The sacroiliac joint, sciatica, and unexplained lower back pain

I often have patients come in with a “mysterious” chronic lower back pain. Sometimes it’s described as lumbar or hip pain. They’ve been to doctors and chiropractors, but it still persists. As soon as they put their hand on it (low and to the side, where the buttocks meet the back) it’s pretty clear that the problem is the SI – the sacroiliac joint.

Pelvis

The SI joint – where the sacrum meets the ilium – is a long vertical area on the sides of the lower back. Back pain is often centered at the top of the SI joint.

At the bottom of your spine is a triangular bone, the sacrum. Attached to that is your pelvis (made up of the ilium, ischium, and pubis). Your femurs, the long bones of your thighs, settle into a socket on the side of the pelvis. A complex set of ligaments and lots of muscles join all these bones. If one or more of these muscles is tight, weak, or spastic, it can throw the balance of the entire pelvic system off. A few of the major players are Iliopsoas, piriformis, and quadratus lumborum. These muscles keep us upright and help us walk, but when they go bad… I call them the Holy Trinity of Lower Back Pain.

Quadratus Lumborum runs from the lower ribs to the top of the ilium. There are also connections to the spine. This is your "hip hiking" muscle - imagine a "belly dance" sort of motion - but if course it's essential in walking and other daily movements.

Quadratus Lumborum runs from the lower ribs to the top of the ilium. There are also connections to the spine. This is your “hip hiking” muscle – imagine a “belly dance” sort of motion – but if course it’s essential in walking and other daily movements.

Iliopsoas starts at the front of the spine and the ilium, goes through the pelvic cavity, and attaches to the femur. It gets tight on people who sit a lot, particularly if you are tense while sitting (motorcylists and people who hate their jobs).

Iliopsoas starts at the front of the spine and the ilium, goes through the pelvic cavity, and attaches to the femur. It gets tight on people who sit a lot, particularly if you are tense while sitting (motorcylists and people who hate their jobs). When tight, it jams the bones together and creates stress on the joints.

 

Piriformis

This is a back view. The piriformis muscle attaches at the sacrum, and goes across the butt to the femur. The sciatic nerve passes under it or through it, depending on your personal anatomy. When the piriformis gets tight, it squishes the sciatic nerve and can cause electric shocks or pain running down the leg.

With every step you take, the sacrum “nutates” – it tilts back and forth in relation to the ilium. If the bones are jammed together and can’t glide properly, it causes pain. Sitting can also be a painful prospect: If the joint is inflammed, the altered pressure of a seated position can be excruciating. I understand this very well because I developed lower back pain and SI problems along with a L4-L5 disc herniation after my car accident in 2001. I wasn’t able to sit at all for the 6 months before I discovered acupuncture and Osteopathy.

There’s rarely only one muscle involved. Usually a primary dysfuction causes a cascade of compensation with other muscles. Nerves can be pinched by either tight muscles directly or by a bone pulled out of place by a tight muscle (bones don’t move by themselves).  Nerve impingement can lead to pain radiating down the leg or into the genital area. Motor control as well as sensation may be affected. The leg may go weak, or a patient may experience bladder or bowel incontinence (If this happens, get to the ER immediately – they will take steps to relieve pressure on the nerve and prevent permanent damage).

In most cases, the first thing we have to do is reset the tension on the muscles. Acupuncture and medical massage will work wonders here. Once the soft tissue is corrected, I can generally realign the bones with fingertip pressure. They just slide back home with no drama or fuss. Now it’s a matter of allowing the irritated nerve to calm down, which can take 20 minutes to months (or never, in worst-case scenario), depending on the extent of the damage. Whenever you are dealing with entrapped nerves, it’s important to get care immediately. Releasing them quickly gives you the best shot at a full recovery like mine. Getting the pain knocked down allows you to rebuild. Rehabilition exercises and stretches (plus some myofascial release) will make your muscles strong and supple again, so they work properly, which will keep your bones in the right places. I no longer have any back pain, and I’m back in the gym doing heavy workouts including Romanian deadlifts!

Anti-inflammatory HTPT – Smell like pancakes *and* feel better!

Last month I mentioned that I was having some trouble with my Arnica distributer (problem resolved – it’s in stock and ideal for bruises, sprains, and strains). I found a fantastic solution: Hai Tong Pi Tang. This is an ancient Chinese anti-inflammatory formula, containing frankincense, myrrh*, saffron, and a number of other herbs. The tincture is in an alcohol base, and made by a local acupuncturist. It comes in a spray bottle, so you can easily apply to any injured or inflamed area. External use only, and not on broken skin, please!

Here’s a fun bonus: The aromatic herbs combine to create a “pancake” scent. Much nicer than Ben-Gay or the usual herbal stinkiness! Watch out, though, you might get nibbled on by fans of maple syrup. :) 1oz bottle for $12, or 2 oz for $24.

frankincense resin

Frankincense resin – anti-inflamatory, anti-bacterial, and calming.

