Pain Around the Sacrum: Causes and How to Treat It

You're listening to the Restoring Human Movement podcast. Thanks for joining the movement, movement. I'm Sebastian Gonzales, show curator and head clinician at Performance Play Sports Care in Southern California. This show is for active people, those who refuse to let pain and injury get in the way of their life and how they want to live it. Trails and trips, fields and courts, whatever moves you. Each episode features rotating host, expert guest, and real clinical conversations that help you move better and trust your body again. Here we go. This one is going to be on what causes sacral pain and how to treat it.

I know that Cynthia had a question specifically about a certain type of dance, Latin dancers, since there is a lot of ballet references out there. I will go into this podcast about some possible things that it could be, as well as irrational about how you guys can look at it when you're going to see your healthcare practitioner and how to talk to them about what you may have going on. Sacral pain, the type of pain I'm talking about is deep into the middle of the low, low back, if you will. It's not in the low back. If you put your hands on the low back, like around your hips, like you're mad, into the kidney region, it's much lower than that.

Down into the SI joints, which is the bumps or divots in people's backs. It's even below that. And it's way down in the middle, kind of just as the crease starts to form. That's what I'm talking about. Now, sometimes people have pain there. It feels like an ache. It's sometimes going into the tailbone region. A lot of times these people also have problems into the upper glute region, just up into the sides, kind of where the, it feels like it's a real rubbery, stiff region. That's not in the low back. It's just in the upper, upper hip. And also, quite honestly, a lot of times people feel pain in the front of their hip too.

Sometimes into the adductor region. Sometimes they'll trigger points and sensitivity up there as well. A lot of people have this issue when they're walking, lifting, and again, yes, simply we do have it sometimes with dance. I'd venture to say that dancers of the bendy types of spines tend to have this quite a bit, and I'll tell you the reasons why later. But I think the principles, at least, of what's going on with ballet and Latin dance, I think they would carry over. I'm not going to say they're always, it's not going to be super unique to each, but I do think that the principles will carry over mainly because of the bend and the movement that happens with the pelvis and the spine when you're doing either one of them.

Now, I'll first start you off with, I always like to figure out what you guys are looking at and what you might encounter as you're going and searching things like sacral pain. Because I have no idea what you guys have really gone through and read until I look, I go into Google like everybody else does and I check it out. And when I Googled sacral pain, the first thing I got was sacroiliitis. And this is what it says. It says it's a painful condition affecting one or both SI joints or sacroiliac joints. These joints sit where the lower spine and pelvis meet. Sacroiliitis can cause pain and stiffness in the buttocks and lower back region.

Pain may travel down one or both legs, standing or sitting for a long period of time, or climbing stairs may make this worse. Sacroiliitis can be hard to diagnose and it can be mistaken for other types of back pain. Here's the thing though with this is, this is like an inflammatory, a lot of times this is an inflammatory problem. It's a, you almost got to see a rheumatologist for it. The reason why I wanted to highlight this to everybody is because if you're going through and Googling and you're talking about sacral pain, you're going to get a lot of mentions of sacroiliitis and also the next one, which we'll talk about, which is SI joint pain, which is sacroiliac joint pain, which is not an itis.

Sacroiliitis is a itis of the sacroiliac joint, which is again, probably an arthritide, inflammatory arthritide, which is something that you may need to possibly even be a medication for. And so, if you are experiencing sacroiliitis and you've been diagnosed that, this might not be the right podcast for you. However, if you have the sacral pain I mentioned earlier, then possibly sacroiliitis is not it. And Dr. Google is just feeding you information that is not really relevant to you. The next thing that you'll get if you search, and this is the second link, was called sacroiliac joint pain. Here's what it says.

Sacroiliac joint pain can be difficult to diagnose as other conditions can cause similar symptoms. How about that? Like, that's the crazy thing is like a lot of times people will be confused about what's going on because there's so many things that mimic each other. And that's okay, that's up to your healthcare provider to help you with. That's their job to cipher out and decide what's the relevant information and what you guys need to chase and treat. Sacroiliac joint pain is most commonly felt in the low back and buttocks region and can refer to the leg and the thigh. Sounds just like the other one, right?

