When your patient complains of lower back or pelvic pain, but your usual treatments are not getting the job done, what do you examine and treat? You may be missing important structures in the lower half of the pelvis. Nearly everyone who has SI or coccyx problems and/or injuries has additional problems in the lower half of the pelvis.
What specific structures should you address? The first would be the sacrotuberous ligaments, their origins near the sacrum and coccyx, and laterally, as they insert into the ischial tuberosity. The second would be the pubic symphysis.
I suspect the lower pelvis gets ignored because it is close to the genitals and lower buttock. How comfortable are you with touching this area? But if you don't go there, who will? If you don't go there, will the patient get the help they need? All of the techniques outlined in this article can be done through thin and flexible clothing, including the instrument-assisted work.
Sacrotuberous Ligaments
Let's get specific about assessment and treatment, starting with the sacrotuberous ligaments (ST). We are going to get up close and personal here with the patient. Tell the patient where you are going to touch, and tell them why. Don't be squeamish, don't be embarrassed; be professional. Your goal is to find the damaged structures and help correct the problem.
The Sacrotuberus Origin: I like to start with the patient seated and check the origin of the ligaments just laterally to the lower sacrum. I put the edge of my finger right up against the lower sacrum and coccyx, and then reach under the buttock, hooking my finger under the medial aspect of the ligament. It is quite palpable as a strong band. As usual, tenderness and changes in tissue texture are the main indicators.
Describing tissue texture changes is challenging. These are not exactly trigger points or areas of increased density. Tenderness is simple. Assess tenderness first, and try to develop a sense of what feels different when the structure is tender. Most of our corrections here are low-force, non-thrust, gentler methods.
You also can use deeper soft-tissue methods. Which style should you use? Even after 36 years, I find this a difficult choice. I try to take into account the quality of the patient and what they are likely to respond to, although I can still be wrong. My younger, more athletic patients tend to respond to the deeper-tissue techniques; my older, more chronic pain patients tend to respond to the gentler methods.
For treatment, start with the patient either sitting or prone. If I am working on the left side, I will use either my right thumb or right index finger. I'll sink under the buttock muscles and find the palpable band of the ST ligament.
I use a simple, gentle myofascial hold. Feel the tension melt under you contact finger. Yes, my finger is active; this is in the Engage, Listen, Follow style. Feel for the direction of the barriers. For a direct technique, release in the direction of the barrier. If you are hitting a brick wall, if nothing changes in 20 seconds or so, try a more indirect approach, moving in the direction of ease.
A contrasting style here would be deeper soft tissue. For example, use your IASTM instruments to strum the medial origin of the ligament. I'll use the lateral inferior border of the sacrum as my guide. For instrument-assisted soft tissue, I want to work on the origin of the ligament; I don't want to sink deeply into the softer buttock tissues.
The Ischial ST Insertions: Another critical place on the sacrotuberous is its insertion, deep on the medial ischium. In my experience, the most tender place here, the most often affected area, is far more inferior and anterior than one thinks, not the first place you touch on the medial ischium. You have to slide farther anterior and inferior along the ischial ramus. You are pressing directly into the bone, feeling the insertions into the periosteum.
The goal is to balance the tensions and feel the structures become less tender. I have used all kinds of techniques over the years; I still don't have a “go-to” technique that works every time. This is a region where I tend toward the more gentle, subtle methods, since these tissues are very sensitive. The ST is unlikely to correct completely in one visit. I always remind chiropractors to be gentle and start slowly.
1. I primarily use manual myofascial release on this area, much more gently than more vigorous manual methods. Myofascial release seems to mean different things to different practitioners. I'll often use some variation of Engage, Listen, Follow here. You are tuning into the barriers. Find the tender spots, see if you can find a direction of gentle pressure that begins to create a release, and then follow it.
2. Treat the ischium as if it is jammed medially. You are not releasing a joint; you are releasing intraosseous restrictions within a bone, a stiff bone. Find the barrier and pull the bone laterally. It's a gradual, push-a-boat-through-the-mud technique. I tend to do this with the patient prone. This is the concept pioneered by Paul Chauffour's mechanical link or George Roth's matrix repatterning (formerly tensegrity) model.
