What is Sacroiliac Joint Pain?

SI Joint Pain

Your Sacroiliac Joints (SIJ) are a critical linkage system between your lower spine and pelvis. The sacrum (tailbone) connects on the right and left sides of the ilia (pelvic bones) to form your sacroiliac joints.

Your sacroiliac joints should be a fairly stiff or rigid link between the pelvic bones, and allow only a few degrees of movement. In some people due to trauma or just extra mobility, your sacroiliac joints have too much uncontrolled motion. This allows your sacroiliac joints to adopt an abnormal or stressed joint position, which may result in SIJ pain. 

When your sacroiliac joints are not moving normally due to either stiffness or excessive movement, it is referred to as Sacroiliac Joint Dysfunction, which normally results in sacroiliac pain.

It is vital that you have both normal SIJ movement and muscle control around this area to avoid SIJ pain and injury. 

Commonly sacroiliac dysfunction can cause lower back, hip, buttock and sciatic pain.

What Causes Sacroiliac Joint Pain?

There are two main groups of sacroiliac dysfunction that cause SIJ pain:

1. Hypermobility / Instability 
2. Hypomobility / Stiffness

Hypermobility issues are the most common and will be discussed further in this article.

Hypomobility is normally associated with pathologies that tend to stiffen your sacroiliac joints such as in Ankylosing Spondylitis.

What Causes Sacroiliac Joint Hypermobility?

Your sacroiliac joints should move a few degrees for normal movement. Like most joints, your surrounding muscles act to stabilise your sacroiliac joints during stressful or vulnerable positions. The most important sacroiliac stabilising muscles are your deep abdominal core muscles and your deep gluteal muscle groups.

Your core muscles: specifically the transversus abdominis and oblique abdominals through their attachments to the iliac bones help closure of the pelvis and improves the position, control and stability of the sacroiliac joints.

Researchers have discovered that contraction of the transversus abdominis muscle significantly stiffens and supports your sacroiliac joints. This improvement is larger than that caused by an abdominal bracing action using all the lateral abdominal muscles (Richardson etal 2002).

Further to this, researchers have discovered that your deep gluteal (buttock) muscles are important for controlling the lateral and rear aspects of the pelvis and hip. (Grimaldi et al).

When these muscle groups are weak or lack endurance your sacroiliac joints are vulnerable to excessive movement, which can lead to SIJ hypermobility dysfunction or instability and subsequent sacroiliac joint pain.

What are the Symptoms of Sacroiliac Joint Dysfunction?

• Sacroiliac joint dysfunction can mimic numerous other back and hip injuries. 
• Sacroiliac joint dysfunction can cause lower back, hip, groin, buttock and sciatic pain. 
• Sacroiliac pain is typically worse with standing and walking and improved when lying down, but not always. 
• It can sometimes be painful to sit cross legged and is normally painful to lie on your side for extend periods. 
• Bending forward, stair climbing, hill climbing, and rising from a seated position can also provoke sacroiliac pain. 
• Sacroiliac pain is  sometimes reported to increase during sexual intercourse and menstruation in women.

How is Sacroiliac Joint Pain Diagnosed?

Accurately diagnosing sacroiliac joint pain & dysfunction can be difficult because SIJ symptoms can mimic other common back conditions. These include other mechanical low back pain conditions like facet joint syndrome or a bulging disc.

X-rays are of minimal diagnostic benefit. MRI may show signs of sacroiliac joint inflammation or eliminate other potential pathologies. 

A thorough physical examination by your experienced musculoskeletal physiotherapist is the best method to assess for sacroiliac joint pain or instability.

This article originally appeared on physioworks.com.au and was written by John Miller

Consult with your Physician and / or Physiotherapist for a diagnosis and follow up with a Massage Therapist, Manual Osteopath, Acupuncturist, or Physical Therapist in conjunction with treatment plans.

Knee Pain: Patellofemoral Pain Syndrome

Patellofemoral pain syndrome is one of the most common knee complaints of both the young active sportsperson and the elderly.