If numbness and tingling or weakness is present, an alternative diagnosis should be considered. I do agree with that part. But if you guys are listening to this and you have sacral pain and you have numbness, tingling down the leg and you are having weakness of the leg, I'm not going to say there can't be something that helps you. We see a lot of people like this at Performance Place, but it's not just a purely sacral problem or an SI joint problem or a tight muscle. Like, there's another part of this. A lot of times that numbness, tingling, weakness, burning, stabbing, shooting, electrical shock, prickliness, those are usually more nerve qualifications or quality that people feel when there's more nerve-related problems.

Not that the nerve problem can't be solved, but it's just another thing. It's not sacral. It's not SI joint pain as we're talking about here. Proiliac pain can be aggravated with prolonged sitting or standing on one leg, stair climbing, going from one seat to another and with running. Potential causes could be arthritides, traumatic injury, pregnancy, postpartum, which is after you get birth, systemic inflammatory conditions, infections, and so on. And so, look at all this stuff that you guys got to decipher. Crazy, right? Now, let's actually go backwards again and consider the reasons why, you know, like you get onto these things like Google and YouTube and you start looking things up.

You're like, oh, I got sacroiliac joint pain now. Well, no, you had sacral pain. And so, we're going to go back into the considerations of what could be bothering you, creating your issues if you have sacral pain and some of the other signs and symptoms to go along with it. So, we're going to consider the musculoskeletal possibilities. As I like to typically say, there's generally four basic diagnostic categories. We did on YouTube, we have a webinar that we actually created where it goes over three basic diagnostic categories. I've added another one since then. But there's basically four things that will create most people's problems.

And it's easy to think of it like this way because most of the time people only think of one category and then they're wondering why things like their MRIs and x-rays and ultrasounds are all negative. It's because there's these other categories. And the other categories are super, super common, but it's just like, oh, I just, I can't, I just, I'm honing in on just that one sacrum region and I just can't think outside of it, you know. So, I'm going to try to expand your mind a little bit today and what you have is to be determined, but I think these are the four basic categories you can consider.

Number one is you have inside the joint or in this case, it's, if we're not talking about actually inside the joint, we're talking about inside the, let's just say the actual deeper structures, we'll say, because we're talking about the actual sacrum. But if there were on one side or another, and then that would be the SI joint. So, there's a joint there. So, there's inside the joint, there's outside the joint, referring to the joint, which can be organ, somatic or structural based or more nerve based. I'll talk about all these in turn. And then there's the too much too soon type of phenomena, which can go along with degrading of tissues because either there's a relevant energy system issue, like you're not eating enough and then your sacrum becomes fractured.

You know, without trauma, perhaps there's a degrade of tendon or muscle because there's not enough energy to supply the demand of the tissue or it's just too much too soon, like you went from nothing to everything. And again, I'll talk about all these in turn here. Now, for a quick pause before we keep going. Hey, everybody, it's Sebastian. If what we've been describing in the show so far sounds very familiar and you've been dealing with some ache, pain or stiffness that keeps coming back no matter what you do and no matter what you try, we're offering a free discovery call today where we brainstorm with you what has been working for you, what hasn't been working, and we also try to unravel what is a critical part of the puzzle that you've actually been missing that's keeping you from full recovery and getting back to full activity.

The links in the description, it only takes a few minutes to fill out the form. Okay, back to the show. Now, inside joint, I think mainly the one we got to consider there is going to be the sacroiliac or SI joints. The sacroiliac joints generally link the pelvis and the lower spine together. There's the ring. As you imagine on the skeleton, there's the ring where the pelvis is. Consider there's one side, there's two sides, and then there's like the keystone in the middle, which is the sacrum. The sacrum is the bottom part of basically the spinal column. And between those, the pelvis and the sacrum is the sacroiliac joint.

