The role of sacroiliac joint pathology in the development of low back pain

The iliopsoas muscle (IPM) is the strongest hip flexor and is involved in external rotation of the femur, playing an important role in maintaining strength and stability of the hip joint. It also acts as a stabilizer for the lumbar spine and pelvis. Pathologic conditions of PPM have been shown to be a significant cause of hip pain and/or dysfunction and include asymptomatic snapping hip syndrome, tendonitis, bursitis, and impingement. In addition, conditions associated with PPM lesions have been associated with lumbopelvic disorders, such as pain in the lower back and buttocks, intense groin pain, especially in athletes, and even pain spreading down the front of the hip and knee.

It's worth noting that MR tendinitis involves inflammation of the tendon or the area surrounding the tendon. Studies have revealed the presence of inflammation in the acute phase of this condition, but it is well established that in chronic tendon pathologies there is no inflammatory process. Rather, they are characterized by a failed healing response and tendon degeneration.

For this reason, it may be worth classifying this condition as a tendinopathy, as opposed to tendonitis, which is more about inflammation. In general, PLM tendinopathy refers to a condition that affects the attachment of the muscle to the thigh and can occur with repetitive hip flexion and other biomechanical abnormalities leading to chronic degenerative changes in the tendon.

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In addition, due to the close proximity of the PMT tendon and its associated bursa, inflammation of one of these structures inevitably causes inflammation of the other. Therefore, PPM tendonitis and PPM bursitis are usually described as synonyms because the clinical presentation, evaluation, and treatment are virtually identical.

Clinically Relevant Anatomy

The iliopsoas muscle complex is made up of three muscles, which include the iliacus, psoas major and psoas minor. The iliacus muscle originates in the iliac fossa and inserts into the psoas tendon and the lesser trochanter of the femur. The psoas major muscle also attaches to the lesser trochanter of the femur and originates from numerous structures, including the transverse processes of the lumbar vertebrae, the intervertebral discs, and the margins of the vertebral bodies from T12 to L5 and the arch of tendinus. Finally, the psoas minor muscle originates from the vertebral bodies of Th12 and L1 and inserts into the iliopubic eminence and fascia iliaca. Only 60% of people have the psoas minor muscle.

The psoas major and iliacus muscles fuse at the L5-S2 vertebral level. Before attaching to the lesser trochanter, the APM exits the pelvic cavity into the thigh region (under the inguinal ligament, where it crosses the anterior part of the acetabulum, between the anterior inferior iliac spine (laterally) and the iliopubic eminence (medially). The largest bursa of the hip joint is The iliopsoas bursa, which is located deep in the iliopsoas musculoarticular junction and anterior to the hip joint capsule, is thought to communicate with the hip joint in ~15% of patients.

Innervation

• The iliac component of the RPM is innervated by the femoral nerve (consists of the anterior branches L2-L4).
• The lumbar component of the PPM is innervated by branches of the lumbar plexus (anterior rami L1-L3).

Blood supply

• Iliolumbar artery and medial circumflex femoral artery.

Function

• Flexion of the hip and torso.
• Participation in external rotation of the femur.
• Lateral flexion of the lumbar spine.

Etiology

Tendinopathy is a structural change in the normal architecture of the tendon that is thought to result from microtrauma resulting from chronic overuse of the tendon. Although the exact etiology of this condition is not fully established, the two most commonly reported causes of MR tendon irritation include either acute trauma or overuse injury.

• Acute trauma is less common but can result in musculoskeletal injury or avulsion fracture of the lesser trochanter. This usually occurs as a result of eccentric contraction of the muscle or sudden flexion against a tensile force that exceeds the capacity of the tendon.
• Overuse injuries to the hip joint can result from any activity that requires repetitive hip flexion, repetitive external rotation, or repetitive flexion of both the hip and trunk.

Some examples of activities that may predispose people to MCI injury include ballet, cycling, rowing, running, track and field, soccer, and gymnastics.

Psoas tendinopathy is commonly called "dancer's hip" or "jumper's hip" because the biomechanics of these movements (i.e., repetitive flexion of the hip in a position of external rotation) predisposes a person to injury. One study found that more than 90% of ballerinas report audible clicking or popping sounds in the thigh.

Adolescents during the growth spurt have relatively reduced hip flexor flexibility, potentially putting them at greater risk. Rheumatoid arthritis has been reported to be one of the main causes of iliopsoas bursitis.

Most importantly, spondyloarthritis is NOT EQUAL to ankylosing spondylitis!

