Pain in the Butt, Sacroiliac Pain as Tendinopathy?

I recently finished the 3rd edition Stuart McGill’s “Low Back Disorders.” I’ve followed his work since reading edition 2 and bulk of my back pain treatments are based on, or consistent with it and his more recent research. For those who don’t know, McGill is a Professor of Spine Biomechanics at the University of Waterloo in Canada, for which he focuses entirely on low back pain. Subsequently, more of my back pain blogs reference his research than any other source.

I was wondering what was new in the 3rd and if it were worth buying and reading through. In short, it was both. The basic gist of his treatment hasn’t changed (but there was a lot of additional detail and ideas). Said gist to eliminate back pain is to lessen the injury causing stress from daily activities, while working on exercises (to make the person fit enough) and motor skills (to make them coordinated enough) to better tolerate the rigors of life without reinjury. I 100% endorse those principles.

All the above is all filler, and sets up what I wanted to get too, which was one of the more interesting sections new to the 3rd edition of Low Back Disorders which I have never seen mentioned anywhere else. The observation appears to be anecdotal, but it’s Stuart McGill’s anecdote, which means something, and I also happen to think this observation is often correct. On page 142 he talks about sacroiliac pain (literally pain in the butt) with the following being a few of his quotes:

“Boguk and colleagues (1996) proved that some low back pain is from the sacroiliac joint itself. The following discussion offers other considerations.”

“One possibility worth considering is that the high muscular forces may damage the bony attachments of the corresponding muscle tendons. Such damage has perhaps been wrongfully attributed to alternate mechanisms.”

“It is known that a large portion of the extensor musculature obtains its origin in the SI and posterior superior iliac spine (PSIS) region (Bogduk, 1980). The area of tendon-periosteum attachment area for connective tissue places the connective tissue at high risk of sustaining microfailure, resulting in pain (McGill, 1987).”

“This mechanical explanation may account for local tenderness on palpation associated with many SI syndrome cases.”

My comments:

McGill didn’t use the the word tendinitis, or more accurately the words tendinosis and tendinopathy. However, when he uses the words “microfailure” of the “tendon-periosteum attachment area” of the spine “extensor musculature” at it’s point of “origin in the SI and posterior superior iliac spine” it sure sounds like he’s describing tendinosis, with the resulting pain being tendinopathy of the spine extensor tendons. So far there is zero research describing tendinopathy in this region, but there is no reason I can think of why it couldn’t be. Also thinking about it, gluteus maximus also attaches right there, along the SI joint region as well, so it’s tendinous region could be involved as well, while all this time it’s been blamed on the SI joint or the piriformis muscle (which I have never seen get better stretches either).

The SI joint as a source of motion or pain has long been a source of debate in physical therapy, with studies and arguments pointing for and against for decades. I’ve never been passionately drawn to either side of the argument. However, I have stress tested a lot of SI joints and rarely do I find those tests positive for pain, and if the tests are painful, I think it’s still hard to tell if the SI joint itself is the source. Also I’m skeptical treatments directed at the SI joint reliably decrease that pain. I wouldn’t go so far as to say they never do, but just not often enough to make such treatments worth routinely doing. I’ll add that sometimes when there is debate and no clear answer, it’s because there’s something amiss and it wouldn’t be the first time that tendinopathy reared it’s head in an unbenounced place. Another reason I don’t usually give SI pain special attention is my SI pain patients generally get all the way better with my somewhat standard low back treatment protocol. So thinking about what McGill wrote above, how I treat back pain and how I treat tendinopathy, I have a idea as to the reason why.

That reason is that my treatment protocol for back pain, bares more than a passing resemblance to my treatment for tendinopathy. In short, I’m basically treating for both already. Besides biomechanical and postural counseling, teaching the person with back pain how to better maintain a neutral spine during the day, I have them work to increase basically total body strength and endurance emphasising spine stability and hip mobility, with an exercise program that is generally 3 sets of 15 reps, with easy-medium-hard resistance levels. I have them progressing the weights on the next visit if the person is able to get all three sets without pain and with good technique on the prior treatment. That’s almost identical to how I treat tendinopathy, with an example being tennis elbow (aka shooter’s elbow described here) or coracoidopathy described here. In both cases I try to increase strength and endurance of all the muscles stabilizing the affected area, followed by focused strengthening of the affected muscle/tendon with 3 sets of 15 reps ( also easy-medium-hard resistance levels).

So if a person has tendinopathy of their spine extensor muscles (or gluteus maximus) where they attach on or near the SI joint, that would explain why my back pain type sets and reps, has hitherto resolved those symptoms without me even considering tendinopathy of the area being a possible cause.