All right, it's basically a combination of the two bones that connect. There's two of them, and below the sacrum is going to be the tailbone, and the whole ring is called the pelvis. And generally, the SI joints support the weight of the upper body when standing. Like, if you think about it, like imagine a skeleton who stands on one leg. Basically, that single leg does all the support, and it has to link that your ability to support through one single, well, I don't want to say one single joint, but the SI joint is one major factor in there. It links the lower leg to the spine, and so it allows you to stand.

And if that area is having issues, or it's inflamed, like the inflammatory component I mentioned earlier, or it's sloppy, or it's sprained, or fractured, then we have kind of a problem. Like, it's going to be very hard to stand on one leg. This is why when people have SI joint problems, typically, by the way, it's usually one, it's not two. If it's two, I would think more inflammatory-based. The rheumatologist might be a good starting point. But if there's one, and there's no trauma, normally, it's going to be this person has some type of history where they do a lot of split-legged activities, lots of split squats, perhaps lots of running.

There's split-legged activities, even skating, things of that nature. Normally, they're not going to be up-down athletes. They're not going to be general population people who are not super physically active. I think over the course of my years in practice, I've been 13 at this point of doing this podcast, I think 13 or 14, I've only found one SI joint, sprain, ever. I think I believe in the past I said I found more, but at the same time, I think I was wrong. Because if you bend over and touch your toes, or you bend backwards, and your feet are just like sitting on a line together, like they're just in a normal stance position, and you have the problem, then this is probably not your SI joint.

If you lean from side to side, or have increased pain with sitting or standing, it's probably not your SI joint, it's probably something else, okay? And I'll cover some of those possibilities in here today. Now, if it only hurts to lunge, or something like a single leg stance, then maybe we're looking at something different. However, as I tell some of the viewers on our YouTube channel, there is not one single test, which is a smoking gun, that's me blowing out the smoking gun, for diagnosing a problem. Like, you can't just say, like, oh, I have this image is positive, it's SI joint, I'm sure of it.

Usually there's more, it has to match. At the bottom of every image, every MRI, every x-ray, every ultrasound, it'll say must be clinically correlated. Meaning your history and the exam must match. And the same note, there's not one single orthopedic test that can smoke and gun. Like, it's usually a cluster of tests that would give us better information. Now, we have outside joint. For this, I thought I would play the game of tendons, ligaments, as well as muscles that are coming from the region. First, I googled what muscles cross the SI joint, but I realized that this was probably not super specific, because this is taking into account the things that are in the front part of the body, too, and to go through the body.

I mentioned the lower back muscles, which do cross the SI joint, but it was talked about some of the core musculature, the rectus abdominis. Technically, they do cross. The iliopsoas, the main hip flexor, the psoas, they do cross. But they're not directly attaching to, necessarily, or kind of in the region of pain. Because we're talking about around the joint pain, we're talking about something like your elbow hurts, and it's your biceps tendon that crosses. We're not talking about, like, something on a different part of the body, or the complete opposite side of the body. It's normally something that generally is in a very close proximity, or we call it adjacent.

It's just next to it. And so, with that being said, there are some ligaments in the sacrum region that connect bones to other bones. So, ligaments connect bones to other bones. Tendons connect muscles to bones, and muscles are, you know what muscles are. Most people know what muscles are. So, here's some of the big players with ligaments in the region. There's the sacroiliac ligaments. There's the sacro tuberous ligaments. And there's the sacro spinous ligaments. Because when we're talking about ligaments, they can go really very badly, very quickly, because it's so, it becomes so semantic-y. I'm not going to bother with talking about these ones in detail.

But I know with some disciplines of soft tissue work, a lot of treatment is supplied to the sacro tuberous ligaments. I think there's a whole fundamental of chiropractic, which is based upon that. I think it's Logan Basics. Active release technique, a soft tissue methodology has some protocols for these ligaments as well. And I think the belief is you hold the ligament and you tension it to decrease the amount of tension or referral pattern possibly too. And so, they're very stiff. Like, ligaments are very stiff. I think it's an, I personally, my belief with ligaments is that you're not going to remove any scar tissue from the region.

