Estimated reading time: 5 minutesI’ve lost count of the number of clients who describe sacroiliac joint or SI joint pain with their hypermobility. This pain can be felt in the lower back, as deep groin pain, in the glutes, and into the leg.
The SI joint stabilization class in The Zebra Club is one of the most popular videos members turn to with this pain. It is so common in the hypermobile population.
We’re often told the SI joint is very stable and cannot move or subluxate (this is probably by the same people who tell us ribs cannot subluxate either). But that’s not always the case. In fact, some clients have undergone surgery to fuse their SI joint because their surgeons could not believe how much the joint was moving.
These are obviously more extreme cases, and surgery would always be a final option. There are many interventions and stabilization techniques to try that can improve exercise outcomes and reduce pain in daily life. We will explore this in greater detail in this article.
What is the SI Joint?
The sacroiliac joint is the joint between the sacrum (bone bottom of the spine above the coccyx) and the ilium (the rear bone of the pelvis). There are two joints, one on each side of the sacrum. They connect the spine to the pelvis and transfer weight from the upper body to the legs (1).
BodyParts3D is made by DBCLS, CC BY-SA 2.1 JP <https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en>, via Wikimedia Commons
There are no muscles that produce active movement of the joint – though the muscles that surround them can still impact their movement (2). The muscles that surround it are some of the most powerful muscles, like the erector spinae, psoas, abdominal obliques, glutes, hamstrings, and pelvic floor muscles (levator ani and coccygeus). These two pelvic floor muscles also help stabilize the SI (2).
Several ligaments run across the joint that provide support and are supposed to limit movement (2). One study showed that a decrease in the stiffness of ligaments results in an increase in SI motion (2). In general, women and AFAB also have more mobility in the SI due to differences in the structure of the pelvis, resulting in more pain (2).
Reasons for pain in the SI can include (1,2):
- Ligament tension
- Hypomobility (reduced mobility)
- Hypermobility
- Compression or Shear forces – injuries from things like abrupt rotation and loading like falling directly on the bum or collisions (sports,driving)
- Fractures
- Prior medical procedures – for example lumbar fusion
- Soft tissue injuries
- Inflammation
- Increase in ligament laxity during pregnancy
- Inflammatory bowel disease
- Gait abnormalities
- Leg length discrepancy
- Osteoarthritis
- Scoliosis
- Excessive exercise
The impact of hypermobility on this joint
Low back pain affects around 30% of the general population, and it is estimated that 20-40% of that is from sacroiliac joint and pelvic girdle pain (3). One suggested cause for this is ligament laxity that can be acquired – like in pregnancy, or a result of systemic connective tissue disorder like EDS (3).
Ligament laxity can contribute to the loss of stabilization and transfer of the load through the joint. This joint is stabilized by neuromuscular control of the muscles around the joint and the ligaments and fascia (3).
Weak or overactive muscles can alter the ligament tension. SIJ dysfunction is reported to come along with altered pelvic movement patterns and asymmetry in the muscles and ligaments. Particularly in hypermobility, this altered repetitive movement can cause microtrauma, acute pain, inflammation, and increased joint instability (3,4).
Subluxation of the SI joint
Subluxation at the SI joint happens when the joint between the sacrum and the ilium of the pelvis is slightly misaligned or unstable. There are several reasons why a subluxation may happen. With hypermobility and EDS, the ligaments supporting the SI joint may experience laxity – just as they could in any other joint. This allows the joint to move.
Hormonal changes such as pregnancy can also loosen the ligaments and destabilize the joint. When I was pregnant with my first son, I suffered from the other side of the pelvis with pubic symphysis instability. This caused a deep ache in my lower abdomen and groin.
I had no idea I had EDS back then. Sometimes the pain was so bad I could not walk. I would often just crouch down on the floor in the middle of the supermarket when out shopping because the pain could come on suddenly.
Other issues, not necessarily related to hypermobility that could cause SI joint issues are trauma or injury like a fall on the pelvis could disrupt the alignment. Car accidents with high-force impact could also contribute to SI joint subluxation.
As a movement therapist, I am interested in muscle imbalances and how these may impact movement and instability. Tight muscles around the pelvis like glutes and hip flexors could cause uneven forces to pass through the SI joint – and the pelvic floor.