Some considerations I’ll be thinking about going forward is that with back pain I endeavor to never have my patients train through pain, however with tendinopathy I try to use a resistance level that causes some pain, noting that pain almost always stays the same/or lessens in spite of increasing weights from set to set. With back pain, for which I might suspect a bulged (nearly bulged) or herniated disc, training through pain usually results in a worsening the person’s condition from one set to the next. Also with tendinopathy I notice people get better faster if they do the exercises every day rather than three times a week and my observation does have empirical support.

So if there is SI region tendinopathy I think it’s probably better to error on the site of caution and not increase resistance levels if there is any pain, which thus far seems to be working well enough. However, if the person has SI region pain, no lumbar or radicular symptoms (leg pain and tingling) I might consider a slightly more aggressive (slightly more specific tendinopathy) type approach. However, I imagine there is a lot of overlap between both conditions, such that if someone has spine extensor tendinopathy, they very likely have some spine disc or ligament issues as well even if they don’t have pain yet, so daily pain free resistance exercise of the spine and hip extensor muscles (with the spine kept neutral throughout) is maybe the safest and best approach.

For the record, I suspect upper back pain and tenderness where the levator scapula muscle attaches to the scapula is sometimes and maybe often be tendinopathy too. Which seems to resolve with my basic neck pain protocol, which like my back pain treatments includes (your guessed it) progressive resistance training with 3 sets of 15 reps (easy-medium-hard).

Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember Spinal Flow Yoga for you or someone you know in the future.

Chad Reilly is a Physical Therapist obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed Yoga Teacher Training at Sampoorna Yoga in Goa, India.

22 thoughts on “Pain in the Butt, Sacroiliac Pain as Tendinopathy?”

  1. Have you had a chance to read McGill’s “Back Mechanic”? I find myself using this book and “Ultimate Back Fitness and Performance” a little more than his “Low Back Disorders”. I was a little disappointed in his DVD’s, the one I have is a glorified video of some of his continuing education courses. All his work is worthwhile. Too bad he is retiring from academics.

    • Hi Ron,

      Yeah I actually just finished Back Mechanic a few weeks ago. I really liked how McGill worded some concepts in it, and with it I think I can better explain some ideas to my patients. Plus, it was a good review of what he thinks is most important. I think it’s definitely more accessible than Low Back Disorders for laymen, but that most people aren’t going to read something that detailed either. And yeah, as much as I agree with McGill’s treatment principles, I do tend to incorporate them into more fitness type exercises like in Ultimate Back Fitness or rather some of my favorite weightlifting/bodybuilding exercises, minus the one’s bad for the back, more so than what’s in Low Back Disorders. Heck, now that I use EMS for abdominal strengthening, I don’t use “the big three” that much anymore. I still think the big three are great for a HEP when patients don’t have any equipment, though I almost always use the “modified side bridge” instead of the normal one.

      My above blog was getting long, but I was thinking that if you had SI region tendinopathy that you would need higher intensity exercise to remodel those tendons than a bird dog would provide, so standing cable rows, squats, RDLs, etc. with weights would maybe work better. I’m thinking the same thing for greater trochanteric pain syndrome and gluteal tendinopathy, where more aggressive progressive resistance exercise (with the spine still locked in neutral) would better remodel the tendinosis region than big three and clam shell type exercises can deliver. Maybe full on side bridges would, but I notice they can be hard on the shoulders of my patients who often aren’t as fit as the McGill subjects in his books.

      As for the DVDs, I guess I liked them all, maybe not the golf one so much, but I agree I get more out of the books. I hadn’t heard about him retiring, but I suppose he’s earned it. I’ve been following some of Jack Callaghan’s stuff regarding standing low back pain in particular. I think they worked out of the same lab at the University of Waterloo. Definitely let me know if you come across anyone else worth reading. I’m on a roll for back pain books, having recently finished Back Pain Revolution and got almost nothing out of it, except I think for a thorough understanding of the holes in the biopsychosocial model. I’ve been meaning to do a blog on that one as well.

  2. hi chad,
    it was because of you that i found out about stu mcgill over a month ago. i had been off work for over 2 months back in late february looking at mckenzie physio videos when i decided to see if anyone had anything critical to say about it which led me to your blog where you referenced stu mcgill. i live close to waterloo and my nephew’s wife teaches pharmacy at u of w. i had never heard of the guy and not one of the physios i had ever gone too mentioned him or his work or followed his recovery path. i spent days watching a lot of his videos and listening to other physios interviewing him on their blogs and then ended up buying back mechanic. i emailed him asking whether he could recommend someone he trained or knew that i could see for an assessment.lo and behold i got a reply 30 minutes later from mcgill himself. he’s retired and living up in what we call cottage country. he still examines and treats individuals for $600 cdn dollars a month if anyone is curious but did recommend a former phd student of his who is now a chiropractor.

    so thanks a bunch there chad. I wish you practiced around here. i’ve watched a few of your videos. keep up the good work and say hello to walter white for me 😉

    • Hi Richard,

      That’s a cool story! It’s interesting to me that none of the local physios to you had heard of him. From what I can tell here in the USA, not that many physical therapists are aware of or follow his research either. I’m glad you were able to find help nearby, it seems a lot of people cant.

