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Seeing the Sacroiliac Joint

Low back pain is a popular subject. This might be the 700th article you have read about it. It is a highly prolific topic when it comes to bodywork and, may I add, widely written about. It is, by far, one of the most common complaints we hear from clients standing in our office, giving neck pain a run for the money. And there is a veritable downpour of things that could be the source of the trouble. From the complexity of the lumbar spine to the roots of the sciatic nerve to the density of the QL and the expansiveness of the thoracolumbar aponeurosis, one can see how things might get perplexing in this anatomical abyss - hence the plethora of commentaries on the subject. Perhaps, though, the success you seek comes from not learning the specifics but, instead, from listening to the story.

Henry David Thoreau wrote, “The question is not what you look at, but what you see.” In the field of massage therapy, we look at the client. We look at the signs and symptoms. We look at the anatomy. We look at the parts and the parts of the parts. We look deep into the details. We look and we read and we analyze. And still, the questions continue to haunt us. Whether or not we used the right technique on the right muscle and for the right amount of time eats at us long after the client has left and often invades our lives away from our work. 

If we were to take Thoreau’s contemplations to task, we ask ourselves then, what is it that we are seeing? Gazing through the details and the data and the complied components that make up this moment, what is it that we are perceiving? Through the herniated discs and spinal stenoses and osteoarthritises and scolioses, can we still see the client? Are we able to see beyond our own narration? Shifting away from the struggle of statistics and leaning towards perceiving a complete person illuminates a whole new approach.

When we study low back pain in massage school, we learn about some of the more common ailments. Most of us have not had the luxury of researching thousands of client cases in order to understand the variants of sciatic nerve compressions or exploring hundreds of cadavers in an effort to analyze altering scoliosis. So we trust what we are taught in school. Having not actually witnessed a raw Quadratus Lumborum in action in a living human, we believe the statistics that we read in our texts. Every once in a while, if luck (good or bad depending on our perception) would have it, we have first hand experience with a particular dysfunction, which deepens our knowledge.  And we proceed from there. Because if we didn’t, how in the world would we work?

Even if we were able to afford the time to tinker and toil, would we still be able to see the issue? Research and science based testing is typically driven towards a specific answer. If the goal is to find the role of past injuries on osteoarthritis, then what is derived is the data that highlights this information. Sometimes we even do this within our own work. A client comes in with a complaint of low back pain that is shooting down the hip and into the leg and we immediately think sciatic nerve. After all, people tend to see a truth that is relevant to their own reality. 

The point is, there is no way to know all the things. There are simply too many things. Even if you are not trying to be the massage therapist who can list all the chakras and meridians as well as all the origins and insertions, there are just too many things. This is where seeing veers away from looking. To see an entire tree as opposed to its leaves and branches - or to perceive a whole painting and not just the type of paint and brush strokes - this is the point. When you see this client’s low back pain, what is it that she is dealing with? What is she telling you? Are you listening to her without ascribing what you might already know? And without having all the wisdom of the universe, how can you help her?

Let’s take a look at the Sacroiliac Joint, for example. 

  1. To start off with, there are 2 of them, one on either side of the sacrum. 

  2. It is the attachment site of the appendicular bones of the leg to the axial skeleton - meaning it is where the limbs connect to the core. 

  3. It is considered a synovial joint which means is is freely moving but, really, what defines it as synovial is the joint capsule that is filled with synovial fluid and not the freedom of movement.

  4. It is also considered an amphiarthrotic joint which means it moves but only a little. 

  5. It is essentially held tightly together by 5 ligaments that pull tighter than the stitches on a baseball.

  6. Those ligaments continue on to wind up the spine into the Supraspinous Ligament and down the leg into the superior tendon of the Hamstrings.

  7. Its main functions are weight bearing and stability. 

  8. Its main movements are referred to as nutation and counternutation which are basically cousins to the anterior and posterior pelvic tilt you might be better aquatinted with. 

  9. There are 35 muscles that attach to the sacrum, influencing what this joint does.

  10. And low back pain originates from the SI joint in as many as 25% of the reported cases.

There is clearly a lot to know here. And this list does not include the nerves and blood vessels and other neighboring important anatomical elements. So what works when a client presents with SI joint pain and we don’t have a scalpel, a clamp, and all the time in the world on hand?

Start with this. Ask more questions. Did she mention that the pain feels sharp? Find out what that means to her. Did she note that she can feel it radiate slightly upwards? Have her point to where it goes. Did she talk about how she sleeps or what she does in a typical day? Ask her more about those things. And then listen. Listen to her answer with no expectations of what she might say. Some of my most successful stories of helping clients through pain comes distinctly from how well I listened to their story.

Once you have your client on the table, there are a number of tests that we can utilize to extract even more information. One of my favorites, though, is the distraction test. With the client supine, legs flat on the table, hook one palm into the right ASIS and one palm into the left. Applying lateral pressure onto these two points softens the articulation of ilium with the sacrum. Check in with your client to see if this relieves any low back pain. This is one of the better indicators that there is an actual issue in the SI Joint.

The thing I like about this test, assuming the client has first seen their doctor and ruled out any more serious issues, is that it reveals a tension across the sacrum into its 2 connections with the pelvis. The more common activities that contribute to pain in this area, like driving or sitting at a computer for long stretches of time, lead to a tightening of the muscles and connective tissues that live here. And if we know that tension exists, we know we can help. 

From here, your work should be exploratory to reveal the level and direction of the tension. More often than not, there are multiple muscles playing a tug of war on this joint. The QL could be locked and not allowing the pelvis to fall down away from the ribs. The Piriformis could be yanking at the sacrum creating an asymmetry. And let’s not forget about the anterior aspect. The Psoas could be gripping onto its lumbar and femoral attachments, not leaving much room for the SI joint to even breathe. 

Any of these are possible. Help your client to understand this simple fact. After all, bodywork is holistic work, which means that we have the element of time on our side. We are not here to numb the pain. We are here to understand it and get to the root of it. We can, eventually, know a lot of the things there are to know. But first, we must learn to see. 


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