Sacroiliac

[sarah001]

Hello everyone, I'm hoping someone can shed some light on a very longstanding and painful problem I have. My right sacroiliac joint is very loose and frequently gets stuck in anterior rotation, I see an excellent physio who aligns it but it doesn't stay there for more than a day. My concern is the left side, the muscles of the leg (all of them, hamstrings, rectus femoris, vastus lateralis, adductors, peroneals and calves, TFL) are all much stronger and tighter than the right side and will not release, I also find when I try to do hip extensions on the left side the leg always laterally rotates and abducts, I have less range of extension when compared to the right side and it feels like it drags the entire pelvis with the leg and twists my back, it also hurts the right SI joint each time I try to extend the leg. When laying supine I cannot lift the left leg in a straight leg raise without the whole pelvis shifting and the right side rotating anteriorly and with a bent leg it does the same but to a lesser degree. In your opinion does this imply the left side is stuck? And what position would it indicate from the details above? Thanks in advance.

Similar Threads:

• Sacroiliac joint i think ?
• Sacroiliac pain SIJ
• Sacroiliac Joint Assessment
• Sacroiliac hell, any ideas anyone?
• sacroiliac joint dysfunction

[karen.hankey]

Hi Sarah,

Its all well and good releasing the sacroliliac joint, but unless you strengthen around the area to keep it in that position, then as it is doing, it will just revert back to causing you pain. Your opposite side will be working overtime to take some of the pressure off the injured area, which is why the muscles won't release.

I would initially strengthen the abdominals with pelvic floor type exercises, then stengthen Glut Med for stability.

[alophysio]

Hi Sarah,

There are some articles on Diane Lee's website which you should read. The one about the stork test and Active Straight Leg Raise is one in particular that will be helpful.

It sounds like your deep hip external rotators are too active. Who knows why. Karen is right when she suggests to stengthen the deep abdominals.

Having said all of that, it does sound like your LEFT SIJ is dysfunctional...it may be causing the right SIJ to anteriorly rotate because the movement is not coming from the left hip, SIJ and L/S. Thus the pelvis is rotating from the right SIJ...

Good luck!

[sarah001]

Hello there, thanks for your reply. My left side does tend to go into outflare and the right side goes inflare with anterior rotation too. I agree about my hip rotators, they hurt too but are refusing to release as the area is so unstable. I tried glute medius training but the medius just wouldn't respond and burnt when I tried to exercise it or the TFL completely took over instead so I'm struggling through basic core stability exercises right now. I find my transversus abs contraction is hit and miss right now, sometimes I get it right and other times I don't but I'm working on it! I have Diane Lee's book "The Pelvic Girdle" and it's very useful but my physio uses the stork test amongst others to check me regularly anyway.
Would the inflare/outflare situation cause the left side to rotate the right in hip extension do you think? I would have thought the outflare side would have had more extension than the inflare side but I'm not really sure.

[alophysio]

Ok,

Firstly, you sound like a physio, esp if you have Diane Lee's text.

Secondly, outflare/inflare is based on muscular control. You will often find an outflare (PSIS moving laterally relative to the other side) will correct with a good lumbar multifidus contraction.

Thridly, it sounds like something else is driving your lumbopelvic hip problems.

I am not really an advocate of 'unstable' unless you can demonstrate on u/s that a good core contraction still leads to excessive, uncontrolled joint motion. However, having said tht, your hip muscles don't want to let go for some reason. They usually don't act in isolation - what is the co-contracting muscle?? It sounds like TFL is dominating the hip.

Your core stability exercises shouldn't be so difficult. If it is, there is an underlying issue that is unresolved, probably apart from the SIJ. Have your thorax checked. The answer may lie there. Also, how do you know if you are doing the exercises right or not? On what evidence are you basing this on?

In general, it sounds like you have a MET background but in my experience, if you have to keep fiddling with correcting your pelvis, you aren't hitting the right buttons - check your diagnosis and consider what other possible areas of dysfunction might be at play. i find that it should only take 1-3 sessions at the most to sort out a pelvic dysfunction - if i have to keep going back to it, i have missed the primary driving factor. If you read Diane Lee's text, you will find that there is not much emphasis on positional diagnoses but rather a functional one.

Where in the world are you from? Also, have you seen Peter O'Sullivan's work on classification of NSLBP??

Thanks - looking forward to more information from you. ACtually, can you please provide a more complete history on what your problems are? Thanks

[sarah001]

Hi again,

I can assure you I'm not a physio, just a very long term patient so I've researched to try to help myself!

