The Do’s and Don’ts of Sacroiliac Dysfunction

Editor's note: The following are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a healthcare professional.

For many yoga practitioners, the sacroiliac (SI) joints are shrouded in mystery. Many yoga teachers say that some poses should be practiced in a certain way “for the health of the SI joints” without identifying where these joints are anatomically or explaining why students should care about SI joint health. Even if knowledge of our own bodies has been refined through years of yoga, we still may have only a vague understanding of the sacrum or SI joints, which are located behind our field of vision, at the back of the pelvis, between and above the buttocks. Nor do most of us feel much sensation in this area—at least not until we experience SI dysfunction, with its signal pain, often on one side of the lower back, which often means that we have to alter our yoga practice and and our life.

The sacrum is not only part of the spine, but also the keystone—or connecting wedge—between the spine and the ilia (pelvic bones). A nexus between these two important structures, its Latin appellation is os sacrum, or holy bone. Essentially a continuation of the lumbar spine, the sacrum consists of roughly five vertebrae fused into one rigid, downward-pointing triangular bone whose endpoint is the tailbone, or coccyx. At the junctures to the right and left of the sacrum, where it meets the ilia, are the two sacroiliac joints. Through these joints, much of the weight of the torso is transferred to the pelvis and the legs, and when we walk, these joints help to transmit the force of the impact of our steps upward and diffuse it.

“The SI joint acts as a shock absorber, and it moves slightly as we move to help us maintain our balance and center of gravity,” explains Bill Reif, a physical therapist with 40 years of experience. His book, The Back Pain Secret: The Real Cause of Women’s Back Pain and How to Treat It, focuses on SI dysfunction as an often overlooked cause of back pain and a cascade of other symptoms.

SI dysfunction occurs when the sacrum moves too much or too little for the joint to be able to function—or distribute force—optimally, causing pain. Since around 15 percent of people with lower back pain could be experiencing SI joint pain, it’s been estimated that as many as 10 million Americans suffer from SI dysfunction. That could mean a heavy toll on the quality of life for a huge segment of the population: According to one survey that attempted to quantify the burden of the disease, the condition seems to be more debilitating than asthma and mild heart failure and as debilitating as chronic depression or severe, progressive lung diseases.

While the most common symptom of SI dysfunction is lower back pain, Reif explains that when the dysfunction is severe, there might also be pain in the buttocks, groin, or thighs. This pain might be sharp or dull, but it often occurs on only one side. “Often, sitting, which ‘unlocks’ the SI joints, making the sacrum a less stable weight-bearing wedge, causes or worsens pain, but so will holding most positions for long periods, even sleeping in a fetal position or on your stomach,” he says.

“Movements like ascending or descending stairs or hills can be aggravating, and so can forward folds. Many people find that asymmetrical movements make the pain worse. Sometimes, SI dysfunction is also accompanied by pins-and-needles sensations in the hip or groin, and urinary frequency. For women, pain can be worse during menstruation and sometimes with intercourse. You might have a sense of feeling uneven or lopsided, and perhaps you’ve been diagnosed with or noticed a minor leg-length discrepancy.”

Those who have a background in manual medicine like Reif (such as physical therapists, chiropractors, and osteopaths) are often inclined to see the SI joint as a key causal factor in back pain, probably due in part to their success at alleviating symptoms through manual manipulation of the SI joint and lower back, but the SI joint is not always appreciated as a potential source of pain. Many of those who come to Reif with SI pain first received other diagnoses, such as muscular strain, spinal stenosis, lumbar disc herniations or bulges, or facet inflammation.

The failure to consider the SI joint as a cause of back pain may be partly because this joint, girded by strong ligaments, doesn’t move much. Once viewed as being entirely immobile, the SI joint seems to allow only an average of 2 degrees of movement in all planes. How could a joint with so little wiggle room shift out of position to an extent that causes pain?

“While the movement potential there is often small, it is important,” Reif explains. “Because this area is richly innervated [contains a lot of nerves], even a small unevenness in the mechanics here can cause irritation to the nerves of the sacrum or lumbar spine. It is also in an important place—because of the sacrum’s location, consequences of small misalignments may reverberate through the spine and pelvis.”

