Chronic Low Back
SyndromeLow back painReferred pain from sacro-iliac joints is mainly down the side of the leg and foot.

Patterns of low back pain

When back pain is due to loose ligaments, acute flare ups of pain can be due to an unstable disc, facet joint locking, or sacroiliac joint dysfunction.

But chronic low back pain usually originates in the ligaments of these joints, which contain many small nerve endings. Healthy, strong ligaments stretch very little when a load is applied to them, but after ligaments have had a strain injury, they stretch excessively, which stretches the nerve endings, and pain and/or a numblike feeling is felt locally over the ligaments or referred into the buttocks and legs, in a specific pattern for each ligament.

Ligament injury is very painful. Partly because of the nerves in the ligaments, but also because ligament injury typically occurs where the ligament attaches to the bone. This layer, on the outside of the bone, (the periosteum), is also full of nerve endings, and is the most pain sensitive tissue in the body according to Daniel Kayfetz, M.D. This also explains why ligament pain can disappear in certain positions where the ligament is not overstretched.

A person with pain from loose ligaments of the lumbar spine and pelvis will often also have an inability to maintain the same position for a long period of time. “Ligaments are worse with inactivity”. Changing posture or position gives temporary relief. Here are some typical pain patterns experienced with ligament injury to the lower back:

In bed, position must be changed repeatedly to get comfortable, sleep is poor, and often disrupted because of the recurring back pain in the early hours of the morning. Getting out of bed and walking around often eases the pain. Stiffness and pain in the low back is worse upon rising in the morning.

Standing too long can aggravate the pain (like standing and watching a sporting event, standing at a cocktail party or in line at the grocery store or bank)

Sitting too long can also aggravate the pain, especially from the coccyx. (tailbone) Commonly, pain from these ligaments can cause trigger points in muscles, which are painful and tender and respond to prolotherapy at the ends of the muscle, to stretching, or to needling of the trigger point itself, with a dry needle or with local anaesethetic. The piriformis muscle, deep in the buttock, is commonly in painful spasm.

Assuming that there is strain of the ligaments of the sacro-iliac joints in most low back pain, prolotherapy injections are used in a wide area, including the posterior sascroiliac ligaments, the ligaments of the lower lumbar facet (or zygapophyseal) joints and the ilio-lumbar ligaments. Once these ligaments are strengthened and tightened, the pelvis becomes more stable and walking, bending, standing on one leg (eg for dressing) become less painful and more efficient 7 . In most cases pain in these movements can be significantly relieved.

Two randomised double-blind controlled trials in low back pain from California showed significantly greater improvement in the treated group compared to controls 8 9. An Australian trial found that both groups improved markedly (20% pain free and about 40% got more than 50% relief of their pain, but there was no significant difference between the two groups – suggesting that needling is effective whatever is in the needle.10

References

7 Dorman TA et al, Energy efficiency during human walking before and after prolotherapy. J Orthopaed Med 1995; 17:24-26
8 Klein R, Eek BC, DeLong B, et al: A randomized double-blind trial of dextrose-glycerine-phenol injections for chronic low back pain. J Spinal Disord 1993; 6:23-33
9 Ongley M, Klein R, Dorman T, et al: A new approach to the treatment of chronic low back pain. Lancet 1987;2:143-146
10 Yelland M, Glasiou P, Bogduk N et al, Prolotherapy injections, saline injections, and exercises for chronic low back pain: a randomised trial. Spine 2004;29:9-16

True sciatic pain is central and into the big toe.


Sciatica

It is often assumed that all leg pain is sciatica. In fact lateral leg pain is more common than true sciatica and is usually referred from the sacro-iliac joint. This is very useful diagnostically, and when the patient indicates lateral thigh pain, palpation will reveal tenderness of the sacro-iliac joints confirming the diagnosis. Unless there are sinister points in the history, Xrays or MRIs for disc lesions etc are usually unnecessary as these pain patterns are so distinctive. They were mapped by George Hackett in the 1930s and 40s and have stood the test of time.

True sciatica is, of course, a surgical condition and should be treated surgically, but the patient may also need prolotherapy to the pelvic ligaments, whose instability may have contributed to the disc lesion.