You're not going to doing that stuff. The soft tissues all remodel. Bones remodel. Muscles, tendons, ligaments all remodel. And they remodel over time, but they usually remodel based upon the demand you put upon them. Meaning that if you don't do anything for 20 years, then your ligaments will probably weaken. Same thing with the musculature, bones. A lot of people are familiar with osteoporosis. That's basically, for most people, it's the decrease of bone density because of less activity. Also, there's other factors like menopausal and hormones and so on. But generally speaking, like the recommendation is do some weight-bearing activity.

And because it helps emphasize the area to grow. And so, I know it's a tangent topic, but I think if we're talking about ligaments in the area, you can do soft tissue work to them. And it may feel good. It may reduce pain pretty well. However, if you're thinking about actually changing the structure of it, it's going to come down to adaptation. It's going to take a little bit of time. Now, muscles that actually attach to the sacrum, there are a few. And there's some that are on the front of the sacrum, which you won't be able to physically touch where they attach because they're inside the protective layer of the sacrum.

Like you're not going to stick your hand around and into the side of that part of the sacrum. However, you can touch other parts of the muscle. The theory is that these muscles can refer and have like a myofascial trigger point or some type of referred pattern of the muscle. There's a great book by Simmons and Travell. I see it actually over here. Let me see it real quick. I can't. It's a red book. I need to I can't reach over there because my podcast mic won't go that far. But Simons or Simmons and Travell wrote a couple books back in the day. There's a few volumes that are pretty standard in deep tissue work, disciplines, as well as chiropractic, physical therapy.

And so a lot of those pictures are actually found online. When you look up piriformis referred pain, you'll see all these little dots on some line drawings of the human body. These are all from Simmons and Travell. And so the piriformis is one that goes to the front of the sacrum. The coccygeus, which is one of the pelvic floor muscles. So for all of you who say, well, I got pelvic floor issues too. Someone told me I had a pelvic floor dysfunction. Well, this is probably part of that whole sacrum pelvis issue that's going on there. And then there's the iliacus, which is one of the, it's the muscle on the front of the, of the, of the Allah of the sacrum.

Would you like to work with us here at Performance Place? Perhaps pick our brain about your situation. You can. For a limited time, we're offering a $29 special. That's 30 minutes to discuss with us any questions or concerns you may have about your current situation. We call this the discovery session. You get to learn if you want to work with us and we get to learn if we should work with you with your specific case. Contact us at info at p2sportscare.com to learn more. Now on the backside there, or in the posterior element, the side that you can actually touch, there are other muscles that will intersect into that region.

The biggest muscle is the gluteus maximus. There's also some very robust muscles from the lumbar spine, which the multifidus intersect into there, as well as the spinal rector muscles. Remember, the sacrum is part, basically, of the spine. It's just the lower, like the keystone. It's the triangle part of the spine. So, technically, we can say that there can be referred pain from any of these muscles that attach into there, and it can create something like sacral pain. And you'll probably see it all throughout myofascial trigger points of the sacrum. And so, the next category is going to be referred pain.

Referred pain is one that we see a lot of, and I don't know if it's because a lot of our material that we put out, such as the podcast and YouTube channel, a lot of them describe cases that we see. And a lot of cases we do see have a lot of referred patterns, which is, it's a really good scenario. Even myofascial referred pain, like muscle tendant referred pain, is a good scenario. So, we see a lot of them. So, I generally say that, man, there's a lot of people that we see that have referred pain to the sacrum, meaning there's nothing wrong with the sacrum itself. There's nothing wrong with the SI joint.

There's nothing really wrong with the ligaments in the area. But it's usually referred from parts of the spine or other adjoining soft tissues, such as I just mentioned earlier. There are obviously things like organs, cancers, and other bad stuff that can refer there. I don't mean to scare anybody, but at the same time, I believe we should all be adults about our healthcare. And if you want to feel good that you're doing the right thing, you need to be examined by someone who knows how to examine you. Typically, these are found in a history-taking process. It's not like you need to have a big image done or go to a specialist, specialist, specialist to reel these things out.