Additionally, Reif does not concede that the movement potential there is always so minimal for everyone. “While those who are more inflexible or older may experience negligible sacral movement, there are some people, usually women, who are more flexible and may find it moves much more than 2 degrees,” he says. If that’s the case, perhaps it is why women are more likely to experience SI pain. Reif estimates that the majority of his female patients who present with back pain have SI dysfunction.

Women have a greater sacral slope, or a more horizontal sacrum, than men, which may add to the weight-bearing stresses on this joint and contribute to SI dysfunction. Women also naturally tend to have have more ligamentous laxity, which can be further increased by the weight gain and hormones associated with pregnancy.

In fact, Reif names pregnancy and childbirth as the major risk factors in SI dysfunction, especially if delivery was difficult or if a woman has had multiple pregnancies. Other commonly cited risk factors include any positions or activities that place the pelvis in an asymmetric position for a long period of time: carrying a small child or other loads, like a laundry basket, on one hip; habitually standing with more of your weight on one foot so the hips are canted, or twisted; tipping the pelvis into a chronic posterior (backward) tilt; sitting for a long period in a cross-legged or otherwise asymmetrical position; or even sitting on a wallet.

Other asymmetric activities that might play a role in SI dysfunction include driving, gardening, sweeping, vacuuming, dancing, bowling, golfing, and playing tennis. Both hypermobility (an SI joint that moves a lot) and hypomobility (an SI joint that doesn’t move) are correlated with SI dysfunction. SI dysfunction can also accompany other conditions. Reif offers this example: “At and after middle age, osteoporosis and osteoarthritis can cause joint surfaces to become rough, more prone to getting ‘stuck’ while doing an asymmetrical activity. If one side is stuck—or hypomobile—motion must come from some other place, often straining joints above or below the SI joint. Commonly, the other SI joint becomes hypermobile.”

Injury resulting from a car accident, falling, or tackles can lead to dysfunction, too. And while a minor leg-length discrepancy might actually be a symptom of SI dysfunction, according to Reif, leg-length discrepancy—especially one of a fairly large magnitude—might also lead to such dysfunction.

Even activities in which both sides of the body are worked fairly equally, like running, swimming, martial arts, and yoga, may contribute to SI dysfunction. “All physical activity requires a firm base from which we generate movement. If core muscle control is poor, the pelvis will be unstable during these movements, and SI dysfunction is one of the many diagnoses that could result,” Reif says.

If a doctor or physical therapist diagnosed SI dysfunction in you, the alignment advice, practice tips, and suggestions for daily life given below may help to alleviate your symptoms, keep your yoga practice low-risk, and prevent your pain from recurring.

It is, however, important to receive an accurate diagnosis, since back pain has many causes. Other conditions will not necessarily be helped by the recommendations below.

The Alignment that Matters: Establishing a Neutral Pelvis & Sacrum

SI dysfunction correlates with pelvic asymmetries; for instance, the sacrum may be in a fixed position tilted backward, tilted forward, twisted—or tilted and twisted—in relationship to the ilia.

If you have back pain, these two self-tests may help you identify a pronounced asymmetry, which would suggest that your pain may stem from the SI joint. (Reliable diagnosis is difficult and depends on a diagnostic injection or positive results to multiple tests conducted by someone with expertise in manual manipulation.)

1. Lie down in savasana. Bring your index and middle fingers to the frontal hip bones (anterior superior iliac spines, or ASIS). They should ideally be level. Are they, or is one closer to your shoulders than the other? Closer to the ceiling than the other?

2. Sit up with your legs straight in front of you, as in staff pose, dandasana. Look at your inner ankle bones to see if they line up. Ideally, both will be equidistant from you. Are they? Or does one leg appear longer than the other?

It is possible that someone who feels no pain may notice one of these asymmetries: sacral asymmetry does not always lead to SI dysfunction. “There are many people with mild sacral asymmetry—or other asymmetries—who have zero symptoms,” Reif says. “But athletes or those who do physical labor will be more likely to experience symptoms, because of the greater stresses on their misaligned skeletons.” In general, according to Reif, whether or not any asymmetry leads to pain will depend on the duration of the asymmetry, its magnitude, and how much force is traveling through it.

When asymmetries are accompanied by pain, physical therapists, doctors, and chiropractors often focus their treatment on restoring symmetry.