    • Hi again Ron,

      A number of people were telling me about that article and I have numerous and mixed feelings. It’s timely because my project for this year is to come up with an ideal yoga routine for low back and neck pain. The aim being a sequence of exercise that maintains a neutral spine throughout, improves spine stability, hip mobility, teaches good motor control, etc. Basically a yoga sequence that incorporates all the good that McGill talks about, including (as best as I can) my strength training stuff, while avoiding all the spine flexion/extension and twisting, which admittedly rules out a lot of traditional yoga asanas. Also I still want to preserve various and positive mindfulness aspects of yoga, which seems to be holding up well in the research. In doing so I’ve taken a fair share of yoga classes, read most of the yoga and back pain research, as well as books. So it’s good timing that this paper came out now.

      It took us a while to find the above paper, but here it is. They don’t list any of the details about either the yoga program or the physical therapy routine in that paper but here is the teacher training manual that describes the yoga routine reasonably well. I had to go back to their 2014 protocol description to see the details regarding the physical therapy program. Basically it sounded like McKenzie stretches into either flexion or extension (and we all know what I think of McKenzie method) plus some very low intensity and extremely long duration lumbar stabilization exercises. Like 30 reps with 8 second holds. It’s hard for me to imagine anything more boring. That was followed by 30 minutes of aerobic exercise, and no modalities. I couldn’t see that they did anything substantial to strengthen hips nor anything to teach good spine/hip motor control in real life situations. The researchers referred to the pain as non-specific, so overall I got the impression they didn’t have any exposure to McGill’s research. So in short I thought it was a substandard (though fairly standard) yoga routine, followed by a substandard physical therapy routine (not that I think most PT protocols are worth bragging about). So I’m not surprised the results were similar. What they fail to mention is the world news outlets and all the press this paper got was that neither the yoga nor the physical therapy program improved pain very much over that of the education group, who just got a book to read. The book itself being a copyright 1999 hodgepodge of what I think was some good and some bad advice. It definitely wasn’t “Back Mechanic.”

      What didn’t make the news was the fact that neither the yoga nor the physical therapy program worked very well. Outcomes for both were better than the education only group, but outcomes weren’t that much better. For example at week 12 the yoga and physical therapy pain scores dropped from 7ish only to a 5ish, while the control group decreased to a 7/10 to a 6, which would make me wonder if any of the routines were worth the effort or if either the yoga or physical therapy programs were better than placebo, and were perhaps just a higher, or more theatrical a placebo.

      I have a lot more comments that I’m working on now about the best way to share them, such that they’ll be well received. I’m thinking that’s the tricky part.

  3. Hi, Chad,
    I really hope this comment reaches you, because I really need help. I’m 35. This all happened a year ago, when I was 34. At the time, I was completely healthy, walked several miles a day, and enjoyed life tremendously. All that is different now.

    Last September I tore the TA muscle partially from the pubic bone. At the time, I didn’t know that was what had happened, so I underwent a battery of ridiculous and painful tests & procedures, including steroid shots to the abdomen. Following a colonoscopy (that is how clueless medicine is with regard to torn abdominal muscles in non-athletes), a nurse moved me improperly while I was still groggy from anesthesia and I fell like a tree on my butt/low back. Hard, from my full height of 6 feet (I’m female).

    This fall might not sound so bad, but it tore both hip labrums; made both hips excruciatingly painful whereas before they’d never pained me at all, ever; triggered chronic SIJ dysfunction; caused L4 & L5 to both bulge and tear (the annular tears are described as “mild,” but they are on the outside where all the disc nerves are); severely bruised (possibly fractured, never did find out) my coccyx; and made the original abdominal injury, which was actually quite mild, worse. I cannot describe to you the agony I went through for the next three months. I remember at my first ER visit (out of a total of 16… long story, but basically the nurse didn’t report the fall, and since I already had complained of abdominal pain, I was labeled as a drug seeker) screaming wordlessly at the top of my lungs. I couldn’t answer any questions; my husband had to tell them basic information, etc.

