Despite its limited range of movement, the sacroiliac joint is prone to instability and is often a source of back pain in patients. 

On this episode of Back Talk Doc, Dr. Sanjiv Lakhia and Tanner Holden, PT from Carolina Neurosurgery and Spine Associates discuss the SI joint itself, some common causes of SI joint pain, and what the latest science has to offer for management. 

Patients can experience SI joint pain during or after pregnancy, pain from the joint itself, or autoimmune pain. However, diagnosing SI joint pain is rarely straightforward because medical imaging is not typically helpful in diagnosing SI joint pain. The pain can present in unexpected places and is often best diagnosed with the help of pain provocation tests. 

Once diagnosed, patients can opt for regular pain-reducing injections for a quick solution. A more holistic treatment plan looks at patient goals and finds ways to improve movement over time. This may also include lifestyle modifications to remove the irritants or activities that cause the pain to flare up. Since SI joint pain sources vary from patient to patient, plans are customized to individual needs. 

Tanner believes that healthy movement, activity, and strength are key to living an active and pain-free life. He and Dr. Lakhia discuss how this approach puts the patient first and removes the need for unnecessary supports like braces and belts. Instead, a strength-based approach allows patients to take their care into their own hands, resulting in fewer medical visits.  

💡 Featured Expert 💡

Name: Tanner Holden, PT, DPT, OCS, CSC

What he does: Tanner is a residency-trained Doctor of Physical Therapy and Certified Strength and Conditioning Specialist serving Charlotte and the surrounding area. He holds a board certification as an Orthopedic Clinical Specialist. 

Company: Carolina Neurosurgery and Spine Associates

Words of wisdom: “We like to get people in and out and living their life.”

Connect: Website |  LinkedIn 

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👉 If you enjoyed this episode of Back Talk Doc, check out our recent episode Rethinking Osteoarthritis and Degenerative Disc Disease.

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🔎 For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.

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Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at CNSA.com.

Voiceover:

Welcome. You are listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health. Brought to you by Carolina Neurosurgery & Spine Associates, where cutting-edge, nationally-recognized care is delivered through a compassionate approach.

This podcast is for informational purposes only and not intended to be used as personalized medical advice. Now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.

Dr. Sanjiv Lakhia:

Welcome back to the next episode of Back Talk Doc, where I, your host, Sanjiv Lakhia, passionate about back pain and everything that surrounds it, put out the most comprehensive podcast in the podcast universe about back pain, which frankly at times, people would think it's a boring topic. But we bring in a lot of exciting guests and I make it fun.

It's disruptive to our healthcare, it's disruptive to our work. I want to knock it out, or at least arm you with the tools, so you can make wise decisions about your care. Today, I'm going to dive back into a topic I briefly touched on many, many moons ago. I did a top 10 non-disc cause episode on back pain, non-disc causes of back pain, and on my list was the sacroiliac joint.

A lot of people talk about SI joint pain, but what are the real truths behind it? What really is it? What causes it? What's the up-to-date science about it? We're going to answer all those questions right now with my guest, Tanner Holden. Tanner, welcome to the show.

Tanner Holden:

Thanks. I'm really excited to be here. Really happy about this opportunity and talking about a somewhat controversial topic in an area that a lot of people have questions about.

Dr. Sanjiv Lakhia:

Yeah. Now, I told the nursing team earlier today we're going to make SI joint pain sound sexy on the podcast, so that's our standard. We've got to hold up to it. Let me introduce you. You're a doctor of physical therapy and strength and conditioning specialist, with a board specialty certification in orthopedics. Tanner's been the manager at our Rock Hill office for about a year now, and has done a fabulous job with our physical therapy department.

He's very knowledgeable about athletics, about fitness. He works with barbell sport athletes of all ages and experiences outside of work. He's been married for five years and is going through the joys of parenthood with a four-month-old and two dogs. That's why he's chronically tired, which I can laugh at, because I have three kids and I can relate to that. I've been there, done that, but he's doing great with it. Basically, Tanner folks is an expert in biomechanics.