Patellofemoral pain syndrome is the medical term for pain felt behind your kneecap, where your patella (kneecap) articulates with your thigh bone (femur). This joint is known as your patellofemoral joint

Patellofemoral pain syndrome, is mainly due to excessive patellofemoral joint pressure from poor kneecap alignment, which in time, affects the joint surface behind the kneecap (retropatellar joint).

What Causes Patellofemoral Pain Syndrome?

Your patella normally glides up and down through the femoral groove. As your knee is bent, pressure between your kneecap and the groove increases. 

This retropatellar pressure is further increased if the patella does not ride normally through the groove, but “mistracks”, meaning it travels more to one side, making it rub against the femur. 

Repeated trauma causes an increase in your retro patellar joint forces, which can lead to kneecap pain, joint irritation and eventually degeneration of your patella joint surface.

The most common causes of patellar malalignment are an abnormal muscle imbalance and poor biomechanical control.

Aching kneecaps (patellofemoral pain) affect 25% of the population at some time in their lives but it is more common in athletes. The sports where patellofemoral pain syndrome is typically seen are those when running, jumping and landing or the squatting position is required. 

Sports include running, tennis, netball, football, volleyball, basketball, skiing and other jumping sports. 

Untreated patellofemoral pain syndrome can also predispose you to patellar tendonitis.

What Causes a Muscle Imbalance?

Your quadriceps (thigh) muscles attach to the patella and through it to the patella tendon, which attaches to the top of your shin. 

If there is a muscle imbalance between the quadriceps muscles: vastus lateralis (VL), which pulls your patella up and outwards, and the vastus medialis oblique (VMO), which is the only quadriceps muscle that pulls your kneecap up and slightly in, then your patella will track laterally in the groove.

Common reasons for a weak vastus medialis oblique (VMO) include knee injury, post-surgery, swelling or disuse.

The longstanding tightness of your lateral knee structures (lateral retinaculum, VL, and ITB) will encourage your kneecap to drift sideways over time. Especially, if your VMO is also weak.

Hip muscles have been shown in the research to be very important in the control of your thigh. Poor buttock muscle control allows your knee to roll in and apply a relative lateral displacement of the the patella. Most successful rehabilitation programs require assessment and correction of your hip and buttock muscle control.

Patellofemoral pain syndrome is more common during adolescence, because the long bones are growing faster than the muscles, tendons and ligaments, putting abnormal stresses on the joints. Active children who do not stretch the appropriate muscles are predisposed to patellar malalignment.

What Biomechanical Issues Cause Patellofemoral Pain Syndrome?

Poor foot posture (eg flat feet) and weak hip control muscles can both allow your knee to abnormally twist and result in a lateral deviation of your patella.

When poor biomechanics are repeated with each step of your walking or running pattern that poor habit repeatedly traumatises your patellofemoral pain.

What are the Symptoms of Patellofemoral Pain Syndrome?

The onset of your kneecap pain is normally gradual rather than traumatic.

Patellofemoral pain symptoms are normally noticed during weight bearing or jarring activities that involve knee bending. 

Stairs, squatting, kneeling, hopping, running or using stairs are commonly painful. As your patellofemoral pain syndrome progresses your knee will become painful while walking and then ultimately even at rest. 

You can also experience kneecap pain when you are in sustained knee bend eg. sitting in a chair. A nickname for this condition is “theatre knee”. 

Patellofemoral Pain Syndrome Treatment

Researchers have confirmed that physiotherapy intervention is a very effective short and long-term solution for kneecap pain.

Approximately 90% of patellofemoral syndrome sufferers will be pain-free within six weeks of starting a physiotherapist guided rehabilitation program for patellofemoral pain syndrome.

For those who fail to respond, surgery may be required to repair associated injuries such as severely damaged or arthritic joint surfaces.

The aim of treatment is to reduce your pain and inflammation in the short-term and then, more importantly, correct the cause to prevent it returning in the long-term.

There is no specific time frame for when to progress from each stage to the next. Your injury rehabilitation will be determined by many factors during your physiotherapist’s clinical assessment.

