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THE LIGAMENTS OF THE SACRUM The Primary Cause of Low-Back Pain, Part 2 Test 1. Flexion Ask the client to bend forward slowly, stopping if and when pain is felt and immediately returning to the upright starting position. If there is pain, ask the client to point to the area or areas that hurt. With a normal range of motion, the person can touch the floor (image 1, page 101). In the previous article, we began our discussion of the ligaments of the sacral area by examining the anatomy of these structures and the various pain patterns they cause when injured. Here, we'll move on to look at the assessment and treatment of these injuries. We'll cover testing procedures to determine which structures are injured and a range of treatment options, from exercises and manipulation to specific friction therapy techniques. INJURY VERIFICATION A pain in the low back can mean many things, varying from simple to serious, and figuring it out can be a complicated process. In addition to a ligament or muscle injury, low-back pain may be caused by cancer, a nerve root compression, spinal stenosis, or another serious condition. Whenever a client has apparent muscle atrophy, bladder or bowel incontinence, extreme limitation of movement, severe pain, or symptoms of numbnesss, advise that person to consult a physician right away. The evaluative tests and treatments described below should be used only after a physician or other fully trained healthcare practitioner has ruled out the more serious causes of back pain. LOW-BACK ASSESSMENT TESTS A full assessment of the low back— which distinguishes between injuries to discs, ligaments, muscles, and other structures—includes 27 assessment tests and is beyond the scope of this article. Here, we'll focus on ligament injuries, which are among the most common and least known causes of chronic low-back pain. Damage to ligaments in the sacral area is indicated by the results of three tests: flexion, extension, and side-flexion. For each of these tests, have the client begin in a standing position with the knees straight and the feet a few inches apart. Ask whether the person feels any pain in this basic standing position. If the answer is no, you'll be testing whether each assessment test brings on pain. If the answer is yes, you'll be testing whether each test increases the pain. Test 2. Extension Ask the client to bend backward from the waist. Again, if there is any pain, have the client stop, return to the starting position, and point to the place or places that hurt. With a normal range of motion, the person can bend at least 30 degrees (image 2, page 101). Tests 3–4. Side-Flexion Ask the client to bend to one side as far as possible, stopping if and when there is pain. Be sure the knees remain straight. Take note of where any pain is felt, and then have the client bend toward the opposite side. With a normal range of motion, the person's hand can touch the side of the knee (image 3, page 101). UNDERSTANDING TEST RESULTS When the ligaments of the sacrum are injured, there is usually pain with one or more of these movements, with the worst pain felt in either flexion or extension. The individual generally feels pain right at the sacrum and may also feel some discomfort across the lowest part of the back and/or in the buttock, thigh, and lower leg. In cases where pain is felt only in the posterior thigh and lower leg, it is usually caused by strains of the sacrotuberous and/ or sacrospinous ligaments. (See images 4-8, pages 102–105, for referred pain patterns from each of these ligaments.) visit massageandbodywork.com to access your digital magazine 99