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The Sacroiliac Ligaments

Injury to the ligaments which hold the sacrum to the hip bones can cause the most devastating low-back and leg pain. Tears and adhesive scarring of sacroiliac and other ligaments of the sacrum account for the great majority of low-back, buttock and so-called "sciatic" pain down the leg. Many people are unaware that the sacral area can cause such far-reaching problems.

What are they?
The sacral ligaments hold the sacrum to the hipbones or ilia; hence, the sacroiliac ligaments. These ligaments hold together and help stabilize the back of the pelvis. They consist of thousands of individual fibers that are deeply layered for about one-and-a-half to two inches.

The sacrotuberous (B) and sacrospinous (C) ligaments stabilize the lower part of the sacrum. They hold the lower sacrum to the bottom of the pelvis, attaching themselves to the ischia; the bone youšre sitting on. Tears of these ligaments cause referred pain down the leg. This pain comes in many different patterns: down the anterior thigh, within the thigh, down the lateral lower leg, down the posterior the leg and so on.

Referred Pain
Referred pain means that you have an injury in one place and you feel the pain in another. Understanding referred pain and its patterns is critical in the assessment of low-back injuries. Patterns of referred pain have been mapped, and they run along specific pathways, known as dermatomes.

Patterns of Pain Onset
While the history of back pain may vary a great deal from individual to individual, there seem to be four different patterns of pain caused by tears to the ligaments in the sacrum. In each of these patterns pain in the low back, buttock, thigh and lower leg may appear either suddenly or slowly over the course of many hours or several days. The pain may have come about as a result of an injury but more often than not, pain in the low back and sacral area appears very gradually over a period of time.

The words "sciatica" or "sciatic pain" are commonly used as a short hand for a referred pain down the thigh and/or the lower leg. Sciatica is NOT a diagnosis but just a general term like stomachache. Referred pain down the leg can be caused as easily by torn ligaments and muscles as by a nerve impingement, commonly referred to as a pinched nerve.

Pattern 1. Periodically, severe back pain, with or without leg pain, or leg pain alone, immobilizes the person. The pain is intense and may come on after activity or prolonged sitting. The person often goes to bed and waits for the pain to subside. This may take several days, a week, a month or longer. The pain may disappear for no reason as suddenly as it came, or it may lessen slowly, until the individual feels completely fine. This pain-free state may last a month or a year until the next attack.

Pattern 2. The person experiences the same type of pain as described above, but it is not so severe. It may appear once or twice a week or several times a month or just before the menstrual cycle begins. It may be brought on by certain activities that the person has learned to avoid whenever possible such as prolonged sitting, lifting heavy objects without bending the knees, or certain twisting motions. There may be a hint of discomfort much of the time, but it is only occasionally bothersome. Pain may be felt straight across the lower back area or on one side, and the pain may switch from right to left, from episode to episode. One thinks of it more as a nuisance than as an actual injury, unless one day it changes to the kind of pain described in pattern 1, 3, or 4.

Pattern 3. The individual becomes "fixed" in a bent-over sideways position, is immobilized on the floor or is doubled over and unable to straighten up. This is referred to medically as a deviation. Sometimes the body is twisted with one hip raised. There is consistent muscle spasm and any attempt to straighten up to a normal standing position causes excruciating pain. No position seems comfortable. This may last for hours, days, or longer and usually abates slowly over many days. It is often a frightening experience, for the body feels beyond our control, immobilized and distorted.

Pattern 4. Fairly intense back pain with or without leg pain, or just leg pain, is felt constantly for many, many years. This may appear suddenly or after experiences described in 1, 2, or 3. Drugs have usually been tried, along with many kinds of therapy, possibly including surgery, but nothing seems to help. Constant pain has altered the individual's life and mental state. There may be difficulty in sleeping and the person's spirit often appears broken, for this is, indeed, a difficult way to live.

How and Why
As a result of repeated injury as described above, adhesive scar tissue forms in the sacroiliac, and other pelvic ligaments. Over time this weak, scar tissue stretches and distends, making the low back more unstable so that repeated injury becomes more likely. Eliminating the pain producing scar tissue in the ligaments through friction therapy is a very effective treatment for low back and sacral pain but unfortunately few therapists are trained in these techniques.

Friction and Massage Therapy
A combination of friction therapy to reduce and eliminate painful scar tissue along with massage therapy to increased circulation to the ligaments is usually helpful. If the deep sacroiliac ligaments are injured, friction and massage therapy will only be partially helpful. Some of these ligaments are very deep and cannot be effectively reached by the fingers. Most commonly, the most superficial sacroiliac ligaments are at fault, which responds favorably to friction therapy. After the therapist breaks down the scar tissue exercises are given to prevent the scar tissue eliminated by the treatment from re-forming.

Therapists with specific training in these techniques can identify the precise areas of damage and give the appropriate friction therapy. Dr. Benjamin developed these particular friction therapy techniques on the sacroiliac and low back ligaments in the early 1980šs by adapting techniques created by the well-known British physician, James Cyriax. Training programs in these techniques are available for therapists in various locations across the country.

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© copyright Ben Benjamin 2001