You're right about the TFL, it is seriously dominant, especially on the left side. My physio watches me do exercises to check what's going on and even with a contraction of the core the pelvis moves around during movement, especially during hip extension. She has also worked on my neck (which was very tight) to release that and manipulates my thoracic spine each time I see her as that gets tight too. One of my shoulders wings but she says that's not unusual with pelvic problems. A pilates instructor tried to help me stretch the TFL/IT bands but my pelvis wouldn't stay still to even get into position so she gave up, and the standing stretch I've been trying to do just ends up not hitting the TFL much but letting everything else twist out of place so I've stopped that.

I think one reason the muscles won't release is I'm in dire need of glute max and medius work but the hamstrings dominate the glute max during all extension exercises and bridging too and the pelvis rotates into anterior rotation and/or twists no matter what I do. Very frustrating! The glute medius seems to be under so much strain from the TFL and piriformis problems that it can't cope with small things never mind trying to strengthen, so it just seems to be a vicious cycle.

I did once have my physio do MET on the rectus femoris of both sides and the hamstrings and this helped but for a very short time.

During the stork test I am unable to balance on the right leg (worst side) and with the left side I can balance but not great. When I lift the legs up during this test I get a shuddering all the way up the torso which no-one has been able to explain too. ASLR testing is impossible, I can get the right side up but with a rotation of the pelvis towards the opposite side but the left side feels very heavy and won't even come off the table without the right side of the pelvis rolling forwards and popping painfully.

I live in the UK and I haven't read any of Peter O'Sullivan's work so if there's anywhere online I can have a look I'd like to, I'll google him.

My sacroiliac joints are sharply painful to the touch, lumbar spine is stiff with the right side erector spinae so tight my physio struggles to do the flank stretch (she also tells me the lumbar spine gets fixed in a rotated position), right shoulder (one that wings) is painful and IT bands also hurt both sides. My peroneals are also sore and tend to get cramp during any attempt to do glute medius work. My hips hurt but not deep in the joint itself more where the piriformis attaches and around the TFL area. Hamstrings are dominant but not painful, rectus femoris is sore and tight, glute max is weak and hurts, likewise with the glute medius. I hope I've told you relevant info and not just waffled on to you!

Thanks for the interest, after 3 physios, 2 osteos and 2 chiros all giving up on me it's nice for someone to try and help so thanks!

[sarah001]

Hi again,

I can assure you I'm not a physio, just a very long term patient so I've researched to try to help myself!

You're right about the TFL, it is seriously dominant, especially on the left side. My physio watches me do exercises to check what's going on and even with a contraction of the core the pelvis moves around during movement, especially during hip extension. She has also worked on my neck (which was very tight) to release that and manipulates my thoracic spine each time I see her as that gets tight too. One of my shoulders wings but she says that's not unusual with pelvic problems. A pilates instructor tried to help me stretch the TFL/IT bands but my pelvis wouldn't stay still to even get into position so she gave up, and the standing stretch I've been trying to do just ends up not hitting the TFL much but letting everything else twist out of place so I've stopped that.

I think one reason the muscles won't release is I'm in dire need of glute max and medius work but the hamstrings dominate the glute max during all extension exercises and bridging too and the pelvis rotates into anterior rotation and/or twists no matter what I do. Very frustrating! The glute medius seems to be under so much strain from the TFL and piriformis problems that it can't cope with small things never mind trying to strengthen, so it just seems to be a vicious cycle.

I did once have my physio do MET on the rectus femoris of both sides and the hamstrings and this helped but for a very short time.

During the stork test I am unable to balance on the right leg (worst side) and with the left side I can balance but not great. When I lift the legs up during this test I get a shuddering all the way up the torso which no-one has been able to explain too. ASLR testing is impossible, I can get the right side up but with a rotation of the pelvis towards the opposite side but the left side feels very heavy and won't even come off the table without the right side of the pelvis rolling forwards and popping painfully.

I live in eastern UK and I haven't read any of Peter O'Sullivan's work so if there's anywhere online I can have a look I'd like to, I'll google him.

