“Not everything on the backside of your body that hurts is menopause lower back pain or spine.” So says our friendly Doctor of Physical Therapy, Meagan Peeters-Gebler PT, DPT, CSCS, CMTPT.

Tailbone pain, “lower back” pain often … aren’t. That pain that’s somewhere in your lower-back-upper-butt region is likely caused by problems with the sacrum and the sacroiliac (SI) joint being irritated.

It’s super common and so we thought it’d be super useful to ask our DPTs to fill us in on the sacrum and SI joint.

If you have problems with sacrum pain, a Gennev menopause-certified gynecologist can give you a trusted opinion, determine if medication is right for you, and they can provide prescription support. Book an appointment with a doctor here.

What is sacrum pain and why does it hurt?


Says Meagan, the sacrum is a triangular-shaped bone that sits just below your lumbar spine and just above your tailbone. Hooked to it on either side are the wing-shaped ilium bones (the knob of your hip bones are at the front of these). The bit that hooks the ilium to the sacrum is your SI joint. Your spine stacks on top of the sacrum.

The spinal column ends above the sacrum but the nerves continue down and through the sacral bone in the form of the cauda equina, a bundle of nerves that resemble a horse’s tail (hence “equina”). The nerves that poke through the middle holes of the sacrum bone feed the pelvic floor, so the system is all pretty intricately linked.

top view of the pelvis

The wedge-shaped sacrum sits within the ring of the pelvis and is intricately controlled by the glute muscles (or what causes knee pain in women) and the pelvic floor. The pelvic floor attaches on the inside of the sacrum and the pelvic ring and is part of the base that provides structural stability to the pelvic ring.

Problems here can be kind of a chicken-and-egg thing, says Meagan. When there’s trouble in the sacral world, it can make pelvic floor problems – pelvic pain, incontinence, and prolapse – worse. Additionally, weakness in the pelvic floor can make the sacrum vulnerable.

Unfortunately, given its shape and location, the sacrum can be vulnerable in women who have poor pelvic strength and health.

Learn how to ramp up your exercise — safely. Consult with one of our Health Coaches via Gennev HealthFix.

How do I know it’s my sacrum that’s hurting?

Before you start treating the pain, it’s useful to be sure what’s actually hurting and why. So, how do you know what’s hurting?

According to Meagan, sacral pain is usually acute, sharp, and localized in one area. It’s often caused by an action such as bending forward (especially if you do a lot of repetitive bending), or by “asymmetrical” body positioning, like bending and twisting or bending and lifting.

Think about how you get out of your car or how you reach for something in the bottom drawer of your desk while you’re working. Do you turn your whole body first, then bend? Or do you twist part of your body and lean?

The pain is often localized to the thick, broad ligaments on the back of the sacrum. These ligaments have pain fibers in them, so pain might be from the disruption of those tissues or from muscle spasms across the buttock in the piriformis muscle. If the sacrum isn’t moving symmetrically and through its full range of motion, things can start to spasm.

How does my sacrum contribute to incontinence?

According to Meagan, “When the pelvic floor muscles are stuck in spasm, they lose their ability to act like a trampoline and rebound and react to the pressure from the inside. And a spasming muscle is weak because it doesn’t have the right blood flow; it’s not contracting and relaxing properly.

“Plus the pain often makes people hold their breath, and incorrect breathing is itself a major risk factor for pelvic organ prolapse. In this case, it’s causing more pressure in a system that’s already failing.”

What are we doing that causes sacrum problems?

A lot of it comes down to sitting too much and not exercising correctly.

Sitting makes hip flexors really tight, Meagan says. The hip flexors travel on the front of the sacrum, giving a structural tug, repeatedly, in just one direction.

And we strengthen the wrong muscles with popular exercises (we’re looking at you, crunches) because we’re not including the pelvic floor or breathing appropriately or safely. Says Meagan, we get too tight from sitting and we’re too weak in the muscles that need to be strong.

How can we prevent SI or sacrum pain?

There are things we can do to prevent this very literal pain in the butt:

  • Be mindful of sitting posture – don’t slouch.
  • If you’re sitting a lot, change positions often.
  • When exercising, strengthen the right muscles: core work should focus on breath and pelvic floor to be sure both are correct.
  • Use a lumbar roll for your sacral pain when sitting.
  • Because she usually see problems with forward bending, reaching, rotating, twisting, Meagan suggests you learn to hip hinge and squat appropriately so when you do bend down, you know how to move your hip in the hip socket, rather than dragging the hip, pelvic, sacrum, and spine all together.

When you bend incorrectly, the sacrum becomes the hinge/pivot point rather than the hips, which is not how the body was designed, Meagan says. Hips are more able to move freely and accommodate the load.

Meagan suggests that women imagine they’re wearing a very mini miniskirt and there are lots of paparazzi around. How would that change how you exit your car, for example? Swivel – don’t scissor.

And when you stand, have equal weight on both feet, not an asymmetrical distribution of weight with one hip flung out, for example. And protect your back by using the right movements: when you’re sitting at your desk and want something in a low drawer, pivot your entire body to face the drawer, then bend to retrieve whatever you want. The idea is to move your body in one plane of motion at a time, rather than twisting in more than one.

And your folks were right: don’t slouch. When you slouch, your sacral bone can disengage from the formation of bones and ligaments slightly, and that makes it more vulnerable to injury from sudden or repetitive movement. When we sit up tall, our spine and sacrum stack neatly, as nature intended.

What if I’m already hurting?

Most important, says Meagan, is not to assume you know what’s hurting, because sacral and SI joint pain are often mistaken for something else. Get to an expert physical therapist or chiropractor for a proper diagnosis.

Next, you’ll want to work on freeing things up and getting normal mobility in the joint and area. Then focus on building core strength properly, with the right breathing, and incorporating your pelvic floor and gluteus maximus.

Too often we just assume back pain is an inevitable part of getting older. Not so! say our PTs. By being conscious of posture, by exercising correctly and nixing bad breathing patterns and habits, we can do a lot to protect our backs.

A big thank you to Meagan Peeters-Gebler PT, DPT, CSCS, CMTPT. for her insights.

Have you been diagnosed with a sacrum or SI joint injury? What did you do to rehab it and prevent recurrence? Share with us in our community forums.



Wendy Sloneker

December 10, 2019

Medically Reviewed By

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