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There’s a Strange Click-Clack in the Back of My Sacroiliac
(Who Gets the Pain When They Do the Mambo?)
Richard Bachrach, DO FAOASM

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 I have to walk to ease it. 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: Through the years, depending on what's been “in” at the time, back pain has been attributed to problems with the intervertebral discs, spinal muscles, joints, ligaments, sacroiliac joints and/or with the emotions. In truth, except in relatively rare cases, we are unable to pinpoint the exact cause of any one episode of back pain. This is primarily a consequence of its multifactorial nature: back pain may be caused by the interaction of any or all the above factors, plus a few others. One of those is dysfunction of the joints connecting the pelvis to the spine: the sacroiliac articulations. (See prolotherapy.) This concept has been in and out of favor for years, but extensive new scientific research indicates strongly that a significant proportion of back pain relates to those joints. Many in the orthopedic surgical and neurosurgical communities still have great difficulty with that idea. They maintain that there is no movement between the sacrum and the pelvic bones. However, if that were true, why would these be synovial joints, (the same types of joints found in your fingers, ankles, knees, shoulders, etc.)? The fact is that they do move, however minimally. Excessive, abnormal, reduced or absent motion of the sacroiliac articulations is an extremely common source of low back and lower extremity pain. According to some researchers, the incidence of sacroiliac joint involvement in back pain episodes may be as high as 35%.

All (well, almost all) pain is caused by stimulation of nerve endings called nociceptors. These are present in many joint structures, as well as in and around the spine and the vertebrae themselves, the joints between them, the ligaments connecting them, the discs between them, the muscles that move them, the blood vessels that supply the muscles that move them, and the sheaths around the spinal nerves. Twisting, stretching, crushing or tearing may stimulate these pain receptors. They may be fired by chemical factors such as the accumulated waste products of muscle metabolism, other toxic substances, lack of oxygen, etc. Any number or all of these conditions may be operative in the spinal, pelvic, or sacroiliac areas at any one time. Small wonder there are so many different, often conflicting, diagnoses and treatments for low back pain.

What about the sacroiliac joints? The sacroiliac joints form the connection between the spine and pelvis. Like all such joints, cartilage lines the adjacent joint surfaces. In this case, the cartilage of 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, iliolumbar ligaments on either side tether the lower two lumbar vertebra, and indirectly, the sacrum to the pelvic bones. The ligaments behind the sacroiliac joints also restrain downward movement of the top 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. This prevents excessive forward or backward tilting of the sacrum and pelvis and provides a self-locking mechanism which allows us to walk, bracing 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 somewhat diagonally between the pelvic bones. With this relationship in place there is maximum stability. With a swayback posture (hyperlordosis) the sacrum tilts downward and forward and becomes more horizontal. The ligaments described above are stretched and the sacroiliac joints become unstable and the self-locking mechanism is impaired. The ligaments undergo further stretching, firing the pain receptors. Alternatively, the unstable sacroiliac joints may become locked in an abnormal alignment, maintained that way by resultant muscle spasm producing pain.

The individual with pain caused by sacroiliac instability and/or low back instability will tell us that he is unable to sustain any one position. Standing, sitting, walking, or often even lying down (morning stiffness is common) for prolonged periods may produce back and/or lower extremity pain. Pain is often relieved by changing position (after some difficulty initiating the move). The pain may involve either or both sides, radiate into either or both legs, usually not past the knee, at the same or different times. 

The spine and pelvis require stability. With failed ligaments, the job falls to the muscles around the pelvis and spine. They are ill suited to that task, designed to move rather than support. As the muscles become tighter, their circulation is impaired. Waste products and inflammatory pain producing substances are accumulated exciting the pain receptors. Normal movement is limited and the cycle of pain, muscle spasm, motion restriction is initiated and perpetuated, establishing (myofascial pain syndromes with trigger points) (q.v.). 

These conditions are amenable to correction by non-surgical procedures including osteopathic manipulation in acute cases, exercises to stabilize the lower back and pelvis, postural retraining, injection of trigger points. In the event these don’t do the job, prolotherapy (q.v.) is the logical alternative. Only rarely is surgery necessary.

 

The information contained in this website is for educational and informational purposes only and should not be regarded or interpreted as anything else. Diagnosis and treatment of disease, injury, pain or disability is the province of your health professional who should be consulted in regard to any medical symptoms or conditions before adopting any course suggested in this website. By proceeding to the table of contents page, you agree to accept the provisions of this disclaimer.

Copyright 1996-2007 Dr. Richard M. Bachrach
317 Madison Avenue, NY 10017 - 212-685-8113

2007 Richard Bachrach- 
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