Iliac Crest Syndrome - A Common Cause of Low Back Pain

Fig. 1: Pain site at the posterior iliac crest region

Pain experienced at the iliac crest is a frequent low back condition affecting patients seeking help from Sports Medicine Acupuncturists®. The iliac crest is the top (or ‘crest’) of the ilium, which is the most superior or upper portion of the pelvic structure. If you were to place your hands on your hips, they would be resting on the iliac crest. Pain at the iliac crest, referred to as ‘iliac crest syndrome,’ is experienced at the posterior (back) portion of the iliac crest and can be persistent (Fig. 1).

Fig. 2: Palpation of yaoyan at 
the superficial and deep vectors

This pain is at an acupuncture point called yaoyan which is a commonly used 'extra point'. Extra points are points which are not on main acupuncture channels, but have been found to be clinically important nonetheless. This particular extra point is found at the attachment site of two important back muscles. Depending on the depth, these muscles are either the iliocostalis lumborum or the quadratus lumborum (Fig. 2).

The iliocostalis lumborum is the more superficial of the two of these muscles. It is one of three muscles which are part of a group called the erector spinae (Fig 3 left image). This is the group of muscles that span the back from the hip through the neck and run parallel to the spine. The iliocostalis lumborum is the ‘lumbar’ or low back portion of this group; it runs from the top of the iliac crest (the ‘ilio’ part of the name) to the ribs (the ‘costo’ part of the name). This muscle then continues upward (but it is then called the iliocostalis thoracic and iliocostalis cervicis) and is the most lateral of the three muscles of the erector spinae. The iliocostalis functions with the other muscles of this group to perform extension of the torso, which is the motion involved in bending backward. However, since this muscle is a bit more lateral than the others in the group, it is also involved in side bending motion. In this case, only one side is primarily involved–the right muscle in right side bending and the left in left side bending.

The quadratus lumborum is a deeper muscle underneath the iliocostalis (Fig. 3 right image). It runs from the iliac crest and has attachments on the lumbar (low back) vertebrae, and ends at the 12^th (lowest) rib in the back. This muscle laterally flexes the trunk. It does this by shortening the space between the top of the hip and the 12^th rib. This would either pull the rib towards the hip (sidebending on that side) or pull the hip towards the rib (elevating or hiking the hip up on that side).

Both of these muscles have attachments on the iliac crest and both can become pain-producing sites. In both cases, these muscles would be in a shortened position when the hip is hiked on the side of pain. This is frequently what is seen with iliac crest pain.

Fig. 3: Image on the left shows the iliocostalis which is the lateral muscles of the erector spinae group. The image on the right has this group removed to highlight the deeper quadratus lumborum muscle. Both are common sites of pain at the iliac crest. Both images are from Netter's Atlas of Human Anatomy.

When the hip is elevated on one side, as is often the case with iliac crest syndrome, it is not simply the muscles discussed which are involved. Other muscles whose job it is to stabilize the hip and prevent it from elevating are also part of the overall picture. The gluteus medius and minimus are the primary muscles which do this, and these muscles have a propensity to become inhibited and fail in their stabilization roll.

When treating iliac crest syndrome, it is important to address all of the muscles involved in the imbalance. This includes both the shortened and overactive muscles such as the iliocostalis and quadratus lumborum, along with the inhibited and overlengthened muscles such as the gluteals. Acupuncture and manual therapy are powerful treatment options to correct these imbalances, and corrective exercises performed by the patient can solidify treatment at continue to return function.

The Many Injures Caused by Foot Overpronation

Pronation of the foot involves dorsiflexion of the ankle, abduction of the foot, and eversion of the foot. In laymans terms this is described below, but the important aspect is that these movements drop the medial arch of the foot.

• Dorsiflexion involves a bend of the ankle in the direction of the dorsum or top of the foot. It brings the top of the foot towards the knee
• Abduction is a turning out of the foot away from the midline.
• Eversion is a turning out of the foot which brings the medial arch down.