    Over the next 8 months, nothing was done about my back or my abdomen, so I was in a holding pattern of doctors scratching their heads and misdiagnosing me with bizarre conditions that I didn’t have (Ehler-Danlos, ACNES, hysteria) and telling me to just live with the pain. When I finally figured out which surgeon to see for the abdomen (doctors locally were absolutely hopeless with the abdominal injury, so I figured out what it was & took action), 90% of the TA was detached (and the TA was a mass of scar tissue), there were over a dozen muscle tears (and related scar tissue) in the rectus abdominis, and tears and scar tissue in both adductors. The back injury caused massive delays in figuring out what was wrong with my abdomen, and forced me to undergo bilateral hip surgery in addition to bilateral abdominal surgery. (The original injury was a small tear on the right side, but it spread and got way worse over time.)

    The surgeries were four months ago. Ever since, the back injuries, which are as yet untreated (except for one round of steroid shots last month in the facets, which didn’t change my situation), have been interfering with PT from the hip & abdominal surgeries, and I don’t know what to do at this point. My physiatrist keeps underselling how serious my back injuries are, even though I’ve told him repeatedly that back pain & related muscle spasms keep me from doing much PT for the surgeries. I can’t even do much walking, and lying on my back or belly is out of the question because it causes so much low back pain. He openly says that he doesn’t have much of a plan for how to treat my back, other than trying injections and PT (which has made my back pain worse, ironically; I’ve been struggling to do PT for a year, but it hasn’t helped much), and that the discs shouldn’t pose any problems at this point, so I am coming to you in hopes that you can guide me in what to do next.

    Do I address the annular tears first, or the bilateral SIJ dysfunction/pain? Do I address both issues at once? Should I try disc injections, even though I’ve read they can cause the discs to herniate? Do I try disc surgery? Should I continue with PT, even though it makes the lower spine / central pain worse? How do I fix the SI joints? Should I try prolotherapy? The SIJs hurt terribly and make walking long distances impossible. Though walking also irritates the central part of my low back (facet joints? discs? both?).

    I know you can’t tell me exactly what to do, but even some general guidance would help. I’ve seen over a dozen doctors for my back alone, and it took a fight just to get imaging done after the fall, which showed fresh annular tears and fresh bulges. (I know the bulges were fresh because abdominal CT scans taken days prior to the fall showed no injuries to my lower back at all.) I don’t know what to do or where to begin, or even what is really going on with my back, and it seems that neither does my doctor.

    Thanks for reading this. Please help.

    • Hi Layla,

      It’s hard to know what to say with regards to specifics as you seem to have both a rare and complicated collection of issues. It seems you know that though so hopefully I can offer some generalities and direction, as well as some impressions based on what you write.

      I haven’t treated anyone with a TA tear, but this sounds a lot like a hernia, and would think would be treated similarly. Unfortunately, there isn’t a lot of guidance as to what one should do for a hernia either, in spite of surgical repair being so frequent. Most surgeons I have heard of ask for 8 weeks avoidance of direct exercise, then gradually working back into usual activities. It’s not something that’s frequently sent to physical therapists. Thus I would think the general advice is sound. After 8 weeks if it were my abdominals I would start strengthening them with EMS, much as described in this blog. [edit, to add my electrode placements are a little different than what I show, so if you get a machine let me know and I’ll upload new images]

      The back pain, I would expect came on strong from inactivity, in what was likely a prolonged slouched posture. Because, what else are you going to with the abdominal and hip injuries. I would think the lessened abdominal integrity resulting from the tear, and likely increased spine mobility during daily activities, compensating for hip pain and lesser strength from the labral tears, didn’t do you back any favors either. Initial stretching and strains of the vertebral ligaments and discs won’t show up on an x-ray or MRI but can still be quite painful and cause “reactive” muscle spasms. For some reason this leaves most health care professionals very confused, and they’ll try make you feel better by stretching those spasms, making the underlying injury (what the spasms are trying to protect you from) worse. So don’t stretch your spine, that’s my advice numero uno.

      You say you don’t have Ehler-Danlos, but I would not be surprised if you don’t have some joint hypermobility, which contributes to all of the injuries. That said, I would think you would want to gradually strengthen everything muscular so that those muscles can better support all your joints. Living with the pain would definitely not be my plan A.

      I think if you try and fix any one thing first, everything on hold will only worsen, so you’ll never catch up. Total body strength and conditioning, starting very light, but if it’s too light for too long you won’t get ahead either. I’m still building out Spinal Flow as a site, but SF5 begun on Level-1, just a few of the exercises might get you going. My Spinal Flow User Rules are to increase reps/levels each time every workout, but in your case it might be more prudent to slow increases to every third workout on the same bodypart. An EMS machine with good electrodes and straps would probably be your best friend and with all your body parts needing it, if it were me I’d order a Globus Triathlon off Ebay direct from Italy. The USA imports all have their software dumbed down so can’t be programmed in the way I think is best. They’re less expensive from Italy too. My pads and straps kit, which you would almost certainly want to go with it is $120 shipped. I don’t have my store up anymore as I’m working on other things, but I could still ship them if you PM me.