He's an expert in physical fitness. He's helped me personally with my hip and back. He's helped pretty much everyone in the office with their hip and back. He's one of the go-to people in our practice, and just someone whose brain I'm happy to tease through his thoughts on the SI joint. Let's dive right in and get talking about it, because I know I get a lot of referrals, Tanner, for people with SI joint pain. The first question I ask myself is, "What really is the pain?"

I would even zoom out further and say it really falls into that black box of buttock pain, which can be a thorn in our side and certainly a pain for people. But let's focus more on what's called the sacroiliac joint. For those listening who don't know much about it, just give us a 30,000-foot description of the anatomy and just some of the basic science behind the SI joint, what it is and how it moves.

Tanner Holden:

Yeah, absolutely. Well, first let's talk about what the SI joint's composed of. The sacrum is basically a triangle-shaped bone that's just below your lumbar spine, and it's wedged between our two hip bones or innominate bones, as we call them. The SIJ or the sacroiliac joint is the connection between those two bones. The sacrum is really wedged and sandwiched in there. It really creates for really, really stable joints.

We also, aside from just the bony anatomy, we have connected tissues that span the joint and create stability. There's various ligaments. We also have multiple muscles across the joint and create dynamic stability. Then we also have the joint is innervated as well. Anything that has innervation is going to be capable of producing perception of pain or nociception, and so there's lots going on there.

Dr. Sanjiv Lakhia:

In reviewing for this episode, I relearned that the SI joint has very little degrees of movement. We're talking millimeters depending on the direction of movement, and it's almost like a pivot point between your spine and your hip. It begs a couple questions and we'll touch on this as we move along, but with such little movement, why is it apparently so prone to being a source of pain?

With such little movement, why is it so inherently unstable sometimes, at least we think so, particularly in women? But before we do that, let me let you lead people down a typical patient that comes in with SI joint pain. What should people be thinking when they hear you describe it and say, "Oh, I think I have it"? What's the history part of it?

Tanner Holden:

Yeah. I think there's really three types of buckets, I think, folks fall into with SI joint pain. It tends to be either someone who is pregnant or postpartum. That's typically a whole beast in and of itself, but we call that pregnancy-related pelvic girdle pain. We also have SI joint-related pain, which is really this broad category where most folks fall into.

Then there's a whole nother side where there's autoimmune sources, which I think you're going to touch on later. Those are those buckets that folks fall into. But as far as someone's coming in and they may have suspected SI joint pathology or pain, typically they're going to have pain somewhere in the region of the buttock and at the sacrum.

They're going to have typically a tender spot in that area as well. They may have had a history of misstepping or they may have had some type of trauma. Those are the big things that we're looking out for. There's a lot of overlap between SI joint pain location and low back pain location, and those referral patterns as well.

Dr. Sanjiv Lakhia:

I wish it was just black and white, but you're totally correct. When I think of SI joint, I definitely think of certainly pain in the buttock, but I've seen it referring to the groin. I don't entirely exclude it in my mind when someone has referred pain down the back of the leg. We know in some of the provocation studies where they've injected and provoked people who have "healthy SI joints," that they can experience pain in many different parts of the body.

Folks, that's how we come to learn about a joint pain and it's pathology. A lot of the research is done where you'll take healthy subjects and you'll provoke a joint, and then you'll just map out where they feel it. It's not always where you think they should feel it. Anytime anyone comes to me with a referral for a hip problem, for a back problem, for buttock pain, for sciatic pain, in the back of my mind, I'm thinking about the SI joint.

Although after 16, 17 years of practice, I'm still not exactly sure at times if it's really the SI joint or the pain is just located where the joint is. Sometimes I view the SI joint as the victim, but not the problem. I've also seen spinal stenosis, claudication where someone when they stand upright, they don't get pain down their leg, but they get it in the joint or they get it in the buttock.

I'm always really just trying to tease it out. When it comes to teasing it out though, Tanner, you see a lot of patients for physical therapy evaluations. What are some of your go-tos in terms of examination? Then just give us your general thoughts about physical exam for SI joint pain.

