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SACROILIAL and LUMBAR FACET COMPRESSION PAIN Stan Andrzejewski PT
The pelvic girdle is comprised of 3 bones : 2 ilia and a sacrum. The front of the pelvis is the pubis, a joint where the 2 ilia meet. The ischial tuberosities are what we sit on [sit bones]. The anterior /posterior superior iliac crests [ASIS / PSIS] are the hip bones. Sacroilial joints connect the sacrum to the ilia. The male pelvis have more massive bones than the female pelvis. There is an 80 mm outlet. The sacrum is more triangular; therefore, more wedging, more locking. The ilia articulate the sacrum at S 1,2,3,4. The male pelvis is a more stable pelvis. The female pelvis have thinner bones. It has a larger, 120mm, more circular outlet for a birth canal. The female pelvis have their acetabulum [hip sockets] set wider. The sacrum is more rectangular. SI articulation surface are only at S 1,2,3. These joint surfaces are more shallow. A hormone, relaxin, during menstruation and pregnancy, especially last 3 months create a less stable pelvis by loosening the ligaments. This of course is necessary for mobility of the S/I joints during childbirth. But unfortunately this mobility allows for more SI dysfunction. As well childbirth strain, intercourse strain, baby on hip strain can contribute to more S/I mechanical stress. The ligament of the pelvis are many. The intrinsic ligaments tie pelvis together. They include the anterior sacroilial ligament, the short and long posterior sacroilial [stretched by anterior ilial rotation.] The extrinsic ligaments hold pelvis together. They include the sacrotuberous ligament [stretched by posterior ilial rotation.] This ligament ties into the biceps femoris [outer hamstring.] This ligament stretched with forward bends is an extension of the hamstrings. Also included is the iliolumbar ligament that attaches from the transverse process [TP] of L4,5 to the ilium. There are 35 muscles attached to pelvic girdle. The pelvic floor is basically the levator ani muscles, which are sling like in shape, maintaining low level contraction, or postural support of internal organs of bladder, uterus, and bowel. They attach to the obturator tendon, pubis, sacrum, inner surface of ilia. These levator ani muscles are named : ö pubococcygeal [pc]-supports urinary sphincter The more internal urogenital diaphragm is another layer of muscles shaped as a triangle of 3 muscles connecting to the pubis, perineal body, and ischial tuberosities. These support urethral sphincter action and sexual function. These muscles are named : ö transverse perineal R/L muscles from perineal body to ischial
tuberosites The accessory muscles include : The energetic locks of the bandas and mudras consist of
: The nerves exiting the tail [cauda equina] of the spinal cord exits as sacral roots. These travel further to form the sacral plexus. The sacral roots in close proximity to the S/I joints have sensory distribution [dermatone] usually from the PSIS, across crest, groin, front thigh. Sensation can go into calf and to the big toe. Kinesiology of the Lumbar Spine We can consider the possible movement of a veretebra to be in any direction within the ranges of motion dictated by structure. We arbitrarily categorize vertebral movement along the cardinal planes, which are perpendicular to each other relative to the vertebra in the center. Flexion P is bending forward along the sagittal plane. Flexion is also called nutation, which is the rotation of the vertebra where the top rotates forward, and therefore the bottom rotates backward. The inferior facet joints gap open relative to the superior facets of the vertebra below. There is actual space created between these facets. Extension Q is bending backwards along the sagittal plane. Extension is also called counternutation, which is the rotation of a vertebra where the top rotates backwards and therefore the bottom rotates forward. The inferior facet compresses, closing of facet joint space in this backbend rotation relative to the superior facet of the vertebrae below. Rotation and Side Bending combine gapping on one side and compressing of the facets on the other side of vertebra. Kinesiology of Pelvic Girdle In stance, body weight transfers down spine through sacrum, locking into ilia. Ground forces move up through femur into ilium into sacrum and spine. In sitting, ground forces move up from weight bearing ischial tuberosities. There is less SI joint involvement when slump sitting on sacrum and not sit bones. The sacrum and ilium move only 5 -8 mm relative to each other . Still some western medical people say SI doesn't move a "measurable amount" or "statistically significant amount." Then why are there so many ligaments. And why is there so much SI pain. Sacro-ilial movement is the sacrum moving relative to ilium, as a continuation of spine [as L 6.] The sacrum , like a vertebra, can nutate [tailbone rotates posteriorly, top of sacrum anteriorly.] This is also called sacral flexion. This backwards movement of the bottom of the sacrum can move the trunk forward as in uttanasana, dog, and seated forward bend. Counternutation is the rotation of the sacrum that brings the tail bone anterior and the top sacrum posterior. This is also called sacral extension as the movement of the sacrum in backbends and upright poses. Left