Spondyloarthritis is a group of inflammatory diseases
characterized by damage to the spine and/or joints. They are grouped according to the mechanisms of their development and similar clinical manifestations. This group is divided into two subgroups - axial and peripheral spondyloarthritis. The difference is that the first affects only the sacroiliac joints and/or spine, while the second can also affect the joints of the upper and lower extremities.

In addition, a subgroup of axial spondylitis is divided into ankylosing spondylitis (this is ankylosing spondylitis) and non-radiographic axial spondylitis. The difference between them is the presence/absence of damage to the sacroiliac joints on radiography. X-ray changes occur very slowly, sometimes it takes 7-8 years for signs of “fusion” to appear, so there is still heated debate about whether these two forms are stages of the same process, or different diseases from the same group.

For a better understanding, below we will talk about the group of axial spondyloarthritis (AS).

Epidemiology

In general, pathological conditions of the groin, such as tendonitis, bursitis, snapping, and impingement, are considered the main cause of chronic groin pain in approximately 12-36% of athletes and in 25-30% of athletes with acute groin injury.

• It is most common in athletes such as football players, but can also occur in non-athletic populations.
• The most commonly reported incidence is in young adults (peak age group is in the 30s).
• Slightly more common in women.

Causes of the disease

The exact cause of the disease is unknown.
Spondyloarthritis, unlike rheumatoid arthritis, is less of an autoimmune disease and more of a hyperinflammatory disease. They rarely cause systemic inflammatory reactions, but affect certain organs and tissues - joints, skin, intestines, eyes. One of the key factors in the development of AS is the presence of the HLA-B27 antigen. Despite the 40-year history of its study, the role of the antigen remains not entirely clear. According to one theory, the process that triggers inflammation may be microbes in which some of the genes are so similar to the genes of the patient - a carrier of HLA B-27 that the human body “confuses” them and begins to work against its own.

However, when the disease has already manifested itself, do not look for these mysterious microbes - most likely the body has long ago gotten rid of them, and the inflammation will continue.

Another theory is based on the possibility of an abnormal structure of HLA-B27, which itself activates a full-blown immune response. Any factor (trauma, infection) can be a factor—a “trigger”—to activate the “improper functioning” of this antigen. Be that as it may, this notorious HLA B-27 can be detected in 95% of patients with AS.

And then a cascade of reactions unfolds: T-lymphocytes, the cells of the immune system, are sequentially activated and the formation of protein molecules, “inflammatory mediators” (cytokines), increases. They lead to changes characteristic of the entire group of spondyloarthritis and AS in particular. Unlike rheumatoid arthritis, where the main mechanism of joint destruction is the formation of erosions—“eaten away”—of cartilage and bone destruction, in AS the inflammation process ends with bone proliferation—the formation of new “excess” bone tissue. The result is ankylosis (fusion) of the joints and ossification (ossification) of the spinal ligaments, resulting in immobility.

Men are affected more often, with onset occurring before the age of 45 years. It is possible to develop AS in childhood with a transition to adulthood, which is usually quite severe.

Clinical picture

The clinical presentation of PPM tendinopathy is variable and depends on various factors. Tendinopathy of this muscle, which is not symptomatic, is often characterized by a palpable and audible clicking sound that occurs when the hip flexes and extends. Constant irritation of the tendon can lead to inflammation of it, as well as the nearby bursa. Chronic irritation will most likely not be associated with inflammation, but will instead be characterized by painful degeneration and fibrosis of the tendon.

Story

The history often contains indications of deep pain in the groin or pain spreading along the anterior surface of the thigh. Pain may be initially triggered by the onset of activity, decreasing shortly thereafter. Symptoms may progress to constant pain during activity that improves only with rest, and finally to pain with both activity and rest. Diagnosis is usually delayed, and the average estimated time between initial symptoms and diagnosis is 32 to 41 months.

• Intermittent pain in the groin, usually described as a deep pain.
• Symptoms worsen with activity (especially kicking) and improve with rest. Other aggravating factors include tying shoelaces, standing up after sitting for a long time, and walking uphill.
• An audible clicking or pinching sensation in the hip or groin area.
• Radicular symptoms may be reported, extending along the front of the thigh to the knee.
• Psoas muscle dysfunction is usually associated with a variety of lumbosacral complaints, which may include low back pain, discomfort in the buttocks or thighs, and inability to stand completely upright.

Physical examination

Inspection

• The patient may hold the affected hip in a slightly flexed and laterally rotated position (a sign of psoas hypertonicity).
• Posture assessment may reveal anterior pelvic tilt and increased lordosis of the lumbar spine.
• When assessing gait, a decrease in step length may be observed on the affected side. Additionally, an increase in knee flexion may be observed during heel strike (initial contact) and mid-stance phase.