Tanner Holden:

Yeah. I think my physical examination is highly predicated on pain provocation tests for the SI joint. There are a lot of other tests out there that are motion or palpation tests, that unfortunately are not really valid or reliable and so they vary. The assessment clinician to clinician will vary, but the pain provocation tests really tell us, "Hey, if we stress this joint in these different ways and someone has a positive pain response."

That gives us an idea that at least part of what's going on can be related to the SI joint. Or at least it tells us those tissues are very sensitive and that we need to address that in order to help them move along. It's those SI joint provocation tests, I won't go through naming them, but there are five of them. Then some other tests, some functional tests as well. If we think a little more globally at what someone's having issues with, I want to see the thing that they're having difficulty with and see if we can modify that.

Dr. Sanjiv Lakhia:

Basically, if you push on it, if you compress it and squeeze it, if you pull it back or distract it, these are some of the exam findings. What you just said, there is a lot of debate about the reliability of physical exam findings. Part of that is because when you study physical exam findings of any type, there's variability from clinician to clinician, so it makes it hard to really validate some of these tests.

Most of the insurance plans nowadays will require three tests that are positive before they'll approve, let's say, a therapeutic corticosteroid injection. That can be challenging as well because when you look at them in isolation, I don't know that the sensitivity and specificity justifies that. But I think they're trying to limit over injections and too many procedures done on the joint. You sent me a list of research articles.

I was so impressed. I looked at a couple. Laslett's article titled Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint and we'll link to that in the show notes. As an aside, folks, if you're listening to my episodes, please make sure you go to my show notes. We invest a lot into making those really valuable and they have all the links of things I talk about.

The other article was by Palsson, P-A-L-S-S-O-N, titled Changing the Narrative and Diagnosis and Management of Pain in SI and Sacroiliac Area. They both point to that these exams are iffy and even diagnostic injections can be iffy, and certainly movement-based diagnosis. Now, Tanner, when I was in osteopathic school, we did a lot of "diagnosis" of sacroiliac strain patterns, like a left-on-left torsion or an anterior-rotated sacral base.

It was very, very challenging because it had amounted to basically putting our thumbs, medial to the PSIS, the little bumps in the back. Then putting them down at the inferior lateral angle, where forms like coccyx. You're just pushing in and you're trying to assess depth and compare side to side. Then teacher would be like, "Do you feel that there?" I'd say, "Yeah, I feel that there. No, I don't feel that there."

But you would predicate your manipulation on that. It's still very prevalent in the osteopathic literature and manipulation world, and chiropractors use it as well, but I don't know if I was ever at peace with it as a reliable way to assess things. But at some point you have to do an exam and figure things out. I think a big part about it, and I know you do this, is you always evaluate the hip joint and the back.

Advise people on why you do that. What are some maybe subtle differences between pain coming from a hip joint clinical presentation versus SI joint, that makes you think that you're in the wrong area?

Tanner Holden:

Yeah. I guess we'll start with the hips. Definitely want to make sure that we're clearing the hip if we think the SI joint could be a cause of someone's pain. I'm typically going to go through a functional range of motion, something like a squat or a sit to stand and see how that affects their pain and see what the motion looks like.

Then depending on what we see, we may go a little deeper, clear the joint by going through different ranges of motion. Someone with primarily hip pain or hip joint pain, is probably going to have some pain elicited with motions of the hip at end range. Particularly when I lay someone down on an exam table and I stress that hip rotating inward or outward and applying forces.

Whereas I wouldn't necessarily expect that from someone who's having sacroiliac joint pain primarily. If we consider the lumbar spine, that gets to be a little more gray, I think, as far as distinguishing those things. But if someone I think may be having discogenic type of pain, if we're trying to achieve centralization of symptoms, if there's someone who responds to that.

If they do respond to that centralization, then that would be more of a thought towards the lumbar spine contributing as opposed to SI joints. But we're also going to go through the lumbar spine and stress the lumbar vertebrae from L1 down to L5, just to see if there's anything that reproduces their pain in that area as well. We're also going to go through multisegmental motions of the lumbar spine as well and try and clear it that way.