A tight pelvic floor has the power to pull on the SI joint, causing pain and issues (5). This is why I always talk about the pelvis needing to be free and not bound down by tension. Overdoing so-called core exercises is not going to help SI joint pain.
Treatments of SI pain in EDS
SI pain can be complex – there is a lot of variability in the biomechanical issue contributing to each person’s pain (6). There are multiple strategies you can use to address this pain.
Some strategies recommended in the literature include (6):
- Pain reduction – speak with your provider about appropriate over-the-counter medications for acute pain, regular icing is good during acute stages
- Rest from “pain-provoking activity”
- Therapeutic exercise (described below) – this can help address the underlying problem
- Physical or physiotherapy
- Manual therapy – This is best coming from an EDS-aware therapist who is aware of the gentle approach that is often needed with connective tissue disorders.
- Many report that SI joint belts can help – it may be worth having a physical therapist or physiotherapist make sure that you have it on effectively
- Shoe orthotics if there is an anatomical leg length discrepancy. Podiatrist Sophie Roberts explained to members of The Zebra Club in her presentation that the feet can impact what is going on all the way up the chain.
- Prolotherapy may help (7)
- There are other treatment options available that you can discuss with your providers.
Exercises for the SI Joint
There are a number of exercises that can help relieve SI joint pain, improve mobility around the pelvis, and reduce muscle imbalances. As always, “go low and go slow”.
Avoid any exercises that increase current pain levels. If your pain persists, it is always a good idea to consult with a physical therapist or movement therapist who can help check your movements.
I often talk to my clients about keeping the pelvis in one piece when dealing with SI joint issues. For example, long lever side-lying work is not generally suitable for SI joint stabilization. I will often use both a band and a ball to fully support the pelvis during exercise.
- Pelvic tilts are a great way to safely start to release tension from around the pelvis. Done slowly, it can build control and activate those deep stabilizing pelvic muscles.
- Bridge with the band and the ball to help build leg and glute strength whilst keeping the pelvis supported. We are looking for a floating pelvis – not pushing and forcing.
- CAT – I tend to hold the ball between the legs. This exercise promotes mobility in the spine and pelvis.
- Child’s Pose is a lovely stretch for the lower back and hips
- Natural pelvic floor and deep abdominal muscle activation with a ball between the knees. Notice the belly naturally rises and falls with the breath. The exhale creates a natural contraction of these muscles. No need to brace and hold.
If you’re looking for more: The Zebra Club members can find more classes in the Hips and Pelvis Program. You can also try this video on stabilizing the Pelvis.
FAQ:
Can SI joint pain be mistaken for hip pain?
Si joint can be mistaken for hip pain, in fact hip tendonitis and hip fracture are part of the differential diagnosis (things to rule out). The pain can be felt in the same are – the glutes, low back and groin)
Can hypermobility cause SI joint pain?
Yes, when hypermobility leads to laxity of the ligaments that stabilize the SI joint, this can cause SI pain.
Literature Review by Catherine Nation
Work Cited
- Raj, et al. (2023) Sacroiliac Joint Pain. StatPearls [Internet]. NIH: National Library of Medicine
- Kiapour, et al. (2020) Biomechanics of the Sacroiliac Joint: Anatomy, Function, Biomechanics, Sexual Dimorphism, and Causes of Pain. International Journal of Spine Surgery.
- Enix & Mayer (2019) Sacroiliac Joint Hypermobility Biomechanics and What it Means for Health Care Providers and Patients. Physical Medicine and Rehabilitation Journal.
- Ali, et al. (2020) Pelvic Girdle Pain, Hypermobility Spectrum Disorder and Hypermobility-Type Ehlers-Danlos Syndrome: A Narrative Literature Review. Journal of Clinical Medicine.
- Waldman, et al. (2024) Sacroiliac joint dysfunction: anatomy, pathophysiology, differential diagnosis, and treatment approaches. Skeletal Radiology.
- Prather, et al (2020) Nonoperative Treatment Options for Patients With Sacroiliac Joint Pain. International Journal of Spine Surgery.
- Ericson & Wolman (2017) Orthopaedic Management of the Ehlers–Danlos Syndrome. American Journal of Medical Genetics Part C (Seminars in Medical Genetics).
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