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!

Headache & migraine treatment options

Got a headache? The biggest cause is dehydration, so first, have a drink of water. Other common causes are caffeine withdrawal, high blood pressure, stress, low blood sugar, and tight neck muscles. If you have persistent or severe headaches, you should get them checked out by a healthcare professional (If only so they can say “It’s not a tumah!”), but for minor annoyances you can treat it yourself with acupressure (points listed below).

Human skull bonesI usually find that migraines are caused by hormonal imbalances, or by neck muscle tension pulling on cranial bones. Our skulls are not a giant fixed globe: There are lots of different plates and oddly shaped bones that make up our brain protection. The joints (called “sutures”) are shaped like jigsaw puzzles.

My favorite cranial bone, the sphenoid. It barely shows at the side of the head, but inside it makes a gorgeous butterfly shape. When torqued, it also gave me a monstrous migraine headache!

My favorite cranial bone, the sphenoid. It barely shows at the side of the head (it’s pink in the other picture), but inside it makes a gorgeous butterfly shape. When torqued, it also gives me a monstrous migraine headache! I keep them away by getting care for my neck, and using the acupressure points below when one threatens to attack…

Our bones move with a subtle pulsing called the craniosacral rhythm. If the neck muscles attached to the skull get too tight, they can jam up those joints and cause migraines. The fix: Acupuncture and medical massage for the muscles involved. Craniosacral therapy by a skilled practitioner is also wonderful, but be sure to see someone who’s thoroughly trained. A weekend seminar is not enough! If there are hormonal causes, acupuncture is superb for that as well.

Here’s a handy acupressure point for any headache, including a migraine: It’s in that “second piercing” spot, below the anti-tragus. Press firmly for a few seconds. If you have an earring in, you should remove it if possible, at least until your headache passes. For more information on ear points, check out this article. Also, look at LI-4KD-1, and GB-21 and TB-5  if you have neck tension. Definitely read this if you’re considering a Daith piercing. 

Press firmly with a fingertip or fingernail. It will hurt, but it'll be worth it!
Press firmly with a fingertip or fingernail to stop a headache or migraine. It will hurt, but it’ll be worth it!

 

Ear seeds – Radishes for reflexology!

If you ever attend an event with me, soon you’ll notice people walking around with funny little stickers on their ears. Ear seeds are my mobile acupressure strategy. When people come up to me and ask what I can do about their back pain in the middle of a party… BAM! On go the ear seeds. These are radish seeds on a tiny piece of band-aid tape. There’s nothing magical about the radish – they are just the right size and shape to apply acupressure to any of the 100 points on your ear (map below).

You’re familiar with reflexology, right? You know how your entire body is reflected on your hands and feet? Same deal with the ears. I can treat pain or dysfunction anywhere in the body, emotional upheaval, anxiety, etc. This is why I’m not a huge fan of lots of piercings. It’s also why ear massages are like getting a full body massage, and terrific for immediately calming someone down. Try it the next time your migraines act up, your dog is freaked out, or your sweetheart has road rage. :) Just gently rub the entire ear – don’t worry about hitting specific points for this purpose.

Once the seeds are on, they are working. They will last 3-4 days, and you can shower normally. If you want to give the treatment a boost, and can’t feel them on your ears, give them a gentle squeeze to wake them up. If you are already aware of them, leave them alone… they will probably be pretty tender to the touch! Sometimes people find the ear seeds annoying or sore, particularly if they are side-sleepers or they are working superhard (the more active a point is, the more it can hurt). In that case, just take them off. The point is to make you feel better!

I never charge for ear seeds. Ask me for them anytime – I always have them in my purse, and you are welcome to drop by the clinic for a quick installation.

Note: Some people use ear staples for quitting smoking, weight loss, etc. I prefer earseeds, since sending someone out with an open wound is an invitation to infection. Acupressure is hugely powerful and hurts less, too!

There are about 100 points on the ear, so I can treat nearly anything. Ear seeds are quick, portable, and give you a few days of acupressure.

There are about 100 points on the ear, so I can treat nearly anything. Ear seeds are quick, portable, and give you a few days of acupressure.