My sacroiliac joints are sharply painful to the touch, lumbar spine is stiff with the right side erector spinae so tight my physio struggles to do the flank stretch (she also tells me the lumbar spine gets fixed in a rotated position), right shoulder (one that wings) is painful and IT bands also hurt both sides. My peroneals are also sore and tend to get cramp during any attempt to do glute medius work. My hips hurt but not deep in the joint itself more where the piriformis attaches and around the TFL area. Hamstrings are dominant but not painful, rectus femoris is sore and tight, glute max is weak and hurts, likewise with the glute medius. I hope I've told you relevant info and not just waffled on to you! If I've missed vital stuff let me know.

Thanks for the interest, after 3 physios, 2 osteos and 2 chiros all giving up on me it's nice for someone to try and help so thanks again!

[alophysio]

how are you going?

[sarah001]

Hi there,
I have found a better TFL stretch to do that keeps a stable pelvis whilst I'm doing it and I've found my hip extension improves for long enough afterwards to do hip extension without using lumbar extension and a twist to get the legs back. Hopefully this will help the glute max to strengthen and the glute medius to remember to work! I'm pretty sure that the lack of isolated movement in the hips (especially the left one) is seriously contributing to keeping the problem going and although I know it will take me a while to begin to correct this I'm determined. Thanks so much for your interest and all the info you've given me. I'll let you know how I go.
Sarah

[alophysio]

No Problem.

I could have sworn i replied to the earlier post...

OK..

1. TFL dominating... Don't do standard "Clams" exercises for glut med - usually the position taught is sidelying and hip over hip, shoulder over shoulder. If you are TFL dominant, this will reinforce the pattern. I am glad you have found a stretch but as you have probably found out, it is only a short term solution. It is unlikely it needs to be stretched, more like it needs whatever is making it dominant sorted out. Excessive L/S lordosis, anterior pelvic tilt or tight hip flexors (rectus fem) will do that.

2. Shuddering is likely to be the psoas grabbing and trying to stabilise at the same time. Likely to be overactive as well.

3. The thoracic spine needing manipulation all the time is likely to be the long erector spinae muscles pulling excessively and jamming your joints. This might also cause a flattening of your natural thoracic kyphosis and causing your scapula/e to wing.

4. Have your tried either the stork or ASLR tests with a "core" cue? If not, see how you go. Also, have you tried the compressions for the ASLR?

Overall, you sound like an excessive compression/active extension pattern of pain. If you can find a book by the name of "Grieve's Modern Manual Therapy - 3rd edition", Peter O'Sullivan has an excellent chapter on "clinical instability" that i think you find illuminating. Try to borrow it from a university library where there is a physio school or from a physio who has it.

Can you detail more about what is going on or maybe a photo side on of your posture? Thanks

[sarah001]

Hello again.

With regards the clamshell, a physio gave me this to do over a year ago and I discovered it didn't hit the glute medius with me but not before I'd done lots, I no longer do this one. The rectus femoris is very tight, it feels like a rod of wood in my legs (especially the left side of course) and I suspect I have an anterior tilt to the pelvis as I seem to over extend at the L5 level in place of hip extension.

The psoas doesn't test short but it does test weak. I struggle to hold my leg over 90 degrees for even 10 seconds but each time it's tested for length it's not restricting hip extension. One physio suggested it was seriously weak and being inhibited further by the TFL and rectus femoris?

My thoracic spine doesn't looked particularly rounded but is very flexible into flexion when I bend forward whereas the lumbar area is reluctant to flex much. The shoulders seem to be kept going by overactive upper trapezius which I've been working on by encouraging the lower traps to work, this has helped a little.

Contracting the core makes lifting the right leg in ASLR easier but not the left. Even with the core activated the left leg will not come off the floor without the right side of the pelvis twisting round to the left and rolling into anterior rotation, compression applied at various points on the pelvis doesn't seem to help this either. I always assumed it was because the TFL and rectus femoris of the left leg were far tighter than any of the abdominals, particularly the right external oblique which seems to be weaker than the left.

Posture wise I used to stand with hyper-extended knees but no longer do this (not through fabulous retraining of the muscles but through refusing to let the knees slide into that position), my feet pronate slightly but more so on the right side (weakest glute medius on that side), a bit of anterior pelvic tilt to both sides, lumbar spine seems to look like it is curved only at the very bottom and this is the only area that moves noticably when I extend the spine. Thoracic area looks normal except for my shoulders are rounded forwards but not so much they cause a hump if you know what I mean (?!) I suspect I'm guilty of forward head posture a bit too.

