Dear Robert,

what´s about radiological examination? Do you already have a CT or MRI scan? Did you exclude a fracture of the transverse process of L4? my first idea was an acute on chronic couse of spondylolysis.

Good luck,

Alexander Hofmann

Thank you Alex,

We already made an appointment yesterday for next week after he will return. Even though I though more about an durangement from other structures. I'll forward your thought to our doctor.

Greetings

A radiological examination to exclude any minor fractures   -    transverse processes,arcus  etc.. The facet joints are quite sensitive to trauma, so perhaps  diagnostic  injections into the lowermost facet joints on the left side (with  local anaesthetic only) could give you additional information as to the  pain generator.

Best of luck,

Josep

Sorry for text, my English is basic.

I agree with colleagues before any intervention see the need to conduct radiological examinations to rule out fractures. Dr Hofmann suggested as well, because I had a case of stress fracture in the lateral malleolus (beginner runner) that we can not evaluate the radiograph.

When you have an answer do not forget to let us know.

Good luck.

What Dr. Hofmann has suggested and rule out / confirm possible bone / structure pathology. After these results can plan your treatment plan.

Good luck.

In addition to radiological investigation earlier suggested, he should be examined well for sacro-iliac joint dysfunction (SIJ dysfn.).

"in the morning, he has pain from sacrum to the head"...... the sleep environment should be reviewed thoroughly and explored for appropriate clue and possible intervention/modification.

Also, I suggest he should be screened for ulcer (stomach, duodenum...). i once had a patient who had mechanical low back pain component which did not resolved appreciably despite EBM deployed towards his management. It was until when an "inactive ulcer" was detected and managed, that he had sustained relieve from the low back pain. (Inactive....because no significant abdominal pain was felt during this period)

Best wishes.

Hi Robert,

                  I agree with above clinicians regarding radiology exam and  rule out any any stress fracture.After that if not a fracture then do not start with intensive training unless you train orthogenic muscles .I mean multifidus lower areas L4,5 and upward.when those tissues healed then move on to intensive training .If you start intensive training condition improves for short time but pain will never eliminate completely.So focus on rotation with small amplitudes in selective positions .then move on further.

                                                                            Good Luck

Hi Robert,

I agree that fractures must first be ruled out, especially stress fractures which may take more than a radiograph.  If ruled out, the most common areas that you and others have not mentioned are:

Proximal rectus femoris - the other hip flexor.  People tend to focus on the psoas, and forget the rectus femoris

Lower abdominals - often a patient will perceive a abdominal injury as back pain.  check both rectus abdominis and obliques/TA.

hip adductors - I have seen groin pain refer to the back

SI is common too as another clinician mentioned above.  

Best of luck

Hallo Robert, wenn die red flags ausgeschlossen sind möchte ich Euch auf die Neuracbehandlung aufmerksam machen. Es ist eine Behandlungsmethode aus Norwegen, die auf "Neuromuscular Reeducation" abzielt. Man hat bei Spitzensportlern auch grossen Erfolg gehabt. 

Robert,

Looks like you got a lot of good pointers. If stress fx ruled out, you may want to look at the possibility of a hypermobility injury. Being a gymnast your patient is probably at the upper range of flexibility anyway, so torn ligament/capsul as a result of hard landing is a hair away. The hypermobile spinal joint is not necessarily the pain producing spinal level as adjacent joint(s) may be over-loaded trying to compensate.  That would include the SIJ. It is also possible that the hypermobile joint leads to a different than normal spinal alignment during sleep (no load situation), which exacerbates morning pain. 

please keep us informed as to your findings and responses to the various treatments.

Hey Menachem, and everyone else 

Thanks for all ideas and pointers.

I did not get news on the MRI yet since everyone is back at home training at the moment.

I'll forwarded every idea to the team doctor and the home collegues.

But I had to lough because he is probably the least flexible gymnast on the globe ;)

Still I'll keep it in mind if there is a local hypermobility compensating the stiffness he has.

If anyone wants to get a picture of him Google for andreas bretschneider from German national team.

By the way he confirmed the I share his case here 

I'll keep you up with neews

I do a lot of work with Pelvic rotation correction while the patient is under anesthesia (MAC).  It looks like you have been doing Iliacus work with him with returning symptoms.  This may mean release of tension temporarily helps, but because of the "displacement" in the illium (pelvic basin) on one side, the symptoms return.  Correction of this dysfunction is really only possible with the patient in a relaxed (but protective) physiological state.  That is what MUA is all about.  I have completed several thousand of these with excellent results.  My cell is 704-223-0765 and I am in NC if you would like to talk further.  I too would like to see the MRI results.  Best regards,  Dr.. Bob Gordon

Look for point tenderness at the PIIS and tenderness across the butt to the trochanter.    Responds quickly to posterior innominate rotation.

Exactly Richard....thank you for those comments....but after a certain amount of time without significant results (2-3 months of conservative care at least), I have found that gentle stretching with specific pelvic manipulation on the side of anterior rotation has helped considerably.  There is a whole process to this with initial clinical evidence based pre-exam first of course. RCG

I offer a few older references that you may not have had access to.

