... my journey from ballerina to triathlete

Wednesday, April 1, 2015

Sacroiliac Joint Dysfunction: My Kryptonite

Triathlons make you feel a little bit like Superman.
Once you make it past your initial stumbling, bumbling, embarrassingly awkward beginnings, nothing makes you feel stronger. Not only does your body become like steel, but your mind becomes unstoppable. You know that you can run for miles and miles without a problem if your car breaks down. Some current at the beach? No biggie, you can swim for hours. Because you've pushed yourself so far beyond where you thought your limits were, you know that you can stay calm and focused in the most difficult of circumstances, and discomfort becomes a non-issue. You feel pain, but it doesn't stop you.

Unfortunately, injuries can.

My experience was sacroiliac (SI) joint issues isn't so much an injury as an ongoing state of being. For as long as I can remember (I'm talking middle school here), long walks have caused a strange, tight pain in my right hip. It was never severe, and I never thought much of it, although once I got up to about 10 miles, it was very noticeable. My mom has bad hips, so I just assumed I'd inherited her problems. When I did the Xterra 21k trail run in December, however, that familiar pain just got worse and worse. By mile 6, it was bad enough that I was stopping to stretch my butt and hip muscles every 5-10 minutes with little relief. By mile 8, it was in both hips. By the end of the race I could barely walk, and for the next week I was absolutely convinced that I had somehow dislocated my hips, because they felt out of place. My gait was an odd, wide waddle, and I noticed that if I support my butt and hip with my hand as I walked, it felt a little better. Clearly, something was off.

Curious and uncomfortable, I went to a doctor, who examined me and suggested that sacroiliac joint problems were causing my symptoms. He sent me to a physical therapist who he considers an expert in this area.

My first PT visit was a revelation. After his initial consultation and examination, he told me that yes, my SI joint was badly out of place and he was going to do a maneuver designed to put it back in. In the strangest feeling I've felt in a while, my entire back and hip clunked into the correct position, and for the first time in over 15 years, I walked with my spine, sacrum, and pelvis correctly aligned. It felt like walking on air. My entire gait felt different -- smooth, light, and painless. I was absolutely in awe that one quick adjustment could give such dramatic improvement.

For about three days I luxuriated in every step I took. Then, the joint slipped back out.

So that you can understand a little more about how this issue happens, take a look at the diagram to the right. What manifested in the form of hip pain was actually a secondary response to my sacrum and ilium (which connects to the leg via the hip joint) being out of alignment, specifically the ilium riding too high on the sacrum. If you're wondering if this may be causing your issues, here are the symptoms I experienced:

- A tight, muscle-soreness-type pain around my hip and radiating into my butt area. At the time I would have identified it as the gluteus maximus muscle, but I have since learned that it is actually the piraformis muscle that is most involved.
- Sciatica-like pain shooting from the bottom of my sacrum down the back of my leg
- Extreme muscle stiffness after long distances on the affected side
- A feeling of the hip being dislocated or out of place
- Modified gate, particularly having trouble bringing the affected leg directly underneath the hip, instead swinging it slightly to the side with each step.

If you are having pain in your hip that radiates to the front rather than to the back, the cause is more likely hip dysplasia, a very different problem with very different treatment.

Unfortunately for me, my SI joints (yes, both) have been out of place for so long that the ligaments have stretched to the point that they cannot seem to hold it in place after an adjustment. Even non-impact movement causes it to go out again. I have now been in physical therapy for three months, and every week my wonderful, talented, and patient therapist (thank you John at BodyPro!) cla-clunks one or both back into place, only to have them slip out within days, despite the exercises I've been doing to strengthen the surrounding muscles. The next step for me, due to the ligament issue, is an SI Belt, which is worn tightly around the sacrum at all times, holding the joints in place long enough that the ligaments can heal and tighten.

What the exercises have done, however, is lengthen the amount of time I can run before the pain forces me to walk. When I began PT in January after Xterra, I could only last 3 miles. I am now up to about 7. The joint/s can go out of place, but using the muscles I'm strengthening I can somehow hold it close enough to avoid serious pain. I am hoping that after Honu, the half-Ironman in May, I can take a break from running long enough to let the SI belt do its job. In the meantime, I will continue to work on the supporting muscles.
Clamshell

Exercises to strengthen and support the SI joint:

1. Clamshells: Laying on your side, place a circular (or tied) resistance band around your legs, just above the knee. Stack your legs and bend your knees so that your thighs and lower legs are at a 90 degree angle. Then, keeping your hip perfectly still and your feet together, lift the top knee. I do three sets of ten daily.