      I would not get my discs injected, nor would I consider back surgery unless, your suffering neurological loss of bowel, bladder, or leg function and your surgeon says it’s an emergency. I hope that’s enough to get you started.

  4. Hi, Chad,
    Thank you so much for taking the time to reply to my comment. I know I have a mixed bag of damage; my physiatrist called me “a complex case” at my last appointment with him last week.

    To clarify, the TA muscle was literally torn off the pubic bone; it wasn’t a classic hernia, although initial work-ups assumed that (or something gynecological) was the case. The surgeon who worked on my abdomen re-attached the TA and repaired the torn adductors as well as the multiple tears on the rectus muscle that resulted from the TA’s having been detached for so long. I tried PT for the abdominal pain for seven months, but all it did was make the tear worse and intensify my abdominal pain. Core muscle injuries differ from traditional hernias; my surgeon, Dr. William Meyers, actually just published a textbook about them. They are often confused with traditional hernias and as such they are not treated correctly, with treatments usually making the injury worse. My initial injury wasn’t that bad, but it was left to fester a long time, plus the fall aggravated everything, so I wound up needing surgery. I don’t think I would have needed surgery if I’d been diagnosed immediately, as some people are lucky enough to experience.

    The back pain is the direct result of the fall that I suffered. All of the back injuries occurred simultaneously as a result of that trauma. I was groggy from anesthesia and so my muscles were not as “awake” as they otherwise would have been, hence, I think, the severity of the fall, as I was essentially dead weight hitting the floor with no reactive muscle tone. The fall is what caused the L3-4 & L4-5 discs to bulge and tear; the SIJs to become dysfunctional; the facet joints to become injured; and the hips’ labrums to tear. I really do not have Ehler-Danlos or anything like that. I think the TA being partially detached also contributed to the severity of the fall. It’s absolutely amazing how much damage that fall did. My back and hips were 100% symptom-free before that fall, even with the abdominal injury.

    I am extremely leery of back surgery, although I am curious about laser surgery to repair annular tears – any opinions? Why do you think I should avoid getting the discs injected? I’m leery about that, too, but it seems the only thing my doctor has to offer is injections. He even said so at the last appointment, that injections and PT are pretty much it. Except PT (including just walking) aggravates my back pain, and facet injections only worked for about 4 days. I am stuck in a pit I can’t get out of.

    Thank you again for taking the time to reply. I appreciate your advice and will avoid stretching my back. Does that include even “sleepy” stretching, the kind you do when you get out of bed?


  5. Oh, and I feel silly asking, but what is an EMS machine, how does it work, what are its limitations as far as results?

    I’m seriously considering prolotherapy for my SIJ dysfunction. In your experience/opinion, does prolo help this issue?

    Thanks again.

    • 1: Regarding the TA being torn like a hernia or differently, I would assume the healing times are similar. “Assuming” and taking an educated guess is about as good as you are going to get regarding how you should proceed as I doubt there is any research on healing times for your type of injury. If your surgeons text book says something different, I would defer to it.

      2: Impact injuries to the spine usually result in vertebral bone injuries, or Schmorl’s nodes (vertical disc herniations), rather than bulged discs or annular tears. I suppose it’s conceivable that you got a disc injury from a fall, but it’s probable that the fall made asymptomatic bulges, symptomatic. However, what caused the injury is meaningless. What matters is how to make things better, and almost certainly improving your posture will help as will lessening habitual spine flexion, while you gradually build up total body strength and fitness.

      3: My opinion is that I would not get laser surgery. I don’t think I could explain why in any kind of succinct way, except to say that I don’t think it will help.

      4: Cortisone injections make tissues weaker. Your tissues are already torn, thus even if they lessened pain and inflammation in the short run, you will likely be worse off in the long run.

      5: Research as shown stretching the spine upon awakening is the most dangerous time to do it. The discs are most full of water at that point and like a “most full” water balloon they are most ready to burst.

      6: EMS is electric muscle stimulation. Done properly, it’s a very effective way to strengthen painful muscles and lessen pain at the same time. Done improperly it’s worthless. I have an entire category of blogs on EMS/TENS that you should be able to find linked up to the right.

      7: When I read up on prolotherapy a few years ago I was unconvinced that it would help people with spine/SI pain. I have never recommended it. I did find EMS on the hip muscles fairly effective, as described in my year long log.

