Injured SI Joints: Healing Through Lifestyle Changes (December 2014)

The Promise
SI joints are sacroiliac joints. They are a pair of long, barely movable, joints in the back of your pelvis. They can be injured by a traumatic event, like a fall or auto accident, or by repetitive overuse during sports or the chores of daily living. Once they are injured sufficiently to cause discomfort, the distress often never completely resolves. The pain can range from intermittent to constant, from mild to severe, and may be felt as low back pain, as pain in the joints themselves, or can cause misery in various muscles in the buttocks and thighs.

I’ve been dealing with achy or worse SI joints for decades. I either injured or further aggravated them when I began doing yoga about 1990. SI pain is known as a yoga teacher’s injury though the joints are susceptible to injury when engaging in almost any sport. For a number of reasons, women’s SIs are more vulnerable to injury than men’s. With aging and inactivity, they tend to become fused.

When at home in the NW, my massage therapist corrects the uncomfortable and recurrent misalignments of my SI joints. But this traveling season, I decided not to let 8 months pass without support for them. I vowed to make my first visit to a chiropractor to gain help in managing them during our 2 month stay in Palm Springs. 

A friend-of-a-friend referral lead me to Shawn Scott, DC in nearby Palm Desert. I was stunned:  he considered my chronic problems eminently fixable and fixable in about 2 weeks. No salves, prescriptions, over-the-counter medications, x-rays, SI belts, endless adjustments, or other external agents; the treatment plan was almost exclusively self care. Talking cure for a condition that other professionals only hope to barely manage, or treat with injections or surgery, was music to my ears.

The Plan
Sleep Position
His recommended change that seemed like #1 to me, though Dr. Scott didn’t prioritize them, was changing my sleep position. "Sleep on your back” was the critical fix in his mind—any other position results in a repetitive use injury to the irritated joints.  It made sense because the  pelvis is supported by the bed and the subsequent natural flop outwards of the legs closes the SI joints when on your back. Other positions open the SI joints, potentially causing 7-8 hours of micro-trauma every night.  

Unfortunately for me, I stop breathing when I sleep on my back. But if you can tolerate the sleep position, try it if you have SI joint discomfort. (I’ve been sleeping on my side for about 30 years as an antidote to my breathing problems and my ears still rebel against the compression.) I did try sleeping on my back again for 3 nights in hopes that my condition had improved but quickly determined that my breathing problems were worse than ever. With sleeping on my back a non-starter, Plan B was my only option, which is side sleeping with support.

Side sleeping with the upper leg supported.

The simplest strategy for side sleepers needing to reduce the strain on their SI joints is to stack their legs, one on top of the other. I knew that the stacked leg position was annoying to my body, though I committed to retraining my being to embrace the position. In the mean time, I placed the equivalent of a 4” diameter pillow roll between the sheets on each side of me so that I could support my top leg at the level of the knee on the roll and keep my thigh parallel to the bed. This propping kept the top leg and the high side of the pelvis at about the same level, which reduced the strain on the upper SI joint.

A stacked-leg sleep position was my best option.

My preferred side-sleeping position had been an especially bad choice for my SI joints even though it relieved my discomfort. I felt most anchored, most at ease, when I bent my hip about 90 degrees and let the knee and foot of the upper leg rest on the mattress. That position pulls the joint open, putting it in a strained position all night. Dr Scott was shocked that I didn’t need pain medication to survive given the high level of ongoing irritation and presumed ligament tears in my SI joints. 

My sleep position of comfort was damaging my SI joints.

No doubt a body pillow would be an easy way to support the top leg when side sleeping, but we have no room for one. Eight months of the year we live in a tiny camper and 3 months we are traveling by bike overseas, so I was highly motivated to master the ‘stacked leg’ position to eliminate the need for sleeping props.

