back/sij problems

[doctor]

Please could someone explain my strange back symptoms? I have had long standing SIJ problems on the right and have seen a physio in the past that may have done one too many manips. As a result of the last one ( a type of horizontal shear) I instantly felt pain around the iliolumbar ligament and L4, L5 became very tight, with a very tight QL and Erec Spinae. This now alternates, day to day with my right lumbar pain and RSIJ symptoms, and both never occur on the same day. You name it, everything is tight -psoas, adductors, quads, lumbo/thoracic junction. I have lots of problems transfering load from one leg to the other, and very poor rotational control. I have a sway back posture (but working on it!) and dominant external obliques and gluts that seem not to work. I am seeing a experienced physio who is working through my problems, but my RSIJ keeps on unlocking, no matter what I do. After a session on the reformer it locks, only to unlock the next day. Would love to know any thoughts on this alternating side back pain pattern and also about this unlocking. Is it possible that I am flogging a dead horse and this right side will never "lock" and I just need to move on? The scarum seems to like a right anterior position, and my Symph pubis sits higher on the right but corrects iteslf with squeezing a ball between my legs. MRIs are normal. Thanks.

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[doctor]

wow...41 views but no replies? Do you guys need more information? Any help would be hugely appreciated

[alophysio]

hi - ok - i will bite

A few points...

1. you name structures confidently and have the name "doctor" - waht is your background? It doesn't really matter to me but it might put other people off...
2. You believe everything is "tight" but it is likely to be overactive
3. The problem alternates which indicates to me that it is likely to be a myofascial or neural (motor control) type of problem rather than a fixed joint. I suppose it could be a joint which has too much laxity from exceiive manips...
4. You state you can't transfer load efficiently and have trouble controlling rotation - again, see point 3 above
5. You believe your RSIJ keeps unlocking - why is that - what test and how is it done that convinces you of this?
6. You can get it to lock doing exercises - see point 3 above!
7. Summary - you are a motor control and myofascial problem - multi joint

Lots of retraining is needed on normal movement, posture and letting the resting tension of some muscles calm down.

It is way too hard to solve over the internet unless someone over there knows what they are doing.

Also, the above is my best guess based on the information you have given me.

Cheers!

[doctor]

Dear Alophysio,

Thanks very much for replying. I am a medical doctor -an endocrinologist, so not much experience of the biomechanics of the back or pelvis. I hope I haven't put too many people off by saying I am a doctor -thought it might allow people to use medical terminology more freely as I will understand it. I hope that me being a doctor doesn't put people off -allied health professionals and all that!
I hope if I can address each point you made you may be able to expand a little -I find this area very complex.

2.) The areas that I mentioned are tight, a term relayed by my physio -but may indeed be overactive. That makes better sense. However I seem to have two main problems 1.) relaxing off the left sided (contralateral back muscles ) through friction or release techniques seem to create more instability in the right SIJ, and that does all sorts of things -anterior rotation/upslip/sacral torsion 2.) when I stretch my quads in prone lying I seem to get pain in the contralateral SIJ(ie if I stretch my left I get pain in my right SIJ.) Would you know why this could be?

3.) You mention that this could be myofascial/neural control problems if this alternates. Excuse my stupidity but can both of these be addressed by rehabilitation?

5.) The test they use is the stork test, where the ilium rises on the "unlocked side", with one leg lifted at 90 degrees in standing.. This seems to be my biggest frustration. It seems no matter how much core exercise/reformer training I do this occurs which creates pain and stiffness.

I guess my real question is, this has been going on for quite a while now, and is it just possible that you cannot gain motor/neural control of this after years of faulty motor patterns. or is it a case of finding the right rehabilitation? I am presuming that the fact my SIJ can "lock" after exercise is a good sign, but I can't seem to keep it there..

Any further thoughts would be appreciated. Thanks.

[alophysio]

Hi Doctor Makes no difference to me who you are, just helps with understanding your background...

...with all due respect though, biomechanical physical therapy jargon can be a different language

All these comments have be taken in the context that i haven't assess you...but i am sure you understand that.