“It is not enough to tell someone with SI dysfunction to line up their frontal hip bones—they won’t be able to,” Reif says. “They need a manual manipulation, like an exercise called a ‘sacral reset’ or ‘sacral correction,’ which will realign the pelvis.”

Some simple and common sacral resets can be safely used as self-treatment. Reif emphasizes that they should be performed to about 50 percent of your capacity—that is, rather than doing them as vigorously as you possibly can, stay well within the limits of your strength—and should not cause pain. If they do, stop the movement and try a different reset. If the pain persists or increases despite working with several different resets over the course of a week or so, consult your physical therapist or physician.

One such reset is described below. For more sacral resets, and a therapeutic practice that focuses on the alleviation of SI joint pain, go to this practice, which contains a series of exercises from the realm of physical therapy that reset the sacrum, strengthen the core and hips, and stretch the hip flexors.

Sacral reset practice: Long arrow leg reach

According to Reif, “Gently pulling or reaching with one leg provides a direct lengthening up through the hip, pelvis, and even the lumbar spine. Students can practice this reset as described, going back and forth from one side to the other, until symmetry and/or relief is attained.”

1. Lie down on your yoga mat, on the floor, or on a firm mattress with both legs fully extended. You can rest your arms alongside you, or bring your hands to your belly to feel the movements of the breath.

2. Point and reach through the toes of your right foot, rooting your right heel down. Hold here for a few breaths.

3. Rooting the left side of the pelvis down, squeeze the right buttock until it lifts slightly off the mat, right heel still down and right toes still pointed. The left buttock should still be on the ground, and your left foot can turn slightly out. Hold here for a breath or two.

4. On an exhale, draw your belly in and lift your head up to engage your core, holding for another breath or two while still lifting your right buttock and rooting the left side of your pelvis.

5. Lower your head, but continue tightening your right buttock, so it’s still off the floor for a breath or two.

6. Lower your right buttock, but continue pointing your right foot for a breath or two.

7. Relax your right leg.

8. Repeat this sequence on the left side, then alternate sides until you have done it five times on each side, or feel a decrease in your pain.

Don’ts of Yoga Practice

If you have SI dysfunction, it is important to modify your practice to prevent further destabilization and pain.

But do not practice yoga if you are experiencing severe SI pain! Instead, consult with your physician, and perhaps do simple, therapeutic movements like sacral resets if they help to alleviate your pain. Practice asana again only when your symptoms are mild or moderate. Desist from any movements, including the resets, if they cause or exacerbate pain, and check with your doctor.

Here is what not to do during yoga practice when you are regularly dealing with mild or moderate symptoms of SI dysfunction. As symptoms abate and your pelvic stability increases, you will be able to do more, as explained below, under “do’s.”

1. Do not do asymmetric poses.

When you are feeling mild to moderate SI pain, lunges, warrior poses, side bends, side planks, and seated poses ranging from cow face pose to easy seat should be avoided. “They will accentuate the asymmetry,” Reif says.

In particular, avoid twists. “One side of the SI joint often has more mobility than the other,” Reif explains. “Unless practiced conscientiously, as part of a reset, twists will allow the hypermobile—more mobile—side of the SI joint to move first and excessively, compounding the problem.” 

2. Avoid deep forward folds.

Though very small amounts of spinal flexion, such as in a pose with a posterior pelvic tilt like cow, are often fine and even valuable, “large forward folds will place stress on the SI joint,” Reif says.

3. Minimize asymmetries in transitions.

Even if we are conscientious about practicing only symmetrical poses, it is possible for us to move asymmetrically between poses: For instance, we may flip one foot at a time as we move into upward facing dog. Better to lower both knees down and flip both feet at once. To the extent that you are able to, aim to come down to, and get up from, the mat through symmetrical movements—from downward facing dog, lowering both knees, then sitting back on your heels (and vice versa), for example, instead of coming down to the mat from a standing position by lowering one knee at at time.

4. Avoid wide-legged poses.

Even symmetrical poses, like all versions of wide-legged forward fold and goddess, or horseman’s pose, may cause difficulty. “The further your legs are spread, the further the upper portion of the ilium goes inward, potentially compressing the upper part of the SI joint,” Reif explains.

Do’s

When your SI symptoms are mild to moderate, the following are good guidelines for your yoga practice.

