A wide assortment of muscle, tendon, ligament, bone, nerve, and vascular injuries in this area is witnessed during posttrauma care. As with other areas of the body, the first step in the posttrauma examination process is knowing the mechanism of injury if possible. Evaluation can be rapid and accurate with this knowledge.

Low-back disability rapidly demotivates productivity and athletic participation. The mechanism of injury is usually intrinsic rather than extrinsic. The cause can often be through overbending, a heavy steady lift, or a sudden release –all which primarily involve the muscles. IVD disorders are more often, but not exclusively, attributed to extrinsic blows and intrinsic wrenches. An accurate and complete history is invariably necessary to offer the best management and counsel.

Initial Assessment

A player injured on the field or a worker injured in the shop should never be moved until emergency assessment is completed. Once severe injury has been eliminated, transfer to a backboard can be made and further evaluation conducted at an aid station.

Neurologic Levels

Neurologic assessment should be made as soon as logical. Muscle tonus (flaccidity, rigidity, spasticity) by passive movements is determined. Voluntary power of each suspected group of muscles against resistance is tested, and the force is compared bilaterally. Check pupil size, ability to follow finger motion, and reaction to light. Cremasteric (L1–L2), patellar (L2–L4), gluteal (L4–S1), suprapatellar, Achilles (L5–S2), plantar (S1–S2), and anal (S5–Cx1) reflexes are evaluated. Patellar and ankle clonuses are noted. Coordination and sensation by gait, heel-to-knee and foot-to-buttock tests, and Romberg's station test are checked. These are typical minimal evaluations.

Initial Assessment

Tenderness.   Tenderness is frequently found at the apices of spinal curves and not infrequently where one curve merges with another. Tenderness about spinous or transverse processes is usually of low intensity and suggests articular stress. Tenderness noted at the points of nerve exit from the spine and continuing in the pathway of the peripheral division of the nerves is a valuable aid in spinal analysis pointing to a foraminal lesion. However, the lack of tenderness is not a clear indication of lack of spinal dysfunction. Tenderness is a subjective symptom influenced by many individual structural, functional, and psychologic factors that can make it an unreliable sign. An area for clues sometimes overlooked is the presence and symmetry of lower-extremity pulses.

Keep in mind that lumbopelvic tenderness as well as pain can be referred from pelvic and lower abdominal viscera.

      LUMBAR SUBLUXATION SYNDROMES

Functional revolts associated with subluxation syndromes can manifest as abnormalities in sensory interpretations and/or motor activities. These disturbances may be through one of two primary mechanisms: direct nerve disorders or be of a reflex nature.

Nerve Root Insults

When direct nerve root involvement occurs on the posterior root of a specific neuromere, it expresses as an increase or decrease in sensory awareness over the dermatome; ie, the superficial skin area supplied by the segment. Typical examples include foraminal occlusion or irritating factors exhibited clinically as hyperesthesia, particularly on the

(1) anterolateral aspects of the leg, medial foot, and great toe, when involvement occurs between L4 and L5 and
(2) posterolateral aspect of the lower leg and lateral foot and toes when involvement occurs between L5 and S1. In other instances, nerve root involvement may cause hypertonicity and the sensation of deep pain in the muscles supplied by the neuromere. For example, L4 and L5 involvement, with deep pain or cramping sensations in the buttock, posterior thigh and calf, or anterior tibial muscles. In addition, direct pressure over the nerve root or its distribution may be particularly painful.

Reflexes.   Nerve root insults from subluxations may also be evident as disturbances in motor reflexes and/or muscle strength. Examples of these reflexes include the deep tendon reflexes such as seen in reduced patella and Achilles tendon reflexes when involvement occurs between L4 and L5. These reflexes should be compared bilaterally to judge whether any hyporeflexia is unilateral. Unilateral hyperreflexia commonly indicates an upper motor neuron lesion.

Atrophy.   Prolonged and/or severe nerve root irritation often causes trophic changes in the tissues supplied. This is characterized by obvious atrophy that would be unusual in athletes and physical laborers. Such a sign is particularly objective when the circumference of an involved limb is measured at the greatest girth in the initial stage and this value is compared to measurements taken in later stages.

Kemp's Test.   While in a sitting position, the patient is supported by the examiner who reaches around the patient's shoulders and upper chest from behind. The patient is directed to lean forward to one side and then around to eventually bend obliquely backward by placing his palm on his buttock and sliding it down the back of his thigh and leg as far as possible. The maneuver is similar to that used in cervical compression. If this compression maneuver causes or aggravates a pattern of radicular pain in the thigh and leg, it suggests nerve root compression. It may also indicate a strain or sprain and thus be present when the patient leans obliquely forward or may arise at any point in motion.

Senior Citizens.   Since the elderly weekend athlete is less prone to an actual herniation of a disc due to lessened elasticity involved in the aging process, other reasons for nerve root compression are usually the cause. Degenerative joint disease, exostoses, inflammatory or fibrotic residues, narrowing from disc degeneration or cord stenosis, tumors –all must be evaluated.

      SPINAL CORD INJURIES

Any shade of sensory abnormality, objective or subjective, should immediately raise suspicion of possible injury to the spinal cord or cauda equina. White/Panjabi report studies showing that, with severe spinal trauma, relaxed muscles appear to be associated with less cord injury than when the muscles are strongly tensed.

Injuries to the lumbar cord or its tail occur from vertebral fractures, dislocations, or penetrating wounds in severe accidents. In rare instances, the cord may be damaged from violent falls. The T12–L1 and L5–S1 areas are the common sites of injury, especially those of crushing fractures with cord compression. Neurologic symptoms develop rapidly. The higher the injury, the more fibers will be involved. More common than these occurrences are cord tractions, concussions, and less frequent contusions.


Pathologic Traction

A scoliotic lumbar deviation must always be attended by a commensurate vertebral body rotation to the convex side. If this does not occur, it is atypical and likely pain producing. If the vertebral bodies were not subject to the law of rotation during bending, the spine would have to lengthen during bending, and its contents (ie, cord, cauda equina, and their coverings) would be subjected to considerable stretching. Thus, in a case of scoliotic deviation in the lumbar area without body rotation toward the convex side, signs indicating undue tension within the vertebral canal should be sought. It should also be noted that atlanto-occipital, atlantoaxial, and coccygeal disrelationships with partial fixation place a degree of traction on the cord and dural sleeves in flexion-extension and lateral bending motions.


Cord Concussion

Immediate signs are usually not manifested in mild or moderate cord concussions; but weeks later, lower extremity weakness and stiffness may be experienced. Reason: It takes time for nerve fibers to degenerate. Deep reflexes become exaggerated and originally mild sensory, bladder, and rectal disturbances progress. The picture is cloudy, often mimicking a number of cord diseases (eg, sclerosis, atrophy, syringomyelia). Life is rarely threatened, but full recovery is doubtful. However, a patient's courage and determination can embarrass a doctor's negative prognosis.


Cord Contusions

If laceration occurs, shock is rapid. Deep reflexes, sensation, and sphincter control are lost. The paralysis is flaccid. Obviously, even a prognosis cannot be made until the shock is survived. Cord concussion usually complicates cord contusion.


Common Tests

Kernig's Neck Test.   Biomechanically, this test is the cephalad representation of Lasegue's straight-leg-raising test. The supine patient is asked to place both hands behind his head and forcibly flex his head toward the chest. Pain in the neck, lower back, or down the lower extremities indicates meningeal irritation, nerve root involvement, or irritation of the dural coverings of the nerve root. That is, some lesion is being aggravated by tensile forces. When the examiner passively flexes the patient's neck and trunk, it is called the Soto-Hall test.

Kernig's Leg Test.   The examiner flexes the thigh at a right angle with the torso and holds it there with one hand. With the other hand, the ankle is grasped and an attempt is made to extend the leg at the knee. If pain or resistance is encountered as the leg extends, the sign is positive provided there is no hip or knee stiffness or sacroiliac disorder.

      DEVELOPMENTAL DEFECTS

Genetic factors frequently leave the lumbar spine unstable, and the gross and subtle implications of anterior-posterior, lateral, and rotational balance are manifold. The incidence of low-back disorders of a protracted and recurring nature is much higher in those whose spines show evidence of development defects and anomalies. This is especially true in the young. Such lumbosacral defects and complications as asymmetrical facet facing, imbrication, sacralization (especially the pseudo type), lumbarization, pars defect, discopathy, iliotransverse ligament sclerosing, retrolisthesis and L5-S1 reverse rotation are important concerns.

Body weight during development wedges the sacrum between the innominates because of their peculiar laterally inclined planes. This allows the sacrum to move inferiorly, anteriorly, and medially, coupled with the anteroinferior angulation of the sacral base. Many abnormal orientations found in the lower spine are because the lumbar facet joints are not determined until the secondary curves are developed in the erect position. Severe forces imposed during maturation contribute greatly to the high incidence of asymmetry.


      SCREENING FRACTURES BY ROENTGENOGRAPHY

Acute injuries to the supporting soft tissues about a vertebra are rarely demonstrable in x-ray films. Their presence is suggested when the normal relations of bony structures are disturbed. However, when ligament lesions heal, hypertrophic spurs and sometimes bridges may develop locally on the margins of the bones affected.

Direct buttock falls upon a hard surface (eg, ice or roller skating, skateboarding) often result in vertical or sometimes oblique sacral fractures associated with other unilateral pelvic fractures, dislocation of the coccyx, and lumbar subluxations. After pelvic or leg injury, spontaneously reduced hip dislocation or consequent instability is sometimes missed. Note pelvic symmetry, deformity, and carefully palpate for bony crepitus about the ischium, rami, and hip areas.

Rolling injuries are usually at fault in pelvic ring fractures such as seen in horseback riding accidents, falls against a hard surface, and vehicular accidents. Vascular, bladder, and perineal injuries are often associated. Even when the ilium and/or sacrum are fractured, the strong sacroiliac joint usually remains intact.


Avulsions

The lower back and pelvis are common sites for avulsion-type injuries. Severe, sudden muscle contraction can produce fragmented osseous tears near sites of origin and insertion. Avulsions in the lumbar area often occur with transverse-process fragmentation at the site of psoas insertion. Although the transverse processes of the lumbar spine are quite sturdy, multiple fractures are seen in football and similar injuries.

Fatigue and avulsion fractures are far from uncommon, but typical injuries are associated with muscle, tendon, fascia, and cartilage injuries of the lower extremity. The common sites of avulsion fractures in one 2-year study occurred at the ischial tuberosity at the hamstring origin, the ASIS at the sartorius origin, and the AIIS at the origin of the rectus femoris muscle. In running strains, sudden severe pain in the area of the hip or buttock may be traced to an avulsion of the hamstring attachments at the ischial tuberosity. Roentgenography may indicate large crescent-shaped bone masses near the injured ischium.


Fractures

While pelvic fractures are not common, they should never be taken lightly as they are the second most common cause of traumatic death –second only to head injuries. They are usually due to violent injuries, are frequently multiple, and result in severe deformity. The most common area involved is about the sacroiliac joints and the symphysis pubis. A fracture or dislocation of a pubis is frequently associated with separation of a sacroiliac joint or fracture of the adjacent sacrum, ilium, or pubis.

Sources of Error.   Colon or rectal gas on film may mimic or obscure a pelvic fracture, but as these shadows are not constant, they can be ruled out on future examination. Other sources of error are the blood-vessel grooves in the ilium, but their branching character and bilaterality help in identification. In examining the young, remember that the pelvic epiphyses are among the last to unite. They are open until 20–25 years of age.

Effects.   Pelvic fractures often cause severe internal bleeding difficult to halt even on surgery. Shock is present in 40% of the cases. The patient is unable to stand or walk, complains of pain in the pelvic region or back. If the bladder or a kidney is injured, blood passes in the urine. A pelvic girth injury is suggested by severe low back pain (especially in retroperitoneal bleeding), severe pain with induced compression of the iliac crests, and acute pubic tenderness.

Transverse Process Fractures.   Transverse-process fractures are frequently asymptomatic or nearly so and lack symptoms to encourage a most careful examination. As reported previously, lumbar transverse-process fractures are sometimes not evident or are poorly visualized in roentgenography (unless markedly displaced or angulated) because of overlying gas and/or soft-tissue shadows that obscure detail. A cleansing enema or other means of clearing overlying soft-tissue shadows is helpful whenever structures are not well visualized.

Ilium Fractures.   Fractures of the ilium appear on film as sharply defined lines of diminished density that are possibly stellate.

Sacral Fractures.   Sacral fractures are difficult to visualize unless there is some displacement. Isolated sacral fractures are invariably related to a direct blow from the posterior or the inferior. The mechanism of injury is sometimes associated with shear when a blow to the knee when sitting erect (eg, dashboard injury) drives the femur posterior, superior, and medial; rotation where the hip is severely hyperextended; and/or leverage where the A-P dimension of the pelvis is flattened. Fracture lines are usually through the sacral foramina, weakening the bone at these points.

Pubic Fatigue Fractures.   On rare occasions, the adductor muscle attachment area at the inferior pubic ramus may be the site of overstress. This usually occurs from a fall or a sudden stop while delivering a bowling ball or throwing a heavy package in an unbalanced position. Avulsion of the inferior pubic ramus, rupture of the adductor longus' origin, and laceration to scrotal vessels may be associated.

Body weight is carried in the lower back essentially by the L5 disc and dissipated to the sacral base, sacroiliac joints, and acetabulae. This weight on the L5 disc is forced slightly anterior on the load surfaces. The lateral line of gravity cuts a point just anteroinferiorly to S2. Weight distribution in the lumbar region is governed chiefly by the inclination of each vertebral body articulation. The lateral centerline of gravity falls on the spinal points because of gradual changes in the angles of the inclined planes of the various articular surfaces. This tends to force each lumbar vertebra more inferior, medial, and anterior or posterior until gravity brings the apex of the curve back toward the balancing point.

The Lumbar Facets

When the spine is in good alignment, facet articulation offers minimal friction. In scoliosis, the articular surfaces are no longer parallel and the result is articular scrubbing leading to impingement, erosion, and arthritis. This is the result of normally reciprocal articulating surfaces operating in an oblique position.

Lumbar Planes of Articulation.   The lumbar facets are moderately sloped surfaces rather than a single-plane angle as seen in the cervical and thoracic area, and they are fairly parallel to the vertical plane at L1 and L2. The laterally convex inferior facets mate with the concave superior facets. From L1 to L5, the plane of the articular facets changes from mediolateral to anteroposterior and lie, for the most part, in the sagittal plane. There are considerable differences between the plane of articulation and the shape of the vertebral canal that progress from L1 to L5. Rotation and lateral flexion is anatomically inhibited by the articular planes in the L1–L2 segments but not in the L4–L5 segments. The upper lumbar joints appear J-shaped when viewed laterally, thus the anterior aspect of the articulations resists forward displacement.

Lumbosacral Facets.   The lumbosacral facet planes are slightly more horizontal than those above, allowing greater A-P and lateral motion but less joint locking as compared to the vertebrae above. This horizontal and anterior inclination of L5, spreading out toward the coronal plane, becomes progressively more vertical upward from L4 to L1.

Facet Angle Variations.   Interspinal posture is directed by the facet facing of each posterior intervertebral joint, with altered facings commonly occurring in the lumbar and lower cervical regions. Articular facings are altered more frequently between L4 and L5 than at any other level in the vertebral column. Normal symmetrical facets glide with little friction. However, if the facets deviate in their direction of motion, the unparallel articulations "scrub" upon one another. Over a period of time even in the absence of overt injury at the level of abnormality, articular variations present marginal sclerosis. This hardening is usually followed by hypertrophy or exostosis. Coexistent with this finding, the interarticular spaces gradually become narrowed, hazy, obscured, and even obliterated on x-ray films.

