Coccyx and lig. sacrotuberous pain after trauma?

A copy of this post is also found under the general discussion.

Background;
- 25y male, no earlier problems at all, highly active on sports.-- Paraglider accident 1y ago. Coccyx pain starting not long after that.
- Accident included; compression fracture T12, L1, L2 and burst fracture L4. Surgery; Posterior lumbar interbody fusion using pedicle screws, collectors. L4-root compression on the right side - included hip-rotators (out/in) - trendelenburg gait and drop-foot.
- Now; Osteosyntesis-metal was removed 5w ago. Almost back-pain free.
- He has little or no sign of the paresis (but strength is not full for none of the affected muscle-groups). Tendency of m. tibialis posterior cramps (functional pes planus with valgus).
- Coccyx pain is still persisting 1y after the accident and that's bothering him most (the pain lowered the first 2 months, stable since then - aggrevated by prolonged sitting (and standing).

Treatment given;
- Initally (1y ago); specific stabilizing exercises for the back and hip, hydrotherapy, training of the dorsal-flectors of the foot. Home-exercises and advices - specially on stability, and balance - terrain-walking and more. Stretching of the hamstring muscle group and hip flexors were not done - as the flexibility has increased as the stability of the back and hip was increased.

- The coccyx pain still persisting. The pain is purely localized on the 2nd coccyx bone (counting up) and over to the start of the sacrotuberous lig (left side - opposite to the paresis).

- Initially I thought the pain was due to strain on the sacrotuberous lig. because of either malalignment (the fixated L3-L5) or because the L4 paresis of the right side. Now to paresis is almost gone - and the pain's still there. Have tried deep stretching the sacrotuberous lig. and tried deep frictions of the ligament.

Also tried 1 month of not sitting at all (used diary and more), less pain that month, but it came back afterwards.

....

So? ... Suggestions? tips? any good explanations?

Another thing: I can see when training global back extensors that he is rotating his right foot outwards (at hip level). Could this be something?...

...

Best regards,
Øystein, Norway

[somasimple]

hi,

many back problems may have a peripheral origin and the contrary happens more often.

You speak a lot about strength but I prefer balance and harmony. A good movement is made with the less strength possible and the most smoothness.

Stretchings may have opposite effects that you're regarding for.

If a muscle is tight, there is a reason but you may find the cause and relax it.

Well, strength in my eyes includes "balance and harmony". I have been using specific stabilizing exercises (balance training) for hip and back. This includes sling exercises in closed kinetic chain.

What about the sacrotuberous pain; it hasn't decreased as the kinetic controll/balance has been bettered. He can now do 1 leg squats with closed. The osteosyntesis-metall was removed this autumn and now he can do squats and front lunges too. Knee controll has been my primary case in the lunges. Squats about 120 kgs and 60 kgs in lunge.

Øystein, Norway.

[alophysio]

Hi - the original reply to this post is in the general section...

Hi!

Good post - good luck!

Form Closure questions:
What is the status of his pelvis - SIJ, pubic symphysis, L5/S1, etc. Does he have alignement issues / aysmmetry of his sacrum or innominates? Did he fall onto his coccyx / ILA of sacrum causing a shear of the sacrum?

Force Closure / Motor Control Questions:
How are his core stabilisers? Are his posterior pelvic floor stronger than anteriorly? is his coccygeous muscle overactive? Is he a "butt-gripper"? Does he have good lumbo-pelvic / thorax dissociation? Is there fascial / soft tissue imbalance? Also, what is the current status of his hamstrings? How are his load-transfer tests (ASLR +/- compression at ASIS, Pub Symph, PSIS, Ish Tub)?

It sounds like a nasty accident so I would be checking the above - only since you did not mention them...

The sacrotuberous ligament has attachments to biceps femoris - and sometimes the hamstrings don't even attach to the Ischial Tuberosity but go to the STL. It is continuous with the dorsal long ligament up to the iliolumbar ligament, whose main function is holding L5 onto the sacral base. Coccygeous is often overactive and can also be causing the pain. Just some thoughts...

Again, good luck!

Antony

Addit:
Aha - you didn't include the headaches in this section of your post (which is interesting).

The headaches and tension could also be related to dural tension since there are fascial connections from the sacrum all the way up to the brain.

The back pain and headaches could be related...