You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves. It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and the frustration of a delay in your recovery.

Phase 1 - Injury Protection: Pain Relief & Anti-inflammatory Tips

As with most soft tissue injuries the initial treatment is - Rest, Ice and Protection.

(Active) Rest: In the early phase your best to avoid all activities that induce your kneecap pain.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Protection: Your physiotherapist will normally apply kinesiology supportive taping or similar to help relieve your pain and commence your patellofemoral joint realignment phase. The patellofemoral taping is normally immediately effective in providing you with pain relief.

Your physiotherapist will utilise a range of helpful tricks including pain relieving techniques, joint mobilisations, massage, strapping and acupuncture to assist you during this painful phase.

Anti-inflammatory medication and natural creams such as arnica may help reduce your pain and swelling. Most people can tolerate paracetamol as a pain reliever.

Phase 2: Regain Full Range of Passive Motion

Your kneecap and knee must be able to glide through its full normal range of motion. Your physiotherapist will assess your motion and apply the necessary techniques to normalise your range of motion.

Phase 3: Restore Full Muscle Length

Your thigh, hamstring and calf muscles will require stretching as they are tight and are causing excessive tension or pressure on your kneecap. It is important to regain normal muscle length to improve your lower limb biomechanics.

Phase 4: Normalise Quadriceps Muscle Balance

In order to prevent a recurrence, your quadriceps muscle balance and its control should be assessed by your physiotherapist. In most instances, you will require a specific knee strengthening program.

Your physiotherapist will prescribe the best exercises for you.

Phase 5: Normalise Foot & Hip Biomechanics

Patellofemoral pain syndrome can occur from poor foot biomechanics (eg flat foot) or poor hip control.

In order to prevent a recurrence, your foot and hip control should be assessed by your physiotherapist. In some instances, you may require a foot orthotic (shoe insert) or you may be a candidate for the Active Foot Posture Stabilisation program.

Other patients may require a hip stabilisation program. Your physiotherapist will happily discuss what you require.

Phase 6: Normalise Movement Patterns

Kneecap pain commonly occurs from poor habits, whether they be an abnormal gait, jumping, landing, running or squatting technique. In order to prevent a recurrence, your walking pattern, jumping and landing technique, running style or squatting method should all be assessed and corrected as required.

Your physiotherapist will happily discuss what you specifically require.

Phase 7: Restore High Speed, Power, Proprioception and Agility

Most kneecap pain sufferers need to return to high speed or repetition activities, which place enormous forces on your knee. Your physiotherapist will guide you in your return to sports planning.

Balance and proprioception (the sense of the relative position of neighbouring parts of the body) are both known to be adversely affected by patellofemoral pain. To prevent a re-aggravation, both aspects need to be assessed and retrained.

Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepare you for light sport-specific training.

Phase 8: Return to Sport

If you play sport and depending on the demands of your chosen sport, you may require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport.

This article originally appeared on physioworks.com.au and was written by John Miller

It’s Official: Acupuncture Doctor Approved

The American College of Physicians formally recommends acupuncture for the treatment of back pain. Published in the prestigious Annals of Internal Medicine, clinical guidelines were developed by the American College of Physicians (ACP) to present recommendations based on evidence. Citing quality evidence in modern research, the ACP notes that nonpharmacologic treatment with acupuncture for the treatment of chronic low back pain is recommended. The official grade by the ACP is a “strong recommendation.” [1]

A major goal of the recommendation is for acupuncture and other nonpharmacological therapies to replace drug therapy as a primary source of pain relief. Treatment with opioids is only recommended, with an official “weak recommendation,” when other modalities do not provide adequate relief. A strong recommendation is also made by the American College of Physicians for the treatment of both acute and subacute lower back pain with heat, massage, acupuncture, and spinal manipulation. [2] The recommendations were approved by the ACP Board of Regents and involves evidence based recommendations from doctors at the Penn Health System (Philadelphia, Pennsylvania), Minneapolis Veterans Affairs Medical Center (Minnesota), and the Yale School of Medicine (New Haven, Connecticut). 

