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.

[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