Expert: Scott F. Gillman, DC, DACBSP - 10/5/2009

Question
QUESTION: I am a thirty year old active woman.  I would consider myself a healthy individual; one who eats well and works out five times a week (usually 45 minutes or so on the elliptical).  I writing to you because I am extremely frightened that I have been permanently damaged.  About 12 weeks ago, I went on a run.  As I was running, I felt a slight pull in the middle to lower section of my back on the left side.  I came home stretched out and when I got out of bed the next morning, I felt a sharp pain.  The sharp pain became a dull ache when sitting or standing for long periods of time. I was not able to feel the pain, although it did hurt along the top of my left buttock.  About six years ago, I was diagnosed with a degenerative disc with a 1 mm bulge (on the right side of the disc) in my L5 S1 disc.  It eventually healed up, as that was what I expected this injury to do.  After 6 weeks of not feeling better at all, I decided to try my luck with a chiropractor.  I went to a reputable chiropractor, whom after doing a number of varied tests on me, determined it was my left SI joint causing this annoying pain.  He did not take Xrays, as I had them done previously and everything was fine.  He was aware of my previous injury.  He did an SI Joint manipulation on me (One that required me to lay on a table sideways and place my left leg over my right in the shape of a four.  He then brought my left shoulder up towards my knee).  I left feeling dizzy and maybe a little better.  As the day went on, my SI joint began to throb, my upper left buttock began to hurt and my left calf began to tingle.  The dizziness subsided after about 24 hours.  I did not go back for further treatment, as I was scared since I hurt worse than my initial injury. Now, 6 weeks later, my SI Joint is tender to the touch, my upper left buttock aches. I can hardly sit or stand for more than 15 minutes at a time.  My calf tingles on and off.  When I lay flat on my back, I feel as though I am laying on a protruding bone on my left side (around my SI joint) and when looking in the mirror from the front, it looks like my right pelvis bone sticks out a little further than my left side.  Not to mention, I have an unbelievable amount of lower back stiffness.  I have a few questions for you. Can a chiropractor permanently damage your SI joint or tilt your pelvis in one manipulation? If so, are there stretches or exercises that I can do to put myself back in allignment? Can a chiropractor fracture your sacrum during an SI adjustment?    I did see a spine specialist after the chiropractor incident and had an MRI of my lower lumbar.  It is the exact same as it was 6 years ago.  In advance, I am really appreciative of your thoughts and advice.

ANSWER: Nicole,

Sorry you're having such troubles.  My suspicion is that you have an irritated disc.  Doubtful it's your SI joint, but it's possible.  Bottom line is that you have to go back to the chiropractor and address this.   Simply tell him what happened.  It's not unusual to have your symptoms provoked by side-posture joint manipulation.   You shouldn't have to endure anything too forceful, if that's what happened.  There are a variety of methods out there to address your condition.  There is gentle pelvic blocking, lumbar flexion-distraction, and exercise prescription.  Run these by your chiropractor.   The chiropractor cannot permanently damage your SI joint unless it was a terribly forceful manipulation (not likely) and the sacrum cannot fracture from this procedure.  The tilting/twisting appearance of your pelvis is from asymmetric muscle contraction which twists your pelvis out of its hoop-like shape.  If your disc gets irritated or internally shifted (or both), your muscles will fire an twist you out of whack. It's called "antalgia." If it twists your pelvis, it's called "tortipelvis."  Pain from discs will refer into the buttock and thigh.  Any chemical irritation that spills against the nerve tissue at the roots of the nerves will give you paresthesias (tingly/numb) into the leg, foot or toes.  If the side posture joint manipulation was way too forceful, it is possible there was a sprain to the joint.  This would cause tenderness and swelling at the joint and also irritate the disc.  Some of these effects can be healed and reversed with skilled soft tissue therapy and exercises.  Again, you need to address this with the chiropractor.   Ask the chiropractor to do a lumbar prone instability test [google: Hicks, et. al. 2005];  If you are no longer comfortable with this DC, then find a new one.  If you have lumbar segmental instability, then you need to do stabilization exercises [google: Stuart McGill, lumbar stability exercises].  If you have soft tissue sprain issues, look up a provider of www.grastontechnique.com.   See if the DC has multiple modalities at his disposal: Low level laser, kinesiotape, analgesic lotions, velcro back supports, whatever means to get you headed in the right direction.  If all you have is a mild SI joint sprain along with disc irritation, then symptoms should resolve with careful treatment within about six weeks.  

'I hope this was helpful.

Dr. G

---------- FOLLOW-UP ----------

QUESTION: First of all, thank you so much for your quick and detailed response.  I really appreciate it.  Due to my disc bulge being on the right side of my back and my symptoms on the left, do you think it might be a different disc (other than L5 SI) that is irritated?  Finally, thanks for explaining the "tilted pelvis."  My only other question is once the disc is no longer irritated, will the pelvis automatically move back into a more symmetric position?  Thanks again.

ANSWER: Hi Nicole,

It is not uncommon to have back, thigh, and leg (sciatic) pain on one side and the MRI shows the disc bulge on the opposite side.  There is conjecture as to why we see this.  When a joint system, SI joint or facet joint or disc joint, becomes irritated, the body will turn on muscles to pull the body away from the irritation.   So in theory, when the joint becomes less and less irritated, the muscle firing lessens and the body returns to a more aligned stance.   Keep in mind that there are many folks walking around with a disc bulge or protrusion and they have no symptoms.   We are questionning more and more the correlation between what is observed on MRI and what is observed on the patient during physical examination.  I recently examined a patient who had a severely degenerated spine, with most of the discs degenerated and bulging, bone spurring and joint hypertrophy everywhere, and with minimal pain in her lower back.  She could bend fully forward and back.   I have others with muscle spasm and limited motion but with MRI's that don't look all that bad.   I think that the soft tissues of the spine deserve more consideration, and that the discs or the interlocking facet joints on the back side of the vertebrae or the SI joint can become irritated as they contain soft tissue structures.    Bottom line: get treatment and aim for resolve...

'Best,

Dr. G'

---------- FOLLOW-UP ----------

QUESTION: I am sorry to keep to bothering you.  I really appreciate all of your detailed advice and have googled all of your ideas.  To be honest, I am really scared to go back to a chiropractor, as I feel that my one and only experience was not a good one.  I liked the chiropractor that I went to, but don't have faith that he will fix me.  Finding a new one scares me as well.  He doesn't know the condition that I started in and I'm nervous that he will try to put me back to a place that I have never been and continue to injure me more.  In your opinion, can a physical therapist help me?  And if all I did was stretch, ice and heat for the next month or so (and obviously do my normal activity, just not work out), can I heal on my own? Bottom line, is it possible (after 6 weeks) to heal up back to normal if I am currently out of alignment, based on my 1 SI joint manipulation? Thanks again.  I can't tell you enough how much I appreciate your advice.

Answer
Nicole,

Chiropractors are trained to diagnose as are MD's.  Clinically, our most frustrating patients are the ones that are scared or overly emotional about their pain.  It often is a sign of psychological barriers.  It would really be best for you to directly address your issue with your current or a new doctor of chiropractic.  I would suggest searching these sites:  www.grastontechnique.com  www.westhartfordgroup.com   www.acbsp.com (look for DACBSP's);   You could easily contact any doctor on the westhartford.com site and they can help you locate someone in your area.   If you have a soft tissue problem, then Graston Technique is a great way to address it.   Also DACBSP's are pretty well skilled in diagnosis and treatment (but I'm biased in this regard).  So don't be scared, just tell the doctor your concerns and take treatment slowly and step at a time.  

'Best,

Dr. G'