Want to stay up to date with the evidence?
All elements now added. This very much focuses on the iliolumbar ligament as a source of nociception, not so much as a biomechanical contributor to another source of nociception.
Would appreciate feedback/ criticism especially from those that do directly treat the ligament.
Do you think maybe you can feel the L4/5 5/1 trunks and avoid pressing on them and bias the ligament in treatment? Or is there a passive technique to isolate the ligament?
www.kieranmacphail.com/the-iliolumbar-ligament-and-chronic-low-back-pain-anatomy-causation-assess...
www.kieranmacphail.com/the-iliolumbar-ligament-and-chronic-low-back-pain-anatomy-causation-assess...
Just the anatomy and iliolumbar lig as a cause so far, will upload the assessment and treatment sections over the weekend.
kieranmacphail.com
The Iliolumbar Ligament and Chronic Low Back Pain: Anatomy, Causation, Assessment & Treatment Written by Kieran Macphail on September 19, 2019. Posted in Uncategorized. Iliolumbar ligament Anatomy Figure 1. The Sacroiliac Ligaments from Grays Anatomy The location of the iliolumbar ligaments is betwe...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.
Have managed to recover 60,000 lost words on causes of low back pain. So more time to post again now. Brace yourselves.
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.