3. You can use the counterstrain concept. My simplified view of this method: Some pain sensor got ramped up and you just need to reset it, via slacking or fold and hold. I tend to use this on exquisitely sensitive points. I like to do this prone for the ST.
Example: For the left ischial insertions, patient prone, touch the tender spot and monitor it with your left index finger, or index and middle-finger tips. With your right hand, reach under the patient's bent left knee; lift the thigh and knee into extension, up off the table.
Next, use your right arm to rotate the lower leg in a medial direction. You are moving the thigh into both extension and external rotation, putting slack on the ST insertion. If you've found the right position and if this is the right technique for this patient, the tenderness will immediately diminish and the tender spot will immediately feel softer under your monitoring finger. You may need to tweak your positioning into more or less extension and rotation.
Continue monitoring with your left hand; continue holding the leg in the position of relief for 90 seconds. Sometimes I ignore the clock and feel for a pulse under my monitoring finger. I stop when the pulse lets up, but it is still a long hold.
The hardest thing for chiropractors is to stop pressing with your left fingers; you are just monitoring. The work is all about the positioning. When you are done, slowly let the leg back down to neutral. Recheck the tender point -– it should be much less tender.
4. I have tried and used IASTM on the ligament's insertions. It is a bit rough, but can work wonders. If you are hesitant to use a metal instrument this deep in the buttock, you can use manual cross-friction.
When using an instrument, I first touch the place I want to work with my fingers, and then glide the instrument under my fingers to be sure of its location. I'll never forget one female patient, early in my Graston training. She had been injured in an MVA. I did Graston technique to these ligament insertions, but a bit too vigorously. She came in five days later and said, “I could not sit for three days, but my pelvic pain is now gone for the first time in months.”
The Pubic Symphysis
In my mind, I think of the pubic symphysis as its own joint. Of course, it is connected to the pelvic ring and the posterior SI joints, but it deserves its own assessment and treatment. Don't assume just because you've corrected the iliac rotation that the pubes are fine. Test them.
It's simple: just press on the pubic symphysis, testing for tenderness. The usual tender points are either directly over the most prominent anterior part of the symphysis, left or right, or at the lateral margin of the symphysis. Pubic misalignment also is significant in SI non-physiological shears (upslips and downslips).
I tend to assume that the tender side is the restricted side. (If my corrections do not change the tenderness, I may treat the opposite pubic bone.) If the structure is tender, evaluate its position by sliding your thumbs down the lower abdomen from above until they contact the pubes. The usual pattern is inferior or superior. This usually will correlate with the ASIS being similarly misplaced. Inferior pubes are on the anterior ilium side; superior pubes are on the posterior ilium side.
If you already use a low-force muscle energy-style technique for the ilium, you can just modify it slightly. Place a hand on the side of the pubes you are treating and gently guide it in the direction you want it to move. Use the usual contract-relax methods, using the leg as the lever.
Another less common pattern is the anterior or posterior pube. When it is anterior, you can use an adjusting instrument or just gently push A-P. When the pube is stuck posterior, you will have to come up with a more indirect method. Try pushing the opposite (anterior) pube P-A while stabilizing from below the involved side sacrum and ilium.
Don't forget the simplest pubic correction. I've always heard it called the shotgun technique. The patient lies supine with the legs bent, feet on the table. You resist as they push inward with knees for five seconds strongly. Chiropractors usually feel the need to deliver a thrust on every adjustment. The thrust here would be to pull the knees apart after the patient has held the isometric inward hold.
Personally, I think this thrust has more risk than benefit; you could damage the symphysis, and its connecting ligaments. (This is a terrible iatrogenic injury, with the potential of creating long-term instability.) I recommend you just have the patient pull inward for five seconds and then release.
Next, same patient position; put your hands on the outside of the knees and have the patient push laterally for five seconds, then release. This simple technique often resets the pubes and can be taught to the patient.
Assessing and correcting the lower pelvis can help your challenging lower-back, pelvic and hip pain patients who have not previously responded. In my next article, I will address the obturator foramen, the adductor region, and the other muscles, fascia and nerves of the lower midline.
Editor's Note: Visit www.youtube.com/c/marchellerdc to view video demonstrations of all the corrections discussed in this article.
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