1. Practice symmetrical poses.

When adapting a traditional yoga practice for SI dysfunction, focus on poses in which the right and left sides of the body are doing the same thing. Plank, chaturanga, baby cobra, chair pose, and bridge are all examples of bilaterally symmetrical poses that will not strain the SI joints.

2. Practice neutral-spine poses.

Because rounding the back places stress on the SI joint, focus on neutral-spine poses (like mountain pose, chair, and plank) in which you can encourage the spine to lengthen and maintain the natural inward curve of the lower back. “The normal lordotic curve of the lumbar spine—not too rounded and not too arched—is mechanically superior for efficient SI movement,” Reif says.

3. Focus on maintaining a neutral pelvis in neutral-spine poses.

In symmetrical, neutral-spine poses, the pelvis should be relatively square, with the two frontal hip bones level and neither one jutting in front of the other. In addition, in such poses, the pelvis should not be tilted excessively forward or backward: There should be just enough of a forward pelvic tilt for the lower back to curve in gently. Maintain this alignment throughout your practice.

4. Focus on even weight-bearing.

To facilitate pelvic symmetry when you are standing, press down evenly through both feet. If you are sitting, make both sitting bones equally heavy.If you are lying down, make both buttocks evenly heavy.

5. Try pelvic tilts.

When practiced mindfully, all variations of cat and cow—whether you’re lying down, seated, on hands and knees, or in a pose like chair—help you to gain control of the movements of the pelvis, and, according to Reif, “Gaining control of the pelvis gives you a strong core. All movement of your arms and legs starts at your center and is dependent upon strength here.”

6. If you’ve been slouching, be sure to include gentle backbends.

A slumped seated position can wreak havoc on the SI joints and the intervertebral discs above them, according to Reif. Disc problems can increase SI pain in what Reif describes as a domino effect: “If your discs are bulging due to too much flexion with sitting, bending, or lifting, other areas, like the SI joint, may end up having to take more responsibility and stress.” So if you have been rounding your spine throughout your day, placing strain on your intervertebral discs, Reif recommends that you “practice extension [backbending] to reset these discs.”

Throughout your workday, take breaks from sitting to do a standing backbend: With your hands on your hips or lower back, boost your heart toward the ceiling. In your yoga practice, be sure to include backbends like bridge, sphinx, and locust. Always move into backbends slowly and carefully, stopping before you feel any strain in the lower back, and draw the belly in toward the spine on the exhale in these poses to facilitate the core support that stabilizes the SI joint.

7. Do symmetrical, neutral-spine core work.

Core work builds the strength that helps you maintain healthy alignment. Because rounding your back excessively, which happens in sit-ups, is to be avoided, try simple core-strengthening movements while seated on a large exercise ball (e.g., lifting the arms overhead with or without dumbbells, or lifting one leg, then the other), or lie on the floor and practice lifting and lowering both legs at once (knees can be bent) while maintaining the natural lordotic curve in your lower back.

8. Strengthen the hip extensors and external rotators.

The muscles of the buttocks and what yogis tend to call the “side hips” (gluteus maximus and medius, piriformis, superior and inferior gemellus, obturator internus and externus, and quadratus femoris) all contribute to pelvic stability. Cues like “firm the outer hips in” are meant to get you to activate some of those muscles, as will poses like chair, bridge, and locust pose.

9. Do symmetrical hip flexor stretches.

Pelvic asymmetry can cause tightness in the hip flexors (the iliopsoas and the rectus femoris, but also the adductor brevis and longus, the gracilis, pectineus, sartorius, and tensor fasciae latae) and can also be exacerbated by such tightness. To facilitate healthy hip mobility, stretch these muscles with symmetrical poses like bridge and camel.

Do’s … with Caution

As the SI problems resolve themselves and you feel minimal or no pain, you can gradually begin to reintroduce asymmetrical movements and poses, but if any of these aggravate your SI joint, return to the more symmetrical practice. “Always start with symmetric poses, and as tolerance improves, gradually introduce asymmetry,” Reif says. “Life is full of asymmetry, and at some point, we need to be able to tolerate all activities of living.”

1. Introduce asymmetric poses lying down.

Start small and lying down to limit the weight-bearing on your sacrum: Draw one knee in and then the other, or practice thread the needle. (While “leveling” or “squaring” the pelvis is an accurate description of ideal alignment in symmetrical poses, note that when practicing asymmetric poses, the pelvis isn’t exactly “square”: Ideally, the two sides of the pelvis will move slightly with their respective legs. The stabilizing muscles of the pelvis can be further strengthened through a practice that encourages these small movements.)

