Himalayan dreaming; sacro-iliac joint instablity – the root of the problem?

Helen popped her head in last week and said she had booked herself in for a quick assessment / treatment, as she has had a very tight left calf since the running workshop with Gayle.  Both were initially sore as you would expect from learning the new mid-foot strike pattern associated with Barefoot running, and waking the calf up to having to work in a very new (and improved) manner, but this left one has persisted.

Those that know me, either fellow professionals or clients, will appreciate I look at things from a very central to peripheral approach.  By that I mean I will clear all the central (spinal and pelvic) issues I find first, assess the effectiveness of this (almost always very effective!) then treat any local issues that may be there too (local scarring / inflammation / tightness / weakness etc) as well as the peripheral joints (foot / ankle /first toe etc).  Over the years I have found this to be the most efficient, effective way to treat musculoskeletal pain in runners, as well as those with pain and discomfort associated with work.  I should clarify this and mention that this approach is best suited to pain and discomfort which is not associated with an injury – such as spraining an ankle or knee, where these need to be thoroughly assessed to ascertain the extent of joint, ligamentous, muscular, vascular or neural injury.  But even here I will look centrally as part of the overall plan to rehabilitation.

Back to Helen. My rationale for this central to peripheral approach is very complex, but a very simple premise in my head is that both legs do the same distance, on the same terrain in everyday living and when running – why does only one get injured?

Now it could be that you have altered biomechanics due to past injury (although here it was Helen’s right fibula she previously injured) or poor habit, either way you need to “Look Up’ and away from the obvious site of pain to find out WHY.  Once you find out WHY then it should begin to settle, and if slow, may need some local attention.  Think of CAUSE (altered biomechanics) and EFFECT (strained calf).  Or irritated neural system and referred pain – another post will have to cover that.

Helen had pain in the left calf when she bent over to touch her feet, and not the right.  She had stiffness in her lower back with side bending.  She had asymmetrical sacro-iliac function when lifting her legs, with either the right one moving more than the left, or the left one being stiffer than the right.  Later on I found she had increased mobility in the left sacro-iliac joint itself, and spasm and tenderness in the left glut complex and lower back (Quadratus Lumborum) suggesting  maybe there is an element of left sacro-iliac joint instability.   This accounted for the relatively stiff movement of the left sacro-iliac joint, as the tight muscles prevent it from moving correctly.  Although when the muscles are switched off, as at rest when lying the joint itself felt unstable.  In effect the muscles are tight to compensate and protect the joint from this extra movement.  However they need more help from other stabilising muscles, to reduce the load through them.  She also had a very mobile lumbar spine.  Please note it was a short session and there may be other elements, neural irritation / tethering etc which could be identified with more thorough examination, such as slump.  But the things I found can affect the slump test anyway and needed to be released.

I released the glut and QL and then reinforced the need for her to continue with her Core Stability (Pelvic Floor and Transversus Abdominus) exercises.  She will also need to do some glut strengthening, such as bridges, lunges, side walking etc.  I also taught her how to fire her Multifidus muscles (in her back) to further help to stabilise her lower back and pelvis.

From my experience instability of the sacro-iliac joint can be hard to fix, but she needs to fully exhaust all the conservative options first and do some very intense and progress to very functional core exercises.  I have used Prolotherapy in the past for more extreme cases of instability, or if the conservative methods fail.  This has proved to be very successful when combined with good functional rehabilitation.

Good on you Helen for committing to this journey – I am excited to see where it ends.  I did not have time to check today but you may also be ‘globally’ hypermobile – we can check next time.  In any effect this sacro-iliac joint instability may have been responsible for all your aches and pain in college, or may have been from your fall in 2007 – I am unable to tell – either way let’s see if we can fix it.

For more posts in this series click the ‘Himalayan Dreaming’ category tab.

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