The Lumbar Intervertebral Foramina

Vertebrae move in the planes of their articulations, and it is at the posterior intervertebral articulations that subluxations occur and influence the IVFs. Changes in the diameter of normal IVFs parallel joint dysfunction that predisposes further subluxation and begins altering the curves of the particular region of the spine that this structural defect is found.

IVF Size and Shape.   Lumbar IVFs are shaped laterally like inverted teardrops or kidney beans, with the diameter of the vertical axes about double the A-P dimensions. There is normally adequate space for changes in vertical dimension during normal movements without injury to the IVF contents as long as there is adequate fat and fluid present and stenosis and adhesions are absent. However, reduction of the already short transverse diameter can produce noxious effects. For this reason, mild disc collapse anteriorly is often asymptomatic, but a slight posterolateral herniation may protrude upon the IVF and produce severe symptoms.

IVF Contents.   Each foramen widens and expands with spinal motion. From one-third to one-half the foraminal opening is occupied by the spinal nerve root and its sheath, with the remaining portion filled essentially by fat, connective tissue, and various vessels. The IVF contains the anterior nerve root, the posterior nerve root, a part of the dorsal nerve root ganglion, a bilaminar sleeve of dura and arachnoid membrane to the ganglion, a short continuation of the subarachnoid space with cerebrospinal fluid that ends just beyond the ganglion, the recurrent meningeal nerve, the spinal ramus artery, the intervertebral vein, and lymphatic vessels.

IVF Diameter Changes.   Common factors altering the diameters of the IVFs are the disrelation of facet subluxation, the changes in the normal static curves of the spine, the presence of induced abnormal curves of the spine, degenerative thinning, bulging, or extrusion of the related IVD, the swelling and sclerosing of the capsular ligaments and the interbody articulation, and marginal proliferation of the vertebral bodies and articulations. These factors can insult the viable contents of the IVF. The result can be nerve root pressure, traction, or torque; constriction of the spinal blood vessels; intraforaminal and paraforaminal edema; induration and sclerosing of the periarticular ligaments with trauma to the receptors; forcing of the foraminal contents into protracted constriction and altered position; and such other consequences. It is not well recognized that acute phenomena are usually the result of friction, toxicity, and derangement from severe or repeated trauma, and encroachment from degenerative thickening or exostosis rather than of neurologic origin.

IVF Impingement.   Lumbar nerve roots run anterior and superior to their facets. The root is often compressed in the IVF by a subluxated facet and less often by a herniated disc or a spur from the posterior aspect of the vertebral body. These disorders can be worsened by spinal stenosis that narrows the vertebral canal and the tunnel in which the nerve roots exit the IVFs.

Sensory Mechanisms.   There are about twice as many sensory fibers than motor fibers in lumbar nerve roots. When the anterior root is irritated, pain is felt in the muscles supplied and often becomes self-perpetuating from the focal spasm produced. In posterior root irritation, pain can be felt in its dermatome, myotome, sclerotome, and possibly in the viscerotome.

The Lumbar Nociceptive Receptor System

The lumbar ligaments and fascia are richly innervated by nociceptive receptors. When the lumbar spine is in a relaxed neutral position, its nociceptive receptor system is relatively inactive. However, any mechanical force that will stress or deform receptors, with or without overt damage, or any irritating chemical of sufficient concentration will depolarize unmyelinated fibers and kindle afferent activity.


Importance of the Spinal Extensors

A strong correlation exists between spinal muscle strength and maximum lifting loads, and the spine withstands greater axial compression (eg, carrying a load) when the normal physiologic curves of the spine are maintained. Prolonged flexion postures and actions are frequently associated with the onset of back pain. It has been found that patients with back pain invariably have significantly weakened extensors as compared to asymptomatic subjects. EMG studies of patients show decreased extensor endurance during postural activities.

Even mild spinal extension unloads involved discs and allows fluid influx. This is important because IVDs need a state of low pressure to imbibe low molecular weight substances for proper nutrition. In addition, strong extensors reach fatigue slowly and are protective of spinal ligaments during light and unloaded activity.

In subjects not complaining of back pain, trunk extensor strength exceeds flexor strength and half of total spinal extension motion is produced by the erector spinae. Thus, this balance (erector strength) should be restored whenever necessary and maintained for both therapeutic and prevention goals.


      POINTS OF GREATEST SPINAL STRESS

Motion at the Thoracolumbar Transitional Area

Because of restricted motion in the thoracic spine and the relatively A-P mobile lumbar spine below, the intervening thoracolumbar area must achieve a degree of hypermobility in all three body planes. Because of this, as is true to some extent in all spinal transitional areas, the thoracolumbar junction is more prone to stress from both above and below.

The superior facets of the transitional vertebra resemble thoracic facets and are designed for rotation and lateral flexion, even though these motions are restricted somewhat by the free ribs. While the stiff thoracic spine tends to move as a whole, most rotation takes place in the lower segments that are not restricted by the rib cage. The inferior facets of the transitional vertebra are of the lumbar type and designed for flexion and extension. Although we readily observe great curves in the lumbar area, most of the apparent rotation seen is from distortion of the lumbar spine's base, tipping, and the lumbar lordosis viewed out of its normal plane (ie, viewed obliquely).

It is controversial whether nerve roots are normally fixed to the margins of the IVFs. We can suspect that fibrotic changes following the granulation tissue of irritation, especially in the lumbosacral region, frequently fix the sleeve at one or more points. This contributes to traction on the sheath and its contents during movements such as in a straight-leg-raising test. These abnormal attachments increase in strength with repetitive trauma, aging, and other degenerative changes. Again we see the noxious effects of fibrosis.


Motion of the Transitional Lumbosacral Area

The coupling of L5 and S1 constitutes a rather unique "universal joint." For example, when the sacrum rotates anteroinferiorly on one side within the ilia, L5 tends to rotate in the opposite direction because of the restraint of the iliolumbar ligament. The effect is a mechanical accommodation of the lumbar spine above assuming a posterior rotation on the side of the unilateral sacral anteroinferiority. It also tends to assume an anteroflexed position, thus producing the three-dimensional movements of the lumbar spine. In view of the intricacy of the lumbosacral junction, anomalies such as asymmetrical facets have a strong influence on predictable movements in this area.

The iliolumbar ligaments connect the transverse processes of L5 to the crests of the ilia and sacral base. Aside from the articular facets, the iliolumbar ligaments appear to be the most important structures limiting axial rotation of L5 on the sacrum and preventing forward gliding of L5 on the sacrum. Because of its deep position below the iliac crests and the strong strapping by the iliolumbar ligaments and spinal extensors, L5 is only as movable as the sacral base will allow. Thus, when lipping of or spurs at the inferior L5 body are seen, a history of instability can be presumed.


      KINESIOLOGY OF THE LUMBAR SPINE

Testing Muscle Weakness

The trunk is held erect by the flexors and extensors of the spine and the extensors of the hip. The muscles and ligaments holding the trunk erect are much stronger as a whole than those of the pelvis. After a long illness, for example, a patient can sit erectly long before he can stand unaided.

Flexion.   Leg raising from the supine position is a two-phase combination between strong abdominals and strong hip flexors.

Extension.   Because A-P trunk motions are the common movements used in daily living and as flexion is assisted by gravity, the spinal extensors are important muscles of the trunk from a biomechanical viewpoint. It is also for this reason that back muscles are rarely weak unless paralysis is present. Kendall places the incidence of weak spinal erectors at less than 1% in the nonparalytic. When signs of extension weakness are evident, differentiation must be made between weak spinal extensors and weak hip extensors.

Lateral Flexion.   Trunk raising from the lateral recumbent position exhibits the strength of trunk lateral flexors and hip abductors.

If active lumbar motions are normal, there is no need to test passively. A patient may be observed, however, who replaces normal lumbar motion by exaggerated hip motion, or vice versa. The range of motion of the restricted lumbar or hip joints should then be passively tested. Any disorder of the hip joint itself (eg, fracture, tuberculosis, osteoarthritis, advanced necrosis, slipped plate) or of hip muscles may result in limited hip motion.

The range of lumbar motion is determined by the disc's resistance to distortion, its thickness, and the angle and size of the articular surfaces. As in the thoracic spine, the movements of the lumbar spine are flexion, extension, lateral bending, and rotation (minimal). While lumbar motion is potentially greater than that of the thoracic spine because of the lack of rib restriction, facet facing and heavy ligaments check the range of rotation.

Distortion Patterns

A feature of any spinal and pelvic distortion is that the segment or segments can be carried into the deviation of the distortion pattern more readily than out of the gravitational pattern of the deviation. Two examples illustrate this:

(1) If there is a right structural scoliotic deviation of the lumbar area, the patient sitting, to fix the pelvis, will find it easier to rotate the torso to the right than to the left.
(2) If there is a left wedging of L5, L4, or L3, lateral flexion to the left is noticeably easier than lateral flexion to the right.

The apices of curves and transition areas are logical points for spinal listings since they are frequently the location of maximum vertebral stress. Subluxations may occur at other points in curves and rotations, particularly at the beginning point of a primary defect in balance such as in the lower lumbar and upper cervical sections. Subluxations frequently occur also at the point where a primary curve merges into its compensatory curve.

A posterior L3 is rare when the apex of the lumbar curve is too high or too low, but common at L4, L5, and the sacral base. When the apex of the lumbar curve is too low, a posterior subluxation will most likely be found in the upper lumbar area.


Lumbosacropelvic Rhythm

Forward flexion takes place in two phases. During the first 60° of flexion, the pelvis is locked by the posterior pelvic muscles. About 70% of this motion occurs at the lumbosacral joint, 20% between L5–L4, and 10% between the L1 and L3 vertebrae. This motion is smoothed by the counterforce of the spinal extensors. During the second phase, from 60° to 85° , the hip releases and the pelvis rotates bilaterally forward around the transverse axis of the hip joints. Near the end of spinal flexion, the sacral base slightly follows L5 anteroinferiorly as the sacral apex pivots posterosuperiorly.

Synchronization of these lumbar-sacral-pelvic motions must be achieved to obtain minimal biomechanical stress. Abnormalities in these mechanisms will quickly point out and help differentiate sites of lumbar, sacral, or hip restrictions or instability.


The Revealing Adams Position

This important test should never be supervised casually. It was a crucial tool in pioneer chiropractic that appears to be depreciated in today's education. The reader should weigh the large array of clinical clues brought out below.

The patient assumes the Adams position by standing erect with the heels together, then bending forward with the fingers as near the floor as possible without straining. For an indication of gross spinal flexibility, the distance between the fingertips and the floor can be measured or at least observed. In bending, the knees should not flex. As a patient advances in age and the spine settles, there will of course be less flexibility. Stiffness would also occur with taut or spastic paravertebral muscles.

During lower back flexion or extension, there is far less vertebral gliding than seen in other areas of the spine during A-P motion. Opening of the anterior disc space on extension or of the posterior disc space on flexion does not occur until movement nears its full range of motion. Even then, it is much less than that seen in other areas of the spine. The anterior longitudinal ligament relaxes during flexion, and the supraspinal and interspinal ligaments stretch. Forward flexion in the adult will not normally result in a kyphosis of the lumbar area as it does in the cervical area. While a number of disorders result in decreased flexion, paraspinal muscle spasm is the prime suspect.


Gross Observation

While the patient moves in and out of the flexed Adams position, the following points are noted:

(1) Is flexion unrestricted?
(2) Is flexion straight forward or deviated laterally?
(3) Do spinous processes line up straight during forward flexion and extension from flexion? This is more easily determined by dotting the spinous processes with a skin pencil when in the standing position.
(4) Are there abnormal prominences or movements of the angles of the ribs during A-P motion? Is the pelvis level?

The two most common clinical signs that appear are

(1) restriction of end motion (motion block, with or without pain) in which the patient's fingers stop far above the floor, and/or
(2) scoliotic rotation of the spine in which the vertebral bodies follow the plane of least resistance (structural or antalgic).


Segmental Faults

As the patient moves into and out of the Adams position, the vertebral column should be examined for individual segments that flatten or arch at the wrong time or do not move evenly with their neighbors. Palpation should be done with the fingerpads on the interspinous spaces. With motion by the patient, the various segments of the spine can be felt to glide closer together or further apart. Should an area be found that remains rather immobile or without the normal gliding action, further tests and x-ray studies should be made of this section of the spine.


Standing Forward Flexion

During the first stage of flexion, the normal lumbar lordosis gradually flattens and then gradually develops a smooth curved kyphosis. The degree of lumbar flexion in many people is up to and only slightly over the flattening of the normal lordosis, thus total possible flexion must be achieved by hip rotation. In fact, some people can bend forward to touch the floor with little change in the spinal curves. This is usually due to hypermobile ilia and hips adapting to lumbar fixation. If the lumbar curve fails to flatten during trunk flexion, the first suspicions should be restriction of the posterior elements from muscle contraction, ligament shortening, or abnormal articular planes.

Unilateral facet asymmetries will often be revealed by a distinct scoliosis exhibited in the Adams position that is not apparent in the erect position. If pelvic rotation fails to occur, the first suspicions should be effects of sciatic irritation, hip restriction, or tight hamstrings. If a hamstring fails to elongate unilaterally, distinct contralateral lumbar rotation will be seen during flexion as L5 follows the low sacrum.


Supine Hyperflexion

In this adaptation to the standing test, the supine patient is asked to grasp his flexed knees, pull them toward his abdomen, and flex his neck forward in an attempt to touch his forehead between his knees. In this position, flexion should occur from below upward and a greater stretch is placed on the lumbosacral area than can be achieved in the standing position. The examiner's fingertips can be placed in the lumbar interspinous spaces to evaluate segmental motion. At the same time, the examiner should note the maximum range of motion and the production, increase, or reduction of pain and its distribution. Before concluding this part of the examination, the examiner should test the effects of repetitive loading.

In contrast to forward flexion in the standing position, flexion in the supine position places little tension on the sciatic nerve. Thus, sciatica aggravated by both standing and supine flexion suggests a disc involvement. Sciatica aggravated in the standing but not the supine position suggests a nerve root involvement.


Extension

Extension occurs from above downward. The maximum range of motion, and the production, increase, or reduction of pain and its distribution should be noted. Testing can be considered a reversed Adams maneuver.

The posterior portion of the anulus is the weakest. The anterior and lateral aspects are almost twice as thick as the posterior aspect. The anular fibers at the posterior aspect of the disc are less numerous, narrower, and more parallel to each other than at any other portion of a lumbar disc. If a person must work habitually in a prolonged forward flexed position, periodic lumbar extension will relieve the stress of the posterior anulus and tend to shift a loose nucleus pulposus anteriorly; ie, away from the spinal cord and IVF. Many manual workers do this maneuver unconsciously.


Standing Hyperextension

To test lumbar extension, the standing patient bends backward as far as possible and given support by the examiner placing one hand firmly on the patient's sacrum and the other hand on the patient's anterior chest. The degree of extension is controlled by stretching of the anterior longitudinal ligament and rectus abdominis, relaxation of the posterior ligaments, and contraction of the spinal extensor muscles. The examiner's fingertips can be placed in the lumbar interspinous spaces to note segmental motion. If posterior disc protrusion, facet inflammation, or spondylolisthesis exist, pain will be increased during extension. Before concluding this part of the examination, the examiner should test the effects of repetitive loading.


