Case Study: The Sacrotuberous and Sacrospinous Ligaments As Sources Of Sciatic Pain
“It is well recognized that radiculopathy, usually due to pressure on the dural sleeve of one of the lumbar nerve roots, can be responsible for this pain (Sciatica). On the other hand, ‘sciatica’ is more often due to referred pain from the sacrotuberous ligament”
I re-read this statement after flicking through my notes on “Movement stability and low back pain” by Vleeming et al (Dorman 1999) trying to find solutions to a client’s long standing radicular pain that was not resolving. His primary symptom was radicular pain sitting after twenty to thirty minutes. He also got pain with prolonged standing, posterior pelvic tilting and anterior pelvic tilting. His inner unit functions well on ultrasound testing, his MRI is inconclusive but there could be some minor compression on the dural sleeve at the L5/S1 level.
He has had ergononimic advice, sat with a towel under his thighs to reduce any potential direct compression on the sciatic nerve. He has had a corrective stretching and exercise programme, but he has plateaued at about fifty percent improved. Manual therapy to normalise the alignment of his innonimates and sacrum has helped short term but nonetheless his symptoms haven’t resolved.
On closer examination his radicular symptoms fit closely with the referral patterns
described by Hackett (1958) for the sacrotuberous and sacrospinous ligaments. Further, reading Dorman’s chapter gives two key features of ligament symptoms;
Positional strain. A pain that comes on after thirty minutes an hour before you have to get up and move around. This may be occurring as the ligament begins to creep and approaches the tissue threshold.
A “numb” like feeling. However, on neurological testing there is no numbness the patients “pain” is more like a numb feeling.
These symptoms fit the patient’s symptoms to a T.
Specifically for the sacrotuberous ligament the “pain” or nulliness symptoms jump the knee. So a patient with referred pain above and below the knee but with no pain behind the knee, may have a ligamentous lesion.
On palpation of the sacrospinous ligament and the lower portion of the sacrotuberous ligament the patient’s symptoms were reproduced.
Unlike the knee, ankle, elbow or even the wrist, treatment of ligamentous lesions using deep transverse frictions is not discussed for the sacroiliac or lumbar spine ligaments. In fact the only article I have found discussing using deep transverse frictions to the sacro-illiac ligaments was a thesis (Mott 2011). This thesis discussed a treatment approach to a case study. They applied a battery of treatments often only once each across the treatment period and did not individually assess the effectiveness of any of them independently. They only applied deep transverse friction to sacrotuberous ligament once, for three lots of one minute and did not assess the effect. As such it’s fair to say there is a paucity of research on this topic.
In contrast, there is a plethora of research discussing and demonstrating benefit from prolotherapy injections to stimulate tissue healing in strained sacro-illiac ligaments. The proposed mechanism of action in deep transverse frictions is not dissimilar from that of prolotherapy. Further, deep transverse frictions have been applied effectively to ligaments at other anatomical sites. As such there may be some benefit to applying them to sacro-illiac ligament lesions.
In this patient I applied 10 minutes deep transverse frictions to the sacrospinous and sacrotuberous ligaments as described by Cyriax (Kesson and Atkins 2005). It may have been more effective to apply ten minutes to each ligament, however there was insufficient time. The following day the patient reported a significant decrease in pain and a decrease in the intensity of symptoms. Further he had been able to sleep much better than before. Needling by another therapist to the ligaments has also improved symptoms further in the interim.
This may be a false dawn, however the initial response is very promising. More importantly in future I will ensure I am more aware of these ligamentous referrals and consider them in my differential diagnosis.
For a full description on the application and rationale for deep transverse frictions see http://bjsportmed.com/content/38/6/675.full(Stasinopoulos and Johnson 2004).
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Dorman, T.A. 1999. Pelvic mechanics and prolotherapy. In: Movement stability and low back: The essential role of the pelvis. Eds Vleeming, A. Mooney, V. Dorman, T.A. Snijders, C. and Stoekart, R. Churchill Livingstone: London.
Hackett, G.S. 1958. Ligament and tendon relaxation treated by prolotherapy. 3rd Ed. Hermwall G. Institute in Basic Life Principles: Illinois.
Kesson M, Atkins E, 2005 Orthopaedic medicine – A practical approach.2nd Ed. Elsevier: Oxford.
Mott, G.A. 2011. The Use of Manual Physical Therapy in the Treatment of Sacroiliitis: A Case Report. Thesis. Presented to the Faculty of the Physical Therapy Department Sage Graduate School. In Partial Fulfillment of the Requirements for the Degree of Doctor of Physical Therapy.
Stasinopoulos, D. and Johnson, M.I. 2004. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med, 38, 675-677.
deep transverse frictions, Dorman 1999, Hackett 1958, kieran macphail, Ligament referral patterns, Nulliness, Posain, Sacro-illiac ligaments, Sacrospinous ligament, Sacrotuberous ligament, Sciatic Pain, Sciatica
prp to tighten saccrotuberous ligament?
It healed up lax and is painful
It’s very difficult to comment on individual cases over the internet. The classic approach for tightening in a ligament if it is truly lax is to use prolotherapy. An injection technique which looks to cause minor trauma to the ligament so it heals back stronger. I have seen patients have good results with this approach but it is painful and does take some time. The evidence is quite promising although far from conclusive around the sacroiliac joint.
how to tighten saccrotuberous ligament?
It healed up lax and is painful
Pls tell me when u know u r ready for prolo. SIJ dys for 7mo. Was level 8 pain, now have plateaued at 5-6, can’t sit or stand more than 15 min. SOT helps am still having SOT. Did 13 PT treamt, tons of stabilize exercises still, steroid inj 2 mo ago out if desperation, ugh. Had to take medical leave, need to go back! So appreciate your time and caring when u don’t even know me. Ty!!! Milena
I’m a big fan of prolotherapy as it makes a lot of sense to me.
Dianne Lee (Physiotherapist) and Andrey Vleeming (Doctor) built on the earlier work of Panjabi when suggesting their integrated model of joint function. It has four parts, passive (think ligaments and joint), active (think mainly muscles), neurological (how the brain controls the area) and emotional. Arguably Panjabi’s model is the more refined as he combined the neurological and emotional components which modern neuroscience is suggesting may be more accurate in my opinion.
The porlotherapy is a way of trying to improve the passive the stability. However, in my experience it is a painful process but can help. Very few people do it. In the UK where I work there are maybe 2 consultants doing this work comprehensively.
When is a difficult question, as it is an expensive and painful process I would keep going with addressing the other aspects of joint stability first and focusing more on function. In my experience most physiotherapists prescribe very inadequate “stability”exercises and the manual therapy is often very poor and general. I probably have scewed view as I obviously don’t see the people who respond well to other therapists treatment!
If you let me know where in the world you are I can recommend a suitable therapist in your area to guide you further.
All the best!