Question
I am a 17 year old female.  For the past three years I have experienced pain in my lower back, left hip and buttocks (around the sacroiliac joint), and occasionally right buttocks (around the sacroiliac joint).  Sometimes this pain is too relentless to even be able to walk.  I believe I may have injured it during a dance class but I didn't go to a doctor until about a year later, because I was able to handle the pain until that point.  The first doctor I went to was a family doctor who sent me to physical therapy.  I completed the therapy (which was two months) and felt pretty good-they said I could continue to dance (I was an irish dancer and danced for seven years) and play volleyball. A month after being discharged from therapy, I began my spring travel season for volleyball and had to quit mid-way through because I could not move. Period. No jumping, no lateral movement-I could hardly walk.  This time I went to a sports medicine doctor who told me to stop dancing, stop volleyball, stop all activity and resume physical therapy at a new place. I did as I was told and was discharged within three months, again feeling pretty good.  They said I was free to go back to volleyball but do not add dance to the mix.  With too many pain killers, ice, and a not-up-to-my-ability performance I completed my school season of volleyball.  I was not able to play the travel season though.  Now here I am trying prepare for my last high school volleyball season.  I can hardly walk because of the pain.  The pain does seem to come and go, however, when it goes, it's always there, just a little bit less.  I am not at all overweight, I have always been active, and I am young--I do not understand why this sacroiliitis is so devastating to me and why I am not able to work through it.  I do not mean to give you a sob story, but the first doctor and the first physical therapist did not believe me to be in that much pain.  I was voted MVP of my varsity team in my last school volleyball season.  I tell you this to show you that I do not give up-I will do whatever necessary to get some relief.  I play through the pain as much as I can, but I am telling you now, I don't know if I can play through the pain I'm currently experiencing.  

Now that you know a bit of my background, I ask you, what can I do?  Do you know of any pain killer that will work wonders (I've take Aleve, Advil, Tylenol, etc)?  Is there a way I can tape my body to make it through practices, games, and tournaments?  If you tell me to go to a chiropractor, then I will ask you, how can they tighten my apparently loose ligaments?  How would a chiropractor tighten my ligaments?  Is there anything I should change about my diet to help?  Will I ever be able to get rid of this problem?  Please HELP ME!


Answer
Dear Megan,

The first question I have for you is do you have any diagnosis other than sacroilitis?  The reason I ask is because this is not really a diagnosis, it only means inflammation of the sacroiliac joint (SI)...nothing more.  Moreover, why do you think you have "loose ligaments"?  The ligamentous complex that surrounds the SI joints are the strongest ligaments in the body and are not prone to laxity except during pregnancy. It takes a fairly severe trauma to injure these structures.  These facts have been well established in the medical literature by the work of Andry Vleeming and others.  

Now I have often seen patients in my office with sacroiliac dysfunction that was resistant to previous therapies that then got great relief from chiropractic care.  This isn't because physical therapy doesn't work, but rather because physical therapy only addresses the functional capacity of the joint and the muscular structures. Most of the time, patients need physical therapy and chiropractic care for the best resolution.  Let me explain this further.

Most of the research I have read indicated that the SI joint moves only 1-3mm.  For many years it was thought that the joint did not move at all, but it is a true synovial joint.  Therefore, fixation can and does occur at this joint structure and can be a significant source of pain.

Concerning manipulation or adjustment of the joint (chiropractic), it is very common to use the side posture adjustment to address SI joint. Technically the doctor is moving the joint with manipulation, but again we are talking about very slight movement.  The key to chiropractic manipulation is not the actual movement of the joint, rather the quick release of pressure within the synovial fluid of the joint...that is what makes the popping sound.  It is a release of gasses that happens quickly and escapes the synovial capsule, just like when you open a champagne bottle quickly.

When this happens joint receptors are firing signals to the brain.  These are called mechanoreceptors because they respond to movement and mechanical stimuli.  There are also proprioceptors which transmit information to the brain about body position and awareness.  Both of these transmitters send information to the spinal cord and brain which will inhibit the pain receptors in the joint which are called nociceptors.  It is a neurological and physiological relationship reducing inflammation and pain transmission.  So the aim is not to tighten up loose ligaments, but to re-establish normal position and motion while reducing inflammation and pain transmission.

There are other ways to adjust the SI joint however without as much of a stretch to your torso and the lower lumbar and pelvic musculature.  A drop table adjustment where you lay on your stomach, or your back could be utilized, or an instrument to vibrate the joint space as well as some "PNF" stretching in the low back.  Moreover the chiropractor could also elect to adjust the sacrum to the pelvis instead of the pelvis to the sacrum which would mean a different hand placement for the doctor on your body.  All of these things will accomplish the same task, but have different effects depending on the patient's general condition.  

As stated before, because of the anatomy of the SI joint and the functional limitations of movement, I find it very difficult to believe that you have any hypermobility in the joint. In my clinical experience as well as a thorough scientific review of the work of Dr. Andry Vleeming, (SI joint research on anatomy and biomechanics), it is unlikely to have hypermobility in that joint unless you have had a forceful trauma such as auto injury.

Additional consideration for complimentary treatment may consist of electrical stimulation, ice or heat depending on the acuteness of the problem, functional stability and rehabilitation stretching and exercises either in office or at home depending on how you are at this point.

Now, there is also another type of therapy you should look into called Prolotherapy.  This is performed by an M.D. and consists of injections into the joint space with a sugar solution (normally dextrose) to stimulate a new inflammatory response.  This may sound contradictory in application, but the research has shown that this can break the chronic inflammatory response, and actually promote tissue regeneration if there has been degeneration in the joint. It may take a few applications, but the treatment is very promising.  I would suggest that you do some research on the internet to learn more and look for a local doctor in your area who has had training in Prolotherapy.

Megan, I hope this sheds some light on your concerns regarding treatment and ongoing symptomatology. I think chiropractic care can help you, what do you have to lose...your still in pain with the traditional approaches.  Otherwise Prolotherapy, and acupuncture is worth considering and researching. If you have any further questions or comments please feel free to respond back.  In addition to read any of Dr. Andry Vleemings research, you can look it up on Medline or Pubmed through the internet.  In addition, I would highly recommend a book written by Dr. Stuart McGill as a reference for low back dysfunction called LOW BACK DISORDERS, Evidence-based prevention and rehabilitation.  I am sure you can find it at your local college library.  Lastly, there is another expert on the chiropractic portion of this site named Dr. Man Tran.  He is an expert in accupuncture, and you may want to ask him for advice on that treatment option.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net