Dr. Sanjiv Lakhia:

That's a great point. If you do have buttock pain and you think you have SI joint pain, I think you first have to do what he just said, clear the hip and clear the spine. Because in terms of commonality, far and away, there's more issues coming from the low back and frankly the hip joint, in my opinion at least, than the SI joint. That's why they do hip replacements and spinal fusions, and we do EMGs and injections. I've covered a lot of this material in my prior podcast episodes. I may want to get you back on some time to talk about centralization of disc pain that you mentioned there with McKenzie protocols and things like that.

Tanner Holden:

Absolutely.

Dr. Sanjiv Lakhia:

One thing I would say is when I send you guys patients, there are times where I'll get notes back from y'all saying, "Can you please X-ray? Can you please MRI?" Because you have some suspicion. I don't get that a lot with SI joint pain. But for those who are wondering, if you think you have buttock pain, in my opinion, probably the only thing that's really indicated is maybe an X-ray, maybe. To me though, I like to really base it on history.

If there's trauma, I'll X-ray it, or like you said earlier, if we suspect there's autoimmune disease. Really, what we're talking about there is ankylosing spondylitis. Men, young men, healthy, who are really, really stiff in their spine, call that bamboo spine. Ankylosing spondylitis is something that frankly, I could do a whole nother episode on as well, but it's an autoimmune issue, folks, that inflammation attacks your spine, attacks your SI joint, your eyes and other systems.

You can see destructive change on imaging with that type of condition. But short of that, I haven't found much usefulness for MRI, pelvic CT, none of that stuff. I think it's overkill 95% of the time. Most of the time, a big take-home point here is that normal X-ray of the SI joint doesn't necessarily mean there's no pain coming from the SI joint as well. There's a corollary to that, so that's all I see. I don't know that for you if imaging provides much usefulness.

Tanner Holden:

No, I think for all the reasons you said, unless there are red flags or there are other things that we may think be going on. If we're thinking it's a musculoskeletal cause, I don't think it adds much.

Dr. Sanjiv Lakhia:

Okay. Now you touched on it earlier, I suspect SI joint pain, number one, is women who are pregnant.

Tanner Holden:

Yes.

Dr. Sanjiv Lakhia:

That has to do, folks, with the hormonal release that relaxes the ligaments of the pelvis in preparation for delivery, and can make it inherently unstable. Actually, I have two patients right now, I'm treating with acupuncture for that. Early in the pregnancy, certainly can benefit from some stability exercises.

In fact, one of them, she's doing some Pilates work and is helping her. But as you get later into the pregnancy, it's more difficult to do the therapeutic exercise, so something like acupuncture certainly has been helpful. That trauma to me, it's three to one women to men. Do you see that?

Tanner Holden:

Yeah, definitely. I would even say potentially higher than that, trending towards women.

Dr. Sanjiv Lakhia:

I think that just has to do with the pelvic dimensions. Look, we didn't talk about, maybe we should before we jump into how you treat it, but I think there are some environmental, occupational risk factors for this. I always come back to sitting and inactivity, that's a big driver. I have people who come in with SI joint pain, who are salesmen.

Or if it's men, it's truck drivers who are sitting on big, thick wallets and it's contributing to some pain. I think like everything else we touch on, the inactivity and the lack of physical fitness, can certainly contribute to increased pain in that area. Do you have any others that you think play a role with people?

Tanner Holden:

I think you hit on the big things there, I don't think that I would add. Because there's so much overlap between SIJ pain and low back pain, and we know that so many different things can cause low back pain.

I think it's really hard to put a label or to profile on folks, but I think the ones that you mentioned are the low-hanging fruits and those are the ones I see most often.

Dr. Sanjiv Lakhia:

If you're interested in learning more about how sitting can negatively affect your back, one of my earlier episodes, I interviewed a trauma surgeon who created a company, a startup company. They created, for lack of better term, a swivel chair to promote core stability. Whether or not that works or not, I don't know.

I have it. I do find that it does activate some muscles. But folks, we'll link to that one in the podcast show notes as well, because we do a pretty good deep dive on the science behind sitting and how it can affect your total health. Okay. Let's get into your wheelhouse, which is getting people better, right?

Tanner Holden:

Yeah.