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.

“Dry Needling” vs. Acupuncture

I had a gentleman ask me last week if I had heard of “dry needling” and if I ever did it. I was flabbergasted… Dry needling is what acupuncture is called when non-acupuncturists do it. Wait – that’s not quite right. It’s what using acupuncture needles is called when someone else does it… but that doesn’t make it acupuncture. True acupuncture requires an understanding of a complex system, while most “dry needling” courses are surprisingly brief.

When comparing acupuncturists vs other practitioners as providers of therapeutic needling, some interesting things come to light. I feel very strongly that the various types of medical providers each have their areas of expertise. A bad injury, a serious infection, and organ failure are just a few of the problems that would send me running to “Western” modern medicine. But in some cases – chronic pain, healing after an injury, neurological repair, anxiety, etc. – acupuncture is highly effective. So….Why not just have your doctor do it?

There are some advantages to doctors doing acupuncture. First, they have a more extensive knowledge of anatomy than the average acupuncturist. I was very lucky to get to work with cadavers when I was at chiropractic school – most don’t. Secondly, the procedure is more likely to be covered by health insurance.

Unfortunately, there are also some disadvantages. Doctors are usually MDs first, and have taken a seminar on acupuncture. This course is a few weekends of instruction. They learn a handful of “recipe” points that are based on symptoms. Some people doing “dry needling” are physical therapists or chiropractors. As a comparison, I have a Master’s degree from OCOM, which consisted of 3,344.5 total hours, including 996 clinical hours. I learned about the Zang Fu organs, the channels, and the 1000 points and how they interact.

Doctors usually don’t spend much time getting to know every detail of your medical history. They tend to have 10 minutes for the whole appointment, and focus purely on your “chief complaint” as we call it in medicine: the main reason you came in. Traditional Chinese Medicine (TCM) is holistic. I prefer to take an hour with my patients. We examine the entire body, not just an isolated part, and our diagnosis is dependent upon that global perspective. For example, you may have a headache due to Liver* Yang Rising, or Qi deficiency, or a Wind Invasion. Or look at it from the other direction: A single diagnosis, such as Kidney Yin Deficiency, can cause varied symptoms like menstrual irregularity, anxiety, vertigo, night sweats… you see the problem. This is why I ask all those rude questions (sorry) in a 10 page form when you come in. What your menstrual cycle is like can actually help me determine how to treat your digestive disorder.

When doctors, chiropractors, and physical therapists use dry needling, especially for internal medicine, their results are not as strong as when a TCM trained practitioner wields the needles. I see this in a lot of research studies that “prove” acupuncture “doesn’t work.” It’s roughly equivalent to testing antibiotics for a runny nose, without separating out bacterial infections from viruses and allergies, then claiming that pharmaceutical drugs aren’t effective.

In this article, a doctor writes about needling. The myofascial part is spot on, but he’s missing the energetic component. Some of the points work on areas far away from where the needle goes! LI-4 and LV-3 are beautiful examples of powerful points that don’t really make sense with the Western understanding of anatomy. If distal points like the hands, feet, scalp and ears are neglected, the treatment may be weaker than ideal. It’s something to think about when comparing someone offering dry needling vs a true acupuncturist.

People with only basic anatomy training like massage therapists, and physical therapists doing dry needling? Super bad idea – and the reason there are so many news stories about dry needling pneumothorax (collapsed lung) problems created by physical therapists. Acupuncture needles are controlled as a medical device, because they really shouldn’t be used by amateurs.

Dry needling is a bad idea, m'kay?

Dr. Andrew Weil, M.D., agrees that TCM training should be comprehensive.

*Remember that in Chinese medicine, capitalized organs are energetic concepts and should not be confused with your anatomical organs.

GB-21 (neck / shoulder tension, rebellious Qi)

Jian Jing (Shoulder Well) is a place many people tend to store their stress. Every day, people come into my office and complain about neck and “shoulder tension.” They really mean the trapezius and levator scapula muscles, not the shoulder joint. I’ve been saying for years that we need a better name for this part of the body, but “noulder” isn’t catching on (for obvious reasons!).