*Frankincense and myrrh have been “Moving” herbs in the Chinese pharmacopia for thousands of years. They are used to treat “stagnation,” which translates to muscular stiffness and pain, among other things. I was once on a cross-country flight when my back seized up. This was early in my acupuncture schooling, while I was still recovering from a traumatic car accident. Somehow I had neglected to pack any anti-inflammatory medication, and the flight attendants weren’t allowed to give me any. I was in so much pain, and I had hours left in that horrible seat! Then I remembered that I had brought along my herb samples to study for an identification test the next Monday. I ate the frankincense and myrrh samples – something I DON’T recommend, as they taste terrible! – and within 20 minutes my pain was gone. I’ve been a big fan ever since.

Posture: It does a body good!

Posture does more than make you look good: It’s important for your health! Being bent over creates tremendous stress on our muscles, squishes our organs, and blocks blood flow. I also affects our mood and digestion. Besides pleasing Grandma, there are a lot of terrific reasons to pay attention to posture.

Modern-evolution

We all sit too much. And that tends to lead to slumping. At work, at home, in the car… it’s actually gotten worse as technology has gotten better. We’re not even staring at computer screens over a desk anymore – we’re looking down at laptops and phones, and as a result, our collective necks are becoming permanently bent!

Posture2

There’s a funny sort of cascade that happens when you are out of whack. A forward head posture, for example, is very common. In that position, the muscles that flex the neck forward are underworked. The muscles on the back of the neck are overstretched and cranky. The hips tend to shift to compensate, and you get a similar pattern at the pelvis.

 

 

Picture a string running from the base of your spine, up through the top of your head. Imagine yourself pulled up by that string. You will naturally straighten, and your shoulders will relax into their proper position. I like this much better than the rigid shoulders that can happen from just trying to “stand up straight.”

Note that her chin is not pointing up – lift the top of your head, not your face.

Of course in about 5 minutes you may find yourself back in the familiar slouch. Pull up on that string again! It takes practice, but like any habit, it gets easier the more you do it, and eventually it’ll be automatic. Yes, your postural muscles will be weak at first, but they’ll get stronger. Stick with it!

Top 8 reasons to use good posture:

Superman has excellent, confident posture!

1) Create confidence and elevate your mood. The link between mind and body goes both ways… you can literally lift your spirits by lifting your head! Did you know your self-talk is linked with your posture? You know how faking a smile can actually make you feel better?  It’s the same thing with your entire body. Career coaches recommend taking on the “Superman pose” (ideally in an empty elevator or bathroom) before an interview, to go in feeling confident.

2) Reduce pain in the neck and shoulders. Your trapezious muscles get pulled tight when you slump forward, which causes all sorts of inappropriate tension.  And as you can see, keeping your head aligned is the best way to distribute the weight of your skull. A forward neck posture creates leverage that works against your body. This graphic below shows the pounds of pressure at various positions.

Good posture helps avoid muscle strain.

3) The individual bones of your spine – both neck and back – will be able to move more freely. This means less chance of spinal injuries or pinched nerves, and can prevent fusion between bones as you age.

4) You’ll look slimmer! Most of those “before and after” weight loss poses can be achieved with nothing more than good posture and different lighting.

5) Increase the flow of blood and cerebrospinal fluid. If you’re a collapsed beanbag, various pathways can be cut off, preventing your body from working as it should. Even cortisol (stress hormone) levels decrease with better posture!

6) Give your digestive organs room to move. Remember, they have to push food around, from the stomach on down, to mix it with the different stages of digestive enzymes and extract nutrients and water.

7) Make a better impression on the people you meet.

8) Look up and see the beautiful world around you! The sidewalk isn’t nearly as attractive as the people, architecture, and nature around you.

Good posture is a HABIT that you need to build. Put up visual flags (sticky notes, or draw an arrow on your hand) to remind yourself to relax your shoulders and lift your head. Just keep doing it, and eventually it will become your new default!

 

Chiropractic, a second look

Many D.C.s are great. If you are seeing a chiropractor and have had good success, fantastic! I am the last person to interfere with something that’s working. But if your “genius” has been “fixing” you for years and you are still the same as when you started… it might be time to rethink chiropractic.

I am NOT a fan of the subset of chiropractors who indiscriminately and overzealously use HVLA adjusting (high-velocity, low amplitude – you know, that violent cracking). Low-force chiropractic like Network, BGI, and activator is absolutely safe, and there are lots of other techniques besides HVLA that are fine. HVLA is appropriate when used to correct an acute injury, like putting a dislocated shoulder back in the socket, but it should not be a frequent therapy. Repetitive stress of supportive ligaments and the resulting inflammation will actually damage the joint.

My information comes from my time at chiropractic school (I completed the first year, including the entire series of cadaver dissection, with nearly straight A’s), my knowledge of functional anatomy as a certified personal trainer and amateur bodybuilder, my 10 year partnership with an Osteopathic medical doctor, my experience seeing patients who have been damaged by repetitive HVLA, and discussions with many physicians of all types. I welcome input from any chiropractor who is interested in a fact-based discussion.