Fig. 1: Comparing a neutral foot (middle) to foot overpronation (left) and supination (right). Notice how the pronated foot turns away from the midline (this is abduction) and the medial arch falls towards the floor (this is eversion). Image Ducky2315 (Own work) [CC BY-SA 3.0 9http://creativecommons.org/licenses/by-sa/3.0)]

A certain amount of pronation is normal in weight bearing as this acts as a shock absorption. Connective tissue structures in the foot elongate and produce a certain amount of tension which, upon recoil, helps propel the movement, thus acting as an energy saving mechanism during walking and running. However, overpronation is a frequent occurrence which is an excessive pronation. This can lead to a range of injuries of the foot, ankle and lower leg, but also can cause or contribute to injuries of the knee, hip and really anywhere in the body.

Frequent injuries are listed below with a brief description of how overpronation contributes.

• Plantar fasciitis/fasciosis: As the foot goes excessively into pronation, the plantar fascia is overstretched. The reoccurring motion eventually irritates the plantar fascia and can lead to chronic pain in the bottom of the foot, usually where this tissue attaches to the calcaneus.

Fig. 2: Both tibialis anterior and tibialis posterior attach to 

the medial arch. In foot overpronation, the arch drops and these 

muscles are pulled long. This can irritate the tendons of these 

muscles and can also contribute to shin splints.

• Tibialis posterior tendinopathy: This condition can be misdiagnosed as plantar fasciitis, but pain is usually more at the medial ankle. The tibialis posterior supports the medial arch and can become irritated with excessive pronation as it too is repetatively overlengthened when walking or running.
• Shin splints: Shin spints can be classified as anterior or medial shin splints. The involve either the tibialis anterior or the tibialis posterior, respectively. Both of these muscles support the medial arch and can have a shearing effect where they attach to the tibia with overpronation.

Fig. 3: Note the affects on the knee and hip

• Knee pain: There are many knee conditions that can become aggravated with overpronation. As the foot pronates, the lower leg turns inward. This becomes excessive with overpronation and the knee tends to collapse in. This can contribute to medial knee pain from conditions such as pes anserine tendinopathy or lateral knee pain from conditions such as iliotibial band friction syndrome.
• Hip pain: Like knee pain, there are many hip conditions that can be aggravated from foot overpronation. One example is greater trochanteric bursitis which is often casued by an excessive raising of the hip during weight bearing. This frequently occurs with with foot overpronation and with the knee moving in.
• Back pain, shoulder pain, neck pain: Foot overpronation can be involved with many other muscle imbalances as described above with knee pain and hip pain. These imbalances can affect regions as far away as the neck.

Sports Medicine Acupuncture® is a great system for treating both the injury and the underlying causes of the injury such as foot overpronation. It employs acupuncture, manual therapy, and corrective exercises in addition to other possible treatment options. Both local acupuncture and manual therapy techniques can be used to reduce pain and improve the health of the injured soft tissue. And, acupuncture to specific points within the muscles can correct the underlying muscle imbalances that occur with foot overpronation which lead to the injury and, if uncorrected, will cause a recurrence. Corrective exercises help the treatment hold and further corrects the underlying muscle imbalance.

Fig. 4

A simple exercise which can strengthen the intrinsic muscles of the foot and help to correct foot overpronation is the short foot exercise. This exercise strengthens the adductor hallucis (hallucis refers to the big toe) muscle (Fig. 4), in particular. The following steps are followed to perform this exercise:

1. Sit upright with both feet flat on the floor. Alternately, the exercise can be performed standing on the foot to be exercised. This is more advanced.
2. Raise the arch of your foot by bringing your big toe towards your heel. The trick is to do this without curling your toes. You emphasis is on lifting the arch away from the floor.
3. Hold for 5-10 seconds. You can perform this exercise multiple times. 

While this exercise is helpful, foot overpronation often involves other structures not only in the foot. These include muscle imbalance in the lower leg, knee and thigh, hip and low back. Comprehensive work with these structures is often necessary for lasting effects. Evaluation and treatment of these contributing muscle imbalances along with treatment of associated injuries are what your certified Sports Medicine Acupuncturists® work with.