I really find that any movement of the left leg (whether flexing it or attempting to extend the hip or trying to rotate the femur without pelvic movement is impossible and I know that keeping the pelvis still is vital for me. These things happen even with a core contraction, although to a lesser degree. My IT bands are so tight they feel solid, there's absolutely no give in them at all and this is after a good year of trying to get the glute medius to strengthen.

I will try and read a copy of the book you mentioned, I'm very interested in the whole subject but just wish I didn't have to live it! Thanks again for all your help so far.

[alophysio]

Hi - your case sounds so interesting (and frustrating for you).

1. Was the clamshell exercise given to you as described above? Hip over hip, knees bent to 90deg, hips bent to 45deg, heels in line with bottom? If so, that exercise usually reinforces TFL/RectFem (RF) dominance in dysfunctional people. I advocate a position that has you quater-turned onto your tummy, only the top leg bent up and the top arm supporting some weight too (simple base of support reasons).

2. You say your psaos tested weak, not short. How did they test for that? If they did a thomas test, the TFL would drag your knee laterally and not allow for proper testing of your true psaos position. Also, with your pelvis anteriorly rotated, the psoas is lengthened but the RF is shortened so it may allow RF to dominate in that way.

If holding your knee above 90deg in standing is your Psoas test, then you may find that tight hip extensors might add extra "load" to the test etc. Also, your positioning during testing will determine what other muscles are being used.

3. Are you sure that it is upper traps that is overactive? It is usually levator scapulae which is overactive and drags the top inside edge of the scapula upwards and points the bottom of the scapula towards the spine. Upper Traps does lift the scapula but by jamming the clavicle into the sternoclavicular joint then pulling on the clavicle (it doesn't attach to the scapula as most people assume) to outwardly rotate the scapula. Lower traps helps this process by attaching to the spine of the scapula and giving the scapula a place to rotate around. THe biomechanics get a bit complicated but people think the lower traps is a depressor or retractor when in fact it stabilises the scapula then assists to outwardly rotate it.

4. I would like to know more about your movement patterns during bending over and leaning backwards and sideways. It is hard for my minds eye to see what is happening. There are many reasons as to why your L/S may not move much compared to your T/S. Are your erector spinae (ES) muscles co-contracting with your obliques to give you this pattern?

5. The ASLR test results are interesting. Can you tell me if your physio has used this test a lot in the past with other clients? I found it is a fine art to get it right in complicated people - the art is in figuring out what is the relevant information from the test.

Is your starting position in neutral spine. If not, then you are asking for biased results. I use pilows etc to get people in the a good position. If you are in too much extension/anterior pelvic tilt, then EVERYTHING will feel hard to do because it puts your TrAb in a weak pos.

Do the compressions of the ALSR make things harder?? i.e. the left leg is heavy and the pelvis lifts and rotates but is it worse with compressions? If it is, it may indicate EXCESSIVE compression by your muscles (eg multifidus/ES, inferior internal obliques with TrAb). Believe it or not, you can over do your "core muscles"!! The secret is to have ADEQUATE compression, not the most amount possible! Just enough to achieve stability with mobility.

6. Anterior pelvic tilt will drive your knees into hyperextension. Fix the pelvis and the knees whould follow...easier said than done by the sounds of it.

7. Have you tried Trigger point injection therapy? Apparently you inject local anaethestic into the trigger points of the TFL and ITB. It has really helped one of my patient's TFL...

Thank you for all your information. It is only 2 chapters of that book that are about what i am talking about - both by O'Sullivan. The chapter by Diane Lee is similar to the Pelvic Girdle book so it doesn't really matter.

Keep us informed of how you are going!

[ginger]

from your descriptions of symptoms you have an assortment of altered sensations and patterns of recruitment in your lower limbs, as would be expected from a low back stiffness problem, leading to irritation of nerves that arise near to joints. This is a common condition that is the natural and non pathological product of protective responses in and around spinal facet joints. The suggestions put forward that these events are somehow linked to perceptions of alignement or position of the sacro iliac joints are misleading. It would appear you have been mislead by a physio making claims about being able to interpret your condition on the basis of ilial or sacral postures. This is a spurious and nonsensical relationship which has only the loosest connection to the reality of SIJ dynamics. Sacro iliac joints are somtimes implicated as biomechanicaly connected to lumbar protective responses and thereby to pain etc. To suggest however that these largely immobile ( though important ) joints can be "aligned " is the stuff of the purest fantasy.
Find a physiotherapist who is able to , by measured and skillfull attentions to the lumbar spine , turn of protective events there and you will find the means to a realistic way out of your painfull ( and doubtless confusing ) situation

[alophysio]

Hi Ginger,

From what i understand, Sarah001's physio has looked at the L/S but for illustrative purposes, would you try to mobilise the facet joint first to release the spasm of the ES on the right or would you try to release the muscle spasm first by some other means and then try to mobilise the joint?

