SI Joint Pain

[jessicalauren]

Background: I’m a 33 year old female who has always been very active. I have been doing the main barbell lifts for about two years using pretty careful, methodical progression and focusing on form and technique.

In March of this year, I went to the gym and went through what I had programmed for the day which was squats, hip thrust, and bench press, as well as accessory movements. I had no pain during any of the exercises, but later that day my lower right back and glute started to feel painful and tight. As the day progressed and into the next few days, the pain got worse but then seemed to dissipate. After resting it for a week (until the pain went away), I went back to the gym and re-did the same workout, again with no pain during the exercises. However, the pain returned and was worse. It got to the point where I was in fairly significant pain, and had to take several months off from lifting entirely due to being unable to perform many movements without pain.

During this time I saw several doctors, starting with my primary care, who then referred me to an orthopedic doctor. He diagnosed it to be an SI joint issue, and had me do physical therapy for a few months. I went to physical therapy about twice a week, did the exercises on my own, and showed slight improvement over time, but it was incredibly slow. After going back to the orthopedic doctor after a few months, he referred me to a pain medicine specialist, who initially thought it might instead be a disc tear and ordered an MRI. The MRI showed absolutely nothing and my back looks to be in perfect shape- aside from the pain. He then agreed with the orthopedic doctor that it must be an SI joint issue, and recommended more physical therapy. After another check up with the pain medicine doctor, he recommended an SI joint injection with cortisone, which I did and it provided almost complete relief for a couple of weeks. After that period of time, however, the pain has come back.

Since I have made slight improvements and the pain is not quite as bad as it used to be, the pain medicine doctor has green lighted me to do my normal exercises “as long as they don’t hurt.” A couple of days ago I started with just the bar for squats, hip thrust, and bench, and experienced no pain during the exercises, but an increase in pain later that day and into today. I haven’t tried deadlifting yet, as hip hinge is one of the movements that in and of itself causes some pain, but that seems to have lessened with time.

My question is: based on this history, do you think that this is, in fact, an SI joint issue and if so, do you have any suggestions for how to work with this in the weight room? Any input would be greatly appreciated, as I love lifting and look forward to it every day.

[Derek_Miles]

Hey Jessica,

I’m sorry to hear you’ve been dealing with this. There is a good bit to unpack here so I’m going to try and work piece by piece through this. I don’t know how familiar you are with BBM material but I would say you have come to the right place to try and work on getting back to full training. Part of the issue when it comes to any issue involving the back/hip/SI joint is it can rarely be pinpointed to just one thing. In terms of things we typically look for, assigning the cause to a single joint misses the multifactorial nature of things. To your original issue, whenever we have symptoms either while training, or shortly after training, complete rest is seldom the answer. If you think about it, we really do need stress in order to adapt and improve and taking away all stress seldom makes us more resilient. It is much more about learning to titrate the stress according to what you can tolerate. If you only rested for a week then returned to the same program there is a good chance you may have overshot what you were ready to do again. This tends to lead towards a reinforcement pattern of doing less overall. In your case we don’t know much at this point in terms of what your programming looked like in terms of set/rep scheme, mechanism for gauging intensity, overall training history, and current programming at the time of injury. All of these, as well as other factors play a role in figuring out what happened and what we need to do to get you back to training more-so than anything seen on imaging. In the same regard, I’m happy you did see some improvement with physical therapy but we don’t know what they had you do and how they progressed you through rehab during the time you were there. Often, if the goal is to get back to lifting regularly, physical therapy can fall far short of sufficient dosing to both alleviate symptoms and facilitate return to training (and that is coming from a PT). If you were not seeing the success you wanted with the current PT place, I would first recommend reaching out to us with the rehab team first as Mike Ray, Mike Amato, and myself have worked with many athletes to get them back training. Otherwise, you can also look to go to another PT place in your town but I would recommend looking for a PT who is familiar with resistance training. If you have taken several months off training at this point it will likely be a progression to get you back at this point.

The problem with injections is that while they may provide some short term relief, they still do not help set you up for returning to training in terms of adaptation. Often this comes down to a discussion of “where do we start?” At this point, if you have been out of training for a few months and it would appear making slight improvements overall, a simple training program is typically enough to get some adaptation. That being said, I would caveat this with two points:

1. It is okay to work into pain and the expectation of training only things that “don’t hurt” often does not give you much to do. Part of getting back into training is signaling to yourself that this is okay which means you do have to push…to a point. Once again, we don’t know the set/rep scheme you were following even on your return to training. Even with just the bar, if you have not trained in a while, you can overshoot what you are ready to do. This brings me to the second point:

2. I would HIGHLY recommend using rate of perceived exertion (RPE) as you return to training. This will let you factor in difficulty based on how you feel. When coming back from an injury, RPE can be especially useful for factoring in symptoms to rating of difficulty. It also moves the scale from a dichotomous “I shouldn’t do this/This is okay” towards a spectrum of “how much of this can I do.” The distinction here allows training and even doing things around the house to slowly become additive again.

I do not think it is an SI joint issue based upon what you said as I think overall the issue is much more multifactorial than that. There are components related to training history, goals, what you have tried in PT and elsewhere, and a host of other factors that all contribute to determining the best path for you moving forward. The question ultimately needs to be framed as “where do we start” as anytime something has been going on for months it often gives the feeling of being stuck. Taking those first steps towards getting back to what you were doing prior can be the hardest part because there is often a more narrow window of tolerance. That being said, once you figure that part out, it is typically trying to chain together as many wins in the gym as possible while accepting there may be the occasional setback as you get back to training. I would also recommend giving these two pieces a read:

Embrace the Process

SI joint Pain