  6. Hi Chad,

    I am hoping you can help. I have had low right back/butt pain for 4 months. I have tried nearly everything without success so far. My PT said it was SI joint dysfunction but my spine specialist & mri said it was more likely due to L1S1 disc protrusion with some facet arthritis. It feels inflammed in the same spot all the time to the right of my tailbone when I clinch it. Up until May I was an active athletic 36 yr old male who loved to play tennis on the weekends. The only times it has felt good/normal has been when taking oral prednisone but the effects aren’t lasting. Can you please help steer me in the right direction?

    • Hi Nate,

      Just playing the odds I would vote in accordance with your specialist/MRI, however it could be more than one thing at the same time, which can make things confusing. On the bright side, and which this particular blog alludes to is that basic strengthening of the body, while keeping the spine neutral works for almost all the things it could be. I wrote it a couple years back when I was treating spine pain out of my clinic with a full gym, with all the weights and machines I could want. I still endorse that, but it wasn’t helping people so much who had questions, but didn’t have access to my gym. Potentially good news for you, is I’m teaching much the same thing but entirely with home exercise. C5 (control-5) to teach the postures and coordination and F5 (flow-5, though I should probably change that to force-5) to progressively build total body, and spine, strength and stamina, utilizing the postures and coordinated movements taught with C5. F5 is my current workout only because it turned out much better than just rehab. That’s the direction I would initially steer you, and depending how you respond I could hopefully offer more input. I would encourage you to also read my pages on the causes of spine pain, red flags, and the user rules. Together I would think that would keep you out of trouble, exercising and during daily life.

  7. Hello Chad
    Don’t know when this was written, if you’re still looking at comments but I want to say how helpful this explanation is.
    I’m just someone who’s gone from fit to not amounting to much due to chronic pain in the SI area. Working with a range of clinical and non clinical support at the moment, the kind of treatment you indicate is similar to what so far has worked for me.
    What I find helpful in your post is the focus in the combination of tendinopathy of the erector spinae attachment to the iliac crest and of the gluteus maximum attachment to the SI.
    I could never quite understand why these two are the main focus of pain for me in general and the g.m. especially when I “use the hip” a lot (I’m an endurance cyclist).
    It makes complete sense to me that they are related.
    There’s some work looking at the ES entheses to the medial posterior iliac crest via ultrasound as a diagnostic route for generic low back pain.

    My main worry is that after more than 1 year the tendinopathy might have become chronic and a lot harder to treat. I had a traumatic injury to the area about 18 months ago but not easy to connect that to they pain.

    Anyway, thank you. Great insightful piece of writing

    • Hi Elena, thanks for the complements! I wrote this blog back in 2017 and as you can see I’m still here. I’m just focusing my time on the development of Spinal Flow the program, but as that’s coming in order I’m hoping to return to more peripheral subjects such as this. I just searched “erector spinae enthesis” and found this, and this, which I expect is the studies you refer to.

      Some comments:

      Regardless of what the latter study found, I would not let anyone inject my tendons with a catabolic hormone. On average with tendinopathies doing so results in short term gain, with long term results being worse than nothing.

      I wouldn’t overly worry about the tendinopathy being chronic. It’s my general assumption that is, and it does not seem to greatly affect treatment. It perhaps makes it take longer, but the basic formula of 3 set of 15 reps, easy medium, hard, is something I still haven’t improved upon.

      One more thing I would add is I’m wanting to write a blog, “Pain in the Butt 2: Gluteal Muscle Death” in which I think people who have lifestyles that require a lot of sitting, the act of doing so causes a pressure injury to the gluteal muscles, resulting in inflammation and cell death similar to the deep pressure injury and ulcers that wheel chair users often end up with, I wouldn’t expect this in your case as I think cycling sits you more on the ischial bones as opposed to the gluteal muscles themselves, but if you had a desk job too, or long commutes, it could be there also. But that’s another story I hope to describe in full.

      Anyway, good luck to you, I appreciate your comments, and you gave me two new papers to read.

