Let me guess, you’re here because you have sit bone pain. Whether you want to call them sit bones, sitting bones, or even sitz bones, (By the way, “sitz” comes from German verb “sitzen,” meaning “to sit.”) what we’re talking about are technically called the ischial tuberosities. Ischial refers to the name of the area of bone on your pelvis and a tuberosity is a large bump. Your sit bone pain is real and I’m sure you want to know what to do about it.
How best to manage sit bone pain depends on the cause of the pain. I’ve learned from working with many clients and students that what we think is the cause of sit bone pain and what the cause really is are often two different things.
In fact, figuring out the cause of sit bone pain can be the trickiest part of managing it! If you can’t figure out what caused it, then you might choose the wrong way of working with your sit bone pain, all the while wondering why it never gets any better. You can always check out my original article on sit bone pain here.
Sit bone pain can come from any of the following:
- Overdoing forward bends in yoga and creating general inflammation at the hamstring attachment.
- Over stretching (tearing) a hamstring which usually happens with an audible pop.
- Trigger points that are referring into the sit bone area.
- Adductor magnus strain.
- A running related strain or injury.
What Does it feel like?
There are some important questions you may want to ask to help identify the source of your sit bone pain.
Is the pain sharp and only when you forward bend?
Does it feel like a dull ache that includes a larger area than the sit bone itself? In other words is it your sit bone and sometimes also radiating lower, perhaps the back or side of the leg?
Does it come on after sitting in a particular position for a while?
Does the pain come and go regardless of activity?
Does the pain go away when you practice yoga or do other activities?
Do you remember the moment that this began?
Has it changed since that moment if you remember?
What & where are the sit bones?
What are the sit bones?
As I mentioned, what we commonly refer to as our “sit bones or sitting bones” are more technically called the ischial tuberosities.
Ischial refers to the ischium, which is the posterior (back), inferior (lower) portion of the three fused bones that make up the pelvis.
Tuberosity refers to a large raised bump on a bone.
Where are they located?
The ischial tuberosities are boney bumps located on the posterior (back) side of the ischium.
We call them sitting bones because if you were sitting “properly” your pelvis would have a slight anterior tilt and hopefully you would be sitting on your sit bones! When we slouch and tuck our pelvis under we are also adding weight to the sacrum and or the coccyx (tail-bone).
Attachments to the sit bones
There are a number of important muscles and other structures that attach to the ischial tuberosities. They include each of the hamstrings (semimembranosus, semitendinosus, and biceps femoris-long head), adductor magnus, and the sacrotuberous ligament.
The gluteus maximus wraps over the top of the ischial tuberosity to attach from the iliotibial band (IT band) to the sacrum.
Let’s take a look at each of the muscles and how they possibly relate to sit bone pain.
The hamstrings are probably the muscles in this group that we’re most familiar with. These three muscles attach to the ischial tuberosity at their proximal (top) end. At their distal (lower) end, they cross the knee joint.
Because of their direct connection to the sit bone, repeated engagement, rapid engagement or stretching of these muscles can lead to inflammation or irritation of the boney attachment area. My observations are that chronically tight hamstrings that lead people to struggle and strain too much, especially in forward bending, can lead to irritation.
Hamstrings that are engaged while stretching may also lead to sit bone pain.
Adductor magnus is sometimes referred to as the fourth hamstring because it also attaches to the ischial tuberosity at its proximal end and a portion of its fibers extend the hip joint.
The most likely reasons for a sit bone injury at the adductor magnus are either being over-adjusted or simply going too far in a wide leg forward bend (upavishta konasana, or prasarita padottanasana).
The sacrotuberous ligament is a thick ligament that connects the sacrum to the ischial tuberosity. The tissue of sacrotuberous ligament is part of the same connective tissue as the paraspinal muscles that then becomes tissue that runs over the sacrum to connect to the ischial tuberosity and finally become the tendons of the hamstrings.