Impeded Extension

Loss of lumbar extension is often the result of poor sitting posture and/or inadequate extension mobilization following injury in which shortened scar tissue prevents a full range of extension. Reduced extension

(1) causes chronic posterior stress on the soft tissues of the vertebral motion unit and an increased intradisc pressure during sitting;
(2) restricts a fully upright posture during relaxed standing, leading to a stooped appearance in stance and gait; and
(3) produces a premature fully stretched lumbar posture when arising from a forward flexed posture. Restricted extension is usually the result of fixation at the posterior aspect of the motion unit that prevents facet gliding. Increased pain during hyperextension suggests a rotational subluxation. When a posterolateral herniation is present, the patient will have restricted extension with deviation away from the side of pain.


Standing Extension from Flexion

Just as much information can be gathered as the patient returns to the neutral position as during flexion. If a load is being lifted, the majority of the force is on the posterior lumbar ligaments until about 60° when the back muscles become active and the abdominals serve to smooth the action. The main function of the longitudinal ligaments is to restrict abnormal motion. If there is segmental restriction, excessive motion is forced on the adjacent segments and the hips. Hip restriction forces excessive motion on the lumbar spine and sacrum. If there is excessive joint laxity, subluxation with or without sprain or strain may occur.

The most common fault recognized in extension from full flexion is premature return of the lumbar lordosis. If this occurs, the first suspicion should be weak hamstrings and/or other pelvic extensors. Associated weak abdominals will contribute to faulty pelvic stabilization.


Recumbent Hyperextension

A patient's spine is automatically placed in extension when the prone position is assumed on a flat surface. The prone patient is asked to lift his trunk upward by extending his elbows, yet keeping his lower pelvis firm against the examining table. This is similar to a push-up where the pelvis is not raised.

A much greater degree of lumbosacral hyperextension can be achieved in the prone position than in the standing position. As in the other tests, the examiner's fingertips can be placed in the lumbar interspinous spaces to note segmental motion and the maximum range of motion and the production, increase, or reduction of pain and its distribution should be evaluated.

A small disc protrusion would be reduced by segmental extension, thus extension should relieve pain. However, an entrapped fragment or protrusion would not be benefited and may be aggravated. Before concluding this part of the examination, the examiner should test the effects of repetitive loading.


Standing or Sitting Lateral Flexion

In the lumbar spine as a whole, lateral flexion is relatively free, followed in order of mobility by extension, flexion, and minimal rotation. Most significant to movements in the lumbar spine is that all movements are to some degree three dimensional; ie, when the lumbar spine bends laterally, it tends to also rotate posteriorly on the side of convexity and assume a hyperlordotic tendency. Testing can be considered a lateral Adams maneuver.

In evaluating lateral flexion of the lumbar spine, the standing or seated patient's right iliac crest should be stabilized as he leans to the left as far as possible. Then the same maneuver is repeated for the other side, and the degree of lateral flexion is noted. The standing patient is asked to flex sideward and move his hand on the side of bending distally down the side of his thigh as far as possible. This point should be recorded. Lateral flexion should occur from above downward. The examiner's fingertips can be placed in the lumbar interspinous spaces to evaluate segmental motion.

The maximum range of motion and the production, increase, or reduction of pain and its distribution should also be evaluated. It is not unusual to find that one side is unrestricted and the other side is blocked. This suggests a degree of scoliosis, with restricted movement on the side of convexity. A laterally displaced nucleus pulposus would have the same effect. Before concluding this part of the examination, the examiner should test the effects of repetitive loading.

During lateral bending in the erect position, considerable rotation accompanies abduction motion if there is a significant degree of lordosis. However, if the lumbar spine is relatively flat or if the lateral bending is performed in the sitting position, the amount of rotation is minimal. The intertransverse spaces of the normal spine open on the convex side and approximate on the concave side. In distinct lordosis, however, the facets are relatively locked and lateral flexion is so restricted that the vertebrae must severely rotate to allow significant lateral bending.


Rotation

To grossly screen trunk rotation, the standing or sitting patient's pelvis is stabilized and he is asked to turn his shoulders as far as possible to the left and then to the right. Only a slight degree of rotational fixation is necessary to affect A-P and lateral bending motions. Because the facial planes are no longer reciprocal, normal motion becomes restricted.


Axis of Rotation

If the axis of rotation of lumbar vertebrae were at the tips of the spinous processes, as sometimes is taught, the spinous process of L1 would be directly in line with the process of L5 during rotation while the vertebral bodies rotate to a greater degree toward the direction of movement. But because the center of rotation of T12 is distinctly anterior, it must pull L1 with it during rotation. This forces the lumbar region into rotation and flexion that jams the facets on the side moving posteriorly and opens the facets on the side moving anteriorly. This lumbar effect is continued to the sacrum, which also flexes and rotates with the lumbars.


Rotation During Flexion

When the spine does not bend straight forward during flexion (Adams position) but deviates to one side, even slightly, a search should be instituted for contractured, thickened, or shortened muscles, tendons, and/or ligaments of the column existing on one side and not on the other. If the spine shows rotation to the right, the patient in a forward bent position can swing his torso into right rotation more readily than to the left.

In common pelvic mechanical pathologies on the side of involvement, there are an observable slanting and anteriority of the pelvis in the forward bending position. There will be a noticeable lumbar scoliosis to the side of involvement. Elevation or prominence of the ribs on either side denotes a rotation of the vertebrae on their axes. Shortening of the ligaments with contracture of the muscles of the spine exhibit as abnormal stiffness or hardness of the muscles on the side of the spine that suffers from contractures. The examiner should compare the position of the dots over the spinous processes with their appearance when the patient was in the anatomical position.


Loading

The importance of spinal load is underscored with weight lifters, bowlers, oarsmen from lifting the shell, and even in lordotic long-distance runners. When an object is held 14 inches away from the spine, the load on the lumbosacral disc is 15 times the weight lifted. Lifting a 100-lb weight at arms' length theoretically places a 1,500-lb load on the lumbosacral disc. This load, of course, must be dissipated, otherwise the L5 vertebra would crush. The load is dispersed through the paraspinal muscles and, importantly, by the abdominal cavity acting as a hydraulic chamber absorbing and diminishing the load applied. This emphasizes the vulnerability of the spine to the mechanical stresses placed on it, especially in people with poor muscle tone. Bony compression of the emerging nerve roots arises as a result of subarticular entrapment, pendicular kinking, or foraminal impingement due to posterior vertebral subluxation.

Effects of Repetitive Loading.   Repetitive loading has beneficial effects on shortened tissues and adverse effects on the disc or an area of inflammation (eg, sciatic neuritis). To test the effects of repetitive lumbar flexion loading, the standing patient is asked to flex forward to the maximum and return to normal ten times in succession. If the patient's pain increases, a disc involvement or area of inflammation is presumably the factor involved. If the patient's pain reduces, shortened tissues are most likely the origin of the patient's pain.

The pelvic basin is the anatomical link between the axial skeleton and the lower extremities. Although the hip joint is anatomically considered part of the lower extremity, it is so closely linked biomechanically to the sacrum and lumbar spine that it must be considered in any discussion of the pelvis.

The common pelvic landmarks are the anterior superior iliac spine (ASIS), posterior superior iliac spine (PSIS), and the anterior inferior iliac spine (AIIS). The summits of the iliac crests are normally on a level with the L4 spinous process, and the PSISs are on a level with the S2 spinous and near the midline of the lower third of the sacroiliac articulation. However, pelvic design differs greatly among sexes and biotypes. In addition, there are wide individual variations, and asymmetry is more the rule than the exception. Thus, static palpation alone can lead to many erroneous conclusions.

The Iliac Facets

Anterolateral to the PSISs and PIISs of the ilium are the convex facets that articulate with the sacrum bilaterally. As they resemble rough bony ears facing backward, they are called auricular surfaces. Some call them boot-shaped, with the toes pointing backward. Regardless, they are slightly wider than their mates on the sacrum. Boorsma describes this boot-shaped articular design as relatively deep, oblique, mobile, and especially related to a hyperlordotic spine. When associated with a chronically flattened lumbar spine, the sacroiliac articulations are more bean-shaped, vertical, shallow, and less mobile.

The short arm or foot of each articulation allows a sliding motion anterior-inferiorly or posterior-superiorly and a rotating action about the pit. The foot of the boot articulates with the S2 and S3 segments. This design has a distinct influence on traumatic iliosacral motion. The upper pit also serves to giver osseous relief to the relatively weak superoanterior ligaments. An important role of this design is to prevent sacral displacement during loaded movements. Superior and posterior to the articular surface is a larger area of rough bone serving for the attachment of strong sacroiliac ligaments.


The Sacrum

To meet with the flared ilia, the S1–S3 segments are wider anteriorly than posteriorly. The concave sacral articulation with each ilia is congruently boot-shaped, and its numerous bumps and depressions offer stability and limit motion. These ridges and furrows, however, are not always ideally reciprocal with those of the ilium, nor are the bilateral planes of articulation commonly symmetrical. This leads to erroneous conclusions during heel checks for functional leg lengths.


The Ischia and Pubic Bones

The body of the inferior ischium serves as the posterior half of the lower two-thirds of the acetabulum. The ischial ramus forms the posterior wall of the lower pelvis and the inferior wall of the obturator (closed) foramen. This foramen, although seen as a large opening in the dried skeleton, is completely closed in vivo by a tough membrane to which several strong muscles are attached to the circumference of the opening.


The Sacroiliac Joints

With the bony architecture of the sacroiliac articulation in mind, we turn to their syndesmology. Here we find slightly sliding, gliding, pivoting, and rotating sacroiliac joints that serve as the sole point where the axial skeleton is attached to the pelvis. Thus the necessity of these joints being bilaterally strong. They are uniquely both diarthrotic and amphiarthotic. The inferior two-thirds of the joint is a true synovial articulation. The superior third is a fibrocartilaginous amphiarthrosis supported by the short but strong sacroiliac ligaments. Thus, a true polysynovitis can involve only the caudad aspect of the joint even though synovial membrane covers the whole joint cavity except its posterior aspect where large ligaments attach to articular cartilage.


Major Ligaments

Excessive motion is strapped posteriorly by the interosseous ligaments, the short posterior sacroiliac ligament on the superolateral aspect of the sacrum, the long posterior sacroiliac ligament, and the sacrotuberous ligament on the inferolateral aspect of the sacrum. White/Panjabi state that the interosseous sacroiliac ligaments supporting the thin fibrous capsule posteriorly and inferiorly are the strongest of the body. These ligaments, the chief bond between the sacrum and ilia, are so thick that they fill the roughened space between the sacral and iliac tuberosities behind the sacroiliac joint. There is an upper part spanding between S1–S2 and the anterior medial iliac crest. Immediately below is the lower part of the ligament arising from S3 that inserts into the iliac crest.

The strength of these ligaments helps prevent displacement of the sacrum even during forceful jumping. The major straps anteriorly are the thinner anterior sacroiliac ligaments on the superolateral aspect of the sacrum and the stronger sacrospinous ligament extending from the inferolateral aspect of the sacrum and coccyx to the ischial spine. The superolateral ligaments appear to be little more than extensions from the anterior capsule. Varieties of interarticular adhesions appear within the joint with age, but they are not reported to restrict motion.

It has been widely reported that Illi found an interarticular ligament at the toe of the boot in the 1950s that he believed has a considerable influence on sacral motion. In fairness, an identical ligament was reported by Dr. Pfitzer [spelling is from the author's 40-year recall], professor of Anatomy at Lincoln Chiropractic College, in the 1940s.


Major Muscles

Strong muscles surround the joint, but there are no intrinsic muscles as seen in the spine. Muscle action is indirect via ilia, ischia, hip, and lumbar attachments. Nevertheless, several muscles have close association with sacral ligaments. For example,

(1) fibers of the lower quadratus lumborum mix with the iliolumbar ligament;
(2) fibers of the iliopsoas mingle with the anterior sacroiliac ligament;
(3) fibers of the multifidi and sacrospinalis braid with the long posterior sacroiliac ligament;
(4) fibers of the gluteus maximus and hamstring fibers intertwine with the sacrotuberous ligament; and
(5) fibers of the piriformis mix with the sacrotuberous ligament and some enter directly into the sacroiliac capsule.

Innervation

Segmental innervation from the lumbosacral spine is shown in Table 1. The gluteus maximus receives an independent nerve (inferior gluteal) from the sacral plexus that leaves the pelvis below the piriformis muscle close to the lateral edge of the sacrotuberous ligament. This nerve and accompanying inferior gluteal artery and vein pierce the gluteal fascia and then spread between the fascia and the muscle. The gluteus medius is supplied by the superior gluteal nerve and vessels that exit the pelvis above the piriformis muscle.

Table 1.  Segmental Innervation of the Lumbosacral Spine

Segment	Major Muscles Supplied
L1-2	Cremaster
L1-5	Iliopsoas
L2-3	Sartorius, pectineus, abductor longus
L2-4	Quadriceps, gracilis, adductor brevis
L3-4	Obturator externus, adductor magnus and minimus
L4-5	Tibialis anticus
L4-S1	Semimembranosus, semitendinosus, extensor hallucis longus, popliteus, plantaris, extensor digitorum longus, extensor hallucis brevis, gluteus medius and minimus, quadratus
L5-S1	Peroneus longus and brevis, tibialis posticus, flexor digiti brevis, abductor hallucis
L5-S2	Gluteus maximus, obturator internus, biceps femoris, soleus, gastrocnemius, flexor hallucis longus
S1-2	Lumbricals, piriformis, abductor digiti, flexor digiti, opponens, quadratus plantae, interossei
S2-4	Levator ani, bulbocavernosus, ischiocavernosus
S4-5	Sphincter vesicae
S5-Cx1	Sphincter ani, coccygeus
Skin-Reflexes
L1-2	Cremasteric
L4-S1	Gluteal
S1-2	Plantar
S5-Cx1	Anal
Tendon Reflexes
L2-4	Patellar
L5-S2	Achilles

Active Sacroiliac Motion?

Although there are no intrinsic muscles of the sacroiliac joints, the intermingling of muscle fibers in the ligaments described above allows the ligaments to serve somewhat as tendons. Thus, not all sacroiliac motions need to be considered purely passive as is so commonly taught. This point is underscored by the discovery of mechanoreceptors, reported by Denton, throughout the sacroiliac ligamentous complex that are similar to Golgi tendon organs.


Innervation and Referred Pain

The posterior aspect of the joint is supplied by the posterior rami from L5–S2. An irritation in the posterior joint usually refers pain to the buttocks and back of the thigh, following the dermatomes. The anterior aspect of the joint is supplied by both posterior branches from the L3–S2 roots and the superior gluteal nerve (L5–S2). Anterior joint irritation commonly refers pain to the groin and anterior thigh. If the sciatic nerve pierces the piriformis rather than exiting the pelvis over or under the muscle, sacroiliac distortion or inflammation can involve any of the numerous sciatic fibers.


      SACROILIAC DYSFUNCTION

There are three articular areas of primary concern in adult sacroiliac dysfunction:

    · An iliac elevation and sacral depression in the upper third of the joint.

    · An iliac depression and sacral elevation in the middle third of the joint.

    · An iliac elevation and sacral depression in the lower third of the joint.


Load Carriage Effects

By puberty, in adaptation to walking and other stresses, all articulating surfaces develop a variety of incongruities and small projections where dynamic stress would be concentrated if not for the smoothing effect of articular cartilage. Of all articulations, the adult sacroiliac joint contains a large array of reciprocal bony hills and valleys. This surface roughness, more prominent in males, is generally considered the result of its segmental heritage; ie, the fused lateral tips of the transverse processes and the intertransverse spaces.