  8. Hey Chad, I’m so happy i’ve found your site, your blog has been invaluable to me with info regarding my spine injury, so thank you for this. Yesterday i signed up and have started your flows this morning. I have a couple of questions I’m hoping you can help me with…
    So I’ve been an indoor cycling instructor and yoga teacher for the past few years and around a year ago I started to notice a niggling pain in my low back and around the SI joint area whilst cycling and after practicing intense vinaysa flows. This was followed by a chronic ache after, which made it impossible to get comfortable when sitting. I was diagnosed by multiple chiropractors/osteos with pelvis rotation SI joint disfunction. I’ve had many Chiro adjustments to realign the hips lots of work done on piriformis and psoas, acupuncture, you name it.. but these would only give me temporary relief. Months later developed pain on the opposite side closer to the spine whilst in flexion and extension mainly during yoga practice, so decided to get an MRI. The scan confirmed i have L5 S1 bulge, which i now believe was also contributing to the SI joint pain. I was advised to go back to strength training which helped a little but I have never been able to get rid of that chronic ache which feels like it comes from the SI area. In January of this year i awkwardly lifted a weight with flexion of the spine and felt I pulled something in the low back, which has now left me with nerve compression and intense sciatica radiating down the leg to the calf muscle. After 6 weeks of physiotherapy and attempting various techniques to try and release the nerve (mackenzie, nerve flossing etc) I decided to get a second MRI. This confirmed the disc bulge had gotten worse and I had nerve compression. It seems that everything I do at the moment makes the nerve more inflamed so I am currently having to take NSAIDs every day. I have seen a neurologist who advised me to do as much spinal traction as I can, prescribed cortisone tablets and I am currently waiting to have a series of Epidural injections. For traction I have been hanging from a pull up bar and also just purchased an inversion table which leads me to my first question; I feel a benefit when hanging but then a lot of sharp shooting nerve pain after – when coming back to upright and putting weight back through the joints. In your opinion do you think the table is going to help or just aggravate the nerve compression even more? My second question is with regard to your F5 routine – as I am having to take NSAID’s every day to reduce the sciatic nerve pain in the leg would you advise me to only do this routine before taking? Or do you think the drugs could help me to get through the routine without the nerve pain holding me back? My final question is regarding cycling. I see a lot of your responses on here relating to getting back to training, which always involve keeping neutral spine. However, i am really hoping that at some point i can return to cycling, so am wondering what your thoughts are on the slightly flexed cycling position with regard to worsening my disc issue? When I’m in this cycling position I feel less nerve pain than standing/walking, in general slightly flexed gives me some release feels a lot more comfortable than extension , although I do however still experience the ache around the SI joint.

    You’re the first person i’ve come across who seems to totally understand these injuries and give clear concise advise. Any information you can give m regarding these queries would be much appreciated.
    Many thanks in advance

    • Also if you have any tips on how i can attempt to release the sciatic nerve, or at least get the pain out of my leg that would be amazing!

      • Hi Craig, thanks for the compliments! First off, I would question the idea that your pain is coming from your SI joint. It could be from there, but since an MRI shows a L5-S1 bulge, I would think that sufficiently explanatory. Of course it could be both, but the combination of C5 and S5 of Spinal Flow should treat both.

        First I would think you would want to read my page about spine pain causes. Both vinyasa and cycling very frequently and repetitively put you into spine flexion, and spine flexion is what herniates discs. In fact, as far as we know it’s the only thing that herniates discs. So the less you do that, the less you will suffer. It’s inconvenient that that’s your job, but if you were to modify your instructions and cycling seat position to eliminate spine flexion you have a good chance of curing things. You still can flex about the hips, but continuing to spine flex will likely turn that bulge into a herniation, which can be an entirely new level of pain and disability.

        I love yoga as a philosophy, but with regards to spine pain, modern day yoga has become a positive feedback cycle of pain, where the stretching irritates the spine. The spine tries to protect itself by spasming. Yogis interpret the protective “reactive” muscle spasms as the source of pain and try and stretch them out, only further damaging the soft tissues of the spine that the spasms are there to protect, worsening spasms and “feelings of stiffness” that they again try and stretch, until finally they are where you are, with a bulged or herniated disc. To break the cycle YOU MUST STOP STRETCHING (let’s call it wrenching) your spine. And I don’t mean to pick on yogis, as your regular doctor, your physical therapists and chiropractor are probably all encouraging you to stretch.

        I would expect the chiropractic adjustments, acupuncture, etc. to do nothing beyond placebo. On the bright side, because they are not in themselves further stretching the spine, they aren’t causing further harm like the stretches are, but since none of them are at all related to improving posture, improving neutral spine awareness, and improving total body strength and stability they aren’t doing you any good either. McKenzie therapy has good points and bad points also (it’s often just another kind of spine wrenching) so on balance is something I would avoid, same with nerve flossing, which sounds like is evidenced by your worsening MRI.

        Strength training is good, so long as the exercises you choose are not further damaging your spine. Crunches are good in a way, in that they increase abdominal strength, but bad in that they entail repeated spine flexion, thus good for the muscles, bad for the discs. Spinal Flow’s F5 should be help, as it’s increasing abdominal (and everything else) strength, while not flexing the spine, thus good for the spine, good for the discs.

        Epidural injections have been shown to work in the short run (if by work you mean decrease your pain while you continue to worsen your spine via the same habits that have hitherto hurt it) but with risk of significant mortality (they have put people permanently in wheelchairs). My recollection is that epidurals lost FDA approval for back pain due to their high risk profile.

