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!

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.