The characteristic of a roughened articular surface allows deformation during loading to increase the contact area and significant recovery during the unloaded stage. Load carriage is particularly enhanced by the cartilage's hydrophilic proteoglycans to retain matrix water and by collagen to resist matrix tensile forces.

Sacroiliac stability is so great that experimental overloading of S1 results in fracture of the lateral sacrum, pubis, or hip while the sacroiliac joints remain intact. Thus, complete fractures or greatly advanced destructive processes are the common causes of clinical instability of the sacrum.


      THE SACROCOCCYGEAL JOINT

The atypical joint between the sacrum and coccyx is considered a symphysis. It is united by a rudimentary IVD and tough ligament bands around its circumference. Slight posterior motion normally occurs during defecation, gait, and much more so during parturition.


      THE SYMPHYSIS PUBIS

The anterior aspect of the hyaline coated pubes join at the fibrocartilaginous pad (anuclear disc) of the pubic symphysis. Slight but important movement takes place at this joint by yielding of the interpubic fibrocartilage. Iliac motion imposes reciprocal compression, tensile, and torsional forces on the pubes. Excessive movement is strapped by the superior and inferior pubic ligaments, and fusion is rare even in old age. Pubic innervation is by L1–S4 fibers. Referred pain is diffuse or unpredictably specific.


      APPLIED PELVIC KINEMATICS

The pelvis and its articulations are located fairly central to the kinematic chain extending from the cranium to the feet. Thus, any alteration in normal dynamics such as a unilateral fixation must manifest biomechanical effects both above and below. Fixation at a link or links of any kinematic chain forces hypermobility on the nearest mobile segments.

Within the lumbar spine, Illi located the axis of rotation posterior to the articular facets. This permits a wide range of vertebral body rotation, restricted essentially by the facial planes and the paravertebral ligaments.

The inclination of the sacral base directs the lumbar curve. However, the axis of movement of the thoracic spine lies far anterior to the facets: near the nucleus of the L5 IVD. Thus, thoracic rotation is characterized by deviation of the spinous processes in a wider arc than that taken by the vertebral bodies.


Coupling Dynamics

The thicker anterior and thinner posterior aspects of the lumbar discs provide the lumbar spine with its unique rotation, lateral bending, and combined phenomena. The coupled lateral bending and rotation of the lumbar spine during forward flexion
(1) protects the axial length of the lumbar spine and its contents from excessive tension; and
(2) causes the peripheral fibers of the anulus to draw inward, thus securing the nucleus more firmly as a protection against displacement.


Effects of Inhibited Coupling

Coupling helps to explain why fixation-inhibiting rotation during flexion invites IVD protrusion. If rotation is not freely allowed during flexion, the segment tends to slide laterally and produce excessive shear forces upon the subjacent IVD and posterior facets. These basic characteristics of the lumbar spine coupled with the mechanics of the ilia are the primary factors governing sacral dynamics.


Pelvic Tilt and Horizontal Rotation

In the neutral position, the ASISs normally lie in the same transverse plane and in the same vertical plane as that of the symphysis pubis. The movements of the pelvis as a whole are forward and backward tilt around the transverse interfemoral axis, lateral tilt (associated with lumbar scoliosis), and rotation in the horizontal plane. None of these motions are produced by intrinsic pelvic muscles; rather, they are made by muscles of the trunk and hip that attach to the pelvis or sacrum. These motions occur at and affect the lumbosacral junction, the heads of the femurs, and the sacroiliacs to a far lesser extent.


Common Determinants of the Lumbar Curve

A-P Tilt.   Forward and backward pelvic tilts describe an arc that appears to follow the arcuate (bow-shaped) ridge and groove of the sacroiliac facets. Forward tilt is related to lumbar hyperlordosis and hip flexion. The anterior thigh muscles are also a strong component in this motion, and thus the frequent involvement of these muscles in pelvic distortions. Backward tilt is associated with lumbar flattening and hip extension. The major actions come from the posterior pull of the hamstrings and the anterior pull of the rectus abdominis with help from the obliques.

Lateral Tilt.   When a person shifts most of his weight to one leg, passive lateral pelvic tilt occurs. The pelvis on the unsupported side is restricted actively by the gluteus medius and minimus and passively by the iliotibial tract of the fascia lata. When weight is distributed bilaterally, lateral tilting of the pelvis is associated with lumboscoliosis, sacroiliac distortion, or a unilateral short leg.

Rotation.   Axial or lateral rotation of the pelvis about a fixed femoral head is produced by actions of the muscles of the thigh, loin, and the abdominal obliques. This is exhibited in walking.

      SACROILIAC MOBILITY

It was an allopathic "fact" for many years that there was no normal sacroiliac or pubic motion in the absence of disease and that the sacrum and ilia moved as a whole. This position has long been disputed empirically by chiropractic and osteopathic physicians and in recent years been proved a fallacy through cineroentgenographic studies. Only since the 1970s has sacral motion been generally recognized in allopathic literature.

Illi believed that a human being is the only vertebrate with a movable sacroiliac articulation. At birth, the joint is only slightly movable. Due to bipedism, sacroiliac function is produced. However, because the sacroiliac and pubic articulations are readily subject to fixation, normal movement is not always found in the adult of modern society where physical activity is often minimal. Nevertheless, several autopsy studies report freely movable joints in individuals over the age of 80.


Multidirectional Mobility

Slight but smooth motion occurs upward, downward, forward, and backward through middle age, and axial rotation occurs around a transverse axis to allow pelvic tilting. Because the sacrum does not have distinct articular planes but moves within the pelvic ring, its motion is multidirectional for 1–3 mm rather than in restricted directions. This multidirectional mobility of the sacrum is likely the result of the wider iliac facet, the longer sacral facet, and the thick articular cartilage of the sacrum.

This multidirectional action is especially passive in the nonweight-bearing positions and affected above from lumbar forces and/or laterally and below from iliac-ischial forces. In vivo, sacrum-ilia movements are always coupled and there is no one normal movement of the sacrum on the ilia.

Gillet's Classification.   Intrapelvic mobilities were classified by Gillet into three categories:

(1) the A-P rotations of the ilia in relation to the sacrum, and to each other at the pubis,
(2) the various movements of the sacrum itself in relation to the ilia, and
(3) the sitting-standing changes in the relationship of the ilia to the sacrum and to each other.

Another motion of the sacrum is at the lumbosacral joint where it moves passively with the ilia such as seen in lateral flexion of the pelvis during gait. Weisl, Gonstead (see Campbell JR), and others also give an inferior or superior gliding motion along the caudal aspect of the sacroiliac facet.

Sacral Changes from Recumbent to Standing Positions

Several studies show there is distinct sacral motion in changing position from the recumbent, to the sitting, to the standing postures. The sacrum approaches its nearest state of static equilibrium in the prone position where inferior and superior forces are significantly removed. This could be an explanation why sacral and para-anal reflex techniques achieve their effect in this position.


General Sacroiliac Motion During Pelvic Tipping.

During forward flexion of the trunk in either the standing or sitting position, the sacral base pivots further anteriorly and inferiorly while the sacral apex moves posteriorly and superiorly. Simultaneously, the PSISs move posteriorly, inferiorly, and obliquely medially so that the space between the spines reduces. The ischia concurrently move obliquely anteriorly, superiorly, and fan laterally. During extension, these pelvic actions are reversed.


Standing A-P Sacroiliac Motion

During erect weight bearing, the sacral base tends to rotate (pivot) anteriorly and inferiorly about the lateral S2 tubercles. When the standing patient lifts his right knee to a maximum, as in taking a high step, the right ilium tends to follow the femur's motion, rotating in the A-P plane with the center of movement near the femoral head. At the same time, the right arm of the pubis moves upward relative to its opposite. This is palpable. The iliac portion of the sacroiliac articulation glides posteriorly and inferiorly relative to its contact with the sacrum. Thereafter, the sacrum must arc posteriorly and inferiorly with the left ilium.

If both the pubic and sacroiliac articulations reach their limit of mobility and the knee is lifted still further, the pubis starts serving as the center of rotation and, at the posterior pelvis, the ilium will start pulling the sacrum down in its course, forcing it to articulate with the opposite ilium. As this latter motion does not follow the sacroiliac facet plane, a certain degree of joint separation takes place. If the knee-lifting test is carried still further, the normal limit of the other articulation (the left in this example) will be reached, and then the whole pelvis rotates backward.

1. Stage of Acute Inflammation and Active Congestion

The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include:

Cryotherapy
  Cold packs
  Cold immersions
  Ice massage
  Vapocoolant spray
Compression
  Pressure bandage
  Aircast
Protection (padding)
Elevation
Indirect therapy (reflex therapy)
Iontophoresis/phonophoresis
Auriculotherapy
Meridian therapy
Spondylotherapy
Mild pulsed ultrasound
Pulsed alternating current
Rest
  Bedrest
  Foam/padded appliance
Shoe orthotic
Immobilization
  Brace
  Rigid appliance
  Inflated appliance
  Strap
Indicated diet modification and nutritional supplementation.


2. Stage of Passive Congestion

The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include:

Indirect articular therapy (reflex therapy)
Alternating superficial heat and cold
Pressure bandage
Light nonpercussion vibrotherapy
Passive exercise of adjacent joints
Mild surging alternating current
Mild pulsed ultrasound
Phonophoresis
Cryokinetics (passive exercise)
Meridian therapy
Spondylotherapy
Rest
  Bedrest
  Foam/padded appliance
  Shoe orthotic
Immobilization
  Brace
  Rigid appliance
  Inflated appliance
  Strap
Indicated diet modification and nutritional supplementation.


3. Stage of Consolidation and/or Formation of Fibrinous Coagulant

The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include:

Mild articular adjustment technics
Moist superficial heat
Thermowraps
Spray-and-stretch
Cryokinetics (active exercise)
Moderate active range-of-motion exercises
Meridian therapy
Alternating traction
Sinusoidal current
Ultrasound, continuous
Vibromassage
High-volt therapy
Interferential current
Spondylotherapy
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Rest
  Bedrest
  Foam/padded appliance
  Inflated appliance
  Shoe orthotic
  Semirigid appliance
Indicated diet modification and nutritional supplementation.


4. Stage of Fibroblastic Activity and Potential Fibrosis

At this stage, causes for pain should have been corrected, but some local tenderness likely remains. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are:

Deep heat
Articular adjustment technics
Spondylotherapy
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch
Active range-of-motion exercises without weight bearing
Motorized alternating traction
Negative galvanism
Ultrasound
Sinusoidal and pulsed muscle stimulation
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Rest
  Bedrest
  Foam/padded appliance
  Inflated appliance
  Shoe orthotic
  Shoelift
  Semirigid appliance
Indicated diet modification and nutritional supplementation.


5. Stage of Reconditioning

Direct articular therapy for chronic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Indicated diet modification and nutritional supplementation.

Painful spastic muscles guarding motion in the lower spine (lumbago) can be viewed by watching body attitude (eg, stiff carriage) and by efforts to bend the spine forward, backward, to the side, and while arising from a chair. If we are familiar with the average range of motility in each direction and at different ages with different biotypes, this test is usually easy and rapid. Spinal extension is typically the least satisfactory motion.

General Approach

The empiric benefits of articular adjustments are well known. To relieve muscle spasm, heat is helpful but cold and vapocoolant sprays have sometimes shown to be more effective. The effects of traction are often dramatic but sometimes short-lived if a herniated disc is involved. It is well to note that a predisposing ankle or arch weakness may exist that requires special stabilization.


Passive Stretch

Mild passive stretch is an excellent method of reducing spasm in the long muscles, but heavy passive stretch destroys beneficial reflexes. For example, hypertonic erectors of the spine can be simply relaxed by placing the patient prone on a split headpiece adjusting table and tilting the abdominal and pelvic section upward to flex the spine. The weight of the structures above and below the midpoint of the flexed spine offer a mild stretching effect, both cephally and caudally. The muscles relax within 2–3 minutes. Thumb pressure, placed on a trigger area, is then directed toward the muscle's attachment and held for a few moments until relaxation is complete. Psoas or quadriceps spasm can be relaxed with Bragard's maneuver by holding the straight leg for a minute or more in extension while dorsiflexing the foot.


Vapocoolant Technique

The patient is placed in the lateral recumbent position with the involved side upward and the knees slightly flexed. Isolate trigger areas and site of major pain, and spray sites. At the same time, ask the patient to pull his knees toward his chest and then slowly return them to the relaxed position. Repeat the spraying and active movement three or four times. Have the patient indicate with his finger the major source of pain. As the pain shifts position, spray the affected area. Once relief is obtained, have the patient turn to the other side if the condition is bilateral, and repeat the procedure. When relief has been obtained in flexion-extension, add rotation and lateral flexion, spraying painful sites as necessary between movements. Have the patient attempt to walk, and spray the painful area if necessary. If possible, have the patient bend forward with his heels on the floor.

Once relief is obtained, correct any subluxations isolated, support the area, and instruct the patient in mild home stretching exercises for 1–2 minutes each half hour during the waking hours. Advise the patient to avoid remaining in any one position for too long. Begin resistance, stretching, and weight-bearing exercises as soon as acute symptoms subside.


Adjuncts

Other methods may prove helpful. Peripheral inhibitory afferent impulses can be generated to partially close the presynaptic gate by acupuncture (needle or electric) or transcutaneous nerve stimulation. Isotonic exercises are useful in improving circulation and inducing the stretch reflex when done supine to reduce exteroceptive influences on the central nervous system. An acid-base imbalance from muscle hypoxia and acidosis may be prevented by supplemental alkalinization. In chronic cases, relaxation training and biofeedback therapy are often beneficial.


      ACUTE LUMBOSACRAL SPRAIN/STRAINS

Sprains

Low back sprains are frequent. Heavy loads or severe blows may rupture some associated ligaments and/or subluxate the joint. Pain may be local or referred. Symptoms are relieved by rest and aggravated by activity. Care must be taken to distinguish lumbar sprains from a sacroiliac or hip lesion.

Diagnosis

Localized tenderness and various clinical tests are helpful in differentiation. In the well-conditioned individual, IVD conditions are more often, but not exclusively, attributed to extrinsic blows and intrinsic wrenches. A comprehensive history is vital to arrive at an accurate diagnosis and offer the best management and counsel. Points in differentiating lumbar nerve, root, and cord lesions are shown in Table 2.

Table 2.   Dissimilarity of Nerve, Root, and Cord Lesions

Nerve Lesions	Caudal-Root Lesions	Lumbosacral Cord Lesions
Usually unilateral	Usually bilateral, but not symmetrical	Usually bilateral and symmetrical
Pain on pressure over nerve trunks is common	Not present; superficial hyperalgesia or anesthesia dolorosa	Not present
Symptoms present in nerve distribution	Symptoms in segmental distribution	Symptoms in segmental distribution
Pain often aggravated by movement, but spontaneous pain not severe	Spontaneous pain is often severe, movement of limbs not painful, coughing, sneezing are painful	Pain absent unless nerve roots are implicated
Sensory loss involves pain, touch, temperature	Same	Sensory dissociation may be present with unilateral lesions in upper lumbar segments
Reflexes lost in areas affected; others are not increased	Same	Achilles reflex may be absent and patellar increased or vice versa, or all reflexes may be lost
Seldom involve dorsal divisions of peripheral nerves	Involve both dorsal and ventral distributions	Involve both dorsal and ventral distributions
Muscle atrophy and reaction of degeneration may be present	Same	Same
Fibrillation in muscles is absent or slight	Same	Fibrillation of muscles active
Trophic sores absent	Trophic sores unusual or mild	Trophic sores common and severe
Sphincters not affected	Sphincters may be affected	Sphincters usually affected
No loss of sexual power	Often some loss of sexual power	Sexual power lost or dissociated-
Roentgenography	Film may show pathology below L1 (fracture, dislocation, caries)	Films may show some pathology in T11, T12, or L1

Horizontal shear forces seem the most damaging forces for disrupting the ligament straps between vertebrae. Because of the lax capsules, a minor sprain can produce a severe synovitis at the posterior joints. If the synovium is torn on the side of tension, severely irritating hemarthrosis results and fragments of fractured articular cartilage and periosteum may form loose bodies in the joint. The distorted articular surface may produce chronic instability from erosion and degeneration, leading to reactionary osteophytoses which in turn are subject to fracture. Repeated episodes of minor trauma and tissue changes predispose progressive degenerative arthritis.