        Traction is a mild wrenching. I’m not particularly against it, I don’t know that it would make you worse, but I’m not for it either. Research suggests no lasting benefit, and my personal experience working with traction was never impressive. If you feel worse afterwards, I would consider that a sign not to continue.

        If it were me, I would stop taking the NSAIDS. Inflammation is the body’s method of healing injuries, so in theory fighting inflammation is only slowing the healing process. Antiinflammatories being anti-heal-atories if you follow that reasoning. Also in doing F5, I think you would want to know sooner, rather than later if any exercises are irritating you. That would allow you to stop the offending exercise sooner, per user rule 6, and hopefully progress more the next time, as opposed to taking a step forward, aggravating yourself, and taking two steps back.

        Regarding getting back to cycling. If you lower your seat and/or raise your handlebars you should be able to pedal with the spine in neutral, therefore not damaging your spine. For indoor spinning there would be no aerodynamic consequence. Outdoor riding, the upright style would have more wind drag, but beats having a herniated disc. FWIW, I had a cyclist, saw him after his second lumbar fusion. His doctor told him he could return to cycling after the first fusion, apparently unaware that the same forces herniating L5-S1 would do the same at L4-L5. After I saw him we got him back to better than 100% strength, but I said if he continues to ride with high seat and low bars I would be happy to rehab him again after fusing L3-L4. He listened, and adjusted his bike for a neutral spine riding posture.

        By eliminating spine wrenching the inflammatory reaction underway now should reabsorb the disc, and when healed, should no longer irritate your sciatic nerve. F5 is the workout that restores total body strength in a spine healthy way, I would suggest becoming an expert in C5 also. It’s teaching the postures you want to take learn to carry throughout your day so as to not further injure yourself. Just sitting in spine flexion, working at a computer, or watching TV is enough to keep the pain going once it’s there. Which I think is why “rest” often doesn’t work well for back pain. The restful postures people chose are often more stress. I hope that helps!

        • Thanks so much for your response Chad. Very interesting what you’ve said about NSAID’s I was not aware that they could hinder recovery, in fact i thought the opposite. The problem I face is that without pain killers i’m in constant agony with the nerve pain, in particular when standing and walking. Therefore a lot of both C5 and F5 routines are very painful to do and after three months of feeling disabled the last thing I want to do is risk aggrevating the nerve any more. I will stop the NSAID’s as suggested and take it slow see if it helps.

          With regard to cycling – towards the end of last year when I was still training I did alter my riding position to try and achieve a more neutral spine and alleviate this ache around the sacrum area the by raising the handle bars. However, this only seemed to aggravate the injury even more, it felt as though the straightness of the spine was putting more compression on the low back. I think maybe the key is to find a slightly flexed position to take the pressure off but not flexed enough to damage the disc further. Interested to hear what your thoughts are on that.

          So currently I am just doing the C5 and the Mcgill big 3 every morning and hopefully if the nerve pain lessens then I will progress to start doing more of the F5. Aside from nerve flossing and keeping neutral spine do you have any other tips on how I can attempt to get the nerve pain out of the leg?

          Also with regard to keeping a neutral spine and sleeping, i’ve been using pillows under my knees and sleeping on my back. Just curious if this would contribute to slight flexion of the spine (as lifting the knees tends to flatten the back). Do you think i would be better off sleeping with the legs straight?

          Thanks again for your help.

          • The parts of C5 and F5 that are painful, I would wait on before implementing. Let things calm down a bit, which unfortunately can take weeks for the body to go through its inflammatory process. I did a blog on massive herniated discs, the good news, that might be of interest. It’s been some years since I wrote it, but my recollection of the findings was that the larger fragments, by eliciting an increased inflammatory response, had a greater resolution of said fragments. Take everything I say with a grain of salt however.

            Yes, it’s true if a disc fragment is impinging on your nerve, being in slight flexion, opens up space for the nerves and might feel better in the near term. The bad news and catch-22 is that same flexion can make the disc bulge/herniations worse. I’ve had people in the catch-22 situation where neutral hurt, in such case we did the best we could, staying as close to neutral as we could, working into fully neutral over time. If it were me, I’d give cycling a rest for a while.

            I personally don’t believe in the flossing. I know McGill talks it up, but bases it on anecdotes. And his technique for flossing the nerves incorporates a lot of neck flexion and extension, apparently not bothered by the fact that cervical discs herniate too.

            Yeah, I’m against pillows under the knees. That “posterior pelvic tilt” physical therapists always talk about is just spine flexion. Personally, I prefer to sleep on my stomach or side.

            Also, check out what I have to say about EMS and back pain and muscle strength. It’s legit, and synergistic with Spinal Flow.

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