33. Hackett GS,  Huang TC. Prolotherapy for sciatica from weak pelvic ligaments and bone dystrophies. Clinical Medicine. 1961. 8(12):2302-2316.

34.  Shuman D.  Technic for treating instability of the joints by sclerotherapy. Osteopathic Profession. 1953. May

35.  Ongley ML,  Klein  RG,  Dorman TA  et al.   A new approach to chronic back pain.  Lancet.  1987. 2:143-6. 

36.  Smith-Petersen M N.    Arthrodesis of the sacroiliac joint.  A new method of approach. J Orthop Sur. 1938. 3:400-405.

37.  Smith-Petersen M,  Rogers W.  End-result study of arthrodesis of the sacroiliac joint for arthritis, traumatic and non-traumatic. Journal of Bone and Joint Surgery. 1926. 8:118-136.

38.  Moore M. Diagnosis and surgical treatment of chronic painful sacroiliac dysfunction.  In: Vleeming A,  Mooney V,  Dorman T,  Snijders R (eds): Second Interdisciplinary World Congress on Low Back Pain.  San Diego, CA, 1995. Nov 9-11, 339-354. 

39.  Keating JG,  Avillar MD, Price M. Sacroiliac joint arthrodesis in selected patients with low back pain.  In: Vleeming A,  Mooney  V,  Dorman T,  Snijders R. (eds): Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. London, Churchill Livingstone, 1997. 573-586.

40.  Lippitt  AB.  Percutaneous fixation of the sacaroiliac joint. In: Vleeming A, Mooney  V,  Dorman T,  Snijders R (eds). Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. London. Churchill Livingstone.    1997. 587-594.

41. Farfan HF,  Kirkaldy-Willis WH. The present status of spinal fusion in the treatment of lumbar intervertebral joint disorders. Clin Orthop Relat Res.  1981. Jul-Aug;(158):198–214. 

42.  Coventry MB, Tappe EM. Pelvic instability: a consequence of removing iliac bone for grafting. J Bone Joint Surg Am.  1972.  Jan;54(1):83–101.

43. Yoshihara H. Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge. Eur Spiine J.   2012.  Sep; 21(9):1788-96.

As I am in the process of collecting patient data and reference for publishing a journal article on our pelvic manipulative technique, this is certainly welcomed Richard.  Thank you so much.  I hope our communication will also help our colleague with his patient.  As a former gymnast, maintaining pelvic ring flexibility is tantamount to perfecting the routines that are required of the gymnasts these days in competition.  Thank you again, Dr. Bob Gordon

You are most welcome.  I have been treating the SIJ since 1964.

What you might look out for here is a muscle separation.  I once saw a woman who had the sacral origin of the G Max separated from it's ilial origin nearly the full width of her buttock.  When  she sat the sacral origin rolled under the ischial tuberosity causing her much grievous pain.  There are more of these around now because most PTs won't look at the SIJ.  It happens when an  anterior rotation of the innominate puts a vertical shear on the PIIS and PSIS.  This will also separate the sacral origin of the piriformis from it's ilia origin on the superior margin of the greater sciatic notch.. Causes piriformis syndrome and sciatica.  Also your patient may have some bilateral dysfunction.  The good side if out just a little, will hold the bad side down and prevent full correction. Good luck with your article.

l put up a program on www.thelowback.com How it works, why it hurts and how to fix it. Richard DonTigny, PT

[email protected]

RichR

I suggest you do an assessment of vertebral curves for if he has the increased or decreased the exercises to be made and postures to perform them must be different. Often forget to check these details and we end up overloading the vertebral column to do the treatment.

probably the key technic is to balance the abdominal muscle and the iliopsoas-i.e.maintaining the abdominal contraction while actvely streching the iliopsoas. Any significant fibromyalgia of the iliopsoas should be clear be fore training.

you did not mentioned, Is your gymnast practice or reduced her activities? Anyway,  I would probably do systematic review and find out the exact cause,weather it is Orthogenic or soft tissue injuries.You should check body mechanics and her daily activities too.Try to train her Orthogenic muscles with low grade exercises, spatially Multifidus muscles.

Good luck

All good answers.  The thing that troubles me is that she hasn't responded to the regular conservative care.  I still feel that Manipulation Under Anesthesia would help considerably.  Now some of you will just address this as some hoax that some have come up with to make money.  And some of you would be right.  I am the author of the textbook however, and the lead author in the new guidelines the have been published on the NGC web site (Please refer to www.guidelines.govenmert (USA of course), and type in search for Manipulation Under anesthesia.  The reason that this works is that it allows the trained practitioner to ability to generate specific passive stretching movements and articular motions that just can't be accomplished in the conservative arena.  If you would like more information please send me an e-mail at [email protected].  Dr. Robert Gordon

I suggest that you do an evaluation of the spinal curves because if the person has rectification or increase of the vertebral curves they can contribute to the perpetuation of the pain in the day to day and during the physical activities.