Dr. Sanjiv Lakhia:

I already beat you up with a lot of history and science and all that nonsense. All right. Let's talk about a new patient evaluation.

Tanner Holden:

Okay.

Dr. Sanjiv Lakhia:

What can someone expect coming to see you who, let's say, I've diagnosed them with SI joint pain? Maybe I've put an injection in there, which I think can be of therapeutic value, corticosteroid and even a little bit lidocaine. It can help diagnostically confirm things.

It is mentioned in the literature as being reasonable, but I always tell people, "If that's all you want to do, that's fine. I have plenty of needles. I'll see you back in two weeks and we'll just keep doing that the rest of your life."

No one seems to want to do that for some reason, but if you do the injection and then you follow up with the PT, which is doing the real work, I think you have sustained benefit. Walk someone through what they'd expect if they came in to see you or won the team.

Tanner Holden:

Yeah. We always start out with an evaluation. The first thing I'm going to do is listen to the patient and ask what's important to them. What is this preventing you from doing and what do you want to get back to doing? Then we shape everything else around that. We've gone through the evaluation and we have identified that potentially the SI joint is a contributor to their pain, and that those tissues are sensitive. Then there, we need to formulate a plan.

I like to take a step back before I throw anything specific at the patient, and think about what are we really doing here and what's going on? If we think about the tissues are sensitive and they may not have the capacity to handle the tasks that you are wanting to do right now, they have a reduced capacity. We need to find ways to improve that capacity. We start there and we say, "Okay. We need X to be able to do this, so we need to figure out how we get X."

Those things are the exercises and ways that we can build resilience and strengthen in those tissues. That's like the big 30,000-foot view of what we do. A lot of what we talk about initially is load management, and this is something that can be applied to every population. Are you doing things that are, for lack of a better way in saying it, ticking it off? If so, we may just want to back off those things or identify what those things are and modify them.

We also want to think about are we doing too little? Are we not doing enough? Which is very often the case as well. Especially if something has been going on for a longer period of time, we need to break that cycle and probably need to gradually ramp up activities or movements that are loading that area. That's going to help improve the resilient and tolerance for activity.

Dr. Sanjiv Lakhia:

If we dive deeper or narrow our focus, are you looking at specific muscle imbalance or weakness patterns that you see over and over again, or is everyone different and it's more customized?

Tanner Holden:

I would love to say there is a specific pattern, but I do think everyone's different. I think in general, people who have this sensitivity to these tissues, have pain with things like stepping up or squatting, walking, running.

Things that involve impact where a lot of involvement of the lower extremities or the legs, those are the things that I'm seeing the most of.

Dr. Sanjiv Lakhia:

For the clinicians and PTs that are listening to this, you're typically looking at, and I look at your notes a lot, stability work, sometimes pelvic bridges, clamshells, bird dogs, one-legged step-ups.

Some hip hinging, really just getting that glute, hamstring, paraspinal ligamentous complex firing symmetrically and with strength, and that supports that joint.

Tanner Holden:

Absolutely. Yeah, that's exactly. We're starting at a different place with everybody, but for someone who, if we take an example of someone who's really, really sensitive to loading, we may just have them start on their back in a comfortable position with a band around their legs pushing out against that band. I may have someone that is able to tolerate a little more, maybe they're able to go ahead and start doing some stepping up.

We also utilize isometrics so longer holds. Those tend to be really, really effective in my own practice for helping decrease sensitivity to loading, sometimes immediately, at least providing a short-term benefit there. Then we always progress back to where the person wants to be, and so we gradually increase the demands on all the tissues. We're targeting the glutes, the hamstrings, the paraspinals.

The beautiful thing about the SI joint, is there's so many muscles that touch it and cross it. If someone is really sensitive its loading in one area, we can go to another area and load that tissue with less discomfort. Then gradually add in those other things as the sensitivity improves.

Dr. Sanjiv Lakhia:

That's great. I never thought of it that way, so it gives you different ways to climb the same mountain. I like what you said earlier about for some people it's a matter of maybe they're not doing enough. I had a patient earlier today, and she was following up from her PT just for her low back. Things were going well, her pain was mostly gone. She made the comment, she goes, "The only time I really have pain is when I go up a step."