The American College of Physicians notes that approximately 25% of USA adults have had, at the very minimum, a one day lower back pain episode within the past three months. The socioeconomic impact of lower back pain in the USA was approximately $100 billion in the year 2006 . The costs include medical care and indirect costs due to lost wages and declines in productivity. [3] Recommendations for treatment options, including those for the use of acupuncture, include considerations of positive medical patient outcomes, the total number of back pain episodes, duration between episodes, alleviation of lower back pain, improvement in function of the back, and work disability reductions. Recommendations are for both radicular and nonradicular lower back pain.

The target audience for the American College of Physicians recommendations includes all doctors, other clinicians, and the adult population with lower back pain. The ACP notes, “Moderate-quality evidence showed that acupuncture was associated with moderately lower pain intensity and improved function compared with no acupuncture at the end of treatment .” [4] In agreement, the National Institute of Neurological Disorders and Stroke (National Institutes of Health) notes that acupuncture is an effective treatment modality for the relief of chronic lower back pain. [5]

These findings are consistent with those published in Mayo Clinic proceedings finding that acupuncture is effective for the treatment of lower back pain. The same Mayo Clinic report notes that acupuncture does not cause any significant adverse effects. [6] The Mayo Clinic findings apply to both nociceptive and non-nociceptive pain. Nociceptive back pain includes musculoskeletal inflammation and pain involving nerve cells wherein nociceptors are activated. Nociceptors are afferent neurons in the skin, muscles, joints, and other areas. For example, nerve impingement (often referred to as a “pinched nerve”) produces one type of nociceptive pain.

Non-nociceptive pain does not involve inflammation and is more relevant to pain processing in the central nervous system. One type of non-nociceptive pain condition is fibromyalgia and acupuncture has been confirmed as an effective treatment modality for this condition. The Mayo Clinic proceedings note, “Martin et al. found a significant improvement between electroacupuncture vs sham electroacupuncture. Differences were seen on the Fibromyalgia Impact Questionnaire (FIQ) scores for fatigue and anxiety.” [7]

Learn more about how to alleviate fibromyalgia related pain in the acupuncture continuing education course entitled Fibromyalgia Syndrome Treatments. Click the following to learn more:

Fibromyalgia Online Course >
 

The Mayo Clinic and American College of Physicians findings are consistent with additional quality research. Memorial Sloan Kettering Cancer Center (New York) and University of York (United Kingdom) researchers note “We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed.” [8]

Doctors understand the true need for effective pain management. Nonpharmacological solutions are important for a variety of reasons including prevention of addiction, effective relief of pain, and prevention of adverse effects. This is often of heightened concern during pregnancy and for children. As a result, university hospitals integrate acupuncture into usual care settings to improve patient outcomes. For example, pediatric doctors at the UCSF Benioff Children’s Hospital San Francisco provide acupuncture to children, including non-needle laser acupuncture. At the University of California hospital, acupuncture is made available for both inpatients and outpatients. Dr. Kim notes that acupuncture reduces nausea up to 70%. She adds that acupuncture is also effective for significant reductions in post-surgical pain and chronic headaches. [9]

Recently, researchers have discovered how acupuncture stops pain and provides other forms of relief for patients. Breakthrough research conducted by University of South Florida (Tampa) and Fujian University of Traditional Chinese Medicine (Fuzhou) researchers documents how acupuncture stops pain. The researchers note, “acupuncture exerts a remarkable analgesic effect on SCI [spinal cord injury] by also inhibiting production of microglial cells through attenuation of p38MAPK and ERK activation.” [10]

Microglia are central nervous system immunity cells that secrete proinflammatory and neurotoxic mediators. Acupuncture reduces pain by attenuating this response. The researchers also document that acupuncture provides neuroprotection. The researchers note that acupuncture prevents brain damage in the hippocampus by “preventing microglial activation.” The University of South Florida members of the research team were from the Department of Neurosurgery and Brain Repair and the Department of Pharmaceutical Sciences. Funding was provided by the United States Department of Defense, University of South Florida Neurosurgery and Brain Repair, and the James and Esther King Biomedical Research Foundation.