Generally, every healthcare provider who is worth their salt will usually take a history that will screen some of these things out. Some of the things that we're referring to the region that we see a lot of are the facet joints of the lumbar spine. These are the little tiny little muscles that are on each level of the spine as one level of the spine connects to the other level of spine. It's on the posterior element, which is the backside of the spine. If you put your hand on your spine, you can almost feel them, although they're protected by muscles. You'll feel the bony areas, which are the kind of the tips of the house of the spine.

And these facet joints would pretty much be like the fascia border where the roof is almost meeting the sides of the house. We can also have myofascial trigger points. Like I mentioned, a few things that we typically see as well are there are low back disc referral to the region. That's super, super common, especially with people of many different types of activities and athletes of the age, usually below 25, below 35, kind of around there. The older you get, I'd say probably in the 50, 55, people who have had a lot of instances of groin issues, sacral pain, low back pain over their years. Like they've had trouble with their spine and their pelvis region.

Generally, those people will be more of like a facet type of referral. Or a nerve referral as the nerves pass out of the facet region. I'll talk about this a little bit later too in regards to why these structures may be involved. But generally, the referral pattern is very real. I'd estimate to see that probably people of sacral pain, I'd say if I were to guess, just ballpark the percentage of people who have inside, outside, and referred to joint problems. I'd say easily 50% of people with sacral pain are referred. Probably another 5% that we see are actually inside the joint. And then we see probably another 10%, which is the local area.

And then we have the last category, which is load management, which covers the rest. Now, load management or the too much, too soon is, I think it encompasses a lot of, it catches the rest of the conversation for many people. I've met a lot of people over the years that, you know, say we say that maybe it's your inside joint, maybe it's your outside joint. I think it's kind of referred and the hang-up point for a lot of them is my images don't show that. I don't see any disc herniation. I don't see any facet problems on the image. My doctor said my spinal X-rays are normal. I did an ultrasound on my piriformis and that looked normal too.

And my blood work looked good. And, you know, like, and so they're kind of stuck on this idea that there's going to be a structural manifestation, a change of structure, which is going to be attributed to the actual problem that they're having, like the sacral pain they're having. It's like seeing is believing, if you will. But the fact of the matter is it's very untrue. And so a lot of times poor movement patterns can create local pain or can create referred pain. A lot of times there's no deformity in the images, the x-rays, the MRIs, the ultrasounds, the blood work. There's no problems at all.

And this really confuses people. But I think, as a lot of us will know, as we go through our life at some point, you go into the January 1st workout and you feel fine. And then you go into, you know, the January 7th week of workouts. You think, God, I feel like crap. What the hell? Maybe I got a problem with my sacrum. And some of you will go get an image and some of you won't. The ones who don't may decide to do nothing and they just rest and all of a sudden they feel better. This is kind of the phenomenon of too much, too soon. You went from nothing to something and the something was too much.

Whatever it may be, whether it be dancing or yoga or weightlifting or running, it was too much. Meaning your tissues have not adapted yet to that demand. It takes time for tissues to adapt to the demand. It takes months to years. Sometimes even decades. Depends what you're trying to attain. So there's that part. There's the too much, too soon, which is the problem with the actual program. Your program is you're running 100 miles a week when previously you did nothing, right? That's a clear presentation of that's why that's kind of reckless. And then so that's kind of a knowingly thing. Like, you know it.

Like, you see it. You have. I love that people have the mindset for like, yeah, I want to do all that. But it's just too much too soon. You need to take a little bit more time to get to that volume. And then when you take the time, then you can. And then there's the people who that's not the case at all. They're like, I did, you know, five minutes of Latin dance and now I have this problem. I did a little bit of kickboxing for five minutes and that was just too much. I even took it easy. I know I was trying to take it easy. So like their mind's in the right place about them not wanting to do too much too soon and then it still happens.

