Background: Treating problems related to the low back can be frustrating because of inadequate justification of long standing; often times with unproven concepts. These beliefs can lead to underwhelming results with this population. Research has revealed inappropriate structural, biomechanical, functional and movement concepts leading to false results and assumptions about low back pain.

 

Purpose: This article will focus on several errors in low back treatment philosophy: the sacrum as a keystone, measurement of movement and mechanics, location of the XYZ axis of the sacroiliac joint (SIJ), intraarticular injections as the gold standard, the disc as the cause of low back pain, testing errors and pelvic asymmetry.

 

Design/Setting: Specific samples of x-rays, photographs and graphic illustrations were taken from previously published articles by the author.

 

Methods: The concept of the sacrum functioning as a keystone was analyzed in a functional position. X-rays of the asymmetric pelvis in the long straddle position were compared to X-rays of the symmetrical pelvis in the long straddle position (LSP). Intra-articular injections of the sacroiliac joints were compared to peri-articular injections. Before and after x-rays demonstrated the results of manual correction of a reversible asymmetric pelvis. 

 

Results: With weight-bearing when the ilia are symmetrical there is a bony transverse loading axis at S1 and movement is on balanced ligaments, negating the concept of function as a keystone. When the ilia are asymmetrical the sacrum was found to flex laterally toward the side of loading and rotate to drive counter rotation of the trunk. Peri-articular injections into the area of the sacroiliac joint are more effective than intra-articular injections. A correction of an asymmetric pelvis to symmetry with a posterior rotation of the innominate on the sacrum was demonstrated. As this movement from asymmetry to symmetry relieves pain so rapidly and completely this lesion is probably more in the nature of a subluxation.

 

Conclusions: Although the sacrum looks similar to a keystone, it does not function as such, but rather floats on balanced ligaments and is essentially non-weight bearing. A commonly overlooked procedural error has indicated that the sacroiliac joint has minimal motion. X-rays in the long straddle position with counter rotation of the trunk demonstrate about 30 degrees of lateral sacral flexion in each direction. Sacral measurements have been made on XYZ axes on the sacral plateau even though examination reveals a commonly overlooked, bony, transverse, sacral loading X axis posterior to sacral S3 at the posterior inferior iliac spines. The gold standard in the use of intra-articular injections for diagnosis of dysfunction of the sacroiliac joint may cause a high percentage (64%) of false positive results if injected into the intact capsule. Idiopathic low back pain has no relationship to the herniated disc although a dysfunction of the sacroiliac joint that may cause vertebral instability may be a factor. An anterior rotation of the innominates on the sacrum can cause a reversible pelvic asymmetry. Less than factual assertions and conclusions remain in current consensus. These have precipitated many self-perpetuating myths that have confused investigators and negated carefully considered results in evidence based research.