The aforementioned research reveals an important biochemical mechanism involved in acupuncture’s ability to alleviate pain and reduce harmful inflammation. Researchers focus on other mechanisms activated by administration of acupuncture treatments. For example, laboratory investigations reveal how acupuncture regulates blood pressure.

University of California (Irvine) researchers find acupuncture effective for the treatment of high blood pressure. In a controlled laboratory study, University of California researchers have proven that electroacupuncture at acupoint ST36 (Zusanli) promotes enkephalin production, which dampens proinflammatory excitatory responses from the sympathetic nervous system that cause hypertension. Specifically, electroacupuncture regulates preproenkephalin gene expression, a precursor substance that encodes proenkephalin, which then stimulates the production of enkephalin. [11]

The formal recommendation for the use of acupuncture in cases of lower back pain by the American College of Physicians is based on modern research. Mayo Clinic findings and research from the Memorial Sloan Kettering Cancer Center (New York) and the University of York support this recommendation. In response to the needs of patients, doctors have already implemented acupuncture into several hospitals throughout the USA and both inpatient and outpatient acupuncture treatments are available.

Now, modern scientific investigations reveal how acupuncture works. University of South Florida and Fujian University of Traditional Chinese Medicine researchers confirm acupuncture’s ability to attenuate microglial activation. University of California researchers have quantified acupuncture’s ability to control inflammation by regulating enkephalins. In addition, the NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine) provides professional certification for acupuncturists, which ensures standards of excellence for licensed acupuncturists. Given the large body of supportive research and the administrative support for providing safe and effective acupuncture to the general public, expect to see greater implementation of acupuncture into usual care settings.

Accessibility to care is dependent upon both availability and financial capabilities. Insurance companies have been providing health insurance coverage for acupuncture for decades. Cigna, Blue Cross, Blue Shield, AETNA, United Healthcare, and many other insurance companies provide reimbursement to patients for use of services by licensed acupuncturists. The level of coverage varies, largely dependent upon individual health insurance policy provisions. Licensed acupuncturists can learn more about providing coverage for their patients in the continuing education course entitled Acupuncture Insurance Billing #1. This basic introductory course covers diagnostic requirements, including ICD-10 coding, and other important procedural requirements necessary to obtain reimbursements for patient care.
 

References
1. Qaseem, Amir, Timothy J. Wilt, Robert M. McLean, and Mary Ann Forciea. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of PhysiciansNoninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of Internal Medicine (2017).
2. Qaseem, et al. Annals of Internal Medicine (2017).

3. Katz J.N. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.J Bone Joint Surg Am200688 Suppl 2214.
4. Lam M. Galvin R. Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis.Spine (Philadelphia, Pennsylvania 1976) 201338212438.
5. ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. Low Back Pain Fact Sheet, National Institute of Neurological Disorders and Stroke, National Institutes of Health.
6. Nahin, Richard L., Robin Boineau, Partap S. Khalsa, Barbara J. Stussman, and Wendy J. Weber. "Evidence-based evaluation of complementary health approaches for pain management in the United States." In Mayo Clinic Proceedings, vol. 91, no. 9, pp. 1292-1306. Elsevier, 2016.
7. Martin DP, Sletten CD, Williams BA, Berger IH. Improvement
in fibromyalgia symptoms with acupuncture: results of a randomized
controlled trial. Mayo Clin Proc. 2006;81(6):749-757.
8. MacPherson, H., A. Vickers, M. Bland, D. Torgerson, M. Corbett, E. Spackman, P. Saramago et al. "Acupuncture for chronic pain and depression in primary care: a programme of research." (2017).