Minimize Hip Flexion
Hip flexion occurs when you move your thigh closer to your chest. When standing well, there is no flexion of the hip. When sitting upright at a desk, you have 90 degrees of flexion at the hip. The amount of hip flexion in my sleep position was similar to sitting in a chair: my top knee was drawn up to the level of my pelvis so I could anchor my the lower half of my upper leg on the bed. My hip flexion was another “no-no,” especially for sleeping. So, in addition side sleeping with my legs stacked or my top leg supported at hip level, I needed to move from a side-lying chair position towards side-lying with an open hip joint like in standing—permanently.

Kneeling: taking a break from standing while maintaining zero hip flexion.
And at least during my initial recovery, I was to minimize hip flexion during my waking hours as well. That simple statement translated into a long list of activities and positions to avoid. Out went about an hour’s worth of my favorite stretches and yoga poses which tend to be done seated on the floor bending or twisting or both. Cycling was frowned upon, though Bill raised my handlebars and we did easy going rides with me emphasizing an upright position. Sitting, like at a table or in a car, was bad for my SI joints, so most of my time in front of a laptop was spent kneeling at our camper dinette with the computer placed on the seat and my toes resting on the floor.  

One of Dr Scott’s clients was so intent on banishing her painful SI problems as quickly as possible that she was eating all of her meals in standing and was peeing in the shower rather than sitting on the toilet. He felt that was a bit much but of course appreciated her commitment to her healing.

Activate the Glutes
Another tip from Dr Scott was to active my glutes, or squeeze my buttocks muscle, especially when transitioning from sitting to standing. Sitting pulls the SI joints open, which is bad for them. Squeezing with the glutes helps to close the joints and protects them during the progression form sitting to moving. He added that frequent glute contractions while in standing would be helpful as well.

The only strength work that Dr Scott recommended was that from spinal extensions, or back bending. Yoga poses like cobra, upward dog, bow, and one-legged standing poses with a backbend were mentioned. I assumed that they were in part a ’substitute behavior’ for all that was going away from my yoga practice as well as providing some timely strengthening to help further stabilize my core. 

Reducing Pain/Distress Elsewhere
Given the combination of a short appointment time of 20-30 minutes for my new patient visit and what I considered to be a complex problem, I had drawn a very crude map of my many persistent pain areas prior to my first appointment. 

Those hot spots were areas like the upper and lower portions of the leg adductors (inner thigh muscles) on both legs; very painful “buttons” mid-length on each lateral thigh; my left low back; my psoas muscles across the front of the hips, and the glutes in my buttocks. Dr Scott looked at my map and said “Yes, yes, yes” as he paused on each area. In his mind, they were all tightening in reaction to the strains and stresses on my SI joints. In addition to looking forward to being free of pain from my irritated SI joints, I would be dropping as much as an hour of my daily maintenance routine that was devoted to quieting those painfully reactive tissues.

The Results
First Days
Even though sleeping on my back was totally out, my mind/body sorted out the needed new side sleeping position quickly. I spent most of the first night in it using props for my upper leg and by night #3 I was starting to adapt to the stacked leg position.

In addition to quickly accommodating to the new sleep position, I was dumbfounded by my markedly improved sure-footedness on the trails when descending a couple of days after seeing Dr Scott for the first time. Suddenly I was trotting downhill on Bill’s heels instead of always lagging behind. I couldn’t fathom why, but I knew it surely was related to my improving SI joints because I could  feel a subtle, new sensation running from the front of my hip to the top of the foot on my most painful side. Dr Scott had repeatedly mentioned “stability” and it looked like I was already experiencing it.

About 5 Days Out
About Day 5 I was further convinced that the lifestyle change treatment program was really working. There was no big change, no abrupt shift, but the new ease in the muscles of my upper legs told me that good things were happening. Curiously, my SI joints were persistently more uncomfortable, not less. But I set that observation aside and focused on the positive changes. Perhaps it was a “2 steps forward, 1 step back” type of healing process.

I also noticed that I was more comfortable in standing. I’ve always been restless in standing, or sitting, for that matter. For most of my life, my body has been most comfortable when moving, even if only a little bit. Dr Scott had mentioned that I would enjoy greater ease in standing and it was happening. It was especially welcome because in order to reduce hip flexion, I was now standing much of the time that I normally would have been sitting.