Lumbosacral Sprain

Acute lumbosacral sprains have a high incidence. They occur commonly in the 25–50 age group, and sedentary workers are involved just as frequently as workers doing heavy labor. Heavy loads or severe blows, especially at an unguarded moment, may rupture some associated ligaments and/or subluxate a joint. The pain may be local or referred. Overt symptoms are usually relieved by rest and aggravated by activity or high heels. Fatigue is chronic regardless of adequate rest.


Segmental Kyphosis

In almost all cases of acute lumbosacral stress, the local multifidi will be stiff or mildly splinted. When this happens, Cailliet states that the vertebral motion unit will be kyphotic. This cannot be true because the multifidi are hyperextenders in the erect position that can only produce locking in lordosis. Shortened abdominals and possibly the psoas major would be the logical muscles in the lumbar area responsible for kyphotic fixation. Mechanically, anterior disc collapse or a fixed facet separation would be a more logical cause if a segmental kyphosis presents. An associated lumbar scoliosis with pain on the side of concavity points to psoas major involvement.


Strains

Acute strains are frequently superimposed on chronic strains. The associated pain may be immediate or not occur for several hours after tissues warmed by exercise begin to cool. Because of the increased lever arm operating on the lumbar segments, the incidence of injury is two times higher in taller individuals than in shorter people. Representative signs of lumbar strain, sprain, and disc protrusion are shown in Table 3.


Table 3.   Typical Signs of Spinal Strain, Sprain, and Disc Protrusion

Feature	Strain	Sprain	Disc Protrusion
Initial feeling	Tearing	Snap	Lock
Onset of pain	During lifting	Unprepared joint	Minor trauma
Area of pain	Over muscle	Convex side of curve	Concave side of pain
Location of pain	Involved muscle	Lumbosacral or sacroiliac area	Segment
Most painful action	Flexion	Hyperextension	Hyperextension with torsion
Major cause of pain	Myositis	Synovitis	Root/cord irritation
Deep pressure pain	Usually bilateral, large area, in muscle	Unilateral pain, localized, usually one joint	Often bilateral, localized, usually one joint
Percussion	Little increased discomfort	Sharp local pain	Sharp pain that radiates
Position of rest	Moves frequently	Still position	Still position
Effect of rest	Stiffens area	Relieves pain	Relieves pain
Curve pattern	Antalgic, if any	Segmental distortion	Segmental distortion
Iliac position	High on pain side	High on pain side	Low on pain side

Although it is the largest nerve of the body and supplies through its branches all the muscles below the knee, the sciatic nerve is rarely injured by sudden trauma. It is often affected, however, by neuritis (sciatica), which is frequently due to intermittent trauma.

Clinical Signs

Sciatic neuralgia or neuritis is characterized by pain of variable intensity to a maximum that is almost unbearable. Pain radiates from the lumbosacral area down the thigh posteriorly and often to the sole of the foot. Muscle atrophy and the characteristic limp are usually present.

Neuropathy must be differentiated from a lumbar compression radiculopathy and vertebral canal stenosis. This is often challenging for all can be considered nerve compression syndromes. As disc herniation rarely involves several segments, neuropathy is first suspected when multiple segments are involved. When the straight-leg-raising test is made just short of pain, internal rotation of the femur increases pain and external rotation decreases pain in sciatic neuropathy but has little effect on lumbar radiculopathies.

Note the comparative height of the iliac crests. If chronic sciatic neuralgia is on the high iliac crest side, degenerative disc weakening with posterolateral protrusion should be suspected. If occurring on the side of the low iliac crest, consider the possibility of a sacroiliac slip and lumbosacral torsion as the cause.

There is a lessening or lack of the deep tendon reflex in sciatica (Babinski's sciatica sign). When the patient's great toe on the affected side is flexed, pain will often be experienced in the gluteal region (Turny's sign). Also in sciatica, the pelvis tends to maintain a horizontal position despite any induced degree of scoliosis (Vanzetti's sign), unlike other conditions in which scoliosis occurs when the pelvis is tilted.


Classic Orthopedic/Neurologic Tests

Lasegue's Classic Straight-Leg-Raising Test.   The patient lies supine with legs extended. The examiner places one hand under the heel of the affected side and the other hand is placed on the knee to prevent the knee from bending. With the limb extended, the examiner flexes the thigh on the pelvis keeping the knee straight. Normally, the patient will be able to have the limb extended almost 90º without pain. If this maneuver is markedly limited by pain, the test is positive and suggests sciatica from a lumbosacral or sacroiliac lesion, subluxation syndrome, hamstring tightness, disc lesion, spondylolisthesis adhesions, or IVF occlusion. Some examiners report that pain at 30° indicates sacroiliac involvement; at 60º, lumbosacral disorder; 80º, L4–L5 problem.

A second mode of using this test is to have the patient attempt to touch the floor with the fingers while the knees are held in extension during the standing position. Under these conditions, the knee of the affected side will flex, the heel will slightly elevate, and the body will elevate somewhat to the painful side.

Studies confirm that when Lasegue's sign is positive, the pupils will dilate, blood pressure will rise, and the pulse will become rapid. These phenomena are not present in the malingerer or psychoneurotic individual.

Bragard's Test.   If Lasegue's test is positive at a given point, the leg is lowered slightly and dorsiflexion of the foot is induced. The sign is negative if pain is not increased. A positive sign is a finding in sciatic neuritis, spinal cord tumors, IVD lesions, and spinal nerve irritations. A negative sign suggests muscle involvement such as tight hamstrings. Bragard's test helps to differentiate the pain of sciatic involvement from that of sacroiliac involvement as the sacroiliac articulation is not stressed by the Bragard maneuver, nor is the lumbosacral joint.

Fajersztajn's Test.   When straight leg raising and dorsiflexion of the foot are performed on the asymptomatic side of a sciatic patient and this causes pain on the symptomatic side, there is a positive Fajersztajn's sign that is particularly indicative of a sciatic nerve root involvement as produced by a disc syndrome, dural root sleeve adhesions, or some other space-occupying lesion. This maneuver is sometimes called the "well" or "cross-leg" straight-leg-raising test.

Demianoff's Test.   This is a variant of Lasegue's test used in lumbago and funiculitis with the intent of differentiating between lumbago and sciatica. When the affected limb is first extended and then flexed at the hip, the corresponding half of the body lowers and with it the muscle fibers fixed to the lumbosacral segments. This act, which stretches the muscles, induces sharp nonsciatic lumbar pain. Lasegue's sign is thus negative as the pain is caused by stretching the affected muscles at the posterior portion of the pelvis rather than stretching the sciatic nerve. To do the test with the patient supine, the patient's pelvis is fixed by the examiner's hand firmly placed on the ASIS, and the other hand elevates the leg on the same side. No pain results when the leg is raised to an 80º angle.

When lumbago and sciatica coexist, Demianoff's sign is negative on the affected side but positive on the opposite side unless the pelvis is fixed. The sign is also negative in bilateral sciatica with lumbago. The fixation of the pelvis prevents stretching the sciatic nerve, and any undue pain experienced is often associated with ischiotrochanteric groove adhesions. Demianoff's sign is valuable in determining local lesions of muscles, upper lumbar nerve roots, and funicular sciatica.

Belt Test.   The standing male patient bends forward with the examiner holding the patient's leather belt at the back. If bending over without support is more painful than with support, it suggests a sacroiliac lesion. Conversely, if bending over with support is more painful than without support, it suggests lumbosacral or lumbar involvement.

Deyerle-May Test.   This test is often helpful in differentiating the various etiologies of sciatic pain and is particularly designed to differentiate between pain from pressure on the nerve or its roots and pain due to other mechanisms in the lower back. Compression or tractional pressure on muscles, ligaments, tendons, or bursae may cause reflex pain that often mimics direct nerve irritation. Reflex pain does not usually follow the pattern of a specific nerve root, is more vague, does not cause sensory disturbances in the skin, comes and goes, but may be very intense.

Instruct the patient to sit very still and brace himself in a chair with his hands. The painful leg is passively extended until it causes pain, then lowered just below that point. The leg is then held by the examiner's knees and deep palpation is applied to the sciatic nerve high in the popliteal space that has been made taut by the maneuver. Severe tenderness indicates definite sciatic irritation or a root compression syndrome as opposed to other causes of back and leg pain such as the stretching of strained muscles and tendons or the movements of sprained articulations.

Management

Referred pain from an organic lesion is first excluded. As direct trauma to the nerve is so rare, careful evaluation of lumbar, sacral, and sacroiliac subluxation-fixations must be made, as well as lower back, pelvic, and hip muscles and trigger points. Corrective osseous adjustments, muscle techniques, and reflex techniques should be applied when indicated. Local heat and corrective muscle rehabilitation speed recovery when applied in the appropriate stage. Of all nerves in the body, the sciatic is one of the slowest to regenerate. The feet, upper cervical area, thoracolumbar junction, and overall posture should be evaluated for signs of predisposing defects in biomechanics.


      THORACOLUMBAR TRIGGER POINTS

The Thoracic Area

The common trigger points of the thoracic region are the scalene, pectoralis minor, and serratus anterior. These points are often sites of secondary reaction to lumbar dysfunction.


The Lumbar Area

Common trigger points of the lumbar area are located

(1) alongside the T12–L1 spinous processes and
(2) alongside the L5–S1 spinous processes. The T12–L1 trigger, often associated with a T12 spinous tipped posterosuperior, frequently refers pain to the iliac crest with secondary nodules found deep along the posterosuperior aspect of the crest. The L5–S1 point is usually in the multifidi. Trigger points may also be found in the erector spinae, when the patient is prone, about an inch lateral from the spinous processes.

Management.   Rest and warmth (to increase oxygen supply) are the best therapy in immediate pain following muscle overexertion. Delayed spasms are best treated by stretching to activate the Golgi tendon organs and the myotatic stretch reflex. Stretching reduces EMG activity, but it would be contraindicated during the acute stage if fresh muscle tears exist.

It is generally agreed that a true diagnosis of disc herniation with or without fragmentation of the nucleus pulposus can only be made on surgical intervention or special imaging techniques. Thus the term "intervertebral disc syndrome" is generally used when conservative diagnostic means are used exclusively. There is considerable dogmatism associated with both diagnosis and management. The terms protrusion, rupture, and herniation are often used to describe the pathologic grade of an IVD lesion. However, to establish a practical guideline in the management of such lesions, many physicians refer to a Grade I, II, or III disc syndrome based primarily on symptomatology.

Classes

In a Grade I syndrome, the patient has intermittent pain and spasm with local tenderness. There is very little or no root compression. Paresthesia and/or radiculitis may extend to the ischium.

In a Grade II syndrome, some nerve root compression exists along with pain, sensory disturbance, and occasionally some atrophy. Paresthesia and/or radiculitis may extend to the knee.

In a Grade III syndrome, there are marked demonstrable muscle weakness, pronounced atrophy, and intractable radicular pain. Paresthesia and/or radiculitis may extend to the ankle or foot.

Beyond these three grades, we find frank bursting. In rupture, there is a severe extrusion of the nucleus through the annulus into the canal or IVF. All the above symptoms are found. In addition, pain is worse at night and not generally relieved by most conservative therapies.


Profile

The IVD syndrome usually has a traumatic origin and occurs more commonly between the ages of 20 and 60. There may be a history of low-back complaints with evidence of organic or structural disease. Most protrusions found in athletes occur at the L4–L5 or L5–S1 level, involving the L4, L5, or S1 roots. Unilateral sciatic pain coursing a specific dermatome and not remissive except by a possible position of relief is often presented. There is usually a C scoliosis away from the side of pain, splinting, and a flattening of the lumbar spine. Lasegue's, Kemp's, and Nafzigger's tests are positive. There may be diminished tendon reflexes and possible weakness and/or atrophy of the muscles innervated.


Roentgenography

As an adaptive change to carrying a load, the lumbar lordosis normally flattens and the sacrum mildly rotates into a more vertical position. Maximum adaptation occurs at the lumbosacral junction with only minor adjustments at higher levels. The L5 disc assumes a more nearly horizontal position with widening posteriorly and compression anteriorly. This produces a decrease in the downward sliding force (shear) applied at the S1 level. These comments of Olsen go on to state that the usual manifestation of disordered function of any part of the vertebral motion unit is weakness. He quotes DeJarnette's 1967 notes that "the position of the sacral base is often compensatory to keep severe situations from becoming worse through weight bearing."

When an IVD leaves its normal anatomical position, routine radiographic examination without a contrast medium may present diagnostic characteristics such as narrowing of the intervertebral space (most typical), retrolisthesis of the vertebral body above the herniated disc, posterior osteophytes on the side of the direction of the herniated disc or apophyseal arthrosis, and sclerosis of the vertebral plates as a result of stress on denuded bone (frequent). Such malformations as asymmetrical transitional lumbosacral vertebra and spina bifida are seen more frequently with herniated disc than in cases in which these anomalies do not exist. Torsion is more common in the L4–L5 disc than in the L5–S1 disc.

Points to especially evaluate are asymmetry and unilateral elevation of disc spaces, limited and impaired mobility on the affected side, blocked mobility contralaterally one segment above the L5–S1 level, and slight rotation of the L4 or L5 vertebral body toward the side of collapse. Abnormal findings suggesting a fixed prolapse in these functional views include flattening of the lumbar curve, posterior shifting of one or more lumbar vertebral bodies, impaired mobility on forward flexion so that the disc space does not change as compared to findings in the neutral position, and impaired mobility on dorsiflexion.


      ACUTE LUMBOSACRAL ANGLE

In this condition so often associated with low back pain, Olsen states that the acute angulation of L5 on S1 is twofold:
(1) There is bursal inflammation due to an overriding of the facets that stretches the bursa.
(2) There is a narrowing of the IVF causing a telescoping from the superior to the inferior of the facet joints. The type of bursitis cannot be defined radiologically. Orthopedically, the problem is described as a facet-pain syndrome.


      FACET PAIN SYNDROME

Cartilage is found between all articular surfaces, and undue stress during weight bearing on facets can damage the cartilage and lead to progressive degenerative changes. Degeneration may cause L5 to slip forward (degenerative disc disease), portray decreased disc space (discogenic disease), or exhibit decreased space with eburnation (discopathy). Sacralization is the only time when it is normal to have a decreased disc space, unless the disc is underdeveloped (hypoplasia).

Along with the facet syndrome, there may also be an increased lordosis of the lumbar spine. A facet syndrome can occur with (1) the sacral base anterior and a normal lordosis or with an accentuated lordosis or (2) with the sacral base at a normal angle in the "sway back" type of individual.

A few clinicians habitually confuse the terms motor unit and motion unit. A motor unit, a neurologic entity, consists of a neuromere, its nerve root and peripheral branches, and the muscle{s) supplied. A spinal motion unit, a structural entity, consists of two contiguous (articulating) vertebrae.

