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C h e c k o u t A B M P 's l a t e s t n e w s a n d b l o g p o s t s . Av a i l a b l e a t w w w. a b m p . c o m . 93 Note: when clients present with excessive lumbar lordosis and bilateral hip and leg pain, refrain from placing them prone on the therapy table and applying downward pressure to the lumbar spine. You do not want to be responsible for additional vertebral fractures. If in doubt, always suggest an orthopedic assessment before continuing therapy of any kind. Put simply: do no harm! ANTERIOR ILIOLUMBAR LIGAMENT STRAIN In Image 4, notice how the taut bands on the anterior surface form "fascial hoods" over the L4 and L5 nerve roots. 1 Once the greater sciatic nerve (about the size of your pinky fi nger) leaves the spine, it must traverse through these taut bands. In a nicely aligned pelvis, this usually presents no compression problems. But visualize what happens to the sciatic nerve in Image 5 when the right ilium anteriorly and inferiorly rotates, causing the iliolumbar ligaments to tighten down on the underlying nerve roots. In the beginning, the client may or may not experience symptoms depending on the brain's perception of the degree of threat. However, prolonged peripheral nerve compression does begin to obstruct axoplasmic transport of proteins and other cell parts to and from the neuron's cell body. Clinically, this breakdown of nerve conduction may lead to what Harvard University plastic surgeons Albert Upton and Alan McComas called "double crush syndrome." 2 This term refers to scenarios where compressed axons at one site cause the nerve to become especially susceptible to damage at another site, such as under the piriformis muscle. (For more on double crush syndrome, see "Double Crush Nerve Damage," Massage & Bodywork, July/August 5 A torsioned pelvic bowl causes the anterior iliolumbar ligaments to entrap a branch of the sciatic nerve. Iliosacral alignment technique—the therapist's right palm cups the client's right ASIS, while the heel of his left hand softly braces above the iliac crest. The client is asked to inhale and gently push her right hip toward the table against the therapist's resistance to a count of fi ve and relax. The therapist uses a counterforce to posteriorly rotate the client's right ilium to relieve iliolumbar pressure on the sciatic nerve. 4 Iliolumbar ligaments form fascial hoods that provide lumbosacral and sacroiliac joint stability. Fascial hoods 2016.) The brain may try to stabilize the lumbosacral joint by layering the area with protective multifi dus muscle spasm, but it does little good to try to release hypertonic spasm in these spinal groove stabilizers until the pelvic alignment problem is corrected. Fortunately, there are many ways manual therapists can successfully assess and correct this alignment problem. The iliosacral alignment technique shown in Image 6 is one of my favorites. A stable pelvis, achieved through proper upper and lower quadrant balance, is essential for long-term correction of sciatic nerve conditions. All ligaments and muscles attaching to the pelvis from above and below should be addressed. Sciatic nerve pain is caused by a combination of pressure and infl ammation, and treatment is centered on relieving both of these factors. Myoskeletal techniques for sciatica include low-force mobilization and graded-exposure stretching to help the brain recognize and reorganize neural input to the affected area. Notes 1. P. Hanson and B. Sonesson, "The Anatomy of the Iliolumbar Ligament," Archives of Physical Medicine & Rehabilitation 75, no. 11 (November 1994): 1,245–46. 2. A. R. Upton and A. J. McComas, "The Double Crush in Nerve Entrapment Syndromes," Lancet 2, no. 7,825 (August 1973): 359–62. Erik Dalton, PhD, is executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfi ng, Dalton has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit www.erikdalton.com. 6