Day 8
A few days later on Day 8, I was even more convinced that my new sure-footedness on the more difficult Palm Springs trails was because of my improving SI joints. It wasn’t a one-off: this was the 3rd of 3 hikes during which I felt the improvement. My descending speed had gradually been increasing since I switched to forefoot striking 5 years ago, but I still was slowing Bill down on the descents. But not now—now I was consistently on his heels. It made no sense to me but I loved swiftly gliding down the narrow, rocky trails instead of hoping for the best with each step. And this new speed and stability was occurring despite my SI joints being more uncomfortable than usual.

Bill hypothesized that my proprioception, my spatial orientation, had improved with the first stages of healing in my SIs. He visualized that the message interpretation that instantaneously occurred when my foot contacted the earth, and was also instantly interpreted in my SI joints, was being more accurately decoded in my brain. Or in simpler terms: clear messages instead of mealy-mouthed ones zipping around in my body were making me more steady on my feet.

Day 10: A Follow-Up Visit
On my 2nd visit, Dr Scott revealed his deep concerns for me when we met for the first time 10 days ago. The edema (swelling) and inflammation in my SI joints were severe and he had been worried. But, upon examine at the 2nd appointment, he said that the irritation had resolved by about 50% and that the home treatment program was working. I knew I was going to miss the "cure in 2 weeks” promise but that didn't matter.

The seeming paradox of my leg muscles feeling better and my SI joints feeling worse made perfect sense to him. He said that my big stretching program every morning had been relieving the discomfort in my SI joints by opening them and thereby decompressing the edema. My stretching was re-injuring the joint tissues while simultaneously relieving my symptoms caused by the pressure from the edema. Now I had to be with that annoying pressure in the joints while they healed. I was very reassured to have the paradox resolved even though the alarm bells kept going off in my head for hours every day from the nagging discomfort that I was in the habit of relieving.

At both appointments Dr Scott did a very passive adjustment of my pelvis by asymmetrically blocking it off the table a bit with 2 padded wedges. The slightly suspended position and a few skillful long strokes on my legs and across my pelvis were all he did to reset my SI joints. It's called Sacral Occipital Technique or SOT. Dr Scott commented that chiropractic focuses on mobilizing joints but that that is counterproductive in someone like me with hyper-mobile SI joints.

My homework for the next 2 weeks was the same: continue with the lifestyle changes that were allowing the joint tissues to heal. That meant continuing to master my side-lying sleeping position with a minimum of hip flexion and providing support for my upper leg. He anticipated that my SI joint tissues would have largely recovered from the chronic trauma in the next 2 weeks. Dr Scott suggested that I continue my healing regime for a month and then resume my SI-stressful activities at about 40% of my former intensity.

At my last appointment with him, he passed the baton to me: I was to experiment with yoga poses and listen to my body to guide my own healing. I didn't feel quite up to the task but I was definitely motivated. He also recommended that I ice the swollen joints rather than release the achy muscles over the joints with self-massage, which is what I had been doing.

The Continuing Story
Not surprising to us, my healing course would continue beyond our 2 month stay in Palm Springs. Dr Scott’s 2 week cure had seemed overly optimistic when mentioned. I assumed that a ligamentous injury would take 6 months or more to heal; Bill was thinking in terms of 1-2 years. But the time line didn’t matter; the important point was that I had a revolutionary way to manage my SI joint injuries. My surrounding muscles were so much better that I’d easily resist returning to my favorite stretches for as long as it took for the SI joint discomfort to melt away.

This chiropractor launched me on a new path, on a new relationship with a chronically troublesome area in my body. It was more than I ever hoped for. And my patience for a slow healing process was immensely increased by my stunning performance improvement on the trails and even when playing our low balance beam games on raised curbs. Between hikes, I was constantly reminded of being transformed into a “stander”—never before could I so effortless stand still. I indeed had been gifted with a previously unknown stability. I looked forward to the possibility of being completely pain free in the coming months, or perhaps years.