Iliolumbar ligament injury | Iliolumbar Syndrome | Iliac crest pain syndrome
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
You are an athlete or someone who does physically demanding work and you have low back pain, groin, and hip pain now significant enough that you need the help of a health care specialist. In the office during your consultation you may describe the pain as severe at times and radiating out from the center of your low back to the top of your hip or pelvis, (the iliac crest) and into your groin region.
As low back, groin and hip pain frequently combine to cause discomfort in many people, your health care provider may begin a process of elimination as to see what is the true cause of your pain. Is it your hip? Your back? Your groin? Are all of them causing you discomfort?
Clues during the examination you may have Iliolumbar ligament injury | Iliolumbar Syndrome | Iliac crest pain syndrome
In the search for the cause of your discomfort, your health care provider may focus on what type of activities, work, or NON-activities you are involved in.
- If you are involved in work where you are required to move or lift heavy loads while rotating your torso (as in unloading a truck or normal movement in construction, landscaping, or delivery, for example,) you may have Iliolumbar ligament injury.
- If you play a sport, such as golf or tennis for example, where rotation of the hip-spine complex is required to drive the ball. You may have iliolumbar ligament injury.
- Basically if you play any sport where running, cutting, change of field or court position is frantic or hurried, you may have iliolumbar ligament injury.
- If you have very little activity, sit for prolonged periods of time. You are also at risk for iliolumbar ligament injury.
When your health care provider presses on the low back, the side and middle portions of the hip and there is tenderness, iliolumbar ligament injury will be suspected. Your health care provider may discuss with you the various names for Iliolumbar ligament injury. These names may include Iliolumbar syndrome or Iliac crest pain syndrome. Regardless of name, your provider will likely discuss with you that you have inflammation of the ligament because it is torn.
Hip, groin, low back pain is usually not isolated to one ligament injury
To the left is an illustration of the iliolumbar ligaments. One can immediately see how important they are to hip, pelvic, and spinal stability.
It is important that when treating pain in the area of the iliolumbar ligaments, that you and your health care provider understand that iliolumbar ligament injury may not sit as an isolated injury, it may be only one component that contributes to spinal instability, hip instability, and pelvic instability. The iliolumbar ligaments may only be part of the story as to why your “core,” is weakened, painful, and possibly unstable.
A tell tale sign that ligament damage is “at your core,” can be frequent or painful muscle spasms in the area.
- The iliolumbar ligaments also work in tandem with the lateral lumbosacral ligament, the ligamenta flava, and the interspinous and supraspinous ligaments. The ligaments that help keep your core strong and stable.
So clearly, when the iliolumbar ligaments are injured and compromised, they can no longer offer the support they usually do to their companion ligaments. Equally if these other ligaments are injured, they are now straining the iliolumbar ligaments.
- This is why we tell our patients that iliolumbar ligament injury, is not typically an isolated injury and we need to broadly treat the low back, hip and groin areas.
The idea that iliolumbar ligament injury usually does not occur in isolation was discussed more that twenty years ago by doctors from the University of North Texas Health Science Center at Fort Worth who speculated that:
- micro-trauma to the iliolumbar ligament is the primary cause of many cases of chronic low back pain because
- it is the weakest component of the multifidus triangle (a collection of supportive soft tissue including the facet joints, various muscles and soft tissue (the erector spinae muscles, lumbar fascia, quadratus lumborum muscle group) )
- there is increased susceptibility to iliolumbar ligaments injury due to the ligament’s angulated attachment.
- it is a primary inhibitor of excess sacral flexion (bending too far – putting a lot of strain on the ligament).
- it is a highly innervated nociceptive tissue; (it has significant pain awareness because of the nerve tissue present – it hurts more than an MRI may reveal it should) and,
- it plays an increased role with progressive disc degeneration.(1)
Treatment of iliolumbar ligament injury
Sometimes we see patients who have been to other health care providers who offer various single inject treatments. This can include a cortisone injection or a Platelet Rich Plasma injection. We will discuss these more below. At this point we want to first bring in the evidence that a successful treatment may require much more that an single shot of anything.
- It is very likely that if you are reading this article that you have been dealing with this issue for some time and your pain and functional instability have not yet resolved. It is also likely that you are managing yourself along with these treatments:
- Rest, Ice and Heat.
- Over the counter painkillers and NSAIDs, non-steroidal anti-inflammatory medications
- Topical ointments and creams
- Physical therapy
The problem can be much deeper, this is why you are not responsive to these self help aids
Let’s look at the physical therapy “solution” and why this did not offer you the success you had hoped for:
A combined research team from universities and hospitals in Switzerland, the United Kingdom, and Germany, discuss the importance to spinal stability provided by the iliolumbar ligament. In their research you can see why physical therapy will not work for many people with iliolumbar ligament damage.