Palpation

• Increased pain on deep palpation of the iliopsoas muscular joint within the femoral triangle. Palpation of the inguinal lymph nodes in this area should be unremarkable.
• Pain may be present at the insertion of the PLM tendon on the lesser trochanter, which can be palpated under the gluteal fold (with the patient in the prone position).

Range of motion

• Passive hip extension may be limited and/or painful (normal ~15 degrees).
• Active hip flexion or flexion against resistance may cause pain.

Functional/orthopedic testing

• The Thomas test or modified Thomas test can detect excessive hypertonicity of the hip flexors.
• “Iliopsoas test”: hip flexion against resistance, with hip external rotation (performed with the patient in the supine position). Muscle weakness and/or pain symptoms indicate that the test is positive.
• Ludloff's sign (isolated assessment of the strength of the PPM): the patient is in a sitting position on the couch with his legs straightened, he needs to lift the heel of the affected leg off the table. The test is considered positive if muscle weakness and/or pain symptoms appear.
• Stinchfield test: the patient performs an active straight leg raise to 45 degrees. He then needs to resist the downward force that is applied to the front of the thigh. Pain and/or muscle weakness indicate damage to the psoas muscle or intra-articular pathology.
• Maneuver that triggers clicking in trouble: The affected hip is placed in flexion, abduction, and external rotation. The hip is passively moved into extension and internal rotation. A positive test is a palpable or audible clicking sound localized in the groin area. Pain caused by this maneuver may indicate tendinitis or bursitis in the pelvic area.

Other

Reciprocal inhibition of antagonist muscles and various dysfunctions located along the kinetic chain may be associated with hypertonicity of the RPM. Therefore, additional testing should include evaluation for hip abductor weakness, spinal instability, inferior crossed syndrome, overpronation of the foot, and dysfunctional breathing.

Diagnostic measures

Symptoms of SPPM can be noticed by the forward displacement of the spine. Then, when the leg is bent, the lower pairs of ribs protrude. It's hard to notice while walking, so it's better to take a horizontal position. To perform this test, lie on your back with your knees bent and raised so that your hips do not touch the floor. If the lower ribs protrude in this position, this indicates SPM.

To identify SPM, which is accompanied by pain, the following studies are prescribed:

• X-rays reveal that the density of the iliopsoas muscle is increased. In addition, the image shows a distortion of the pelvis and the associated excessive deflection in the lower back (hyperlordosis).
• Using magnetic resonance imaging, you can see that the contour of the psoas muscle in the area of ​​2–4 vertebrae is enlarged, most likely due to its increased tone.
• Needle electromyography is used to detect involuntary activity in the joints of the pelvis and hips.

SPM and associated unilateral or bilateral pelvic pain can be diagnosed using a special test. To do this, the patient lies on his back, bends his leg at the knee, then with the palms of both hands, presses on the knee and alternately (10 seconds each) tenses and relaxes the limb for 3 minutes. The movements must be repeated for the other leg. If pelvic pain improves after the test is completed, this indicates SPM.

To check the status of the MRP, you can perform the following tests:

Trigger points that cause pain when pressed

• The patient turns his back to the table, his knee and hip are flexed, then he pulls his leg up, trying to touch the abdomen. Then he lies down on the table so that the tailbone is closer to its edge (lordosis is avoided). The second thigh should fall freely onto the table. If this does not happen, then the psoas muscle is shortened.
• To assess the condition of the psoas muscle, place the edge of one palm on the upper chest and the other perpendicular to the pubic bone. Then you need to bend the body to evaluate the angle between the planes; in a healthy person they should be parallel to each other.
• When you press trigger points (an area of ​​increased sensitivity within the muscle tightness), pain, burning, and numbness appear in the lower back.

If SPPM is at an advanced stage, then it can be detected immediately after palpation.

Differential diagnosis

• Rupture of the labrum of the hip joint.
• Sports hernia.
• Bursitis PPM.
• Inguinal hernia.
• Osteitis of the pubic bone.
• Tendinopathy/abdominal muscle strain.
• Hip adductor tendinopathy/groin injury.
• Osteoarthritis of the hip joint.
• Damage to the obturator nerve.
• Neoplasm.