The subluxation of lumbar facet structures, states Howe, is a part of all lumbar dyskinesias and must be present if a vertebral motion unit is deranged. In a three-point articular arrangement, such as at each vertebral motion unit, no disrelationship can exist that does not derange two of the three articulations. Thus, determination of the integrity or subluxation of the facets in any given motion unit is important in assessing that unit.


Roentgenography

Any method of spinographic interpretation utilizing millimetric measurements from any set of preselected points is likely to be faulty because structural asymmetry and minor anomaly is universal in all vertebrae. However, the estimation of the integrity of facet joints is an acceptable method of assessing the presence of intervertebral subluxation.

Evaluation of the alignment of the articular processes comprising a facet joint may be difficult from the A-P or P-A view alone when the plane of the facet facing is other than sagittal or semisaggital. In this case, oblique views of the lumbosacral area are of great value in determining facet alignment since the joint plane and articular surfaces can ordinarily be visualized.

Fergurson's Angle.   Evaluation is made by drawing a line through the superior border of the sacral base and through the inferior border of L5. If these lines cross within the IVF or anterior to it, a facet syndrome is indicated. Olsen recommends the use of Fergurson's angle, where the body of L3 is X'd and a line is dropped perpendicular from the center of the vertebral body. This line normally falls over the sacral promontory or the anterior edge of the sacrum and reveals normal lumbosacral weight bearing (Fergurson's line of gravity). The L5 disc spacing is normally symmetrical with the one above, and weight bearing is on the nucleus pulposus.

Hadley's S Curve.   When one cannot visually identify disrelationships of the facet articular structures, Howe suggests use of Hadley's S curve. This is made by tracing a line along the undersurface of the transverse process at the superior and bringing it down the inferior articular surface. This line is joined by a line drawn upward from the base of the superior articular process of the inferior vertebrae of the lower edge of its articular surface. These lines should join to form a smooth S. If the S is broken, subluxation is present. This A-P procedure can be used on an oblique view.

A persistent notochord may be seen where the disc is normal but embedded into the body of the vertebra. This is seen in a postural facet syndrome where the anterior disc space is wide at the expense of narrowed disc space posteriorly and the body of the vertebra has rocked on the nucleus. It is not pathologic. For example, a normal vertebra presents decreased disc space posteriorly with the lines crossing in the IVF. There is normal disc space anteriorly, but for this to happen requires herniation. The disc is normal, but the symmetry of the disc interspace is broken.

Differentiation

To help discriminate the low-back and sciatic neuralgia of a facet syndrome to that of a protruding disc lesion, two tests are available.

    1. With the patient standing with feet moderately apart, the doctor from behind the patient firmly wraps his arms around the patient's pelvis and firms his lateral thigh against the back of the patients' pelvis. The patient is asked to bend forward. If it is a facet involvement, the patient will feel relief. If a disc is involved, symptoms will be aggravated. This test is an adaptation of the classic belt test.

    2. In facet involvement, the patient seeks to find relief by sitting with feet elevated and resting on a stool, chair, or desk. In disc involvement, the patient keeps knees flexed and sits sideways in his chair and moves first to one side and then to the other for relief. If lumbosacral and sacroiliac pain migrates from one to the other side, related arthritic changes should be suspected.


      SPONDYLOLISTHESIS

Anterior or posterior sliding of one vertebral body on another (spondylolisthesis) can result from either traumatic pars defects or degenerative disease of the facets. There is a separation of the pars interarticularis that allows the vertebral body to commonly slip forward, carrying with it a portion of the neural arch.

An increase in the S1 sagittal diameter in spondylolisthesis occurs during teen maturation. Displacement tends to increase before the age of 30, but this trend sharply decreases thereafter unless there is an unusual cause such as chronic fatigue coupled with a prolonged unusual posture.

Davis points out that many authorities classify the condition as congenital, while others are of the opinion that trauma in early childhood is more often responsible. Regardless, when witnessed in an adult, the lesion dates from childhood rather than from some recent injury. Rehberger reports it occurs in 4%–6% of people, but is present in about 25% of people complaining of constant backache.


Profile

Predisposing spinal instability is frequently related to a degenerated disc at the spondylolisthetic level. Quite often the lesion is asymptomatic during the first 2 decades of life. Dimpling of the skin above the level of the spondylolisthesis may be observed or extra skin folds may be seen because of the altered spinal alignment.

When the condition becomes symptomatic, the pain is usually recurrent and increases in severity with subsequent episodes. Low-back pain often develops after insignificant injury or strain, with recurrent pain gradually increasing in intensity. Weakness, fatigue, stiffness, unilateral or bilateral sciatic pain, and extreme tenderness in the area of the spinous process of L5 are associated. Pain usually abates in the supine position.


Roentgenography

Disc tone is best analyzed through neutral, flexion, and extension views. As with spondylolysis, the most common site of spondylolisthesis is in the lower spine, but it has been reported in all areas of the lumbar spine and the cervical area. The typical situation is slippage of L5 on the sacral base (75%–80%), but it is occasionally seen at the L4 segment.

Meyerling's Guide.   Spondylolisthesis is graded by dividing the sacral base or the superior end plate of L5 into four equal parts when viewed in the lateral film: the Meyerling method. The part occupied by the posterior-inferior tip of the vertebra above indicates the degree of forward slip.

Meschan's Method.   In suspected cases where obvious slippage has not occurred, the Meschan method is used on the lateral projection. A line is drawn across the posterior, superior, and inferior tip of L5's centrum. A second line is drawn from the posterior-superior tip of the sacrum to the posterior-inferior tip of L4. Normally, these lines should overlap or nearly so. If they are parallel or form an angular wedge at the superior, it indicates anterior shifting of L5. If the angle formed is greater than 2º or if the lines are parallel and separated more than 3 mm, spondylolisthesis exists.

Meschan's Stability Analysis.   To determine the degree of instability, flexion and extension studies in the lateral projection are recommended by Meschan. The degree of angulation formed in flexion is subtracted from the degree of angulation formed in extension because the maximum degree of slippage is seen during extension. The result of these two measurements reflects the degree of instability present.

The Terrier's Collar Sign.   Oblique views show a defect in the isthmus or pars interarticularis where the neural arch is visualized as an image of a terrier's head. The pedicle and transverse process form the head of the dog, the ears by the superior articular process, the neck by the pars interarticularis, the body by the lamina, and the front legs by the inferior articular process. When the defect appears as a collar on the dog, a spondylolysis is present. If the terrier is decapitated, a spondylolisthesis is present.

Associated Signs.   Other roentgenographic findings include an unusual lumbar lordosis with increased lumbosacral angle and overriding of facets adjacent to the defect that is usually visible on the A-P view. In time, the overriding apophyseal joints show osteoarthritic changes. The amphiarthroidial joint between the vertebral bodies frequently shows narrowing, spurring, and associated osteoarthritic changes. A lumbar kyphosis is rarely seen, indicating the possibility of a herniated disc.

The term spondylolysis refers to the destruction of vertebral structure, and spondylosis means vertebral ankylosis. Thus, they can be considered the first and second stage of the same degenerative process. Spondylolysis is similar to spondylolisthesis in that there is also a defect in the pars interarticularis, but there is no slipping of the vertebral body. Disc narrowing and facet sclerosis are usually associated. In time, a clinical picture of degenerative arthritis, ankylosis, and IVF narrowing is produced. Spondylolysis is a degenerative condition generally associated with early middle life, is more common to males, and is often associated with repetitive athletic or occupational overstress.

Profile

The most common site of spondylolysis is in the lower spine. The associated disc narrowing is the result of anular tears decreasing intradisc pressure and allowing the vertebral bodies to approximate and the IVFs to narrow. As the process continues, the involved disc becomes dehydrated and thinning increases. Elastic anular fibers become replaced by fibrous tissue. The ligamentum flavum may buckle and/or the anulus may exude between the ligament and the vertebral body and form a hard mass (ie, canal stenosis).

Helfet/Lee feel that the ligamentum flavum rarely thickens in itself and that the appearance of thickening is due to underlying laminal growth and a layer of superimposed fibrous tissue. The anterior longitudinal ligament may also weaken and lead to spur formation. This process of disc and associated tissue destruction places excess weight on the apophyseal facets. The capsules weaken and allow increased shear, and this produces joint synovitis, articular degenerative changes, capsular thickening, adhesions, osteochondral fractures, loose bodies in the joint, and possibly nerve root entrapment.


Misdirected Terminology

In describing spondylolysis, Davis states that the word "prespondylolisthesis" as used by Finneson and others is a misnomer as it indicates that spondylolisthesis will occur. This term is also inaccurate to describe an exaggeration of the sacral base angle. It is true that spondylolysis will contribute to spinal instability much the same as an exaggerated sacral base angle, but it is not true that spondylolisthesis must progress in either condition.

Degenerative arthropathy of the apophyseal joints will most likely result from the stress and strain placed on the facets. This defective arrangement will also predispose the individual to spinal fatigue. The condition is sometimes called hypertrophic osteoarthritis, and this is also a misnomer as there is no inflammatory involvement. The appropriate nomenclature is discogenic spondylosis.


Roentgenography

Turner describes film findings as primary changes in the IVD with progressive loss of turgor and elasticity contributing to softening and weakening of the disc margin. Marginal spurring, lipping, and the consequence of osteophytic formation ensues. Narrowing of one or more IVD spaces may develop when the disc space and changes in the curvature of the spine appear narrowed. The clinical picture, often associated with spondylosis deformans, is usually referred to the area of structural deformity that results in compromise of contour and diameter of the related IVF. The sacroiliac areas are not usually involved.


Management

Mild and moderate cases of spondylolysis and spondylolisthesis respond well to chiropractic anterior lumbar techniques. Adjunctive care includes low back traction in selected cases, positive galvanism, ultrasound, and alternating contractile currents to improve muscle tone. Immobilization using a lumbosacral support helps in the more severe and advanced cases. Once the disorder becomes asymptomatic, corrective exercises should be recommended to maintain optimal muscle tone.


Prognosis

Prognosis is good in first- and second-degree types with minimal neurologic symptoms. If conservative measures fail, surgical fusion and removal of the neural arch are recommended by many authorities. Prognosis is good in cases of minimal separation but poor in cases of gross separation where the patient is usually left with a residual rigidity and stiffness in the lower spine.


      REVERSE SPONDYLOLISTHESIS

Retrolisthesis is often the result of some infectious or degenerative disc process according to Finneson, but Gehweiler reports that such changes may be absent. It is common at the L2 and L1 segments. It is occasionally seen at the L5–S1 joint and associated with a traumatically herniated disc. Some authorities feel the cause can be attributed to a decreased sacral angle that flattens the lumbar lordosis and forces the upper lumbar segments into kyphosis.

Regardless of the initial cause, the disc space narrows and the posterior facets compress and "telescope" as the superior segment tends to slide posteriorly on the inferior segment of the motion unit. This tears or at least stretches the posterior aspect of the capsules. This establishes a chronic inflammatory process within the apophyseal joints that is easily aggravated by stretching of the involved posterior elements (eg, hyperflexion, wide lateral bending). The result is pain and spasm of the erectors.


      SPINAL STENOSIS

A large variety of congenital or acquired factors may be responsible for narrowing of the vertebral canal or IVF. Movements that would never produce symptoms in the normal spine will cause difficulty in the spine whose spinal canals are narrowed. The common factors are congenital narrowing, degenerative hypertrophic stenosis of the anterior or posterior elements, posterior or posterolateral disc herniation, spondylolisthesis, posttraumatic stenosis, postsurgical stenosis, pathologic stenotic enlargement (eg, Paget's disease), ligament thickening or buckling, or a combination of these factors. In unusual cases, tumors, cysts, and inflammatory swelling may be responsible.

Regardless of initial cause, the process typically progresses from IVD degeneration to apophyseal arthritis, segmental instability, and various attempts of repair that result in fibrotic or new bone encroachment on the cord, nerve root, arteries, veins, or a combination of factors. The most common sites are at the L3–L4 or L4–L5 level. When lumbar spondylosis is accompanied by spinal stenosis, cauda equina claudication is likely.

When a case becomes symptomatic, constant or intermittent pain may be local or referred to the lower extremities especially in the posterior thighs and calves. Muscle weakness, sensory deficits, and reduced circulation of the lower extremities that differ bilaterally are usually associated. Exercise usually aggravates symptoms, but casual walking often relieves night pain if there is circulatory impairment.


      ANTERIOR AND POSTERIOR PELVIC TILT

Profile

Forward tilt of the ilium is essentially the product of weak abdominals, hamstrings, or both, hypertonicity of the lumboextensors or hip flexors, and tightening of the rectus femoris. This distortion is by far the most common postural fault of muscle origin. Strengthening the inferior pull of the hamstrings posteriorly and the rectus abdominis superiorly comprise an in-line force couple to correct anterior pelvic tilt. The erector spinae, quadratus lumborum, and iliopsoas usually need stretching.

Abnormal pelvic posture is one of several clues signaling evaluation of balance among lower back, hip, and lower extremity muscles. A thorough understanding of these tests and their findings will accurately pinpoint musculature requiring treatment. These tests show that the body itself can be its best diagnostician for those with a trained eye.


Management

Conversely, posterior tilt of the ilium is typically the result of hypertonic abdominals, shortened hamstrings, or weakened lumboflexors or hip extensors. In either case, biomechanical correction must incorporate (1) mobilization of fixated facets, (2) strengthening of weak musculature, (3) stretching of contractures, and (4) relaxation of established hypertonicity.


      LATERAL PELVIC INCLINATION

Profile

A lateral pelvic sag when noted from the front or behind can be caused by several abnormalities. The most common causes are muscle shortening or weakness, a unilateral lower extremity deficiency, sacroiliac dysfunction, and hip or lower extremity alignment problems. Muscle fixation from lack of stretching is the second most common cause: second only to the common leg-length deficiency syndrome. After studying 200 patients with a presenting complaint of low back pain, Greenman found that 64% exhibited lateral pelvic tilt (sacral base inferiority) of several types.


Management

It can be appreciated in the biomechanical sense that pelvic inclination directs the lumbar curvature and that pelvic inclination is essentially determined by hip posture: thus the hip muscles strategically involved in controlling pelvic inclination and the lumbar curve. In the upright position, the thighs are fixed points from which these muscles act. For example:

    · Shortening of pelvic extensors (eg, glutei, hamstrings) reduces the A-P dimension of the lumbar curve and rotates the pelvis posteriorly.

    · Shortening of pelvic flexors (eg, iliopsoas, rectus femoris) increases the lumbar lordosis and tips the pelvic basin forward.

Obviously, weakness of the antagonists would have the same effect. Thus, once articular fixations have been released, rehabilitation should be directed to relax and stretch muscles shortened by spasm or contracture and to strengthen counterparts weakened by inactivity or other factors. This need not be a dual activity as a muscle relaxes as its antagonist contracts against resistance.

Several kinesiologists postulate that, in bilateral muscle checking during posture analysis, the overwhelming majority of patients presenting postural defects have muscle weakness rather than primary spasm. It appears to be this weakness that causes contralateral muscles to contract into an apparent spasm. Thus, the weakness is said to be primary and the spasm to be secondary. The spasm is thought to be the result of the prime-mover/antagonist reciprocal relationship. For example, an elevated iliac crest on the right relative to the left may be due to weakness on the right of the psoas, gluteals, and tensor fascia lata or weakness on the left of the adductors, quadratus lumborum, rectus or transverse abdominis, or the sacrospinalis.