Rotation of the sacrum is the front of the sacrum turning to the left. The movement of the sacrum to the left can occur with the right side of the sacrum [relative to the ilium] moving forward or the left side moving backwards. Because the movement of the sacrum can initiate the movement of the spine and vice versa. As the sacrum rotates, so does the spine. Likewise as the sacrum nutates [or counternutates] so can the spine. The spine and sacrum can also rotate in opposite directions, as in Matsyasana or passive supine bolster extensions. Ilial Sacral movement is the movement of the ilium relative to sacrum.The ilia can be considered extensions of the femurs. So when the femur flexes the ilium posteriorly rotates. When the femur extends, the ilia anteriorly rotates. Anterior Torsion is the ilial rotation that brings ASIS down and PSIS up. When the hip is in extension as the back leg of a lunge, Virabhadrasana I, or Padangustasana I, the ilium anteriorly rotates relative the sacrum. The whole leg appears longer when the ilium is in anterior torsion. This rotation closes or compresses the S/I joint. Posterior Torsion is the ilial rotation that brings the ASIS up and the PSIS down. When femur flexes as the forward leg of lunge, Virabhadrasana I, Padangustasasana I, the ilium posteriorly rotates. This rotation opens or gaps the S/I joint. The leg appears shorter with the ilium in anterior rotation. Outflare is the external [outward] rotation of the ilium on the sacrum. As the leg externally rotates or abducts, the ilium outflares. This movement closes the SI joints and opens the pubis. Baddha Konasana and Padangustasana II cause outflare. Inflare is the internal rotation the ilium on the sacrum. As the leg is in internal rotation, the ilium inflares. This will open the SI joint in the back and close the pubis joint in the front. Upslip is the upward movement of the ilium on the sacrum. This is not a normal movement, but the ilium can jam up into the sacrum when one falls off a curb. Downslip is the downward movement of the ilium on the sacrum. This can be caused by bungy jumping, or when dragged by horse with foot in stirrup. Movement Pathology of the S/I Joint
When the sacrum is stuck in left sacral rotation, the left side usually doesn't move forward because this left side is stuck back. This is seen when the both sides of the top of the sacrum should move forward [nutation] when in a prone extension position. The right side of the sacrum usually doesn't move back because right side is stuck forward, as in the counternutation of child’s pose. The same goes for one stuck in right sacral rotation. In prop prone the right side usually doesn't move forward [nutation] because the right side is stuck back. In child’s pose, the left side usually doesn't move back because the left side is stuck forward. The lumbar vertebrae can likewise be stuck in the same compressive manner of rotation, because one side does not nutate or counternutate when it is suppose to follow the lead of the other facets. Non-physiological movement of sacrum is not a nutation,
counternutation, or rotation. But nonetheless, the ilium in other ways, can be
stuck within ilia. The pain and inflammation due to compression usually in extension is caused, for example by : ± collapsed lordotic standing
or one foot standing nutating sacrum on L5 The pain and inflammation from overstretch of sacral ligaments usually in flexion is caused by: ± associated or continuous
with overstretched hamstring insertion Sciatica may be caused by sacro-ilial compression leading to inflammation of nerve roots from L4 - S4. The pain, tingling, numbness often starts at the S/I travels across the iliac crest into the groin down the front thigh into the knee. People with S/I dysfunction often report similar complaints of : ± relief when supine [hips
flexed, pain wih hips extended or prone Hatha Yoga for the Compressed Back First quiet down inflammation with poses that gap or open lumbar facets. One needs to understand what provokes compression of facets or sacrum into pelvis or pelvis into sacrum. These relieving poses are the forward bends without ground forces jamming the dysfunctional joint up from the leg or sit bone in weight bearing. Typically sacral extension [counternutation] in forward bends, down dog, passive supine poses are appropriate. Opening the joint space can stabilize hypermobile joints when support is provided. This gapping can begin to unstick sticky joints. Then once the acuteness of pain and inflammation have begun to be decreased, the student can attempt to move toward spinal or leg extensions. This are provocative actions that demand the skill of lengthening the spine, creating space within facets and S/I joints, or stabilizing hypermobile joints. Without these skills, the student goes right back to compressing their vulnerable joints. Relieving Poses for Compression Forward Bends with sacral counternutaion, not nutation Lumbar Flexion / Pelvic Tuck : Sacral Counternutation ±supine neutral Unsticking Ilial Posterior Torsion for Stuck or Sticky Anterior Torsions Sacral Rock for Stuck or Sticky Sacral Rotation ±prone, prop prone Provocative Poses ±supine
opposite approach with overstretched sacral ligaments Judith Lasater - keep spine and pelvis together in neutral John Friend - hug muscle to bone with muscle energy |