Although it is possible to injure this ligament, usually during some kind of sports activity, injuries tend not to occur at the sit bone attachment. This ligament is far less likely than either the hamstrings or adductor magnus to be the culprit in sit bone pain.
Sit bone pain
Why might you experience pain at or around the sit bones?
Sit bone pain is not uncommon even for those that don’t have a yoga practice. It is also common among activities that require running, such as soccer.
There are a couple of overlapping issues related to sit bone pain, so it can be coming from a number of different places. Figuring it out isn’t always so easy. However, there are a couple of scenarios that are somewhat common. Which scenario is occurring will change the way in which you work with sit bone pain.
Hamstring Tear or Irritation
One likely culprit if you are experiencing sit bone pain is a torn, irritated, or inflamed hamstring.
Clues that suggest the hamstrings are involved:
- There was an audible “popping sound when the original injury occurred.
- Pain is felt at the sit bones when forward bending, but only when keeping the legs together, not when stepping the legs wide
- The area of the hamstrings just above the knee joint is also sore when palpated
- It hurts when sitting for long periods
How to modify practice for suspected hamstring tear or irritation?
- Try keeping the legs straight when forward bending (best when doing the seated version). Lengthen the spine and get the pelvis to tilt forward, but only fold to the point where you begin to feel sensation. This keeps consistent tension throughout the hamstrings rather than directing additional pressure into the already sore attachments.
- Another technique that can be used in forward bending while doing sun salutations is to bend the knees slightly as your hands go down to the floor. Then, lean about half of your body weight into your hands. By taking the weight into the hands, you take it from the feet, and the hamstrings don’t have to contract as strongly to keep you from falling forward.
- You can bend the knees when transitioning in or out of standing postures and then straighten the legs again once in the posture. One student reported that using a strap around her feet during seated forward bends, when her legs were straight, helped her keep even pressure throughout the hamstrings and significantly reduced her sit bone pain.
- Try a PNF technique for re-balancing the tension between the quadriceps and the hamstrings
This exercise is appropriate for someone experiencing generally achy hamstrings and/or mild sit bone pain. If you’re experiencing more intense sit bone pain, explore some of the other contributing factors and modifications first. This is an exercise that I usually give to students at the end of practice as it seems particularly effective when the tissues are warmed up, however, you could really do it anytime.
You can read an explanation in this article or watch the video on this technique below.
Another possibility if you’re experiencing sit bone pain is trigger points.
Clues that suggest trigger points could be involved:
- Sit bone pain comes on and/or increases when sitting for a long time, in a car, a long flight, or even just in a chair
- Palpation of gluteus minimus or gluteus medius reproduces the pain sensation
It’s important to note that trigger points can accompany other contributors to sit bone pain. It’s possible to have torn or inflamed muscles (hamstrings or adductor magnus) and also have trigger points contributing to pain sensations. It’s also possible that tension in the piriformis muscle is contributing to this pain pattern.
How to work with trigger points?
You can check your own muscles by placing a tennis ball where you see the X’s in the diagram and leaning some pressure into that spot with your body weight. You may also want to start with a larger or softer massage therapy ball if you are feeling a lot of sensation from trigger points.
Additionally, seek out a qualified massage or neuromuscular therapist.
A final possibility for contributions to sit bone pain is a torn, irritated, or inflamed adductor magnus.
Clues that adductor magnus might be contributing to pain:
- Sit bone pain is felt in forward bending, but only when the legs are stepped wide, not when they are kept together. Students have also reported sit bone pain in other postures like trikonasana that could indicate a torn or inflamed adductor magnus is contributing to pain sensations.
How to modify practice for suspected adductor magnus tear or irritation?
- Work wide-leg forward bends into your practice to continue stretching the adductors, but don’t fold as deeply. Keep light steady pressure on the muscles and go only as far as you can go without experiencing pain.
Remember that muscles will tend to lengthen as they warm up during movement. The sensations of pain may change as you warm up during practice, so be cautious about not overdoing the stretch as the muscles may also tighten somewhat as they cool down after practice.