What then? Well, this is still an issue with load management. It's not that the actual volume of the exercise is too much, but where the load of those reps or the time spent is going. And this is where people tend to have, like they get, usually they have a long history of things normally. I don't think I've met a lot of people who it's their first week having something into the sacrum or SI joint region or pelvis or low back. And all of a sudden this is, you know, the phenomenon happening. Normally it's people who actually, quite honestly, it's a lot of time it's people who are bendy. The bendy spine people, the Latin dancers, the ballet dancers, the gymnast.

These are the people who tend to have more sacral pain than anything else. Or it's the people who have had ongoing, ongoing lower back pain that is no longer the same as what it used to be. And now it's sacral pain. It's just a different feeling. It feels like a different evolution of a similar problem. The reason why I think a lot of people will have, the bendy people will have this sacral issue is mainly because what their activities will tend to extract from their body and they tend to bend more at the spine than they need to. I want everyone to first know this is, I know this is not a voluntary thing.

Like it's not that you're trying, most people aren't trying to bend at the spine. And it's not that it's bad to bend at the spine in a lot of situations. But if you're bending a lot in a certain region, then that area may start to speak up. It may. I like to observe people when I work with them. I like to see where their movements are coming from dominantly. But also too, you can see things like creases in the skin where they've had most of their movement occurring. Like that's, I have a friend who's a dermatologist. He has a good saying. He says, the skin doesn't lie. He says that the skin tells you a story.

It tells you if they are their smokers. It tells you if they've spent a lot of time in the sun. It tells you that you look at their hands, you can see scars. You can see how they lived their life. And so the same thing happens with people's movements. Sometimes you can, sometimes it tells a story. And so people who have a dance background or are generally bendy, typically at some point they bend too much at the upper lumbar spine, which is L1, L2, T12, kind of the junction where the low back turns into the mid back. What this tends to do is it tends to create, we call it an open scissor position.

I want to give credit to Richard Ulm who brought this, he called it the extension compression stabilization system. He has a good article on it. Again, extension compression stabilization system. It's on his website. I think it's Athletes Enhancement, I think. He has a few articles you can download, which I think are really good. He brought the idea to weightlifting, but also you can use that same central concept with something like dance or ballet as well, or not less load bearing activities. And so typically as it starts is the person has poor intra-abdominal pressure. Intra-abdominal pressure is the, it's the balloon pressure that comes from the inside of the abdominal cavity.

It's supposedly increased with the compression of the pelvic and thoracic diaphragm. It's the diaphragm that goes from the rib cage down. And then it's the pelvic diaphragm, which is your pelvic floor. Generally, those have the ability to compress together and then create an outward, an outward pressure, which supports the spine and also decompresses the spine too. For that reason, a lot of times the people who are dealing with the pain in the sacrum, they tend to use a compressive strategy in the spine. And so Richard brings out this idea of the extension compression stabilization strategy. And so, as I mentioned earlier, a lot of times people will have referred pain from things like the nerves or the facets in their spine, which is on the backside of their spine.

It's a, it's a posterior element and it typically stabilizes things like extension, like terminal lumbar extension, low back extension will at some point be blocked with these, these structures because actually the facets rather, the nerves are just in the holes between the facets, but the extension will be blocked with those facets, but also the facets become challenged and sometimes irritated with so much compressive load. And so if you don't have good intra-abdominal pressure to create a decompressive effect, then you'll use a compressive effect to, to accomplish the same task, which in this case would be Latin dance or, or dance.

And so it will compress those facets at some point. It may create local pain or it may refer, or it may refer to the sacrum or the acai joint or the side of the hip or the upper glute or the front of the hip and so on. People who have compressive, excessive compressive loads into their lumbar spine, the lower lumbar spine will things have typically things like sciatica, leg pain, back of the thigh issues, calf, sometimes foot pain or plantar fasciitis, which it would be a fake plantar fasciitis, a pseudo plantar fasciitis. But these things are super common with people who have things like, um, uh, facet arthropathy, which is, or a foraminal stenosis, which are things that you'll see in an image.

