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Yoga poses and how it Works Part 3


Sacroiliac Joint Derangement

SACROILIAC JOINT (SI) derangement is perhaps the most under-recognized and untreated cause of low back pain. Some say 15 to 30 percent of individuals with chronic back pain that is not neurological and does not originate in the spine suffer from this problem, but I believe the percentage is higher.1 In the past, a poor understanding of this condition, and the refusal by some medical professionals even to recognize its existence, made it difficult to get a diagnosis and successful treatment. Recently there has been more interest in this condition, partly because it is so painful, and partly because it can lead to other spasm and piriformis syndrome.

Sacroiliac Joint Derangement
Sacroiliac Joint Derangement


You have two sacroiliac joints, one on each side of the midline sacrum a little below your waist. While other major weight-supporting joints—the knees and ankles—are flat and horizontal, the SI joints, which are in line with the kidneys, are vertical. Did nature make a mistake, giving us a central weight-supporting joint that is nearly vertical? If we walked on all fours, the sacroiliac joints would be horizontal and the forces these joints bear would be more evenly distributed. They would be less susceptible to injury. But in humans, who are upright and walk on two legs, their position and shape make them more vulnerable than other joints in the body. The sacroiliac joints support the heavy torso, arms and head, and hold us steady when we move and twist. That’s a big burden for these structures, and because they do so much and bear so much weight, they need very strong ligaments to hold them in place. Yet they must be capable of adaptive movement. As I will explain below, these strong ligaments are two sides of a double-edged sword.

The SI joints are complex, three-dimensional bony junctions that have many irregular depressions and ridges. To function properly, everything must fit together perfectly, like the pieces in a complicated jigsaw puzzle or a key in a lock. The SI joint has a very small range of motion. In fact, its movement is measured in millimeters. When it moves out of alignment, the pain is terrific. Worse, when alignment is faulty, those strong ligaments that usually keep the joints in place play a negative role by holding the joint in misalignment, concentrating all the pressure usually spread across the entire joint on tiny, ill-fitting areas. Realignment is often gradual, despite the joints’ small range of motion.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can produce good results when used early, and because spasm often accompanies derangement, some physicians prescribe a muscle relaxant in the early stages of this condition. Physical therapy, chiropractic, osteopathy and anesthetic injections are sometimes used with greater or lesser success to treat SI joint problems. I have found yoga to be an excellent tool for repositioning the structures and for pain relief.


Diagnosing SI Derangement

If you have SI derangement, X-rays, MRIs and EMGS won’t show any but the most egregious pathology. Still, you may be able to diagnose yourself. The pain is usually restricted to the small, specific area where the joints are, below your waist and about two inches from the midline. The pain can be on one or on both sides, but usually it is more intense on one side than the other. The pain can move from side to side. Unless there are complications, pain doesn’t usually radiate down the leg, but it intensifies when you go from a sitting to a standing position. Exiting the back seat of a car can really hurt.

Diagnosing SI Derangement
Diagnosing SI Derangement

 The grinding or gnawing ache may get worse with certain movements, such as reaching up while standing, bending down while your knees are locked, or getting out of bed in the morning. Twisting to one side is likely to hurt more than twisting to the other side. Neurological symptoms such as weakness, numbness and tingling are absent unless the problem has become chronic (which it often does) and has caused you to make adjustments in the way you walk and stand—adjustments that create additional and possibly neurological problems. SI derangements are considered chronic if they last more than six months. SI derangement can be the result of an injury such as stepping into a pothole, but it can also come from having legs of different lengths, and pregnant women are susceptible.

Pregnancy is a triple whammy because distribution of weight is changed, the placenta secretes the hormone relaxin, which loosens ligaments, and, late in the game, women sleep on their sides. If you have SI derangement, the sooner it is diagnosed and treated the better. The longer one or both sacroiliac joints are out of alignment, the more difficult it is to correct the situation.
Since the nineteenth century, movement and positional abnormalities of the sacroiliac joint have been documented, and treatments have been suggested.3 Yet the condition continues to defy easy diagnosis and cure, and more research is certainly warranted. Nevertheless, I recommend a simple test for SI derangement.

 Lie flat on a table or other hard surface that is off the floor. Move one side of your body and one buttock off the edge. Using a wall or furniture for balance, to prevent a fall, let one leg hang over the edge. If that causes pain below the small of your back, you may have SI derangement.

There are other tests, the best of which requires an experienced person to put their thumbs on your posterior superior iliac spines (PSISs) and assess if they move asymmetrically as you bend forward. If they do, and your legs are the same length, it’s likely a sign of SI derangement. While the pain of SI derangement is always in the lower back, it’s difficult for some people to pinpoint it. Some of my patients think mistakenly that the pain is in their hips.


Yoga for SI Derangement

SI derangement is relieved by yoga for several reasons, not the least of which is that it can be worked on little by little over time. Unlike a dislocation in another part of your body, say in your shoulder, the SI doesn’t just slip back into place. The more usual course is physical therapy which causes the bones to move back into alignment little by little until the pain disappears.

Unlike physical therapy, chiropractic or osteopathy, yoga enables you to work on the problem at home, at your own pace. As you do, you are likely to reduce the tone and spasticity of the muscles around the joint.

