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”

Dorman (1999)

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;

Posain

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.

Nulliness

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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References

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. 3^rd Ed. Hermwall G. Institute in Basic Life Principles: Illinois.

Kesson M, Atkins E, 2005 Orthopaedic medicine – A practical approach.2^nd 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.