2. When transitioning into or out of an asymmetrical pose, stabilize one side of the pelvis before moving the opposite leg.

Whether practicing on your back or doing standing poses, try not to let the pelvis wobble or list during transitions, and instead activate the strong muscles (gluteus medius and maximus, hamstrings) that help to create pelvic stability. In other words, keep the left hip firming in as you step the right foot forward, or the left buttock heavy on the ground as you draw the right leg in.

3. Reduce the size of standing poses.

Practicing poses like warrior 1 and 2 with your feet closer together—say, two or three feet apart, instead of four—“places less stress on the sacrum,” according to Reif.

4. Let the pelvis move with the twist.

While thinking of the back hip as an anchor in twists is a good way to intensify the twist for those without SI problems, for those with SI dysfunction, “allowing the forces in a twist to be shared by both hips means the SI joint is under less strain,” Reif says. “If you are twisting to the right in twisting triangle, then do drop your left hip as you turn.”

5. Gradually introduce forward folds.

“A slight forward fold is good to reinforce symmetry,” Reif says. By moving only a few degrees from staff pose into a forward fold and keeping your hands on the earth alongside your hips or thighs, you can practice paying attention to symmetry as you eventually go deeper. Root down evenly through both sitting bones and aim to keep both sides of your waist evenly long as you fold. “Go only as far as you can go while feeling no strain in the lower back or SI joint,” says Reif, who recommends following forward folds with backbends. “These poses reset the lumbar discs, the shock absorbers of the spine,” he says. After practicing a gentle seated forward fold, or even drawing your knees into your chest when you are lying down, counterpose with sphinx, baby cobra, and bridge.

For Daily Life

Reif recommends wearing a sacral belt like the Serola belt throughout your day, especially while you do any of the activities or exercises that seem to aggravate your SI joint. “An SI belt goes around the pelvis itself, about two inches below the waist, where it can help to do some of the stabilizing work your muscles or ligaments may not be doing,” he says.

However, it’s important to put the belt on only after you’ve reset your pelvic alignment. “You must make the correction before you apply the belt; otherwise the belt is holding the misalignment in place,” Reif says.

If part of your SI joint problem stems from a leg-length discrepancy, it may be helpful to place insoles or lifts in the shoe of the shorter leg to minimize the difference.

In addition, Reif suggests making a practice of sitting symmetrically: “Don’t cross your legs or put one foot under the opposite hip. Sit on the edge of your chair, curving the lower back in, or use lumbar support.”

When standing for long periods, do not slouch or lean your weight on one leg. If standing bothers your SI joint “bring one foot to a yoga block, step, or footrest,” Reif says. “When you’re experiencing pain, you can often lessen it by unloading that side. So if the pain is on the right side of your SI joint or lower back, place your right foot up onto some sort of support to take the stress off that side.”

As far as the movements of daily life go, Reif points out that walking is generally easier on the SI joint than jogging and that walking over flat surfaces is easier than walking up hills or stairs. While walking or climbing stairs, keep in mind that “the bigger the asymmetric movement, the greater the shear, or stress, on the SI joint.” So a shorter stride may cause less stress than a longer stride; climbing steps that are only two inches high may be less stressful than climbing steps that are eight inches high.

Lifting heavy objects is something those with SI problems should do with care, cautions Reif: “Step your feet apart to give yourself a wide base of support, bend your knees, and keep the object close to you as you lift it. Hold the object in front of you instead of resting it on one hip. If you need to turn while you are holding something heavy, turn your whole body, not just your spine.”

Avoid sleeping on your stomach, which will probably entail bending one knee and thus placing the pelvis in an asymmetric position. (“You will also be turning your head sharply to one side, which is bad for your neck,” Reif adds.) Instead, to cultivate symmetry even as you sleep, lie on your back with knees bent over a pillow, wedge, or bolster.

Maintaining an awareness of the effects of our positions and movements on the sacrum—throughout our yoga practices, in our daily lives, and even as we sleep—is the keystone to the health of the joint that is itself a keystone, not only to our inner structures, but also to our overall sense of well-being.