From the research: The iliolumbar ligament connects the transverse process (the bony projections on either side of the vertebrae where ligaments and muscle attach themselves), of L5 to the iliac crest (uppermost part of the pelvis) and contributes to lumbosacral stability and has been associated with low back pain (when it is damaged or injured). However, different opinions exist regarding the functional relevance of the ligament.
We will stop here for a comment: For some the importance of the iliolumbar ligament in core stability is a matter of opinion. What the researchers in their study were investigating was just how important this ligament was to spinal stability. In our opinion it is very import, we will turn back to the research to see why:
From the research: What the researchers found was the tissue that connected the iliolumbar ligament to the bone, was of the more sturdy and stronger type fibrocartilaginous entheses, as compared to fibrous enthesis. What does that mean? It means according to the researchers:
“The existence of fibrocartilaginous entheses suggests that the insertion sites of the ligament are subject to both tensile and compressive loading. . . Our findings support the suggestion that the iliolumbar ligament might play an important role in the stabilization of the lumbosacral junction.”(2)
- Simply, the iliolumbar ligament connects to the bone with special connective tissue called the entheses.
- A ligament that has a stronger entheses attachment is subjected to having greater loads placed on it.
- The iliolumbar ligament has a stronger entheses attachment, it can stretch farther and bear greater weight than other ligaments
- When the iliolumbar ligament’s entheses is damaged, it cannot stretch as much or bear the same compressive, weight loading
- Physical therapy requires resistance in the musculoskeletal system to work
- If the iliolumbar ligaments and its companion ligaments are damaged and weakened, physical therapy success is greatly compromised.
Prolotherapy is an injection treatment that strengthens and rebuilds ligaments and their entheses on a cellular level. In our more than 25 years experience in this field, we have developed our own approach to fixing the problems of iliolumbar ligament weakness and damaged entheses. This simple treatment will be explained below.
Prolotherapy treatment strengthens the ligaments and damaged entheses of the iliolumbar ligaments
- In the illustration above you can see how the iliolumbar ligament plays an important biomechanic role in anchoring the spine to the pelvic ring. Doctors in Ireland describing the possibility of using various injection techniques to treat Iliolumbar Syndrome in the medical journal Pain Physician (3) also offered a good summary of the importance of the iliolumbar ligament. They wrote:
- “The iliolumbar ligament plays an important biomechanic role in anchoring the spine to the pelvic ring and stabilizing the sacroiliac joint.
- Iliolumbar syndrome is a back pain condition caused by pathology (wear and tear injury) of the iliolumbar ligament.
- History and physical examination are important in the assessment of back pain, but they lack sufficient specificity (pinpoint ability to find the pain generator).
- Injection of small volumes of local anesthetic into the structure considered to be the source of the pain increases the specificity of the diagnostic workup.”
In Prolotherapy treatments, we know that we need to find the source of pain and instability. A Prolotherapy injection at this site and the work of the anesthetic in the solution can tell us immediately if we have found the spot because the patient has immediate pain relief.
A patient’s story reported in the medical literature
A case study in the Journal of Prolotherapy describes the effects of a single Prolotherapy injection series on the left iliolumbar ligament. To be clear this is not a single injection but a single treatment as the one displayed above.
- The patient is a 32 year-old female.
- Her job tasks as a physical therapist required her to twist turn and bend; putting pressure on her pelvis and the ligament system.
- Treatment results indicated that after the initial Prolotherapy treatment, there was growth in the left iliolumbar ligament.
- Patients that experience lower back pain and or pelvic shifting may benefit from the usage of Prolotherapy to strengthen the ligaments surrounding their pelvis.
The research concludes: “Our positive findings move us one step closer to showing how, for patients with lower back pain, Prolotherapy can prove to be a good adjunct to increase stability in the lumbar spine and pelvis.”(4)
If this article has helped you understand problems of Iliolumbar ligament injury and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
1 Sims JA, Moorman SJ. The role of the iliolumbar ligament in low back pain. Med Hypotheses. 1996 Jun;46(6):511-5. [Google Scholar]
2 Viehöfer AF, Shinohara Y, Sprecher CM, Boszczyk BM, Buettner A, Benjamin M, Milz S. The molecular composition of the extracellular matrix of the human iliolumbar ligament. The Spine Journal. 2015 Jun 1;15(6):1325-31. [Google Scholar]
3 Harmon D, Alexiev V. Sonoanatomy and injection technique of the iliolumbar ligament.Pain Physician. 2011 Sep-Oct;14(5):469-74. [Google Scholar]
4 Auburn A, Benjamin S, Bechtel R, Matthews S. Increase in Cross Sectional Area of the Iliolumbar Ligament using Prolotherapy Agents: An Ultrasonic Case Study. Journal of Prolotherapy. 2009;3:156-162.