2.i - releasing the left sided back mm is kinda like giving Oxygen to a CO2 dependent breather - the L sided back mm can be compensating for the poor control in the R SIJ - just speculation of course. If you take a compensation away, you better have a good replacement strategy! Based on what you say, it would seem that the L back mm are a secondary problem and the focus should be elsewhere...by all means release the L back mm but only when you are ready to correct the R SIJ and tehn teach it to control itself better than the current strategy - when you release it, apparently you are seeing more "instability" - again, a term not preferred as it infers ligamentous disruption - which you might have - have you had your SIJ joint glides checked to see if local muscle ("core") activation can control the glides? If you can't control the joint glide with a proper "core" contraction, then you may have a disrupted ligamentous system and no amount of treatment will restore the ligaments. Preferred examination would be under real-time unltrasound.

2.ii. the only thing i can think of at the moment (i prefer to see things obviously!) is that you aren't really doing your quads stretch in an isolated way and are actually flexion your knee, extending your hip and causing an intra-pelvic torsion causing "strain" on your SIJ or even rotation in the L/S which may be irritating the disc. The SIJs each have only 1-4 degrees of rotation each and each L/S vertebrae can only rotate about 3deg before the disc gets tensioned - of course, the more disc degeneration you have, the more rotation you will have.

3. Simple answer is yes. What your physical therapist needs to do though is to work out what the problems are in your joints, myofascial system, neural (including motor control), visceral fascial pulls and even your beliefs and psych status. i would check all the joints of the thorax, L/S, SIJ, hips, knees and ankles/feet. Effiicient load transfer needs to occur at each of those joints. Unwinding the primary problem/s and the secondary issues will lead to targeting the right problems.

5. Stork test is ok to use - it is when it unlocks that is more important - does it unlock before the other leg gets off the ground or only when the swinging leg gets off the ground? If it is early, it is more likely to be primary...the first joint to "give way" is considered to be the primary problem for me - the reason why it gives way is based on whether it is the joint structures (ligaments, bones, cartilage etc), myofascial structures, neural reasons (neural input, motor control/coordination, neural length etc), visceral pulling (think abdo/visceral scarring, dieseased organs exerting pressure on fascial structures etc) or psych reasons.

Lastly, i once helped a woman who got assaulted 12 years earlier. SHe had terrible pain and couldn't bend over for 12 years past her knees because of back pain. One treatment restored her range of motion to touching toes (so her hamstrings weren't really tight like she had been told), her pain disappeared (because the joints bore load properly) and she was able to run without pain - which was the presenting problem - she needed to run to lose weight to get a tummy tuck since having triplets caused a diastasis that didn't reduce and thus caused a myofascial problem (unable to exert enough pressure to locally stabilise the L/S).

So yes, once you get the right treatment, things should improve - do i get all my patients better? No. Of course not...but i continue to learn from all my successes and failures.

Hope that helps you

Cheers!

[Dr Damien]

To Alophysio

a very refreshing response...thank you

[doctor]

Thanks Alophysio for your considered response -much appreciated.

[alophysio]

You are welcome doctor.

Dr Andry Vleeming is in the Netherlands...perhaps you could email him? Perhaps he can direct you to some clinicians locally or suggest a course of action.

If you look up any research by him, i am pretty sure his contact details come up.

BTW, did the information in my posts assist you at all?

[doctor]

Dear Alophysio,

Your information did indeed help - thanks. I asked my physio if my he thought my ligaments were disrupted but he felt in the glide test the right SIJ felt "jammed", and weren't loose in true ligament disruption. Also they modified my quad stretches which now no longer hurt

Things have changed a little more - If you can bear it I would love to know your thoughts on a few more questions I have, you seem to very clued up in this area. As an endocrinologist I live up to the stereotype of pouring over the details!