9. Leslie Lingaas. ucsf.edu/news/2014/04/113966/acupuncture-helps-young-patients-manage-pain. Acupuncture Helps Pediatric Patients Manage Pain and Nausea, 2014.
10. Lin, Lili, Nikola Skakavac, Xiaoyang Lin, Dong Lin, Mia C. Borlongan, Cesar V. Borlongan, and Chuanhai Cao. "Acupuncture-induced analgesia: the role of microglial inhibition." Cell transplantation 25, no. 4 (2016): 621-628.
11. Cevic, C and Iseri, SO. The effect of acupuncture on high blood pressure of patients using antihypertensive drugs. Acupuncture & electro-therapeutics research 2013; 38(1-2): 1-15. ncbi.nlm.nih.gov/pubmed/23724695.

This article originally appeared on http://www.healthcmi.com

5 Reasons You Should Try Acupuncture Right Now

In the West, acupuncture is still sometimes dismissed — even as more western doctors are incorporating the practice into their treatment plans. Nonetheless, acupuncture is becoming increasingly recognized as an effective treatment for relieving pain, easing stress and even combating insomnia. And in the right hands, acupuncture can also be used to treat a wide array of other symptoms and disorders — as it has been in China and many other countries for centuries.

There is nothing magical or superstitious about it. A doctor's office in Shanghai or Hong Kong is not so different from what you'd find in the United States. What is different however, is that acupuncture is a highly respected and frequently used modality for a range of health and medical conditions.

As practitioners and patients in Asia know quite well, the benefits of acupuncture extend much farther, into areas that might even surprise you. Here are five reasons why acupuncture could soon go mainstream as a form of treatment:

1. Allergies

While Western medicine focuses on treating the uncomfortable symptoms of allergies, Traditional Chinese Medicine — using a combination of acupuncture and herbal treatments — treats the whole person from the inside out. This approach works not only to treat the acute symptoms felt during an allergic reaction, but to regulate the immune system. A healthy functioning immune system will improve an individual's health overall, and reduce the severity and frequency of symptoms.

2. Weight Loss

The inability to achieve a healthy weight can be one of the most stubborn problems patients face, and part of the problem lies in the hypothalamus — the part of the brain that regulates hunger, among other things. Acupuncture can be used to stimulate the hypothalamus, quieting its hunger signals and normalizing appetite. And because acupuncture also relieves stress, it inhibits "stress-eating" and rids the body of fat-storing stress hormones like cortisol.

3. Chemotherapy Side-Effects

Chemotherapy uses drugs to inhibit the growth of cancer cells, a critically important action in fighting cancer. But its side effects — nausea, sore joints, dry mouth, hot flashes and fatigue — are tough on the patient. Acupuncture and electro-acupuncture work to activate chemicals in the brain that block pain. This creates relaxing, pleasurable sensations that can provide much-needed relief for patientsundergoing treatment. Patients can also choose acupressure and cold laser acupuncture, which achieve similar results without the use of needles.

4. Infertility

When the body's physiological systems are impaired by stress, or when neurological connectivity is unbalanced and hormones are being triggered in unhealthy ways, infertility can result. Frustratingly, modern fertility treatments are often hampered by these underlying issues. Acupuncture works to help reset neurological circuits. This can reduce hormonal imbalances and overall stress, and boosts the efficacy of fertility treatments.

5. Smoking Cessation

Nicotine is highly addictive, and the symptoms provoked by quitting smoking include intense cravings, irritability, anxiety, poor sleep, headache, increased appetite, fatigue and difficulty concentrating.

Western aids like the nicotine patch merely delay the onset of symptoms. True relief and success in quitting are possible through the use of acupuncture, which can reduce cravings and alleviate withdrawal symptoms. When you add stress relief to the process, quitting smoking can become easier and totally possible. A qualified practitioner will also provide personalized exercise and dietary recommendations, herbal supplements and an analysis of your triggers for smoking and how to avoid them.

Acupuncture has countless applications for patient health. When combined with other modalities from Traditional Chinese Medicine, or in an integrated fashion with western medicine, the results can be highly effective. This ancient discipline treats the whole person, restoring balance, strengthening immunity and helping physiological systems thrive.

This article originally appeared on mindbodygreen.com and was written by Dr. Daniel Hsu