How to Train Clients with SI Joint Pain in Pregnancy

Sacroiliac joint (SIJ) pain can be a common experience for pregnant moms. This discomfort is felt on the back side of the pelvis. We have a sacroiliac joint on both the left and right side of the pelvis, where the hip bones (the ilium) meet the tailbone (the sacrum).

These are robust joints supported by strong connective tissues.

For some moms, SI joint pain is present immediately in pregnancy, leading to the assumption that it could be a hormonal change causing the sensation of pain. Whereas for others, the discomfort can build as pregnancy progresses, perhaps meaning that the baby’s growth is pulling on the connective tissues of the pelvic bones and causing stress in the body.

It's often possible to keep moving, even with SI joint pain. That said, there can be instances when irritation and pain increase with exercise and physical activity, so as coaches of pregnant fitness clients, we need to have strategies to help our clients manage this.

1. Start or Continue Strength Training.

Strength training is useful in keeping expecting moms active because we can modify exercises, loading, and the body position to help alleviate symptoms.

Here are some ways your strength training programming can help keep the SI joints pain-free or help your client manage their pain:

Cue your client to distribute the load throughout the body.

For example, in a deadlift variation, ensure that your client is feeling the tension through the glutes, hamstrings, back muscles — really, the whole body — and not feeling the exercise solely in the SI joints. Physiotherapist Antony Lo refers to this as “spreading the load.”

Use good exercise technique when under load.

It’s important to note that “good form” in exercise looks a bit different for everybody, and that's normal and fine. I strive to teach my clients to lift and move in a “neutral” body position, with the rib cage stacked over the hips.

It isn’t bad to be in body positions other than neutral — in fact, it's a great thing. We simply want to ensure that the client can lift loads well and efficiently in an alignment in which the body is “stacked.” This position tends to feel most stable and supported, and can give the deep core and pelvic floor system a good opportunity to generate tension.

Pictured above: rib thrust (left), bum tuck (center), ribs over hips (right).

Use breathing strategies to help the core and pelvic floor do their job.

There are different strategies to breathing during exercise (and no single correct way).

What I've found to be helpful with my pregnant clients is to ensure that they continue to breathe as best as possible while performing an exercise. There are likely going to be times when they're holding their breath for short durations, both in their workouts and in life, but, in general, cue them to keep breathing throughout. This will help them feel more “in their body” and stable while lifting.

Additionally, matching the exhale breath to the toughest part of the exercise movement might help the body, belly, and pelvis feel more supported. I cue this as “exhale on exertion.” Most people will feel an increase in abdominal muscle tension and, if focusing on it, a lift and engagement of the pelvic floor muscles.

Note: The degree of core engagement on the exhale breath, or in a particular exercise rep, does not need to be extremely strong or aggressive.

Sometimes when clients are trying so hard to “work their abs” in exercises it can ramp their symptoms up. It sounds counterintuitive, but discourage your pregnant and postpartum clients from gripping and sucking in their abdominal muscles to try to support their pelvis. Instead encourage more relaxation and a natural response to loads!

2. Troubleshoot walking.

The common physical activity advice given to pregnant women is to walk, walk, and walk some more. This is great advice if you enjoy it and if it feels good on your body. Unfortunately, for many pregnant women, walking can often irritate the SI joints.

Here are some recommendations if your client’s symptoms are flaring up when she goes for a walk:

Shorten the distance.

Do her symptoms ramp up at a certain time during her walk? Have her try going for multiple, shorter walks throughout the day if that feels better. If your client enjoys going for a daily 30-minute walk but notices that at the 15-minute mark the SI joints start aching, she can stop the walk at that point and try for another 15-minute walk later in the day.

Play with the pace and step length.

If a client is typically a fast walker and is noticing symptoms, suggest walking at a slower, more leisurely pace. Walking at a slower pace can also be incredibly relaxing and can help balance stress hormones.^1,2 She can also try shortening her step length instead of stepping far in front of her body to see if that helps reduce symptoms.

Lean slightly forward when walking.

Cue your client to move her body into the direction she wants to go. She should try to get her body into a slight forward-leaning position, instead of walking completely tall and upright. This is a small shift and should not make her feel like she's going to fall on her face.

3. Specific Strength Training Modifications

Your clients might have specific issues come up with certain patterns of movement in their workouts. This commonly occurs in unilateral and lateral exercises.

Examples of unilateral exercises are split squats, lunge variations, step-ups, or upper body exercises such as standing rows and chest presses done in a split stance position.

Examples of lateral exercises are lateral step-ups, lateral band walks, and lateral farmer carry variations.

Your client’s symptoms might increase with all of these types of movements or with only a few. Test these exercises out with bodyweight loading and see how she responds physically to them.

If the above exercises are troublesome, your workout programming might need to include a lot of lower body bilateral exercises. Here are some examples of movement categories and variations you could use:

• Squat: Bodyweight, goblet, front, back, offset
• Deadlift: Romanian, band, kettlebell, dumbbell, barbell, elevated, conventional, sumo, trap bar
• Glute bridge: Bodyweight, mini band, 1-leg (potentially)
• Hip thrust: Bodyweight, mini band, superband

As always, I encourage you to refer your clients out to other health professionals who are skilled in treating prenatal body aches and pains. You might refer out to a pelvic health physical therapist, musculoskeletal physical therapist, or chiropractor who's skilled in Webster’s technique.

Most importantly, do not stress about your workout programming being perfectly balanced with all movement variations. It’s OK to double up on upper body exercises and include only a few variations of squats and deadlifts for lower body training because those are pain-free movements. Focus on helping your client continue moving and staying strong, healthy, and comfortable throughout her pregnancy.