This will make them less likely to fix the joint in the wrong position. At the same time, yoga loosens nearby joints, relieving stress on the SI joint. This sharing of movement will help the SI joint itself if it is misaligned, and also help prevent reaggravating it. If the joint is out of alignment, yoga can open it and enable its constituent parts to move. Body awareness is a big benefit of the practice of yoga, and it is important when it comes to relieving pain and preventing it in the future. Yoga is also suitable for pregnant women, who are unable to take medications.

These poses can be done as often as you like, before or after meals, without any danger. In all three of these poses, you may hear a click or feel a pop as the sacrum slips closer to its true position, or you may hear and feel nothing. If the pose succeeds, you will feel better almost instantaneously, whether you’ve heard or felt something or not.


Gomukhasana(Cow Pose)

Benefits and How It Works: This pose separates the lower parts of the pelvic bones from the sides of the sacrum, enabling the sacrum to readjust itself and slip back into its proper position.

Contraindications: Total hip or knee replacement, trochanteric bursitis.

The Pose: Sit on a flat surface, right thigh directly in front of you, knee bent off to the left. Lift your left leg and carry it over to your right, aligning the knees straight in front of you. Raise your right hand over your head and drop the hand down your back. Extend your left hand behind you, and raise it. Clasp your left hand with the right. Straighten and lengthen your back, puff out your chest and gaze straight ahead.

Gomukhasana(Cow Pose)
Gomukhasana(Cow Pose)


VARIATIONS:
1.To make conditions more favorable, submerge yourself in a warm bath for five to ten minutes, and do the leg portion of the pose for a few minutes while you are in the tub. Then stretch out on your back in the bathtub for another five to ten minutes. Submerge to your jawbone.

2.If it’s difficult to align the knees straight in front of you, press your palms against the outsides of the thighs to approximate alignment as best you can. Straighten and lengthen your back, puff out your chest and gaze straight ahead.

3.If you have rotator cuff syndrome or frozen shoulder, do just the leg portion of the pose.


Garudasana(Eagle Pose)

Benefits and How It Works: This pose separates the lower parts of the pelvic bones from the sides of the sacrum, as you tighten the pose by squeezing one ankle against the opposite calf. The sacrum can then readjust itself and fit back into its proper position.

Contraindications: Do not do this pose if you have had a total hip replacement. Do it carefully or not at all if you have had a total knee replacement or a medial or lateral meniscal tear.

The Pose: Sit on a chair, cross your right leg over your left and hook your right ankle behind your left calf. Place your left upper arm in the crook of your bent right elbow; orient your palms vertically, place them together and raise them to eye level. Elongate your spine. The classical version of the pose has you standing, but you can remain seated if getting up is painful. Then repeat the pose with the other leg on top, the other arm giving the support.

Garudasana(Eagle Pose)
Garudasana(Eagle Pose)


VARIATION:

Place your palms on your thighs and push your torso gently upward as you inhale. Even though one thigh is above the other, make the pressure symmetrical. As in Gomukhasana, the legs-only version may be more helpful than the classical pose. By lifting all the structures that press down on the sacrum, this version enables the sacrum and iliac bones to regain equilibrium and return to their anatomical alignment.

Mayurasana(Peacock Pose, a distant variation)

We call this pose “Leaning,” and many of my patients find it extremely helpful.

Benefits and How It Works: Uses gravity to pull down the iliac bones while the sacrum, spine and all higher parts of the body are being held up. This applies some force to separating the sacrum from the iliac bones and lifting up and away. This pose reduces the downward force that gravity exerts on the joint itself, permitting the sacrum to recenter itself between the iliac bones, thus reestablishing proper alignment and movement.

Contraindications: Carpal tunnel syndrome, severe osteoporosis.

The Pose: Stand facing a table or between two chair backs. Place your palms, facing forward, against the edge of the table or on the chairs approximately as far apart as your shoulders. Bend your elbows and lean forward to press your lowest rib against your elbows at the table, or straighten them if you are using two chairs. Transfer some of your weight from your feet via your ribs to your elbows or your shoulders (with the chairs). Relax your abdominal muscles: front, sides and back. Take shallow breaths for 20–30 seconds.

Mayurasana(Peacock Pose, a distant variation)
Mayurasana(Peacock Pose, a distant variation)

VARIATION:
Sit in an armchair, as pictured, palms on the chair arms, forearms parallel to your torso. Lift your torso slightly. It is not necessary to actually raise your thighs off of the chair, just to lessen some of the gravitational force on them. This makes it easier to relax the abdominal muscles. Remember, the abdomen has front, sides and back: paraspinal muscles and quadratus lumborum in the back, latissimus dorsi on the sides. All must be relaxed if this pose is to work. This is not an athletic event; relax all the muscles, get a jelly belly.

In this modified pose you can slant to the right and left, forward and back, and twist to either side. You can therefore relieve the pressure on your sacroiliac joint in all three dimensions, and combine these motions, e.g., slanting to the right, leaning forward and twisting to the left. In this respect, it is the more versatile and useful version of the pose.

Relaxing the abdominal muscles is not easy for everyone. You’ll know you are doing it correctly if you feel some stretching and a dull ache in the lower spine, just above where you feel the broad expanse of the iliac bones. You may have to experiment with this pose, whatever version you use. It may come easily, or it may take you a week or more to find the position that relieves your pain. Once you find it, the pain may recur in a matter of hours, and it may take more attempts to find the right position again. Over time, the solution will come to you faster and last longer.