Iliolumbar ligament injury; Iliolumbar Syndrome; Iliac crest pain syndrome

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

Iliolumbar ligament injury; Iliolumbar syndrome; Iliac crest pain syndrome

You are an athlete or someone who does physically demanding work and you have low back, groin, and hip pain. You had significant enough pain that you needed the help of a health care specialist. During your consultation, you may have described the pain to your health provider as severe and acute 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 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?

Before we begin this article and research findings, if you would like to contact our medical team, please use our contact form page. We can help assess your candidacy for our treatments and answer your questions.

Clues during the examination you may have Iliolumbar ligament injury; Iliolumbar Syndrome; Iliac crest pain syndrome. Do you have a job that is physically demanding?

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, where rotation of the hip-spine complex is required to drive the ball. You may have an iliolumbar ligament injury.
  • Basically, if you play any sport where running, cutting, or court position is frantic or hurried, you may have an iliolumbar ligament injury.
  • If you have very little activity, sit for prolonged periods of time. You are also at risk for iliolumbar ligament injury.

If you are described by any of these above activities, and you have a health care provider who does a good physical examination, when the 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 the name, your provider will likely discuss with you that you have inflammation of the ligament because it is torn or stretched out.

Sometimes the doctors are keenly focused on the low back and the iliolumbar ligament connection is put on the back burner

Sometimes people tell us stories about their doctors not responding to the idea of iliolumbar ligament injury even though the patient themselves have a revealing medical history. These people’s stories go something like this:

L5-S1 and cortisone

I work out a lot, lift weights. I do a lot of off-road biking. I have had low back pain for years. A few times a year I have acute episodes that radiate into my pelvis, hips, groin, thigh. My last episode was very acute. I got an MRI and it showed developing stenosis at L5-S1. I got a cortisone shot, it helped a little but I know that my problems are not isolated to L5-S1. I have asked about iliolumbar pain syndrome and we seem to be staying focused on L5-S1 and cortisone. This seems to be the path to surgery. 

Low back pain, no idea where it is coming from

I have chronic low back pain that flares up from time to time. My last x-ray “showed nothing,” but I was able to get physical therapy because of acute pain. The PT helped a little, both my physical therapist and I think it is an Iliolumbar ligament injury. My doctor says rest, anti-inflammatories, and ice. I have tried all these “remedies.” They have limited benefits.

What are we seeing in this image? Spinal, hip, and pelvic ligaments

In this image, we see the front of the pelvis and the many ligament attachments that hold the two halves of the pelvis together and connect the pelvis to the spine. When you look at the pelvic/spinal ligaments you can see how the spine and pelvic and spinal instability should not be treated in isolation. In this image, we see how the intertransverse ligament, anterior longitudinal ligament, anterior sacroiliac ligaments, iliolumbar ligaments, and the pubofemoral ligaments all interact to provide a “firm girdle.”

In this illustration we demonstrate the positioning and importance of the pelvic, hip, and spinal ligaments

 

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 telltale 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 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 than twenty-five years ago by doctors from the University of North Texas Health Science Center at Fort Worth (1) who speculated in the journal Medical Hypotheses 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 ligament 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.

The iliolumbar ligament has a direct restraining effect on movement in the sacroiliac joints

What are we seeing in this image?

The complexity and interwoven nature of the sacroiliac ligaments and the iliolumbar ligaments. The iliolumbar ligaments help keep the two halves of the pelvis in alignment. Damaged iliolumbar ligaments cannot do this job and impact the sacroiliac joints.

Twenty years ago in 2001, publishing in the Journal of Anatomy (2) doctors wrote:

“The iliolumbar ligament has been described as the most important ligament for restraining movement at the lumbosacral junction. . . .The existence of this sacroiliac part of the iliolumbar ligament supports the assumption that the iliolumbar ligament has a direct restraining effect on movement in the sacroiliac joints.”

Pelvic ring ligaments, pelvic stability, and low back pain

What are we seeing in this image? We are seeing the components of the pelvic ring. The arrow shows the direction of the body weight’s force as it is transferred between the pelvic ring, truck, and femurs. The keystone of the pelvic ring is the sacrum which is wedged between the two ilia and secured bilaterally by the sacroiliac joints.

We are seeing the components of the pelvic ring. The arrow shows the direction of the the body weight's force as it is transferred between the pelvic ring, truck, and femurs. The keystone of the pelvic ring is the sacrum which is wedged between the two ilia and secured bilaterally by the sacroiliac joints.

The influence of the posterior pelvic ring ligaments on pelvic stability is poorly understood.