I am wondering if you can get past the thick fascial layer of the ES and then past the lumbar multifidus down to the facet joint (which has some seriously strong ligaments at L5/S1) to begin to mobilise the facet joint...

Thanks

[ginger]

I have no trouble mobilising spinal joints through layers of soft tissues. The first proceedure that I would consider would be to restore normal lumbar facet mobility by reducing protective tone around them, this is best achieved with longest term effect with continuous mobilisation to fact joints. Further attentions to adjacent larger muscle ( MET or trigger point release ) may be warranted under some cirtcumstances , though I rarely find this necessary. By reducing focal irritants to nerve roots in this way , there will be restoration of normal patterns of recruitment to the lower limbs and the "muscle imbalances " will dissapear.

[alophysio]

Thanks for your reply Ginger.

Is it at all possible that the initial period of your mobilisation is the effect on the paraspinal muscles (multifidus etc) before actually effecting joint mobilisation?

Also, in the case of chronic muscle imbalance and resultant morphological changes, do you think that the muscle imbalances will sort themselves out once the facet joints have been sufficiently mobilised?

[ginger]

An observation that tonic changes take place when muscles are stimulated with lateral stretch is of course common place . What is interesting in the physiological changes relating to continuous mobilisation however , is that the changes are more lasting. In addition , the nerve related events that would be presumed to be caused by focal irritants around the nerve root are routinely relieved with Cm in a way that I have not observed with muscle stimulus. Proponents of the trigger point approach have plenty of satisfactory reasons to follow this treatment , however I find best results occur with a combination of muscle and soft tissue release and guided specific passive movements at facet joints. Having not derived my own approach from analysis of others work , so much as rigorous and lengthy observations of cause/effect , it is my opinion, that both treatment methods have merit. Also that both deal to some degree with stretch reflexes. Mobilisation, when done according to the protocol I call CM, allows speedy and long term elimination of referred events. For this reason I use it as a first line therapy, followed up in some cases with attention to other soft tissues at or near joints.
I don't think it will ever be possible to fully resolve the question you pose. What gives me good cause to use mobs regularly and to zero in as best I can on specific lateral masses , is the sense that good results provided this way is best explained , not by stretch reflexes, but by somewhat more complex means.
I know that when my thumbs stray away from the lateral mass, results diminish, strongly suggestive of another physiological player beyond muscle in tonic changes.
Muscles don't become "unbalanced ", muscles only do what they are instructed to do. Patterns of recruitment however , are routinely altered by protective responses leading to joint/nerve irritation. This is routinely restored to normal with effective reductions in those protective responses leading to reductions in tone and subsequent reduction/elimination of focal irritants to nerve roots. I find that discussions heralding these so called imbalances are usually by those who have not experienced these immediate and lasting restorations to normal recruitment at the effect of CM.
One example of this is with PFS. ten minutes of L3 mobs and VMO dysfunction commonly observed, along with pat/fem pain , are gone. This is a permanent change , provided the protective events at L3 are completely turned off.

[sijproblems]

hi alophysio

i was wondering if you can tell me where you are in sydney? i'm also like sarah... i've been everywhere ... spent a house deposit on this stuff and am still suffering. i flew to brisbane to see mark comerford (who is a nice guy, just for the record), only to discover that despite teaching pelvic courses, didn't have much of a clue. i've also seen barbara hungerford, but although she helped me, i think she failed to take into account that my pelvis had been moved excessively because of incorrect diagnosis and treatment by some local physios which resulted in a seriously anteriorly rotated right innominate and a seriously posteriorly rotated left innominate and some what i think was anterior shear of the right ilium with respect to the sacrum .... which i walked around with for many, many months. so i think that she missed a couple of things and i went back and told her but well ... she kind of treated me like my problem hadn't become complicated ... clearly that didn't work so i gave up because of the cost and time travelling to sydney.