Referred pain and trigger points for the trapezius.

Referred pain and trigger points for the trapezius.

The trapezius is a big muscle, and it does a lot. Carrying heavy loads (especially unbalanced ones – so carry a small purse and use both straps of your backback!), working with your arms up (I’m talking to you, hair stylists!), or just general hunchiness over a computer… all are common causes of tension. The traps refer pain over the head to the eyebrow area, so shoulder tension can give you a severe frontal headache.

GB-21 also descends energy, so it’s good for rebellious rising Qi causing headaches, dizziness, heartburn, or vomiting.

GB-21 for relieving neck and shoulder tension.

 

Find GB-21 at the top of the upper thoracic area (aka “noulder”), halfway between the shoulder joint and the spine. Press firmly for 10-15 seconds with a healing intention. NOTE: Do not use GB-21 on pregnant women.

Also – look into some better ways to release your stress!

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. :)

LV-3 (irritability, hormones, leg, hip, or lower back pain)

LV-3, Tai Chong (Great Surge)

Liver 3 is found on the top of the foot, between the long bones of the 1st and 2nd toe. It’s a very important point for the Liver, and helps to move stuck energy from the waist down. You can use it to treat lumbar back pain, leg or knee pain – pretty much any stagnation in the lower body. It’s also great for red eyes and other “Yang Rising” problems, and for dysmenorrhea & hormonal imbalances. LV-3 is an excellent point for treating irritability and grouchiness, particularly if it’s due to hormonal issues like PMS.

LV-3 – “The grouchy point” – will also soothe the lower back.

When used in combination with LI-4, these points are called the Four Gates and can really blast out some stuck Qi. DO NOT use these points if there is any possibility of pregnancy, since they can induce a miscarriage. In fact, they are some of my favorites for evicting overdue babies. It will also increase menstrual flow if the patient is having her period.

Press firmly for 10-30 seconds.

The Knee

Let’s talk about the knee joint. It’s not quite as complicated as the shoulder, because it doesn’t move in as many directions. Having that kind of mobility with all of our body weight on top of it… well, that would be a recipe for disaster.  Instead, we have a modified hinge joint. The knee folds, but it also twists a little bit. The trick is keeping this twist under control.

Front view of the knee joint.

Collateral ligaments run along each side, and the cruciate ligaments (named so because they form a cross) inside the joint create stability. Strong quadriceps (a set of 4 muscles on the front of thigh), hamstrings (three muscles in back of thigh), adductors (inside) and abductors (outside) also support the knee. Slick cartilage lines the surfaces where bones meet. The meniscus, a pair of special horseshoe-shaped cartilage structures, help absorb shock and guide the movement of the femur. And there’s a bursa on top of the patella (kneecap) to provide some extra cushioning. Pretty neat design, huh?

Sp-9 treats the knee, and drains Damp (a concept in Traditional Chinese Medicine).

If your gait is off, it can affect your knees and eventually your hips and back. Good shoes are important for knee health. Avoid heels as much as possible. If you have flat feet, use shoes with good arch support. To prevent injury, frequent light workouts are best. If you are a bigger person or have joint issues, try to reduce impact: walking or using an elliptical trainer is better than running, and staying on grass or a rubber track is better than concrete.

 

 
    Did you know that babies are born without kneecaps? They have a cartilage wedge but it doesn’t ossify (turn to bone) until about 3 yrs old. Lucky for them – It makes crawling around on a hard floor much more comfortable.
Acupuncture can reduce inflammation, increase blood flow, relax tight muscles, and speed healing. I can also do Osteopathic medical massage to break up scar tissue, release myofascial adhesions, and retrain the neurological system. This allows chronically tight muscles to return to normal. In most cases, therapeutic exercise is important for complete healing.

Acupressure you can do at home: LV-3

*Please note that I’m simplifying the anatomy quite a bit  for the purposes of this newsletter. If you’re interested in all the marvelous details of our bodies, I highly recommend Netter’s Atlas.