In the same context, an elevated shoulder on the right relative to the left may be due to weakness on the right of the latissimus dorsi, lower trapezius, anterior serratus, pectoralis major and minor, subscapularis, teres minor, infraspinatus, and levator scapulae or weakness on the left of the upper trapezius.


      PELVIC MUSCLE CONSIDERATIONS

For Review: Posterior pelvic rotation of the innominates in the erect position is essentially produced by contraction of the hamstrings, gluteus maximus, and fascia lata. Anterior pelvic rotation is produced by the iliopsoas and anterior muscles of the thigh. Femur abduction is the product of the gluteus medius and minimus and the muscle fibers of the fascia lata, and femur adduction is made by the adductor group of the medial thigh. Femur lateral flexion is essentially the product of unilateral and reciprocal action of the pelvic extensors, flexors, and rotators.

Pelvic Spasm

Spasm or contractures in the pelvis generally reflect in the trunk, thigh, or both. Contractures of major muscles acting on the pelvis have a restrictive influence on the mobility of the femur and an adverse effect on an individual's stance and gait. When evaluating relative muscle function, mild unilateral hypertonicity is difficult to differentiate from contralateral hypotonicity. In differentiation, palpation may reveal more than kinetic tests if the tissues can be palpated.


Piriformis Spasm

If the patient has deep gluteal pain, sciatic neuralgia, and walks with the foot noticeably everted on the side of involvement, involvement of the piriformis should be suspected. Increased piriformis tone tends to subluxate the sacral base anteriorly and externally rotate the thigh.

Note   The sciatic nerve should pass under the piriformis and follow the "wisdom" of the textbooks. In many cases, however, the nerve takes a different course and is found on surgery to be stretched over or even pass through the belly of the muscle
in 15%–20% of the population (ie, about one of every 5–7 "sciatic" patients).

Piriformis Spasm Test:   The patient is placed supine on a firm flat table. His heels are grasped and firmly inverted and abducted, and the feet are externally rotated. If one foot resists this effort and the act is attended by pain in the gluteal area, the piriformis should be suspected. Differentiation of piriformis spasm from other causes can often be elicited by reproducing the pain on internal rotation of the femur when it is at a lower level than the original point of pain.

Piriformis Myofascitis

Piriformis Myofascitis Test:   The patient is seated on a table with his hips and knees flexed. Resistance is applied by the examiner as the patient attempts to separate the knees. Acute pain and weakness in piriformis myofascitis will be noted on resisted abduction and external rotation of the thigh. Inflammation will be confirmed by rectal examination finding acute tenderness over the lateral pelvic wall proximal to the ischial spine.

Iliopsoas Spasm

In the normal erect posture, only about 12% of the weight of the abdominal organs is borne by the suspensory ligaments. The majority of weight is supported by the inclined psoas and held there by the abdominal wall.

Characteristics of Iliopsoas Shortening.   Increased iliopsoas tone tends to pull the lumbar spine into anteroinferior flexion and externally rotate and flex the thigh. The psoas minor, which runs from T12 and L1 to the arcuate line of the hip, assists its "big brother." The thigh is usually somewhat flexed on the trunk in psoas spasm, though this is usually concealed by forward bending of the trunk.

Research Findings.   Nachemson's electromyographic studies show that the iliopsoas is just as important a lumbar stabilizer against gravitational forces in standing as it is a hip flexor during gait. Some authorities believe that the iliopsoas is the key to postural correction. Michele, who asserts that 30% of the population has an iliopsoas imbalance, makes the bold charge that any and all defects of the spine and hip structures should be evaluated in terms of iliopsoas dysfunction. His theory presents some evidence that practically all conditions working against the "straight child" are attributable to the failure of the iliopsoas to elongate during bipedal maturation. "When the abnormal force of the nonelongated iliopsoatic musculature is presented bilaterally, the directional force is symmetrical, with the formation of an exaggerated dorsal kyphosis," he claims. [These are clues that all clinicians should give concern.]

Iliopsoas Inflammation

If the kidney-bladder complex, colon, appendix, pancreas, or lumbar lymph nodes or nerves are diseased, the sheath of the psoas is likely to be secondarily inflamed and painful. As the muscle also crosses the sacroiliac joint, inflammation is likely to lead to a protective reflex to fix the joint from irritating motion. In any case of low-back pain, elimination of an organic cause should be the first act in differentiation.

Inspection.   Bilateral iliopsoas shortening results in lumbar rigidity, anterior pelvic tilt, and hip flexion. When associated with acute back pain, the patient tends to flex the knees and hip to help decrease the degree of pelvic tilt and lordosis. When the hip flexors are short, the lumbar region does not flatten in the supine position unless the knees and hips are flexed.

Palpation.   Iliopsoas hypertonicity can be confirmed by tension and pain during deep palpation of the abdomen below the umbilicus, lateral to the linea alba, medial to and slightly inferior to the ASIS. It will feel as a taut longitudinal bundle. It is also palpable in the upper sulcus of the pubic arch.

Ely's Test.   To support iliopsoas spasm suspicions, the patient is placed prone with his toes hanging over the edge of the table, legs relaxed. One or the other heel is approximated to the opposite buttock. After flexion of the knee, hip pain makes it impossible to carry out the test if there is any irritation of the psoas muscle or its sheath. The buttock will tend to rise on the involved side. However, a positive Ely's sign can also be an indication of a lumbar lesion, a contracture of the tensor fascia lata, or an osseous hip lesion.

Thomas' Test.   This is another test to determine excessive iliopsoas tension. The supine patient holds one flexed knee against his abdomen with his hands while the other limb is allowed to fully extend. The patient's lumbar spine should normally flatten. If the extended limb does not extend fully (ie, the knee flexes from the table) or if the patient rocks his chest forward or arches his back, a fixed flexion contracture of the hip is indicated (as from a shortened iliopsoas muscle). Michele uses the degree of pain elicited on forceful extension of the flexed knee as the primary sign of iliopsoas tension. This should always be tested bilaterally.

Differentiating General Hip Spasm

Two forms of spasm in the hip joint are common: (1) that which is due to irritation of the psoas alone, and (2) that in which all the muscles moving the joint are more or less contracted. The normal range of hip flexion is 120° . In isolated psoas spasm, the ranges of motion of the hip are not impeded.

General Spasm of the Hip Muscles.   Test with the patient supine and the leg flexed at a right angle, both at the knee and at the hip. A child may be tested on its parent's lap. Using the sound leg as a standard of comparison, the examiner draws the knee away from the midline (abduction), toward and past the midline (adduction), and toward the patient's chest (flexion). Rotation is tested by holding the knee still and moving the foot away from the median line of the body or toward and across it.

Note   It has been the author's experience that the results of any one orthopedic test has little value in itself, as a positive or negative finding can be influenced by various factors. Only when several tests support the same working diagnosis can such tests add weight to clinical judgment.

Sacroiliac sprains with overt rupturing infrequently occur. Overloading and severe blows are the typical allopathic explanations, but these causes are considered infrequent by chiropractors and osteopaths unless severe ligament ruptures are associated.

Etiology

Straightening or lifting from a stooped position can cause a traumatic unilateral or bilateral displacement of the sacrum within the ilia, thus spraining the sacroiliac and iliolumbar ligaments. In this position, body weight (plus external loading) pulls the sacrum anterior, while taut pelvic extensors pull the ilia posterior.

Most sacroiliac sprains, however, are not the result of severe overloading or drastic trauma. They are more frequently the result of a misstep, an awkward twist during flexion, or torsional overexertion (eg, shoveling). These common occurrences could hardly be classified as traumatic enough to tear the strongest ligaments of the body. The question arises: What makes this normally strong and slightly movable joint displace? The explanation is the same as that previously projected in this paper for the cause of many vertebral subluxations.

Inhibited motion at some point within the normal range of sacroiliac movement is compensated by hypermobility at adjacent segments such as the lumbosacral, pubic, and proximal femur articulations. Likewise, a degree of lumbosacral or hip fixation leads to adaptive sacroiliac and pubic loosening and instability predisposing sprains by normal activity. For this reason, the direct cause of a sacroiliac sprain-subluxation may not be within the joint itself, and recurrence can only be avoided if the coupled joints, ligaments, and muscles are kept elastic. Once the coupled restrictions are normalized, the unstable joints will slowly tighten to meet their natural requirements.

Because the sacroiliac joint is so often the site of referred pain and tenderness (eg, lumbar disc, upper cervical fixation), it is unrealistic to automatically attribute these signs to the joint itself. However, we should also avoid the tendency to generalize that all such symptoms and signs are referred –a fault of doctrinal overspecialization arriving at tunnel vision.

Pregnancy.   Pregnancy is another cause of adaptive loosening of the sacroiliac and pubic joints, but the cause is hormonal rather that adjacent fixation. Grieve's studies showed that the normal symphysis pubis width of 4 mm increases during pregnancy to 9 mm, and some separations have been recorded to 2 cm. Obvious changes can be recognized as early as the fourth month of pregnancy, and normalization does not return until 6–12 weeks after delivery.

Bowling.   Some chiropractors have considered bowling very stressful to the sacroiliac joints because of the unilateral weight activity. Biomechanical principles, however, do not support this hypothesis. Most sacroiliac injuries that occur during bowling do not arise during the locomotion phase. During delivery with "good form," the unilateral loading is compensated by a shift in body mass and the momentum of the ball. The greatest force is made when the body is balanced on one extremity. Translational and torsional forces are automatically relieved by the body sliding and turning on the ball of the foot with minimal friction. When injuries do occur, they result from poor technique and especially when the ball is lifted from the return rack in flexion when body weight is balanced on both extremities, thus fixing the base of support. Rather than the body responding as a whole, the weight-bearing joints must adapt or fail.

Symptoms.   Jarring the spine causes a sharp localized pain in the affected sacroiliac joint. The pain usually radiates from near the joint to over the ipsilateral hip and down the anterior thigh. These symptoms are usually relieved by rest and aggravated by activity. When the gluteus medius shortens to abduct the hip when the patient is laterally recumbent, the contraction tends to separate the ilium from sacrum. If the sacroiliac joint is inflamed from trauma or disease, abduction of the thigh against resistance is acutely painful.

Signs.   Stress on the joint should increase pain such as in lateral compression or torsion of the iliac crests. A variety of clinical stress tests have been developed from this principle. Tenderness will be found inferomedial to the PSIS and often at the pubic symphysis, contralateral anterior acetabulum, and fascia lata. Care must be taken not to confuse sacral base tenderness from local ligamentous stress with that of tender sacrospinalis muscle fiber insertions. Lasegue's test is unpredictable. If the sprain is "hot," Lasegue's test will definitely be positive between 30° and 60°

Visual Clues.   The patient assumes the characteristic standing posture with a flattened lumbar area and weight placed on the unaffected side. The trunk is inclined away from the painful lesion. There are a guarded gait and limited spinal motion, especially spinal flexion due to hamstring tension. Trunk rotation is rarely inhibited as this takes place primarily in the thoracic spine. Because of gluteal inhibition, a definite Trendelenburg lurch may be seen during gait. In most cases, restricted mobility will be found in thigh flexion or hyperextension.

Differentiation.   Careful discrimination is important because the intrinsic strength of the posterior ligaments makes severe sprain unlikely and because the joint is the common site of diffuse referred pain and tenderness. Special care must be taken to differentiate the symptoms of sacroiliac sprain from a sacral base lesion, lumbar subluxation, or pelvic pathology. Special roentgenographic and laboratory analyses are necessary if symptoms do not respond to treatment as anticipated. Localized point tenderness and the standard neurologic and orthopedic tests are helpful in differentiating mimicking neuromusculoskeletal disorders.

Erichsen's Pelvic Rock Test.   With the patient supine, the examiner places his hands on the iliac crests with his thumbs on the ASISs and forcibly compresses the pelvis toward the midline. This tends to separate the sacroiliac joints posteriorly. If done carefully, this test can be quite specific. Pain experienced in a sacroiliac joint suggests a joint lesion that may be postural, traumatic, or infectious in origin.

Yeoman's Test.   The patient is placed prone. With one hand, firm pressure is applied by the examiner over the suspected sacroiliac joint, fixing the patient's anterior pelvis to the table. With the other hand, the patient's leg is flexed on the affected side to the limit, and the thigh is hyperextended by the examiner lifting the knee upward from the examining table. If pain is increased in the sacroiliac area, it is significant of a ventral sacroiliac or hip lesion because of the stress on the anterior sacroiliac ligaments. Normally, no pain should be felt on this maneuver.

Hibb's Test.   With the patient supine, the examiner extends the patient's thigh on the affected side and rotates the hip joint internally by rotating the leg at the knee. This tends to open the ipsilateral sacroiliac joint. An increase in pain is a positive indication of a sacroiliac lesion only if the possibility of a hip lesion has been eliminated.

Mennell's Test.   The patient is placed prone, and one hand is used to stabilize the contralateral pelvis. With the palpating hand, the examiner places a thumb over the patient's PSIS and exerts pressure, then slides his thumb outward and then inward. The sign is positive if tenderness is increased. When sliding outward, trigger deposits in structures on the gluteal aspect of the PSIS may be found ("ouch" response). If when sliding inward tenderness is increased, it suggests sprain of the superior sacroiliac ligaments. Confirmation is positive when tenderness is increased when the examiner pulls the ASIS posterior while standing behind the patient or when the examiner pulls the PSIS forward while standing in front of the supine patient. These tests are helpful in determining that tenderness is due to overstressed superior sacroiliac ligaments.

Management.   Management of acute sacroiliac sprain with or without a fixed subluxation rarely presents a clinical problem. Standard sprain therapy will relieve the acute pain and enhance healing. A trochanteric belt is sometimes helpful in the acute stage, but if ligamentous rupture is extensive, a larger stiff support is necessary. Mobilization of fixations, correction of subluxations, activity and lifting counsel, and muscle therapy incorporating strengthening and stretching where indicated are the best procedures to avoid recurrence. A back support while sitting may be an occupational benefit.

It should be apparent that a sacroiliac or lumbar adjustment may release an adjacent lumbar, hip, or pubic fixation and lead to erroneous cause-effect conclusions. This is an example of why empiric results often lead to the various misleading theories often expounded at weekend seminars.

      SACROILIAC SUBLUXATION

Sacroiliac subluxations produce
(1) irritative microtrauma to the interarticular structures;
(2) induction of a vertebral subluxation and/or are contributions to chronicity of spinal, hip, and knee subluxations;
(3) induction of spinal curvatures and/or are contributions to the chronicity of curvatures present; and
(4) biomechanical impropriety of the pelvis in static postural accommodation and in locomotion.



Clinical Features

Local pain and acute tenderness are rarely reported in chronic cases unless the fixated site is irritated by trauma. Old lesions appear to enjoy confusing an examiner by referring signs and symptoms far above or below. Roentgenography is quite helpful but rarely is it an end in itself. Thus, immobility, stress tests, and spinal balance are the most reliable clues. The most common errors of analysis stem from misleading visual signs, subjective responses to testing procedures, structural symmetry, and subjective descriptions of pain and its course.

Piedallu's Sign.   When a sacral base is subluxated unilaterally anteroinferior and lateral so that the adjacent ilium is subluxated posteroinferiorly and medially, the ipsilateral PSIS on the side of inferiority will be low in the standing and sitting positions. If this PSIS becomes higher than the contralateral PSIS during forward flexion, the phenomenon is called a positive Piedallu's sign. Such a sign signifies either ipsilateral sacroiliac locking where the sacrum and ilium move as a whole or muscle contraction preventing motion of the sacrum on the ilium. Regardless, it shows that sacral dysfunction is present.

