UNDERSTANDING CHRONIC PAIN

Kieran is passionate about helping people get out of chronic pain and back to what they do best.


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Kieran is a chartered physiotherapist, registered nutritional therapist and corrective exercise specialist who specialises in helping people in chronic pain get back to what they do best.

Kieran is fascinated to understand the causes of someone's pain. From here he puts together a plan using physiotherapy, exercise, nutritional therapy and education to help you get back to what you do best.

Kieran is based at the Bowskill Clinic, 4 Duke Street, W1U 3EL near Bond Street tube station. Where patients are unable to attend the clinic he can do home appointments.

To find out more about Kieran see his bio here

To ask Kieran a question or book an appointment; call 07830160323 email kieran@kieranmacphail.com

Looking at this image of the superior and inferior bands of the iliolumbar ligament (IB &SB) and their proximity to the L4 and L5 lumbosacral trunks (LST) it's easy to see how we could be applying pressure to these trunks when trying to palpate the iliolumbar ligament. ...

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Have managed to recover 60,000 lost words on causes of low back pain. So more time to post again now. Brace yourselves. ...

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2.5.1 Iliolumbar Ligament As A Cause of Low Back Pain

Viehofer et al (2015) suggested 50% of non-specific low back pain may be attributable to Iliolumbar syndrome. Iliolumbar syndrome involves a strain, tear, or rupture of one or both iliolumbar ligaments, and may be caused acutely by a heavy-lifting or a fall (Naeim et al., 1982) and chronically by rotation sports and manual work (Harmon and Alexiev, 2011). Patients with Iliolumbar syndrome present with chronic low back pain and sensitivity around the PSIS and iliolumbar ligament aggravated by standing or sitting for long periods of time (Naeim et al., 1982).
Sims and Moorman (1996) hypothesised that micro-trauma to the iliolumbar ligament is the primary cause of many cases of chronic low back pain because (1) it is the weakest component of the multifidus triangle; (2) there is increased susceptibility to injury due to its angulated attachment; (3) it is a primary inhibitor of excess sacral flexion; (4) it plays an increased role with progressive disc degeneration and (5) it is a highly innervated nociceptive tissue.
Kilter et al (2010) reported finding many proprioceptive fibers specifically in the iliac wing attachment site of the iliolumbar ligament. However Wang et al’s (2018) dissection study did not identify nerve fibers within the iliolumbar ligament. However, surrounding tissues were found to have innervation. Nervous tissue has been discovered within the fat anterior and posterior to the iliolumbar ligament. Thus, the fat may be a mechano-sensory organ that conducts neural information. Nerve cells in fat within the iliolumbar ligament may actually transmit nociception (Viehofer et al. 2015). Perhaps this is what Kilter et al (2010) found, or innervated adipose tissue may have infiltrated the iliolumbar ligament. Indeed fat tissue at the enthesis of ligaments and tendons has been included as part of the “enthesis organ” and described as valuable in proprioception at other sites such as the Achilles tendon (Benjamin et al. 2006). Benjamin et al (2006) argued that fat tissue accumulation around the enthesis of tendons and organs was not a sign of degeneration, but rather a functional adaptation. Benjamin et al (2006) lean towards almost suggesting some sort of subconscious decision process in depositing this fat in the way they write about it. In contrast it is probable this fat could be susceptible to overuse/ microtrauma leading to hypertrophy as with fat in other mechanically challenged locations.
The common tender spot 5-7cm lateral to the PSIS has been attributed to the iliac insertion of iliolumbar ligament, however Maigne and Maigne’s (1991) dissection study of 37 cadavers demonstrated that the iliac insertion of the iliolumbar ligament was impalpable because it attaches anteriorly on the iliac crest. Conversely, the dorsal rami of L1 and L2 were superficial and palpable as they crossed the iliac crest 7cm lateral to the spine bilaterally. This supported the claim that the tender point originates from the cutaneous dorsal rami of L1 and L2 (cluneal nerves) rather than the iliac attachment of the iliolumbar ligament.

References
Basadonna PT, Gasparini D. 1996. Anatomy of the iliolumbar ligament: a review of its anatomy and a magnetic resonance study. Am J Phys Med Rehabil; 75 (6):451-5.
Benjamin, M., Toumi, H., Ralphs, J.R., Bydder, G., Best, T.M. and Milz, S., 2006. Where tendons and ligaments meet bone: attachment sites (‘entheses’) in relation to exercise and/or mechanical load. Journal of anatomy, 208(4), pp.471-490.
Harmon, D. and Alexiev, V., 2011. Sonoanatomy and injection technique of the iliolumbar ligament. Pain Physician, 14(5), pp.469-474.
Kiter, E., Karaboyun, T., Tufan, A.C. and Acar, K., 2010. Immunohistochemical demonstration of nerve endings in iliolumbar ligament. Spine, 35(4), pp.E101-E104.
Maigne, J.Y. and Maigne, R., 1991. Trigger point of the posterior iliac crest: painful iliolumbar ligament insertion or cutaneous dorsal ramus pain? An anatomic study. Archives of physical medicine and rehabilitation, 72(10), pp.734-737.
Naeim, F., Froetscher, L. and Hirschberg, G.G., 1982. Treatment of the chronic iliolumbar syndrome by infiltration of the iliolumbar ligament. Western Journal of Medicine, 136(4), p.372.
Sims, J.A. and Moorman, S.J., 1996. The role of the iliolumbar ligament in low back pain. Medical hypotheses, 46(6), pp.511-515.
Viehöfer, A.F., Shinohara, Y., Sprecher, C.M., Boszczyk, B.M., Buettner, A., Benjamin, M. and Milz, S., 2015. The molecular composition of the extracellular matrix of the human iliolumbar ligament. The Spine Journal, 15(6), pp.1325-1331.
Wang, J.M., Kirkpatrick, C. and Loukas, M., 2018. The Iliolumbar Ligament Does Not Have a Direct Nerve Supply. The Spine Scholar, p.3661.
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