works with a lot of patients with back pain. I haven’t found many such positions for my SI pain, however. Sleeping on my belly (for a while) with my feet dangling off the end of the bed gives me some relief. A friend stretches out on her couch with a pillow under her knees, which also helps me.

When I asked the chiropractor I saw in December 2014 about using ice packs over my SI joint for pain relief, he changed the subject. I eventually tried it and it was very effective. I slap a soft gel pack or a package of frozen peas, beans, or spinach over the joint and hold it in place with a stretchy exercise band for 20 minutes. Repeat no more often than every 2 hours for the best results when ever you ice tissues or joints.

Ingestible Pain Relief
I no longer use over-the-counter anti-inflammatories, so can’t speak to their effectiveness for SI pain. They have become an even less attractive remedy with new reports about their contribution to cardiac ill-health.

In  May of 2015 we began taking niacinamide, or nicotinamide, for skin cancer prevention. A friend with whom I shared that information discussed it with her naturopath who commented that it was also good for pain. Her naturopath recommended 1000-3000 mg/day. She found that 1000 mg/day gave her welcome pain relief for her chronic hip and back pain and that she received no additional benefit from increasing the amount to 1500 mg. I didn’t notice any pain relief with this form of B3 though I only have episodic pain whereas her pain has been chronic for decades. Interestingly, 1000 mg is the recommended amount for skin cancer prevention.

Curiously, my SI pain peaked a little past the mid-point of our 3 month "bike and hike” trip overseas even though the intensity of our activities peaked weeks later. "Was the late improvement coincidence or was it because I was managing my SI joint pain more effectively?" is a question for which I have no answer. I do know that even though the pain became worse, it also became more isolated, which was very exciting.

A year ago, my SI related pain was more prominent as pain in my left low back. It was only when I followed the chiropractor’s suggestion of discontinuing yoga twists and forward bends that my SI joint pain itself shot up. He explained that my yoga practice was relieving the pressure on the joint, making me more comfortable, but actually increasing the injury to it. Unfortunately, putting up with more pain for months, or maybe years, was a necessary part of the healing plan. 

But after having both low back pain and increased SI joint pain for 9 months, the low back pain abruptly stopped near the end of our trip. That gave me hope that I was indeed making progress on my healing journey even though I may have slowed it by my intense summer activities that included 8 hour hikes. And I’m happy to say that about 2 weeks after the back pain disappeared, my SI pain also suddenly diminished. Now I’m back to “wait and be surprised” by my vulnerable left SI joint. I am however hoping that I’ve learned enough lessons about its needs that we may again live together in peace.