i never had SIJ pain but now i have pain in both SI joints. i don't walk like a normal person. after seeing a few more osteos and physios i now am the only person who diagnoses and treats myself which is difficult because it's hard to find people to help me (for them to do the techniques correctly) and it's hard to trust their interpretation of sacral sulcus depth, ILA posterior/anterior/inferior/superior etc., ASIS orientations etc. people say you can't diagnose yourself but i have had the best results from my own interpretation and correction of the misalignments. but i'm a bit stuck now ... and i'm wondering what role the QL, multifidus in particular are playing in what i see is going on with my sacral/ilium orentations.

my sacrum has been moved up and down and all around the place by myself and another lovely physio who tried to help. but like i said, i think the problem is that it's important to listen to the patient regarding their sensations and examine the muscles ... these are things i've learnt along the way. i've been reading the "malalignment syndrome" which has helped me understand the muscular aspects of my problem but despite my best efforts, my pelvis and sacrum sit in non-optimal orientation which causes knee pain and hip pain, back pain and a weird gait. i feel that if i could step out of my body and examine myself i would have more of a chance of nutting out what's going on.

i;ve started doing pilates. i'm guessing that the ligaments and muscles which hold the ilium to the sacrum are now structurally compromised.

so if you could tell me where you are in sydney, i can consider coming to see you. i'm currently doing a masters but plan to start a phd in the biomechanics of pelvic misalignment next year ... out of shear frustration and desperation.

thanks so much

[sijproblems]

i'd like to comment just on the technical aspect of the sacrum not being able to move with respect to the iliums ... i have experienced, with my previous physio, that if he pushed my sacrum down with respect to my iliums, i experienced a very interesting gait pattern (both femurs rotated laterally) and subsequent medial knee pain on both knees. upon pushing my sacrum up (which i had to do to relieve this gait pattern) the knee pain disappeared and my gait was retored to something more "normal". if the sacrum was pushed too high, i felt pain in the lumber spinal region.

however, i do agree that the muscles attaching to the iliums and sacrum can and do affect gait patterns ... which is now why i pay particular attention to muscles like my QL.

i understand that the muscles respond to something ... but i am also sure that my sacrum and iliums can and have been seriously rotated/moved in the past to directly affect my gait ... as, i suspect, a response of muscles to changes in structural orientation of bones.

if you think that your sacrum cannot move up or down or your ilums cannot be rotated, i propose you to try getting somebody to push down (inferiorly) on your sacrum, or anteriorly or posteriorly rotate one of your iliums using a muscle energy technique or brut force and see what happens. of course, first orientating the femur in such a way which facilitates opening of the SI joint.

i would love to see some of the experts have their SI joints manipulated as excessively as mine have been (out of a lack of understanding of the problem) and then try to tell me that restoring correct function and alignment is not that difficult... and that the ilium doesn't rotate THAT much. i understand that alot of the sensation of a rotation etc can be a result of a muscular response to a "slight" change in SI joint orientation, but i propose that hte ilium can move more than expected with respect to the sacrum... if enough force is applied.... which is what happened to me in the beginning by some unsuspecting health professionals

of course this kind of manipulation shouldn't have happened in the first place. but before all that happened, there was one sensation that i experience after the accident which confirms my belief that my sacrum had reorientated itself with respect to my left ilium in particular ... barbara hungerford corrected that "fixation" and now that side has the ability to pop like the other side does if i perform a certain test on myself... previously, this was not possible.

it seems to be that from being out of wack so badly for so long, i actually suspect that i do have some soft tissue changes in the facia or muscle attachments, in particular .. the iliac crest for glut medius, obligues, QL....it's kind of knotty ... which i believe could be forcing my weird gait sensations.

[alophysio]

Hi sijproblems,

It would be of help for anyone reading this to have some of your history (when did it start etc) and treatment approaches.

Also, what is your professional background? Is it medical in nature or something else?

Thanks!

[msk101]

HI All,

I would like to ask the pelvic specialists amongst you about the merits of pelvic/trochanteric belts.

I have been interested to read the posts on this issue and know that pelvic girdle examination and treatment is not my strongest point. I have definitely found that troch belts can be really useful with SIJ pain in pregnancy and was wondering if something along these lines would be useful to provide some external stability to the pelvis thereby allowing strengthening exercises to be done more effectively if the pelvis is just too "unstable" to allow them otherwise??? but not as a long term solution as such.

Looking forward to your input.

Thanks
msk101

[sijproblems]

Hi sarah … sorry I was so self absorbed I forgot to look at what you wrote …

I think I know what your problem might be … you’re describing what happened to me which BH alluded me to. I can suggest that “perhaps” you might have your sacrum in anterior fixation on the left, which is accompanied by an upslip and a posterior rotation on the left. Or at least, at the very least, it sounds like you might have an upslip on the left which is causing all these muscles on the left leg to tighten up. Do you have knee pain on the left? Another question that I have is, no matter what you do, can you get your left SIJ to pop or not?