Personally speaking, I suffered a terrible injury when my car was broadsided in the first week of chiropractic school. Their treatments were making me worse, and the more I learned in school, the more I understood why.

1) It doesn’t treat the cause of the problem. Bones don’t move by themselves. If a bone is repetitively out of place, it’s because there’s a tight muscle pulling it that way, or a weak muscle failing to hold the bone in place. Jamming the bones back will cause micro-tears of that tight muscle. It feels good immediately, because you get a nice adrenaline rush along with your temporary fix. An enlightened chiropractic teacher compared HVLA to the shock and rush you get from a shot of vodka. Addicting, but not necessarily good for you. Unfortunately, as soon as the muscle goes back to its usual tight, spasming self, the bone will be pulled back out of alignment. That’s why you need to go back to the chiropractor the next week. Acupuncture and medical massage use the neurological system to retrain those tight muscles, so real healing can begin.

2) Our ligaments and tendons are there for a reason. They provide much-needed joint stability and hold us together. Repetitive HVLA weakens them, and can destroy your joint integrity. We all know that an ankle, having been sprained three times, is pretty much guaranteed to twist again. You do not want that floppiness in your spine. You should not able to crack-crack-crack your back simply by stretching. That’s called hypermobility and it means you can move too much. If you have already been damaged by too much HVLA, you will need to strengthen your back and abdominal muscles to help support those loose ligaments and tendons. Hypermobile backs are more likely to suffer a serious injury if you have an accident (this is what happened to me!).

3) Your reflexes work against HVLA. Quickly yanking on a muscle – even a relaxed one – can cause damage and inflammation. There’s a built in protective reflex that tightens a muscle when it is suddenly lengthened. You can feel this: Fold your friend’s arm at the elbow and put your hand on their bicep. Straighten the arm quickly, and you can feel the bicep twitch under your hand. Now imagine that happening to an already-sore neck muscle being snapped.

4) The pop means nothing. The cracking sound doesn’t necessarily mean you’ve been adjusted properly. It’s called cavitation, and it means that nitrogen gas, naturally occurring in your joint fluids, has been released. A similar thing happens when you open a can of soda. The sound means the bones have been rapidly separated (opening the joint space) and then have come back together. They may have come back to the same position, a better one, or a worse one. Misalignments, when corrected gently OMM style, do not make a cracking noise because the joint space is eased into the correct position rather than violently forced.

5) First, do no harm. Some chiropractors don’t bother to diagnose which level is dysfunctional. They just “shotgun” you by cracking all the vertebrae in your spine. Then they flip you over and do the other side. Why cause stress and create inflammation in a joint that’s working? Added bonus: Whenever you have inflammation, scar tissue forms. Trauma (HVLA) every week leads to more and more scar tissue building up. That’s the last thing you need when you’re already hurting.

6) With repetitive strong adjustments, your body becomes dependent on that input. In chiropractic school we joked about “welfare spines.” I had a discussion with an instructor who was brutally blunt about the temporary nature of his treatments. “Of course they have to come back. That’s how you buy your boat.” I found that model of “medicine” distasteful and unethical. I prefer to help the body heal itself. I love acupuncture and OMM because they truly correct how your muscles function.  Combined with proper exercise*, this creates a body that is strong and capable of bouncing back after a minor injury. I don’t want to see you every week for the rest of your life. I’d prefer to get you better and self-sufficient, and then stay in business by fixing all your friends and family. :)

BTW:  “But I can’t help it!” When you are out of alignment, your body will naturally feel compelled to snap itself back in place. After my injury I used to violently crack my neck and back all the time. It never really solved the problem, though… refer to point 1 above! The good news is that the desire to self-adjust melted away when my muscles – and more importantly, the neurons controlling those muscles – were corrected by acupuncture and Osteopathic medical massage.

*Exercise is essential to strengthen weak muscles, remind tight ones how to relax, and get all your muscle fibers integrated and working together. We are built to move! I know firsthand how pain makes you want to curl up on the couch and wait for it to heal, but the hard truth is that it won’t really repair until you put in the work. Get on an anti-inflammatory diet, see me for basic physical therapy-type exercises, and start walking! Better yet, see an expert personal trainer.

 

BL-40 (back pain, knee pain, hot flashes)

BL-40, Wei Zhong (Middle of the Crook), is located in the center of the back of the knee. It’s the Ruler of the Lower Back, so I often use it to treat lumbar problems. It’s also great for deep knee pain and to cool the Blood* – try it if you’re overheated next summer, or if you’re suffering from hot flashes. Other good points for lower back pain: LV-3, GB-34, Du-4.

BL-40, the Ruler of the Back.

*Remember: The Chinese concept of “Blood” is different from your physical blood. I am not talking about your literal circulatory system. :)