This is a statement from a 2013 study in The Spine Journal (3). Here are the rest of the observations presented in this paper:

  • Low back pain and sacroiliac joint pain are described as being related to these ligaments. Posterior pelvic ring cartilage and ligaments significantly contribute to pelvic stability. They can also contribute to low back pain. This is noted when load concentrations occur at the iliolumbar ligament, interosseous ligament, and posterior (PSL) sacroiliac ligaments, which goes in coherence with the clinical findings of these ligaments serving as generators of low back pain.

What we are presenting is research that demonstrates the complexity and importance of the pelvic ligaments in back pain and the lower back ligaments in pelvic and hip pain.

First Danielle R. Steilen-Matias, MMS, PA-C explains the common problems we see in our patients.

Learning points summary:

  • Hip-spine syndrome is a pain syndrome characterized by injuries in both the hip and the low back that impact each other. Iliolumbar ligament injury; Iliolumbar Syndrome; and Iliac crest pain syndrome can be components of Hip-spine syndrome.
  • At 0:27 of the video, the interactions of the hip and the spine are demonstrated with a model of the pelvis.
  • Hip-spine syndrome commonly involves your hip and your sacroiliac joint or even your low back part of your spine. When you develop injuries or degenerative wear and tear in both the hips and the low back, these injuries impact each other. The back pain can make the hip pain worse, the hip pain can make the back pain worse as the degenerative disease is accelerating in both areas.
  • Many times we will see a patient in the office. They will have a very specific diagnosis that their problems all come from the hip, or they will have a very specific diagnosis that their problems are all coming from the lower back or Iliolumbar ligament injury. After we do a physical examination and talk to the patient about their medical history, it is clear that this patient has issues in both the hip and spine. This is characteristic of Iliolumbar ligament injury.
  • Often we find that patients have completed a conservative care treatment course for their lower back or they have completed a conservative care treatment course for their hip, yet they still have pain. In this situation, conservative care may have been directed at the wrong pain triggers.
  • In patients like this, we treat the hip, spine, sacroiliac joint, sacrum areas with Prolotherapy to bring stability into the area by restoring normal function to damaged or weakened spinal and hip ligaments.  (The treatment is explained below in greater detail).
  • At Caring Medical we have a very high success rate treating patients effectively and alleviating their chronic pain with Prolotherapy.

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 successful treatment may require much more than a 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 of 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 important, 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.”(4)

  • 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 are 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 their companion ligaments are damaged and weakened, physical therapy success is greatly compromised.

A December 2020 study published in the Indian journal of radiology and imaging (5) noted that injury to the iliolumbar ligament or iliolumbar syndrome’s treatment “lies upon the specific diagnosis of the iliolumbar syndrome.” Further : “The ultrasound guided interventions have the potential for the specific diagnosis and treatment of the iliolumbar syndrome.

What the doctors in this study did was to look at 45 patients with nonspecific low back pain and suspected iliolumbar syndrome. Two-staged ultrasound-guided interventions were performed: Primary diagnostic and secondary therapeutic interventions (platelet-rich plasma (PRP) injection).

Out of forty-five patients, forty-two patients showed significant clinico-radiological improvement defined as a reduction in iliolumbar thickness reduced  Visual Analogue Scale (o- no pain 10 – unbearable pain) score of less than 3 (mild pain) from an earlier very severe pain score.

Prolotherapy is an injection treatment that strengthens and rebuilds ligaments and their entheses on a cellular level. In our more than 27 years of 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 (5also 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.”(6)

Questions about our treatments?

If you have questions about your pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

 

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References: 

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 Pool‐Goudzwaard AL, Kleinrensink GJ, Snijders CJ, Entius C, Stoeckart R. The sacroiliac part of the iliolumbar ligament. Journal of anatomy. 2001 Oct;199(4):457-63. [Google Scholar]
3 Hammer N, Steinke H, Lingslebe U, Bechmann I, Josten C, Slowik V, Böhme J. Ligamentous influence in pelvic load distribution. The Spine Journal. 2013 Oct 1;13(10):1321-30. [Google Scholar]
4 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]
5 Nayak BK, Singh DK, Kumar N, Jaiswal B. Recovering from nonspecific low back pain despair: Ultrasound-guided intervention in iliolumbar syndrome. Indian Journal of Radiology and Imaging. 2020 Oct;30(04):448-52. [Google Scholar]
6 Harmon D, Alexiev V. Sonoanatomy and injection technique of the iliolumbar ligament.Pain Physician. 2011 Sep-Oct;14(5):469-74. [Google Scholar]
7 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.


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