The symptoms you describe, shoulder pain on the right etc and all those tight muscles on the left leg is what I had … is it your left leg that feels shorter?

Regarding the right side, she told me that if the left is dysfunctional, the right side tends to “overactive” to compensate. But for me, this is all old news since now both sides of my pelvis are a bit of a dogs breakfast.

Anyways, hope this helps.

[sijproblems]

hi alophysio

firstly, sorry for my spelling. i'm an engineer so hopefully can be forgiven :-)

well, my history is long. but now, so much has happened ... i think i'd exceed my character limit on this website if i explained it all. originally it was a snowboarding accident in switzerland where i studied for two years. original pain was thoracic , left knee and left foot pain although i had no impact to the knee or foot in teh accident. i just realised that after the accident, i couldn't run at all without terrible knee pain. i realise now it was due to a biomechanical change in my gait as a result of a pelvic misalignment. initally i saw a few orthopedic surgeons and sports doctors, and chiros and physios in switzerland ... most of them associated with the swiss olympic ski team ... poor ski team. they'd do an MRI on my knee and couldn't find anything ... and and sports doctor and knee doctor finally refused to see me, they thought i was crackers. also i had this terrible shoulder pain and clicking of my ribs into my sternum and spine .. it was hell. then one of the doctors gave me a terribly lame diagnosis of arthritis and suggested a course of pain killers for like 3 months....funny hey.

finally i came back to australia out of dispair and desperation. went to see some chiros and physios again. until that time, i could still walk long distances with the misalignment (at this stage me nor anybody i saw knew all my problems was a result of a pelvic misalignment). anyways, in switzerlnad i was still able to hike for 7 hours in the mountains but i could no longer ski or run without knee pain.

anyways, back in oz, a few chiros, massage therpists, physios and exercise physiologist later, i saw a chiro who did an adjustment and created a very ugly situation in my left leg... i started to get symptoms like sarah was describing. then i went back to see him adn he did something which created an ugly situation in my right side of my pelvis. after that i could no longer walk for long distances... it was hell. that's when i started doing my own research ... three months later, i figured out that the problem originated in my pelvis. then i went to see some physios in my local area who had done a course ... but i think the problem was that htey failed to take into consideration teh orientation of my sacrum. what they did do subsequently created excessive posterior rotation of my left innominate and excessive anterior rotation of my right innominate. then i went to see well, MC and BH and then a few other physios and an osteopath and now i run on my own steam... since i got pain i never had before and i walk like ... really a bit funny... although, like it said, it's improved alot since i do my own diagnosis and adjustments.. the right anterior hip pain has practically gone.

my background is engineering ... i'm currently doing a masters ... but alot of my spare time and not so spare time is trying to get my hands on literature pertaining to lumbo-pelvic dysfunction ... so it's useful being at uni, having access to all libraries in australia and many on-line journals.

i plan to do a phd in the biomechanics of the pelvis starting next year. but obviously my supervisor has already suggested me doing many physio courses, which i will embrace with gusto. i have some understanding of how cells respond to load and tissue repair from my time studying biotechnology in switzerland.

thanx a mil

[sijproblems]

hi

sorry i was a bit mad yesterday ... as you can see. i went on a bit, can get like that sometimes ... where i put my focus upon the failings i've experienced so far. but that doesn't help me - blaming the shortcomings of others. i also know i'm not perfect and my impatience/desperation has probably gotten me in this worse situation... being persistant with physios etc. so i wanted to outline the problems now.

the original accident was january 1st 2005. i think that having my right ilium in excessive anterior rotation and possibly forward shear for about 8 months from nov 2007-june 2008 has created some soft tissue or muscle thing that's causing me to walk funny on the right (originally i felt no problems on the right for almost 3 years until i saw the chiro and physios towards the end of last year). walk funny ... well it's not so bad now but there's still something weird going on with the gait and i have pain in my right leg which seems to extend from hip to knee ... seems like a combination of ITB and lateral side of hamstrings type area. also i have SIJ pain on the right but that occurred after too much manipulation on the right to try to get these shear/rotation out of hte right side. there are some schools of thought that say that anterior shear of the ilium is not possible but i know what adjustment caused that sensation in teh first place so i don't know ...