I said, "What type of pain?" She says, "Well, it's not really pain, it's more just feels a little unstable and weak. I typically just try and use my other leg." I said, "Whoa, time out. Let's demonstrate." I had her step up on the stool. She didn't have any acute pain. We did side to side. I said, "That's just asymmetry. One side is stronger than the other. I want you to move into that, not away from that."

Tanner Holden:

Absolutely.

Dr. Sanjiv Lakhia:

"Eventually, I want you to put a few weights in your hands and do that as part of your therapeutic exercise program. I bet you in three months, you're not going to have that issue." Frankly, you taught me that in my own rehab with my hip, is sometimes just moving through an area where you're nervous about or uncomfortable with, and the tissues in the body will respond. I feel like that's definitely the case with the SI joint.

Because like I said earlier, to me, SI joint pain, I think it is real, but I think it's still the victim and not the problem in 95% of the cases. If you look at an SI joint of most people under microscopy, you're going to see healthy joint lining, healthy tissue and be like, "Well, what's the problem then?" Well, there are also a lot of nerves that innervate it, and this podcast, I wasn't going to go geek out on anatomy of the SI joint.

Anyone's listening, I do know the anatomy, we don't really need to get into ablation and all that stuff. But you can have sensitized tissues, like you said, that cause pain in that joint, but doesn't mean the joint itself is a bad knee or a bad hip or shoulder. It's totally, totally different, folks, so it makes it more complex. But I think the rehab potential is always really high with SI joint, just because it's still naturally very healthy and preserved.

I feel like your approach there is really comprehensive. You look at the whole kinetic chain, and try to improve the movement and really gain confidence. I think that's a huge part of rehab that I've noticed for patients from my own experience. Getting that confidence in those small wins week to week, eventually lead to huge gains in return to function and enjoying life, which is ultimately the goal, because I know you don't want to see people forever, right?

Tanner Holden:

No, not at all. Right. We like to get people in and out and living their life.

Dr. Sanjiv Lakhia:

That's right. Okay, I want to touch on one more thing. We're wrapping up here. I do have a lot of people ask me about sacroiliac joint belts. If you don't know what a SIJ belt is, it's not really a back brace.

It's like a strap that squeezes your hips from the trochanters or the bump on the side of your hip, and just provides the little compression to the pelvis.

When I first was introduced to SI joint belt is in the context of treating women who are pregnant. I've seen it be helpful, but for the average public, what are your thoughts on that?

Tanner Holden:

Yeah. I have only really seen success in folks, in the pregnant population using these. I think that is due to the changes that their bodies go through during that process, and the stability or sense of stability that the belt can provide.

Whereas in most folks, that is something that really doesn't provide much benefit. I think can even be, if it does, it can become a crutch to lean on. And can potentially prevent them from using more active ways of getting that joint and the tissues around that joint to be more resilient to activity.

Dr. Sanjiv Lakhia:

I agree. One of the things that people should understand about your approach to PT and why I wanted to get you on, is you're a big advocate for healthy movement activity and strength. I think when I first started working with you, you said to me there really shouldn't be a movement you shouldn't do or can't do. Obviously, there are exceptions to that, right? If you have a fused spine, there's going to be a loss of some flexibility.

But folks, when you come to PT at our group and you work with Tanner and all of our partners, who have a very similar philosophy, we're trying to move you from a term I hear a lot, pain to performance. That's like a tagline for some companies and actually some friends who have businesses right now. I like that tagline and I think that makes sense for what we try to do here as well. It's more about improving your exercise capacity, because that's the foundation for functional movement and enjoying life.

It's not about belts, it's not about braces, it's not about ultrasound, it's not about iontophoresis and electrical stimulation. None of that has ever led to sustained benefit in my experience. I'm not disparaging it. I think there can be a role for people, because short-term pain relief is a good thing and those tools are tools in the toolbox. But if you're someone who's listening who has struggled with SI joint pain for a while, even years.

