Expert: Gerald Anzalone, D.C. - 3/20/2009

Question
Hi,
I have had chronic back pain for the past three years following a car accident.  I was just discharged from yet another round of physical therapy where the therapist was unable to figure out what to do to fix my problem.  This therapist located my problem which is that my pelvis is dropping when I walk and that there is something that is restricting my pelvis from moving.  When I lie flat on my stomach and pull my leg up toward the side of my body (keeping my leg on the ground), my pelvis does not lay flat on the ground.  When I do this on my opposing leg, my pelvis touches the ground.  When I pull my leg up on the side of my body where my pelvis movement is restricted, it produces pain in my back.  The pain in my back is on the opposing side of my body where there is restriction in the movement of my pelvis.  The PT thought that I have a tight psoas muscle which she worked on once but yet she still discharged me, giving me some back exercises and stretches.  My strength and ROM in my hips is good.  My next step is to see a chriopractor and I'm curious to know if a chiropractor would do any work on my psoas muscle to loosen it up.  Can you please tell me if it is in the scope of a chiropractors practice to work on the psoas muscle and movement of the pelvis.  Thank you.

Answer
Danielle,

A number of studies have indicated that the sacro-iliac joint is a significant cause of pain in patients with certain patients with chronic low back pain (Schwarzer, Anthony C.; Aprill, Charles N.; Bogduk, Nikolai. The Sacroiliac Joint in Chronic Low Back Pain. Spine, 1995; Maigne, Jean-Yves; Aivaliklis, Alain; Pfefer, Fabrice. Results of Sacroiliac Joint Double Block and Value of Sacroiliac Pain Provocation Tests in 54 Patients With Low Back Pain. Spine, 1996).

Other studies show that the psoas muscle actually degenerates, or atrophies, in cases of chronic low back pain, as well as contributing to the actual perpetuation of back pain (Smeets RJ, Wade D, van Leeuwan J, Vlayen JWS, Knottenerus JA. The association of physical deconditioning and chronic low back pain: a hypothesis-oriented systematic review. Disability and Rehabilitation, 2006).

One study states that with chronic low back pain, there is often an imbalance between relatively overactive muscles and their less active opposing muscle. A functional muscle imbalance in the lower back and pelvic regions can promote poor biomechanics and chronicity of pain (Ian F, Effie K, Gordon K, Brian F, Jag D. Ultrasound-guided injection of the psoas muscle with Botulinum Toxin A: Novel approach to treating chronic low back pain).

All this is by way of saying that the source of your back pain is probably not limited to just one muscle or joint, but may probably involve a larger biomechanical chain. Chiropractors who are musculo-skeletal in their approach to patient care assess the functional integrity of the muscular system as well as the joints of the spine and pelvis, and when indicated, of the extremities as well.

Manipulation of the spine and/or sacro-iliac joints may be helpful to some people with symptoms such as those you have described; manual therapy to the psoas muscle may be indicated but must be approached cautiously, as the psoas is a fairly deep-lying structure in the abdomen.

Additionally, the solution to your problem probably necessitates the use of some specific therapeutic exercises to be done at home, to reduce the dependency upon purely passive care.

I hope that this helps to answer your question.