2. Side stepping: standing up, place a circular or tied resistance band around your legs, just below the knee. Bring your feet to shoulder width apart, and bend your knees. Keeping your upper body and hips as even and still as possible, take a step out to the side with your right foot, then take a step (in the same direction) to return to your original position with your left foot. I do this across the room and back, three times, several sets per day if possible.

3. Off-box lunges: standing on a 6-inch platform, get a set of very light hand weights, like 1-3 pounds. Extend one leg as far behind you as you can reach to touch the floor with your toe while bending your standing leg and reaching your arms in front of you with the weights, one in each hand. Return to standing position but keep all your weight on the standing leg. Do the same thing, but this time extend the working leg at a 45 degree angle between the back and side, then return to standing. I do 15 sets on each side.

4. Squats: Stand in front of a box that is comfortable to sit on with a fairly large dumbbell placed evenly between your feet, just in front of them. Your feet should be just wider than shoulder-width. Keeping your back as straight as possible, lower yourself into a squat until your butt touches the box and immediately pick up the dumbbell. Do not allow yourself to rest on box, but immediately push back up to a standing position still holding the dumbbell, making sure to keep your back upright. Lower back down, touch your butt to the box and set down the weight, then push up to standing. Repeat this. I do 10-15 reps, 3 sets, with a 35-lb dumbbell.

5. Planks: Apparently, the deep abdominal muscles work in conjunction with the booty muscles, so it's beneficial to work on those too. Make sure to keep your back straight and don't let your hips sag. Most people know how to do a plank, or so they think. What I wasn't aware of, however, was that you are supposed to keep your belly button pulled in as far as possible and your glutes fully contracted during the plank. This was a total game-changer for me, making them a million times harder. They make me feel like I'm dying. In theory, I do three 60-second planks. In reality, I rarely make it that far.

There are also a couple of stretches and an adjustment that you can do at home to keep yourself in alignment, although I can tell you from experience that the home adjustment is more of a "help keep it there" kind of thing, rather than a "it's totally out, fix it" solution.

The self-adjustment goes like this:
You will need a bar, stick, or thick dowel at least three feet long. I use a dowel I bought for $5 from the hardware store, the largest diameter available. Lay on your back, and bring your knees up so that they are bent at a 90 degree angle. Your thighs should be perpendicular to the floor, your shins should be parallel to the floor. There should be about 6 inches between your knees. Weave the dowel through your bent knees -- you want it to to be touching the back of your leg just above the bent knee on the side that is affected, and resting against the front of your leg just above the knee on the opposite side. Hold one side with your hand to balance it.
Simultaneously, contract your hamstring on your affected side and your quad muscle on the opposite side. With your affected leg, push the bar toward your toes as hard as you can. At the same time, push the bar toward your face with the opposite leg as hard as you can. Make sure to hold the bar steady with your hand so it doesn't actually move. Push for 10 seconds, then relax your muscles. Do it three times.
I can't say I fully understand how this works, but it's something about the opposing muscles that pulls one side of the pelvis downward toward the correct position. I find that it makes a definite improvement in my symptoms, at least for a while.

Another issue that comes along with SI joint issues, due to the misalignment, is muscle stiffness, which then in turn continues to pull the joint out of place. The stretches that I do are a piraformis stretch in which I lay on my back and draw the affected leg, knee bent, toward my chest as far as I can. I pull the calf area toward my body and push the knee outward to get the most of the stretch. The other good one is for the front of the hip flexor, in which I stand facing a couch or chair with the affected leg on the ground, slightly pigeon-toed, and the opposite foot up on the chair with the foot directly in front of the foot of the affected leg. Then, keeping my butt as "tucked under" and in line with my leg as possible, a push my hips toward the chair.

Between the stretches and the self-adjustment, my symptoms stay pretty well under control.

More than anything else, if you are having symptoms similar to what I was experiencing, GO TO A DOCTOR! Don't try to tough it out, because for most people, it's something that can be fixed very easily! I am seeing consistent improvement and hoping that eventually I'll be good as new. For now I guess I have to settle for being Clark Kent...

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