Ask yourself, "What has been my approach? What has been my rehab approach? Has it been based upon my function, my activity, and the ability to build strength in my back, hips and legs? Or has it been more about someone else doing something to me?" There's active rehab and passive rehab, and I always encourage my patients, "We really want to teach you how to really take care of yourself."

You don't necessarily need to get dependent upon medical systems where you have to come in the rest of your life. There's a role for all of that. I work with, I'm an acupuncturist, so I have people that come in. They can only get acupuncture if they come in, and I got to see them multiple visits, multiple times. I work with some really excellent chiropractors and they have people that come in frequent visits.

I just say, "If you're doing that, add to the equation what Tanner's talking about here, which is a really holistic PT approach to building up your strength, your movement patterns, your exercise tolerance and your results, they'll be taken to the next level." All right. We covered a lot. I think that was a pretty sexy conversation about the SI joint myself.

Tanner Holden:

Yes.

Dr. Sanjiv Lakhia:

Before I let you off the hook, I always like to learn a little more about my guest. I'm a big geek about holistic health, and nutrition and fitness, and you are someone in our office who models that.

If you guys don't know Tanner, he looks the part. He's physically fit, he's got a lot of good energy. What are some of your go-tos that keep you at the top of your game?

Tanner Holden:

Yeah. I'm not going to overcomplicate it. It's something I hear you talk about a lot is the pillars of health. Those things, I think, are the foundation upon which everybody should really build their healthy lifestyle.

But those pillars for me are nutrition, exercise and sleep. I'll just share a few brief things about each of those just so you can get an idea of some examples.

Dr. Sanjiv Lakhia:

Awesome.

Tanner Holden:

Nutrition-wise, one thing that really helps, I think, is creating a habit, and cooking or preparing meals in advance. Planning those things out can save you time, money, and can probably also add years to your life. Once a week, my wife and I, we cook on Sundays. It takes three, four hours. I'll be honest, it sucks because it such a time suck, but it gives us back time during the week. I know what I'm eating, I know it's healthy, I know who made it and I really enjoy that. It's just one less thing I have to worry about.

I know I've already made that healthy decision every day. There's that, exercise. I'm a big proponent for resistance training. I think it has so many benefits for not only physical strength, but your mental health. There's even studies showing improvements in cardiovascular fitness. If you've ever lifted weights or if you've never lifted weights and your heart rate hasn't gone up, you're probably not doing it the right way because your heart rate will go up. There's so many benefits to that.

I think getting strong is one of the best things that anyone can do. Then sleep, I love sleep. We are big sleep hygiene people at my house. We're air condition at 68 degrees. The room is pitch black, we've got a sound machine going.

Dr. Sanjiv Lakhia:

Awesome.

Tanner Holden:

We love to get our six to eight hours plus a night.

Dr. Sanjiv Lakhia:

I need my wife to listen to this, because she wants 71 and I want 68, 69, and I always lose. Let's unpack that a little bit. I really like what you said, the meal prep. People will pay themselves first with a 401k, most will if it's available to them.

I feel like meal prep is the same thing. Take care of yourself first. Put it on autopilot. When you have your 401k deposit, you never see it. It happens automatically.

Tanner Holden:

Right.

Dr. Sanjiv Lakhia:

If you had to manually every two weeks or every four weeks, go in and send in a deposit to your mutual funds, you're never, ever going to do it. If you have to make all your meals the moment that you're hungry, you're never, ever going to do it. You have to prepare your meals, folks, preferably Mediterranean, anti-inflammatory diet. Then you can modify based upon your genetics, your desires, your goals.

I myself, I don't do that extensive of a meal plan on Sunday. But I typically will make, and I just do mine the night before. So that way, the next day I'm at clinic, I'm not running out to some restaurant at lunch that I don't like, that's not healthy and nourishing for me. The other thing about that, what I love is that you're doing it together with your wife, and that's you can bond through the misery.

Tanner Holden:

Yes, we do.

Dr. Sanjiv Lakhia:

But you're really investing in your health. The other part of what you said about the sleep, I'm laughing because I know you're probably not getting a whole lot of sleep lately with your beautiful newborn that's four months old. But now you're able to understand how important that sleep is.

Tanner Holden:

Yes, absolutely.