Other Causes of Anterior Thigh Pain

• Inflammatory synovitis.
• Crystal-induced synovitis (gout).
• Stress fracture of the femoral neck.
• Avascular necrosis of the femoral head.
• Avulsion of the tendon.
• Muscle bruise.
• Femoro-acetabular impingement.
• Strain of the rectus femoris muscle.
• Tension of the iliotibial tract.
• Referred pain from the lumbar region (L1-2).
• Paresthetic myalgia.
• Displacement of the epiphysis of the femoral head.
• Snapping hip syndrome (SHS). The “internal” SSC, as mentioned earlier, is associated with the tendon of the PPM.
• The “external” GBS is caused by either the iliotibial tract or the gluteus maximus tendon passing through the greater trochanter of the femur.
• “Intra-articular” GBS can occur due to the presence of loose bodies, ruptures of the labrum, or recurrent dislocation.

Diagnostics

Laboratory diagnostics

Laboratory tests, indicated only if the diagnosis is unclear, may include complete blood and urine tests, as well as erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, anti-cyclic citrullinated peptide antibodies, and antinuclear antibodies. These tests are useful in evaluating abdominal and pelvic pathology, which may present as groin pain due to colon cancer, diverticulitis, prostatitis, salpingitis, kidney stones, appendicitis, and psoas muscle abscess.

Visualization

X-ray diagnostics

• It is generally not indicated for soft tissue disease, but radiography may be used as an initial investigation if other osseous pathology is suspected (eg, loose bodies, osteitis pubis) or if red flags are present.
• In a child or adolescent with hip pain, displacement of the epiphysis of the femoral head should be excluded.

Ultrasound diagnostics

• Ultrasound (US) is a non-invasive and accessible method for assessing muscle and tendon injuries. In this case, thickening of the tendon is usually detected.
• PLM bursitis is associated with excess fluid in the iliac bursa, which is usually visualized on ultrasound.
• Ultrasound allows for dynamic assessment of the muscle and will therefore identify any tendon snapping that may be present in these patients.
• Ultrasound is used to guide needle guidance for lidocaine and corticosteroid injections (see below).
• It is not always the optimal diagnostic method, since its accuracy greatly depends on the skills of the specialist.

Magnetic resonance imaging

• MRI is currently the “criterion standard” for assessing hip and pelvic-related symptoms. One study that looked at imaging to determine the cause of hip pain in athletes compared x-rays, radionuclide bone scans, and MRI. The results showed that MRI was the most sensitive imaging modality.
• Provides the most accurate assessment of the condition of the PLM tendon and bursa.

MRI results in assessing musculotendinous injuries:

• Spin echo T2-weighted images will show increased signal intensity, which is associated with swelling and inflammation. A severe musculotendinous injury with associated hemorrhage will have high signal intensity on both T1-weighted and T2-weighted images.
• Evaluation of peritendinitis - Peritendinous tissue will display increased fluid content, which is detected on spin-echo T2-weighted images or short T1 inversion recovery (STIR) sequence as a focus of high signal intensity surrounding the normal tendon.
• Tendinosis - Spin echo T1-weighted images demonstrate increased signal intensity in the tendon, which is associated with myxoid degeneration or angiofibroblastic proliferation. Spin echo T2-weighted images may show abnormal signal (usually less than T1-weighted images) or normal signal.

Lidocaine injections

It is necessary to inject lidocaine into the PPM tendon under ultrasound guidance. If pain relief is achieved after the injection, the diagnosis of PPM tendinopathy is confirmed.

What to pay attention to when performing botulinum therapy

Individual approach. The Botox dose and injection site are determined by the doctor for each patient individually, taking into account the nature and severity of the process, as well as other factors. Therefore, a preliminary consultation with the neurologist who will carry out the treatment is necessary.

Control . The procedure is carried out under the control of electroneuromyography, CT navigation, when the position of the needle in the muscle is controlled using computed tomography, or ultrasound diagnostics.

Professionalism. It is important that the treatment is carried out by a neurologist who is fluent in botulinum therapy. Otherwise, the procedure may be unsuccessful and even dangerous.

At the Yauza Clinical Hospital, botulinum therapy is carried out by certified doctors, candidates of medical sciences with extensive practical experience.

Treatment

Conservative treatment

• Conservative treatment of PP tendinopathy includes relative rest, activity modification, and exercise.
• Soft tissue techniques, particularly myofascial release, can be useful in reducing muscle tension and producing a neuromodulatory effect.
• Manual therapy to mobilize the hip joint, lumbar spine, pelvic bones and other joints with limited mobility.
• Range of motion, stretching, and strengthening exercises should target the hip flexors and antagonist muscles.