This is the long-term thing that sometimes happens with people when they use an extension compression stabilization strategy. They tend to load their, their joints on the backside of their spine. Uh, even by the way, there's facets that go down into the, to the, to the sacrum too. And so those ones could be irritated locally as well. If we're going to talk about this as a local thing, not a referred thing, it'd be referred if it was coming from the higher lumbar facets and it would be local if it was from the lower lumbar facets. So I like how we pair that thing together. Also, because extension is driven a lot of times by the lumbar multifidus, paraspinous muscles, the QL, even the glute muscles that cross the SI joint.

These, all these things could be quote unquote overused. A lot of activity going on. So we could literally say that this extension compression stabilization strategy from rooting from poor intra-abdominal pressure could create into inside or outside joint problems or referred to joint problems. And then it can create a load management issue. If you take a rest, rest, rest, and then go back and do it again, then it's, it's low management issue because you're, you have poor movement patterns that are very hard to break. So I tend to think it roots from the poor intra-abdominal pressure. Quite honestly, I don't know how people start by getting that.

I really don't. I wish I did, but generally speaking, I can, I can honestly say that people who have things longer, when they have a longer history of things, I'm not even going to say one specific thing, like your sacrum, the longer you have things in that region, like irritations or big flare-ups or things like that. Generally, the more apt you are to have the, have this type of presentation. However, in dance, there is this thing where they've been coached to suck in. And so I'd venture to say that sometimes the coaching of sucking in and the aesthetics of dance, not just ballet, but in this case, Latin too, sucking in or the coaching that the coach, that the dance instructor uses may perpetuate this problem.

I'm not going to say create it, but it might perpetuate it because usually when you're going to decrease the amount or increase the amount of decompressive, if you're going to work on decompressive effects of that region of the spine and the sacrum and the facets and so on, then you normally, you would put your hands on the sides of your body, like you're angry and you would breathe into four points. It's a, it's a decompressive strategy to rehabilitation. While a compressive strategy would be bracing, bearing down or sucking in. Now, treatments that I've tended, I find that tend to work, ice and skin rolling, rolling the skin over the air work very, very well for people with sacral pain. Even SI joint pain tends to work pretty well with diaphragmatic breathing, which I just mentioned. By the way, this is something that's a little bit nuanced to teach. So we do have videos on YouTube. You can look up performance, play, sports care, and breathing, and you'll probably find some videos. I was just editing some of our videos today. We literally have over 1,000 videos on YouTube. I'm embarrassed to say it because not all of them are very popular, but some of them are really, really popular. I wish all of them would be popular, but diaphragmatic breathing is one, one of those ones that if, if you haven't been told that you're going to be looking at, need to do it, then no one's looking for it. Also, glute facilitation exercises work very well. I like banded glute bridges, clam shells with a band would work okay, or things like single leg RDLs. But people who have this type of sacral pain, I would add a lot more knee bend. Don't go stiff legged, go with a slight knee bend and make sure that you're, it feels seamless. You should feel your butt cheek working when you do it.

Something that I've found over the years that's worked very well when you're trying to implement a decompressive strategy to help people with sacral pain who have poor intra-abdominal pressure is you need to get the thoracic spine moving. If it doesn't move and it's stiff, it's hard to align the diaphragms and it's hard to coach the activity because the person can't line them up. They can't find the position that it's easiest to teach in. I should do a side note. There is no perfect position for doing diaphragmatic breathing. You should be able to do it in all positions, but it's easiest to teach in a certain position. Usually that's on your, on your back, legs in the air in the 90-90 position, um, or crocodile breathing tends to work okay too. We have videos on all these, by the way. Sitting less tends to work very well, walking more, and then doing some core stiffness exercises. Treatments that people tend to try, but I think don't work very great if they're not, if they haven't had a long history with things. Or foam rolling, stretching the area, passive care, tissue, soft tissue mobilization, adjustments, acupuncture, medications. I think all these things will hold merit. They, they, everything has its place. I don't want to act like I'm dumping on these things because I'm not, we use these in our practice quite a bit, but it's usually for people who have more chronic, they're more chronic with this problem. Like they've had it for over six months. Normally that's more appropriate to them. Not everybody requires it. Some will benefit from it because it's really hard to beat yourself up. But I think we need to be clear about this. I don't think there's anything that we're going to do to break up any scar tissue in the area. I do think you can improve some slide amongst adjacent tissues. I think you can help out with movement in areas, just input movement into areas manually and with things like foam rollers and so on. Like, I think those are very helpful, but I think we need to go back into the idea of the adaptation. Like people don't just start moving like this overnight unless they've been coached into it. So they need to be broken of these habits and usually picking an exercise, which does not create the pain, but just makes it hard in the glutes or abdominal area usually is a first great starting point. And after that, you should get into foot on ground movements, single leg RDLs with or without weight. Goblet squats are a great thing.