Dr. Sanjiv Lakhia:

I've talked about it before, and I'll say it again, of all the dominoes to fall, if you could only do one thing, option A is eat better, option B is exercise more. Option C is reduce your stress, or D is improve your sleep duration of quality. Far and away, do your sleep, folks. That is the one that has the most bang for the buck, and really has the best research behind it. Obviously, I want you doing all four of those.

Then on the resistance training, I don't look the part, but I definitely do resistance training. I don't have the physique that you have and people who do CrossFit and other things. But the reason is important for me is I get, let's just say, I'm closer to 50 than I am 30. Number one, weight training boosts testosterone for men and women. I've learned a lot about that in the last year through my coursework and training.

Low testosterone correlates with pain, joint pain. There are testosterone receptors in the joints, in our cartilage cells, and it's critical. Our testosterone drops naturally for men, but women also, it's a very important hormone for them. The natural ways to boost it far and away, one of the best ones is weight training, particularly for women as well. I talked with Dr. Plummer about this on my last episode on bone health, and we'll link to that as well.

The resistance training builds bone. Swimming doesn't, walking does, but let's be honest, not really, not much. I don't see it. I know in the literature it does, but if you really want to build bone density, weight train. You can do it safely, that's another reason to bring you back on the show. We can maybe talk about free weights versus bands, all those things that are out there. There's a lot of stuff that's out there.

Tanner Holden:

That'd be fun.

Dr. Sanjiv Lakhia:

Yeah. I really like that. The other thing with resistance training, it helps normalize blood sugar. There's research that it lowers the risk of depression. There are some head-to-head studies with cardiovascular fitness in terms of longevity and mortality that are very interesting. I think it can be a little more efficient for people.

It doesn't take long to get a really good total body workout in, and frankly, it just makes you feel good and look good. I really like that. I'm glad you brought that up. When I interviewed Ryan Klomparens and even Jay Murugavel, other PTs in our group, they always had a favorite app. Ryan talked about the Ready State, I think.

Tanner Holden:

Okay. Yeah, yeah.

Dr. Sanjiv Lakhia:

Kelly Starrett.

Tanner Holden:

Yep. Yep.

Dr. Sanjiv Lakhia:

We can link to his work. Mind Pump, do you have any of that you love, or not really?

Tanner Holden:

Yeah. Mine, the app that I love is actually a boring one, but MacroFactor, it's actually a nutrition tracking app. There's another one out there called MyFitnessPal, which most people will be familiar with.

But MacroFactor is a newer and frankly, better version, but it helps me keep track of my protein, carbohydrates, and fat intake. Haven't been using it recently as nearly as much as I should, but it is one that I love. I love the interface and I love just how easy it lets me track those things.

Dr. Sanjiv Lakhia:

How do you keep track of your fitness, or are you just on autopilot and you do what you do?

Tanner Holden:

Combination of Excel, so I'm old school. I'll type it out in Excel, and I have some templates that I've created for myself, that I can fill in and track that way, and never really runs out.

You can have so many different cells in Excel, so it goes on and on forever. That's typically how I'm tracking it.

Dr. Sanjiv Lakhia:

What's your calendar? Are you doing three days a week strength and some cardio, or how do you break it up?

Tanner Holden:

Yeah. I'd say at minimum, three days a week of strength training. That's just purely strength training where I'm taking a fair amount of rest between sets and lifting fairly heavy weights, relatively heavy weights.

A few of those other days are spent doing CrossFit, which is a combination of very high-intensity cardiovascular movements and strength, and other fitness movements, kind of combines all those things in one.

Dr. Sanjiv Lakhia:

Awesome. All right, my friend, I'll let you go here. I know you want to get home and work on that sleep optimization.

Tanner Holden:

Yeah.

Dr. Sanjiv Lakhia:

Yeah, that recovery. Thanks for a terrific episode. It was packed with a lot of useful information for people who are struggling with SI joint pain, and just wanting to improve their health and fitness. I look forward to having you back on the show in the future.

Tanner Holden:

Awesome. Thanks so much.

Voiceover:

Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery & Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com.

We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.