Hey, Doc! I’ve got this pain in my lower back. It changes from right to left and back again. It’s really bad when I stand still or walk for too long, then it feels better when I sit. Sometimes the pain goes into my butt and the back of my thigh, but never past my knee. Every once in a while, my leg will buckle and I’ll stumble and occasionally almost fall. If I sit, stand or stay in any one position for too long, my back aches like crazy. What’s the matter with me?" 

Way back when and probably even before, low back pain complaints were registered as: "My back hurts, it must be lumbago." Or "My butt hurts, I’ve got sciatica". Or "My sacroiliac is out." Well, it sounds like this guy has the latter problem.

Maybe this sounds familiar. So, a few words of explanation:

Back pain is caused by stimulation of nerve endings called pain receptors (nociceptors). These are present in many structures in and around the spine: the vertebra, the joints between them, the ligaments connecting them, the discs between them, the muscles that move them, the blood vessels that supply the muscles, and the sheathes around the spinal nerves. Twisting, stretching, crushing, or tearing may stimulate these nociceptors. Or they may be fired by chemical factors such as the accumulated waste products of muscle metabolism, or by insufficient tissue oxygen. Any number or all of these conditions may be operative at the same time. Small wonder there are so many different, often conflicting, diagnoses and treatments for low back pain.

What about the sacroiliac joint? The sacroiliac joints (there are 2, one on each side) form the connection between the spine and the pelvis. Like all such joints, there is cartilage on each of the joint surfaces. In this case, one side is rough, the other smooth. Strong ligaments connect the sacrum to the pelvic bones in the back of the sacroiliac joints with weaker ligaments in the front. Just above the sacrum, the iliolumbar ligaments on either side tether the lower 2 lumbar vertebrae, and, indirectly, the sacrum, to the pelvic bones. The ligaments behind the sacroiliac joints also restrain downward movement of the sacrum and connect to the hamstring muscles in the back of the thighs. The net effect is to stabilize the sacroiliac and lumbosacral joints, preventing excessive forward tilting of the sacrum and pelvic bones, and providing a "self-locking" mechanism which basically allows us to walk, locking the sacroiliac joint on one side as weight is transferred from one leg to the other.

What can go wrong? Under ideal conditions, the sacrum is positioned diagonally between the pelvic bones (innominates). With this relationship in place, there is maximum stability. The sacrum becomes situated more horizontally in a sway-backed posture (increased lordosis). The ligaments described above are stretched with resultant instability of the sacroiliac joints and impairment of the self-locking mechanism. Additionally, these ligaments are replete with pain receptors that are extremely sensitive to further stretching. 

All of the above implies movement between the sacrum and the innominates. Indeed, there is ample scientific evidence of significant movement, however slight, at the sacroiliac joints. 

So, what are the consequences of failure of the sacroiliac joints and their ligaments to function normally? Further stretching of the ligaments through prolonged sustaining of any one position (standing, sitting or even lying down) produces pain. Something has to support the spine and pelvis, and with the ligaments failing, the job falls to the muscles, ill suited to that task. The muscles connecting the spine to the pelvis and hips tighten. Circulation is impaired. Waste products are accumulated and pain receptors excited. Normal movement is limited and the cycle of pain, spasm, motion restriction is perpetuated establishing myofascial pain syndromes. 

If you fit the profile in the first paragraph, it’s quite possible your back pain is primarily the result of dysfunction at the sacroiliac joints. What’s the next step? First, most low back pain will just simply go away within three weeks to three months. Just that simple. No matter what you do or don’t do about it. So, if this is your first episode, the pain does not extend into your leg below the knee, there is no disturbance of your bowel or urinary function, then your best bet may just be to take some acetominophen (Tylenol) put some ice on it and go have a life. On the other hand, in case of repeated episodes of low back pain fitting the description above, or those incidents persisting longer than a few weeks, perhaps it’s time to see us at Catskill Rehabilitation & Sports Medicine.

Our evaluation includes posture and gait analysis, strength and endurance testing, neurologic and orthopedic examination, and X-rays if necessary. In the assessment of your back problems we consider not only the musculoskeletal system, but also the inter-relationship of all body systems including the emotions. The effects of the environment at home, work and recreation are assessed.

We offer the full range of state-of-the-art non-surgical therapies for all types and stages of low back pain. Manual proceedures including muscle energy, strain-counterstrain, myofascial release and cranio-sacral techniques. Therapeutic exercises, stretches and trunk stabilization are used by our physical therapists. Adjunctive modalities such as ultrasound, electrogalvanic stimulation, iontophoresis, cervical and lumbar traction are employed when appropriate. 

Myofascial pain syndromes, frequently accompanying back pain due to sacroiliac dysfunction or disc disease, may be treated through trigger point injections with local anaesthetic and by dry needling or acupuncture. 

Whatever the cause, the odds are good that we’ll be able to help.