My symptoms now seem to have more or less confined themselves to the right and currently my pelvis is "holding" as my physio puts it ie level and locking, for one week. The problem I have now is right lumbar pain (as opposed to left lumbar /right SIJ as previously) which may be attributed to a tight Q L and psoas. My physio says he is reluctant to release these off incase in creates an imbalance in my pelvis again, but as this area is the main source of my pain I would love something to stop it. Is it possible that once the pelvis becomes stronger with force closure through rehab, this may take off some of the overactivity of these lower back muscles? In which case I need to just be patient with this pain as the stronger the weak muscles become (ie gluts) this should in theory help? Or should we be treating these muscles in spasm as otherwise the gluts etc won't be able to fire properly due to pain inhibition. At the moment these right lower back muscle spasms are worse on sitting and leg lifts (specifically on lowering the left leg is when I feel it in my right back).
I know you can only give your best guess.

Also what are you feelings about direct manipulation of the sacrum for sacral torsion rather than MET /manipulation of the surrounding bones? Some people say it is not necessary as the sacrum can correct itself if the innominate bones are corrected.

Also do you know of any recommendations for experts in London - I will be based there for work for a while.

Thanks!

[alophysio]

Hi doctor,

ok...

1. It is likely that your R SIJ is myofascially compressed which can give a jammed feeling...if a joint is truly jammed, then it wouldn't move would it? Therefore your load transfer tests would show moving bones and be "+'ve"..i know it is just a small terminology thing but i think the disticntion is important
2. Again, "tight" or overactive? You know, a truly "tight" muscle often doesn't hurt. Ask someone who has a contracture after coming out of a cast if it hurts...they say "no...unless you stretch it..." - so yes, the R QL and other muscles are probably overactive and trying to protect you from something or are in a poor motor pattern. Retraining needs to occur to replace this motor pattern or correction of some kind needs to occur. Also, it could be your disc or facet joint that is the source of the pain...
3. I think your physio is right to be reluctant to release these muscles off...i think previous experience as described would suggest that it doesn't help you unless you are retraining etc. Also, you have recently changed in your pattern which is good...he is probably just being careful.
4. Yes, your pelvis should get better with rehab but the overactive muscles need to allow the occrect pattern to occur. it is a subtle correction in your case as the point above makes...too much without good support = dysfunction, not enough release = dominance over the targeted muscles...ah, the art of physio. I guess it is like keeping the INR in the right range for those on rat poison!
5. Yes be patient, sitting sounds like a posture or disc problem and you shouldn't be doing leg lifts!! If you can't control the position of the pelvis and L/S, then you can't load up long levers!! This might be the source of your spasms! Go shorter lever like bent knee lifts or drop-outs - more like Hip ER - decrease the torque loading on your body.
6. manipulation is a term we use in the land of Oz to mean a sudden short sharp force producing a cavitation. You only do them if the joint DOES NOT MOVE at all. It doesn't sound like your case so i would say "no" to manipulation. If you mean a "mobilization", then yes i do them and they can be equally effective at decreasing muscular tone...again, as in previous posts, find the main problem and deal with it...it will tell you what to mobilise, down-train, etc.
7. Best to contact Diane Lee or LJ Lee at Discover Physio - Diane Lee and LJ Lee - they have the contact details of hundreds of therapists but know the key therapists to contact in different regions of the world. If you are truly interested in learning more, their textbook - the pelvic Gridle 4th edition is coming out on US Amazon at the end of Dec.

I hope that helps! Cheers!

[vam44]

Hi,

My initial response would be to emphasise stability exercises and leave the SIJ alone for a little while until you have corrected the strength/control issues. I agree that you should not be doing leg lifts....they will exacerbate the overactive Q?L and psoas. I would consider giving you a strong trocanteric belt to stabilise both SIJs while you do your exercise programme and I would probably be OK with releases but not stretches to the Q?L and psoas

Also your physio should check for any factors that put an assymetrical load on your pelvis This can be internal factors such as slight leg length differences, one foot pronated more than another. Also there can be ergonomic factors such as your work station/computer setup not being ideal especially if you need to sit a lot and twist to one side for work.

Another thought would be for your physio to show you how to reduce your SIJ yourself it can be very effective. This should be done very carefullyunder your physios supervision and only once you have more neuromuscular stability.

good luck! I have seen many of these types of back problems resolve with good management and dedication to an appropriately prescribed exercise programme.