Rehabilitation

Acute phase

• The main goal of the first phase is to reduce pain symptoms, muscle spasm and swelling. If the patient has stopped participating in daily activities, then returning the patient to these activities is also an important goal of this phase.
• Rehabilitation in the acute phase includes relative rest (avoiding any pain-inducing activities), use of cold, medication, and gentle stretching. Ice: exposure time 20 minutes, apply every 2 hours for the first 1-3 days.
• Drug treatment: short-term course of non-steroidal anti-inflammatory drugs (NSAIDs).
• Gentle stretching helps reduce muscle spasms. To avoid overstretching, do not stretch immediately after using cold as Local hypothermia can increase a person's pain threshold, making them less sensitive to pain.
• The PPM stretch is carried out for 20 seconds, then rest for 30 seconds, repeat 5 times. Stretching should be painless and can be combined with breathing phases.

Recovery phase

• The main goal of the second phase is to restore range of motion, strength, endurance and proprioception. Ultimately, this includes sport-specific activities.
• Range of motion: Along with stretching, it is necessary to perform a fork and a cool down.
• PPM injury may be associated with increased lumbar lordosis and anterior pelvic tilt. Achieving a neutral posture can be achieved by both stretching and strengthening the relevant muscle groups.
• Stretching: Stretching the rectus femoris muscle helps bring the pelvis into a more neutral position. This will take the tension off the RPM, reducing the likelihood of tension or spasm.
• All stretches in this phase are performed as described in the acute phase (hold for 20 seconds, relax for 30 seconds, repeat 5 times).

Maintenance phase

• Continue stretching the RPM and rectus femoris.
• Gradually increase the load using resistance exercises (eg, seated hip strengthening with an ankle weight, supine hip lift, seated hip external rotation with a weight or elastic band).
• Strengthening Exercises for PPMs and Hamstrings - Gradually progressive resistance can be achieved either by increasing the number of repetitions performed or by increasing the weight (each individual). Examples include standing hip curls (machine), supine and seated knee curls (machine), and step-up lunges (lunges performed at a slower pace, providing a smooth, controlled rhythm).

Return to sports

• The patient must be asymptomatic or able to tolerate pain before considering return to sport.
• Range of motion, flexibility, and strength of the hip flexors and antagonist muscles should be restored to the level of the contralateral side.

Surgical treatment

• Surgery is considered only when minimal improvement is achieved with long-term conservative treatment, which usually includes rest, activity modification, physical therapy, NSAIDs, and corticosteroids.
• Two surgical techniques have been described in the literature that involve either complete or partial release of the PLM tendon. Both options have good results, including pain relief and no residual weakness.

Other

Peritoneal injection of corticosteroids.

• The injection consists of a local anesthetic that is combined with a corticosteroid.
• One study assessed the outcome of patients treated with an iliopsoas bursa injection for suspected PPM tendinopathy. The results showed a corresponding improvement 1 month after the injection. Additionally, the study reported that most patients experienced a noticeable reduction in pain 15 minutes after the injection.

How to forget about joint pain? Self-medication for SPM and more

Joint pain may not only be associated with iliopsoas syndrome. There are many reasons, and they are all equally unpleasant. Common arthritis or rheumatism, so well known to most older people, causes a lot of trouble. And although it is often impossible to get rid of pain forever, you can use simple techniques to reduce pain and improve your quality of life.

Ginger

Many people do not like the taste and aroma of ginger, but these shortcomings are more than compensated for by the medicinal properties of this plant. Ginger root has many properties in common with ibuprofen, but is completely devoid of side effects. At a minimum, ginger does not cause stomach pain and does not interfere with blood circulation.

Ginger root shares many properties with ibuprofen

The easiest way to prepare ginger is to grate it on a coarse grater and brew it at the rate of 1 tablespoon (without a slide) per 1 glass of water. Boil to get a good decoction. Drink 2 times a day - morning and evening - in any quantities, but without fanaticism - you can take 2-3 tablespoons, or you can take half a glass.

Green tea

Green tea contains many antioxidants - useful allies in the fight against diseased joints. A cup of green tea with breakfast has a huge positive effect due to its high content of vitamin E. It is also found in abundance in almost all green vegetables.

Green tea is a great help in the fight against sore joints

Healthy foods

There are a huge number of products that have a positive effect on human joints. They are useful even for a healthy person, and even more so for the “lucky” owner of diseased joints.

Diet

Diet does not mean giving up food in general, but rather giving up certain foods that negatively affect the joints. With healthy joints, this food does not harm anyone, but if a person is sick, for example, with arthritis, these foods should be excluded from the diet.

Forecast

• Provided the underlying biomechanical deficiency is corrected, the overall prognosis is favorable.
• Identifying this deficiency early may play a role in preventing the development of chronic symptoms. However, as mentioned earlier, the diagnosis of PPM tendinopathy is made approximately two years after symptoms develop. In these cases, recovery may take longer.
• The patient should not return to sports until they have achieved a full and pain-free range of motion.