Even something that works really well for people when there's a thoracic spine component, like I mentioned earlier, like sometimes mobilizing the mid back works really well. Sometimes something like a simple single arm dumbbell row works really well if they don't round the upper back while they're doing it. Like they have to keep the spine uprighted. Normally we coach this with present your logo of your shirt to us if we're standing in front of them. And so the exercise, how you do the exercise really does matter because we're either trying to encourage a pattern or break it. If there's a pattern that's deeply ingrained and we're okay with it, by all means do it. I won't coach it.

But if there's something we're trying to break, then we'll, we got to make sure that we find a coaching cue that works and we need to make sure that the person does it so that we're trying to break a pattern. Normally doing some form of heavy or heavy for you activity like single arm dumbbell row will help out to seal the process. It saves the process. Personally, I don't think any stretch, any foam rolling, any skin rolling, any diaphragmatic breathing exercise will stick unless you challenge it with some type of seal, which is a hard, harder, heavy for you weight training exercise. Um, one example that would, that would help up possibly with sacral pain is normally going to be some type of form of a box squat, like a goblet squat. But if the person has a bad movement pattern with it, we may need to go back and coach it, breathe into my fingers, go ahead and push the floor away just to make sure they're actually getting the right, um, uh, uh, uh, we're encouraging the right adaptation anyways. Timeline. I think as we wrap this up, I think everyone should know a timeline generally of what they should expect if they're trying to improve their pain with their sacrum.

Generally, I think most people like simple, simple cases, two to three weeks, like generally, like they should be like, wow, this feels way better. Now, if you have a more difficult case, like you, it might take a couple months and that's not what we necessarily want, but you know, there's not everybody's a simple case. And sometimes there's other considerations of things that you may be working with. And when you, when you try to get rid of the sacral pain, sometimes with something else as well, you might rob Peter to pay Paul. And so you need to make sure that you have a clear eye on the prize of what's the most important thing on that day with, in regards to activities or exercises that you may be doing that aren't related to reducing your pain, but breaking movement patterns, those may take, you may be doing those for, you know, a couple of days a week, for six months. And it's not because they take your pain away, but it's because we're trying to encourage a positive adaptation. We always want to encourage a positive adaptation because you need to reverse engineer the process, the reason why you got there. So if you find someone really good to work with, normally they have a keen eye for this type of thing. And hopefully they have a good history with working with people with it. Uh, I know we've seen hundreds of people just last, this is the beginning of the year. So within the last year, we've seen hundreds of people with sacral SI joint, upper glute pain. Um, I'll say hundreds, but I think, you know, into the probably two, three, four hundreds, even if I had to go get my nose, probably not thousands, but it's, it's, it's a very, very common scenario to have sacral pain. And so if you find someone who knows what they're doing, normally they'll help you out pretty well. So if anything in today's episode resonated with you, visit the link in your podcast player, there you'll find any free resource that we mentioned in the show, any guest links and a link for a free discovery call with us. We're licensed to work with our outdoor active people via telehealth across many States in the U S at this point. In fact, we cover almost half of the population in the U S and we add more States every year.

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