my left leg feels short and my right leg long. despite the fact that i think now that my right side might be slightly posteriorly rotated and/or outflared (again ... i know some schools of thought who say on outflare is not possible ... but that's what i see). but i don't move it from that position at the moment.

lying down, also, no matter what, my right ILA is inferior (no matter how much i try to push it superiorly), and well, if i can trust what my friend says, anterior ... but there have been periods where it's been stuck posterior no matter what. i understand that this could be a piriformus thing and also i was wondering, since the multifidis attaches there ... if it could be keeping the ILA posterior at that location ...

i know BH also can attribute tightness in the coccygeus muscle to some things witnessed by some in the orientation of a sacrum. but i have't had enough experience to know.

my sacral suclus is deep on the right, no matter what i do. the ichial tuberosity on the right is inferior (so this combination of inferior right ILA and ichial tuberosity could be what's causing the right leg to feel long, despite it's slight/possible posterior rotation). so that leads met to think that there could be some ligament stuff going on at L5/S1 which is allowing the right side to be inferior.... but my QL is tight on the right ... which in theory lifts the back of the iliac crest superior, which could keep my right side in an anterior position despite when i see it posterior when lying down.

thoracic pain is excessive ... but BH corrected a right superior first rib and posteriorly fixated 3rd and 4th ribs. not sure if it worked, still feel a bit of pain there, which she attributed to overactivation of the upper abdominal muscles ... i know that i do overactive the upper abdominal muscles.

i am also hypermobile in some muscles and not in others. abductors are sore but hypermobile, hamstrings are tight, tight, tight on both sides. piriformis ... the stretch indicates left is tighter but the physio told me the right is tighter. ITB is tighter on the left, despite this right leg pain from hip to knee.

so for the moment i don't adjust more my SI joints. (oops, pubic symphis is ok). now i focus on pilates to strengthen core and lengthen and strengthen limb muscles. also i get some massage to help me identify tight and weak muscle patterns to see if i can explain from this what i see in my orientation of pubic bones. i also conciously concentrate on my gait patterns to override modified motor control... i notice if i go off guard, muscle compensation patterns kick in more .. hence a more funny walk :-)

thanx a mil

[alophysio]

Thanks msk101 and sijproblems.

msk101 - pelvic belts help but the issue is whether the SIJ needs compression or not. I think you will find that in pregnant ladies, they will often help because it is usually a combination of the relaxin and baby's head pushing the joints apart. But in non-pregnant patients, it depends on your assessment findings.

sijprobelms, thanks for your history. It would be interesting to assess you because of the fall - i have some questions if i may...

1. You seem convinced that the primary lesion is the SIJ - no doubt after all this time, there is a lesion (problem) there but i am wondering if it is induced from something else...

2. When you do a self-adjustment or other form of treatment to yourself, how long, on average, does the relief last - the more specific you can be here the better. Usually if the relief is seconds, minutes or hours (less than 24-48) than the problem is usually from somewhere else.

3. i believe you when you say you ilium is twisted a certain way and your sacrum is twisted in a different way. The difficulty for anyone who is going to assess you is that *normal* morphology in bones is more likely to asymmetrical than symmetrical. Therefore things like ILA, SS depth, etc *might* be unreliable. I say might because i still use them, i just understand their limitations. Research has shown that "correction" with a manual therapy change agreed upon by experienced therapists showed no change on XR with RSA. The reference is Tullberg T et al (1998) Spine Volume 23(10), 15 May 1998, pp 1124-1128.

4. Apart from BH, has anyone else ever looked at your T/S properly? To me, from your history, that is the first place i would expect to treat. You still have pain there - you use the word "excessive" to describe it. It is entirely possible that IT is the primary which is why no matter what you do, your sacral treatments do not change the orientation. The muscles that attach to the ribs attach to the sacrum and iliac crest. The abdominals like external oblique attach all the way up to rib 5 and interdigitate with the serratus anterior. Also, fascially, there are connections from the T/S muscles down to the feet. I once fixed an "ankle sprain" that wasn't getting better by treating the rib on that side - the pain in the ankle stopped...

5. "Tight" and "overactive" are often used interchangeably by people (including physios who should know better!). Often a muscle described as "tight" is just overactive because it is in a protective spasm. A truly tight muscle will be the same length when you are passive - best done under aneasthetic (but impractical!).

ANyway, these are just some of the issues that came to mind when reading your posts...

Cheers