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92 m a s s a g e & b o d y w o r k j a n u a r y / f e b r u a r y 2 0 1 7 technique MYOSKELETAL ALIGNMENT TECHNIQUES What typically comes to mind when a client presents with chronic sciatic symptoms— disc herniation, facet joint osteoarthritis, sacroiliac fi xation, or maybe piriformis syndrome? It's true that any one of these issues may cause nerve compression that leads to radicular hip and leg pain. However, in this article, we'll investigate an underappreciated sciatic nerve antagonist: the iliolumbar ligaments (Image 1). Iliosacral Alignment and Sciatic Nerve Entrapment The Curious Role of Iliolumbar Ligaments By Erik Dalton, PhD There are two ways iliolumbar ligaments may contribute to sciatic nerve compression: weakness on the posterior side, and anterior tightness. To begin, let's review the pertinent anatomy and biomechanics leading to "iliolumbar ligament syndrome." Then, we'll review some myoskeletal techniques to relieve strain and sciatic compression. The primary role of the iliolumbar ligaments is to prevent excessive lumbar side-bending, but these ligaments can indirectly contribute to sciatic nerve entrapment when injured. Notice in Image 1 how the iliolumbar ligaments blend with the interspinous and supraspinous ligaments to help prevent forward shifting of the fi fth lumbar vertebra on the sacral base. This stabilizing force relieves pressure on the intervertebral disc and allows normal functioning of the facet joints. A traumatic event—for example, a forward-bending and twisting maneuver while attempting to lift a heavy object—may strain the iliolumbar ligaments and their multifi di neighbors. Pars interarticularis L3 L4 L5 3 Spondylolisthesis—a fracture of the pars interarticularis causes L4 to slip forward on L5, compressing one or both sciatic nerve roots as they leave the spine. 2 Extended index and middle fi ngers form a "fl ying V" tool for scrubbing the iliolumbar ligaments. The therapist assesses for ART (asymmetry, restriction of motion, and tissue texture abnormality) with this fast-paced scrubbing technique. 1 Iliolumbar ligaments, shown here, attach the ilia to L4 and L5 and blend with the supraspinous and interspinous ligaments. Supraspinous ligament Infraspinous ligaments Iliolumbar ligaments As these ligaments weaken from such trauma, they lose the ability to prevent the fi fth lumbar vertebra from shifting forward on the sacrum. The subsequent forward shifting creates narrowing of the intervertebral foramen and, eventually, degenerative entrapment of the sciatic nerve. Left untreated, the result is tearing of the outer layer of the disc, formation of fi ssures in the annulus, and possible triggering of sciatic nerve infl ammation. Corrective exercises such as planks and bird-dogs may restore strength and stability to these stretch- weakened ligaments, and some believe that fast-paced, low-force "scrubbing" helps tighten ligaments through enhanced fi broblastic proliferation (Image 2). In extreme cases, slippage of the fourth or fi fth lumbar vertebra may result in spondylolisthesis, where the pars interarticularis cracks from excessive pressure, allowing sciatic nerve entrapment on one or both sides (Image 3).