Pop quiz: What musculoskeletal issue could result in chronic low back pain, chronic muscle strains, lower extremity tendinopathies, periscapular pain and tightness, glenohumeral and shoulder girdle pain, or tension headaches? I am sure you can think of a few possibilities, but few can result in all. Often, when a patient reports to our care with one of the aforementioned we immediately think locally. Unfortunately, the real problem could be pelvic upslip, anterior pelvic innominate, or both. Despite being oft-overlooked, these malalignments are not hard to identify if you know what to look for. Continue reading
Introduction and Anatomical Overview:
Muscle is made up of two types of fibers, intrafusal and extrafusal. Extrafusal fibers are the contractile fibers and intermixed within the extrafusal fibers are intrafusal fibers. Housed within intrafusal fibers is a specific type of mechanoreceptor. Mechanoreceptors, in general, are interspersed through the entire body – hair, skin, ligaments – and are responsible for sensing tissue pressure and distortion and give our body a sense of proprioception by detecting position of our muscles, bones, and joint. There are many types of mechanoreceptors, but one specifically – the muscle spindle – lives within the intrafusal muscle fibers. The muscle spindle transmits sensory data regarding changes in muscle length, and therefore movement, to the central nervous system (CNS) via the primary afferent (sensory) neurons. The intrafusal fibers receive neural stimulation from gamma efferent (motor) neurons. Think of the gamma motor neuron as a type of sensitivity adjuster. The efferent input adjusts the length of the spindle so that it remains at an optimal length to detect changes within the muscle.
Do you have a patient with chronic low back pain, pelvic pain or lateral hip pain? The problem could be an oft-overlooked Anterior Innominate Lesion, commonly referred to as Anterior Iliac Rotation. This malalignment is hard to identify unless the clinician is specifically evaluating for body alignment.
Simply described, anterior innominate is anterior / inferior rotation of the ASIS when compared to the contralateral ASIS. This unilateral rotational movement of is often a result repetitive movement patterns. Repetitive movement results in hypertonicity of hip flexors (primarily the rectus femoris and TFL), hypotonicity of the abdominals, hamstrings, and glutes, as well as increased laxity of the sacrotuberous ligament. The force coupling caused by the hyper/hypotonic structures yields the unilateral rotary movement of the pelvis.
The result is a chronic, dull achy pain that is unrelenting at times. Pain is typically felt across the entire low back. Focal tenderness upon palpation is commonly unremarkable. The patient may also have complaints of thoracic pain, lateral hip pain and potentially groin. Pain maybe exacerbated with athletic activity, or static postures such as prolonged sitting and standing.
As with many postural disorders, treatment for anterior rotation is best served through the use of manual therapy techniques. In my experience, there are two quick and easy treatments: muscle energy techniques (MET) and spray and stretch. Spray and stretch technique is a nice way to inhibit and elongate tonic musculature. Ischemic pressure massage to active trigger points of involved muscles followed the application of a vapocoolant spray, during a passive stretch works well. Although both treatment forms are effective, I prefer MET, as it is fast, effective, and incorporate a semi-functional component through contraction and relaxation of muscle.
When it comes to MET (or most manual therapy techniques for that matter) I often refer to anything by Leon Chaitow’s methods. In this particular instance, I have provided a video clip of a MET that can help both anterior and posterior pelvic rotation in one treatment session. I think the physiotherapists across the Atlantic do a great job of manual therapy, thus I chose a video that was made in the UK.
It is not uncommon to relieve patient pain with just one application of MET. For patients with significant malalignment this treatment may need to be performed twice daily for several weeks in conjunction with traditional functional rehabilitation designed to enhance neuromuscular efficiency.
So, if you have been a patient complaining of low back pain, be sure to observe for postural malalignment. You might find anterior innominate rotation. If so, you can utilize these techniques to resolve the problem quickly and restore optimal function.