Berry's Sign.   If backache is relieved when the patient goes from a standing to sitting position, such relief is said to be indicative of a pelvic lesion rather than a lumbar condition. This relief, a positive Berry's sign, comes from hamstring relaxation.

Sacroiliac vs Lumbosacral Differentiation.   To differentiate these two common disorders, the patient is placed supine on a firm flat table. A folded towel is placed transversely under the small of the patient's back. The doctor stabilizes the patient's pelvis by cupping his hands over the ASISs and exerting moderate pressure. The patient is instructed to raise both extremities simultaneously with legs straight if possible. If the patient senses discomfort or an increase of discomfort in the low back or over the sacrum and gluteal area at about 25º–50º leg raise and before the small of the back wedges against the towel, sacroiliac involvement is suspected. If, on the other hand, discomfort is experienced or augmented only after the legs have been raised beyond 50° and the small of the back wedges firmly against the towel, lumbosacral involvement should be the first suspicion.

This frequently occurring condition is often mistaken for sacroiliac slip, although sacroiliac displacement may have occurred and been spontaneously reduced. The disorder is also associated with lateral hip subluxations. In pure pubic subluxation, the predominant evidence will be found at the pubic symphysis. The sacroiliac area will not be excessively tender, but acute tenderness will be found over the painful pubis. After severe trauma, pubic and sacroiliac displacement may coexist. In fact, they must function reciprocally.

Keep in mind that there is a good degree of bone elasticity between the extreme A-P points of the pelvis except in the very elderly or osteoporotic pelvis. Healthy bone is not brittle. Normal iliac movements are bilaterally reciprocal. This places torsion on the pubic fibrocartilage that can be likened to slowly wringing a damp cloth by hand. Thus, it is no wonder that the symphysis often becomes fibrotic.

When pain in the area of the symphysis pubis is the complaint and a bladder lesion has been ruled out, x-ray views should be taken in the weight-bearing position –first with full weight on one limb and then the other to seek signs of instability. Oval or semicircular lucency and avulsion sites may appear at the pubis near the symphysis at the origin of the gracilis muscle and the adductors longus and brevis. In addition, symphysis widening, instability, ragged corners, fluffy margins, pubic osteoporosis, and muscle attachment periosteal reactions may be seen. Stress sclerosis of the iliac aspect of the sacroiliac joints is often associated in these conditions.


      COCCYX SPRAIN AND SUBLUXATION

An irritating coccygeal displacement referring pain to the sacroiliac area is sometimes overlooked. It is more common among women than men. The typical coccyx lies in the same curved plane as the sacrum when viewed during inspection. Slight but clinically important displacements are never obvious on x-ray films. The direction of displacement is usually anterior, but it is infrequently seen posterior. The cause is usually a fall in the sitting position. Ligamentous tears may be associated with subluxation and/or fracture. If a gluteus maximus is unilaterally weak, the coccyx will deviate contralaterally.

Coccygodynia may be from mild to severe, and urogenital, rectal, sciatic-like complaints, and disturbing general nervousness may be related. The associated pain is usually far greater than the degree of displacement would indicate. In traumatic situations, pain and local levator ani spasm may be pronounced and often episodic. Local tenderness is consistently present, and pain is aggravated by pressure in the direction of displacement.

The terminal of the spinal cord is attached to the cornua of the coccyx. As the segment moves anteriorly, the apex of the sacrum acts as a fulcrum. As the cornua moves backward and downward, traction is applied to the spinal cord. Thus, symptoms from the resulting cord tension need not be confined to the pelvic region alone (eg, occipital headaches, rarely torticollis).

The coccyx enjoys confusing smug examiners. Ossification of the sacrococcygeal disc, for example, is easily mistaken for a fracture. A congenital lateral deviation of the coccyx from the midline can be mistaken for a dislocation by those who use roentgenography exclusively to confirm their diagnosis.

Management of the common anterior displacement is by inserting an index finger into the rectum and against the lower anterior aspect of the coccyx and applying pressure to patient tolerance directed posteriorly. From 3 to 5 visits should resolve the problem.


      THE USE OF LIFTS IN MANAGING LUMBOSACRAL DISTORTIONS

A shoe lift should be considered a clinical brace, with all its implications. It is not only an adjunct to basic therapy but often an important modality. Functional leg deficiencies and pelvic distortions, like myopia, should never be corrected 100% by a mechanical appliance if disuse atrophy is to be avoided. The body should always be allowed to make some correction (eg, 20%–50%) by itself. The neuromusculoskeletal system readily adapts to its requirements and outside stimuli unless there are mechanical restrictions. If prolonged standing or walking does not aggravate a low-back pain syndrome, it is unlikely that a small difference in femur height, compensated for over many years, is a significant factor in the syndrome.


The 1-2-4 Ratio

Studies by Logan, Steinbach, and others show that a 1-2-4 ratio, from above downward, exists between the lumbar spine, the sacrum, and the plantar heel. That is, a 1/4-inch heel lift will raise the ipsilateral sacral base 1/8 inch and the lumbar spine 1/16 inch. This general rule has been applied within chiropractic with excellent results since the early 1930s, with adaptations taken for an unusually narrow male pelvis or unusually wide female pelvis.

Other investigators report an average 3:1 ratio between leg shortness and L5 tilt; ie, a 9-mm femoral head height deficiency would be related to a 3-mm L5 slanting that averages a 10º–15º Cobb's angle. The difference between these two ratios is clinically insignificant unless a severe anatomic deficiency is involved (eg, over 1 inch).


Common Types of Lifts

Inserts within the patient's shoes (bilateral or unilateral) are practical because their use is usually temporary. When a relatively permanent shoe lift is necessary, it is best done exteriorly by shoe reconstruction or by an internal molded appliance constructed for long-term use. A heel drop (shortening) may have the same effect as a heel lift on the opposite side or an ipsilateral sole lift. Common distortions related to the application of shoe lifts are shown in Table 4.

Table 4. Common Distortions and Related Shoe Lift Applications

Type	Ipsilateral Application	Contralateral Application
LATERAL DISTORTIONS
Lumbar scoliosis (convexity)	Heel lift	Sole lift or heel drop
Sacral anteroinferiority	Heel lift	Sole lift or heel drop
Sacral posterosuperiority	Sole lift or heel drop	Heel lift
Iliac anterosuperiority	Sole lift or heel drop	Heel lift
Iliac posteroinferiority	Heel lift	Sole lift or heel drop
Unilateral pelvic anteriority	Sole lift or heel drop	Heel lift
Unilateral pelvic posteriority Unilateral low femur head	Heel lift Plantar lift	Sole lift or heel drop
Unilateral short ischium	Ischial lift
ANTERIOR-POSTERIOR DISTORTIONS
Type	Application
Sprung back (lumbar)	Bilateral heel lifts
Kissing spines (lumbar)	Bilateral sole lifts or heel drops
Lumbar hyperlordosis	Bilateral sole lifts or heel drops
Lumbar flattening	Bilateral heel lifts
Fixed pelvic anterior tilt	Bilateral sole lifts or heel drops
Fixed pelvic posterior tilt	Bilateral heel lifts

Heel Lifts.   A heel-only lift does nothing more than raise the heel, yet its biomechanical and biologic effects are registered as far as the atlanto-occipital joints. When the heel is raised, the pelvis is raised and rotated anteriorly. That is, the ilium rotates anterosuperiorly and laterally and the ischium posteroinferiorly and medially. As the sacrum is lifted and rotated anteriorly, the base of support for L5 is altered accordingly. Thus, the body of L5 tends to rotate away from the side of lift. Bilateral heel lifts increase the lumbar lordosis and this is somewhat compensated by an increase in thoracic kyphosis. This may be beneficial in cases of lumbar flattening or the rigid "military spine." They also remove stress from minor cases of sprained posterior lumbar ligaments (sprung back).

Sole Lifts.   A unilateral or bilateral sole-only lift or a reduction in shoe heel height is sometimes indicated. This has insignificant effect on extremity length, but it tends to place a stretch on the posterior ankle, calf, thigh, and pelvic extensors. When applied bilaterally, they are beneficial in reducing the lumbosacral angle in cases of anterior pelvic rotation, lumbar hyperlordosis, thoracic hyperkyphosis, or kissing spinous processes of the lumbar spine.

Contraindications.   To avoid possible tendinitis, a sole lift or heel reduction is contraindicated for patients whose Achilles tendons have shortened, stiffened, and possibly ossified. Gradual reduction in heel height, along with progressive stretching exercises of the calf, has been beneficial in many of these cases. Heel height reduction would also be inadvisable in any condition where stretching the posterior muscles of the lower extremity, posterior rotation of the pelvis, or flattening the lumbar lordosis would be contraindicated.

Full Plantar Lifts.   A plantar lift extending from the heel to the toe within or without the shoe tends to raise the femoral head without altering pelvic rotation. This is most helpful when it is desirable to shift weight laterally but not alter ipsilateral iliac posture. Its common use is in anatomically shortened limbs such as from severe femur or leg fractures, unsymetrical growth patterns, and the effect of childhood poliomyelitis.

Ischial Lifts.   If the axial measurements of the ischia are asymmetrical and aggravating a sacroiliac dysfunction or lumbar scoliosis in the sitting position, a lift under the deficient ischium is sometimes advisable. This is especially pertinent with patients whose occupations require prolonged sitting on a firm surface (eg, typists, computer operators, students).

      SACROILIAC INFECTION

Almost any type of bacterial infection may originate in or extend to the sacroiliac joints. Tuberculosis is the first suspicion. The highest incidence is in children regardless of the type of infection. As the sacroiliac lesion is usually painless, diagnosis must be made by laboratory, roentgenographic, and thermographic evidence when classic signs of infection arise. Fever and a high sedimentation rate are invariably present. Infrequently, an abscess may appear early. Differentiation must be made from septic arthritis and Ewing's sarcoma. Ankylosing spondylitis, spondylitis associated with psoriasis, spondylitis related to bowel disease, and Reiter's syndrome attack the sacroiliac joints but they are rarely related to trauma in any way.


      PELVIC BURSITIS

A bursa is formed between the lateral capsule of the proximal femur and the gluteus maximus muscle's tendon as it passes over the greater trochanter to insert into the iliotibial tract. Inflammation from an external blow is not unusual.

Another bursa is formed at the internal obturator tendon and the superior and inferior gemelli. It runs below the piriformis and passes posteriorly to round the sciatic notch, largely filling the lesser sciatic foramen. Inflammation is evaluated by testing external rotation of the thigh against resistance and signs of tenderness upon deep palpation. It is easy to confused bursitis here with an inflammatory piriformis lesion.


      ENTRAPMENT SYNDROMES OF THE PELVIS

Sciatic Nerve Compression

The common site for the sciatic nerve to become "caught" is at the sciatic notch as the nerve exits the pelvis between the piriformis and sacrotuberous ligament. Here it can be squeezed against the bony ridge by piriformis spasm, thickened fascia, or adhesions. Tumors and cysts in this area are rare.

Clinical Features. Pain behind the greater trochanter that radiates down the thigh and lateral leg to the foot is typical. It is usually aggravated by walking and relieved by rest. The pain is also increased by flexing the knee and hip to right angles and forcing the thigh into internal rotation and adduction (ie, piriformis stress). Tenderness is most acute near and below the notch. Other features include a positive Lasegue's sign, hypesthesia of the weight-bearing surface of the plantar surface, and numbness and tingling restricted to below the buttocks.

Signs of sciatic entrapment must be differentiated from disc failure, inflammatory sciatica, and acute sacroiliac sprain, but it may coexist with these disorders. Tumors within the buttocks, a neurofibroma, bursitis, or a gluteal compartment syndrome can also mimic an entrapment syndrome. A fall on the buttocks producing hematoma or a posteriorly dislocated femur head may irritate the nerve at the inferior buttock and produce identical signs and symptoms as that of an entrapment syndrome.


Obturator Nerve Compression

The obturator nerve originates from the L3 and L4 nerve roots, passes through the pelvis, and enters the thigh to supply the gracilis and adductor muscles and the skin of the hip and medial thigh. An obturator hernia and pressure from the edema of osteitis pubis are common causes of obturator neuritis or neuralgia. Some circulatory impairment may be associated.

Clinical Features. The obturator nerve supplies the adductors of the thigh. Thus, the major signs are weak thigh adductors and an unusual gait: the involved leg is brought outward in a wide arc during the swing phase. Even in chronic cases, there is little or no atrophy because of dual innervation from the sciatic nerve. The typical case presents with pain usually radiating from the groin to the medial thigh and is aggravated by any Valsalva maneuver. Cutaneous numbness (infrequent) and paresthesia (frequent) may be associated.


Femoral Cutaneous Nerve Compression

Once the lateral femoral cutaneous nerve leaves the L2 and L3 roots, it courses across the lateral border of the psoas muscle before it descends along the posterior wall of the pelvic cavity. Here it enters and travels within the fascia covering the iliacus muscle, then pierces the lateral V attachment of the inguinal ligament just medial to the ASIS. It then travels in a fascial tunnel under the ligament, pierces the fascia lata, and finally enters the thigh. It offers cutaneous branches to the anterolateral thigh from below the hip to the knee and motor branches to the anterior thigh.

It is at the point where the nerve leaves the subinguinal tunnel and enters the fascia lata that entrapment of the nerve usually occurs. Here the nerve's sheath is firmly fixed to adjacent tissue. Thigh adduction increases tensile forces on the nerve, and if this occurs simultaneously with severe trunk movements above or thigh movements below, the nerve becomes severely stretched. In some cases, just prolonged sitting with the legs crossed can produce a compression syndrome in the upper thigh. An improperly fitted brace may cause compression, and, in obese women, a tight corset may produce compression. The nerve infrequently becomes entrapped by a pelvic tumor or encapsulated psoas abscess, hypertrophic arthritis of the upper lumbar spine, a pregnant uterus, or occupational pressure. Visceroptosis may also produce a stretch syndrome.

Clinical Features.   The typical syndrome, called meralgia paresthetica or lateral femoral cutaneous neuropathy, features severe unilateral burning pain (late stage), possible hyperesthesia, and a distinctive patch of paresthesia on the anterolateral thigh. The onset is usually spontaneous. Major signs are aggravation of pain when the nerve is pressed against the medial side of the iliac crest and relief of pain when the patient is recumbent. The focus of irritation is usually found (1) in the pelvis from repetitive trauma as seen in athletic injuries and late pregnancy or (2) at the L1–L3 IVFs from subluxation encroachment or arthritic hyperplasia. Pathology anywhere along the course of the nerve may be responsible whether it be intraspinal, intersegmental, paraspinal, retroperitoneal, pelvic, or, uncommonly, abdominal.

Differentiation.   Special care must be taken to differentiate this syndrome from trochanteric or iliopectineal (iliopsoas) bursitis, both of which refer pain to the anterolateral thigh. It should also be kept in mind that pronation or supination of the ankle, genu varum, genu valgum, genu recurvatum, flexion contracture, etc, can cause or contribute to anterosuperior thigh pain.

Management.   Associated lumbar subluxation-fixations should be freed immediately unless there is some contraindication. Low wattage ultrasound applied paraspinally at the L2 level for 3 minutes and for 2 minutes at the area where the nerve leaves the pelvis may be of value. High voltage stimulation in the area of L2 and again in the anterolateral aspect of the thigh may also assist recovery. Massage, muscle stripping, and moist heat of the involved thigh are recommended. Weight reduction, to relieve the pelvic basin of excessive weight, should be recommended if obesity is a factor.