My previous article [October 2016 issue] outlined evaluation and treatment of pelvic issues involving the sacrotuberous ligament and the pubic symphysis.
Case #1: Axial Discogenic Pain – Fix What You Find
Our first case illustrates how the lower half of the pelvis can influence a patient with probable axial discogenic pain. The patient, a 50-year-old female, comes in with low back pain and pain going down into her buttock, not below her thigh. Pain is worse on bending forward and sitting. Neurological exam, including SLR and slump testing, is negative. She does not bend with ease. She has midline tenderness to palpation at L5-S1.
I suspect axial discogenic pain, a flexion-intolerant lower back. The usual approach to this would start with standing decompression and/or McKenzie extension exercises, and teaching her to hip hinge while bending forward, maintaining lumbar lordosis.
I test her midline tenderness and her discomfort on flexion after each exercise. In this particular case, these exercises did not change her pain or tenderness. That does not mean she should not use these new movement patterns. It does mean directly addressing the flexion intolerance is not enough to downregulate her pain pattern. If she had even a subtly positive SLR, I would likely add neural flossing.
In this case, we need to look at what other dysfunctions could be impacting the disc. I palpate her left buttock. She does have tenderness over the sacral origins of the external rotators. This tender spot is over multiple layers of structures, including sacral ligaments, the gluteus maximus origins, the medial gluteus medius origins and the piriformis origins.
Addressing the Problem
What can we do, what can she do, for these tender points? Are they contributing to her midline tenderness? Continuing with the active care model, show her a supine piriformis stretch. The patient should simultaneously pull the knee toward the opposite shoulder and actively push the buttock toward the floor. This is dramatically different than the typical figure-four supine piriformis stretch, which forces the lumbar spine into flexion.
I already know this patient has flexion intolerance. She needs to stretch that tight buttock without compromising her flexion-intolerant lower back. My favorite piriformis stretch works, does not compromise the spine into flexion, and is simple. The key is to have the patient actively push their ischium and tailbone toward 6 o'clock, into anterior pelvic tilt, while simultaneously pulling the bent knee toward the opposite shoulder. They should feel the stretch in the deep buttock, and should not be pushed into lumbar flexion.
Back to our clinical audit, our reality check. Does this exercise change the midline tenderness? Can she bend with more ease? Did we diminish the tenderness at the lateral sacrum? If not, what's next?
Let's try manual therapy to address the lateral sacral tender point. If this point is exquisitely tender, start with counterstrain. Here is my interpretation of the counterstrain theory in brief: Some area became hypersensitive and does not know how to let go, how to turn off. You are not doing anything dramatic; you are just helping turn off the pain signal.
Lift the thigh into extension and external rotation by bringing the lower leg medially, while monitoring the tender point. As you feel the point soften under the palpating hand, ask the patient if the pain has diminished. It should be at least 50 percent less tender. If you can find a position that quiets the tender point, hold the leg in that position for 90 seconds.
The hardest thing for the clinician who is new to counterstrain: quit pressing hard on the tender point. All the work is being done by positioning. Just have a relaxed finger or thumb monitoring the tender point. After 90 seconds or when the pulse that you feel under your monitoring finger diminishes, slowly let the patient's leg back onto the table.
If you cannot find a position of ease that relieves the tenderness and/or the tender point has a more "gnarly" feel, switch gears. You can use either Graston technique tools, your elbow or knuckles, or whatever tool you use to break up muscular knots. Do deep oscillating pressure on that area. You can use FAKTR or ART principles here, adding motion.
These deeper methods help address an injured or dysfunctional ligament or tendon origin. These often benefit from deep stimulation; for neural effects, to break up congestion and trigger points, and to enhance blood supply and speed healing. When done, recheck the tender point. Once again, after you have successfully addressed this local tender point, go back to the L5 midline and see if it is less tender.
Your chart notes have real value here to you and your patient (beyond just getting paid by a third party). What worked? Note that. It may take a few sessions of whatever worked to normalize the pattern; or you may need to address additional issues or use different techniques on your next visit. This interactive process is so much more fun; so much more stimulating for you, the clinician. It is also much more likely to be effective than adjusting or rubbing the same thing over and over.
What is the primary diagnosis here? In this case, I suspect that the L5-S1 disc is the pain generator. What are you going to treat? We are function docs, we don't change anatomy; we help our patient move better and improve function. We really want to figure out what additional dysfunctional patterns are having the most impact on the inflamed disc. Finding these additional lesions is the critical second aspect of the diagnosis. We want to address these.
Recognize that using our treat-retest mechanisms may not be perfect, and that the clinical effect may be a summation of several things. But ideally, during the office visit we are able to quiet the indicators that come from the primary pain generator.
Case #2: A Hip That Lacks External Rotation
Our second case is a 60-year-old woman with right hip and right knee pain. She states that she cannot put her socks on normally and can't place her right ankle up on her left knee. On exam, she lacks hip external rotation and the hip has a hard end feel. Her hip internal rotation is also diminished on that right side.
What fascia, what joints can affect this? Obviously, the hip itself can be the problem. She could have significant degenerative changes and be on her way to a hip replacement. Our job is to attempt to restore normal motion to a joint or at least increase pain-free motion.
Anything medial to the hip joint can affect this external rotation motion, including the psoas and iliacus muscles, which share a common insertion on the lesser trochanter of the hip. The pubic symphysis, when misaligned, can affect hip motion. Just lateral to the pubes, you'll find the obturator foramen. The proximal adductors also impact this area.
Are you familiar with the obturator foramen? It's a hole in the pelvis which faces obliquely outward. Why is it important? It is an access point, and a connection between the viscera inside the pelvis and the pubic ramus and ischial ramus.
How do we assess it? We want to know if it is tender to the touch and if it has tissue texture changes. It is not a place we will adjust; it is a place where we will use gentle soft-tissue-release techniques.
Are you assessing the various nerves that run through the medial pelvis? The obturator nerve comes from L2, L3 and L4, and supplies the medial thigh. I talked about the ilioinguinal, genitofemoral and lateral femoral cutaneous nerves in a recent article [June 2016 issue].
A major nerve trunk, the femoral nerve, runs through this area and supplies the anterior thigh. The nerve supplies to these nerves that traverse the lower anterior pelvis are from the upper lumbar spine. Check these segments for tenderness and restriction, and palpate the nerves themselves.
What You Can Do
In this case, here is what worked. I started by doing muscle energy-style adjustments to her hip, lying supine, with the knees bent. I guided the knee into abduction, testing for the end range; then had her pull the knee medially against resistance for 5 seconds. I asked her to relax and I gently pulled the knee further laterally into abduction. This gained a few degrees of motion, but clearly we were not done.
I then palpated the obturator, finding it quite tender and releasing it with an Engage, Listen, Follow (ELF)-style of gentle myofascial work. I retested again; it had gained a bit more motion. Her right pubic symphysis was quite tender and inferior to the left pubes. I mobilized a right anterior-superior pelvis using muscle energy, adding a pubic contact to help move the right pubes superior. We finally had half-decent motion both on supine ROM testing and when asking her to simulate putting on her socks.
An excellent description of the anatomy of this area, as well as sophisticated manual treatment to this region, can be found in Barral and Croibier's Manual Therapy for the Peripheral Nerves. Barral is the originator of modern visceral manipulation.
I'll finish by quoting Karel Lewit; "He who treats the site of pain is lost." You will improve your clinical results if you explore the region of the pain, looking for weakness and tightness, fascial issues, and other stuck joints.
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