A Tiger’s Tale… or rather its Sacrum!

You may have seen over the last few days the news about how Tiger Woods sacrum ‘popped out’ during the Bridgestone Championships and how it was ‘popped’ back into place, and how this quick ‘fix’ had Tiger ready for the US PGA tournament five days later, only to see him grimace and wince his way around the first two rounds looking uncomfortable and off form and eventually not making the cut.

Now in a game like golf I’m well aware there are a myriad of other reasons why a golfer doesn’t make the cut, but to me it looked like Tigers back pain was a major factor.

So was Tigers sacrum to blame and was this miracle cure of ‘putting the bone back in’ that miraculous?

Well lets not sugar coat it, of course it bloody wasn’t.

The notion of anyone’s sacrum (a key bone in your pelvis) can just ‘pop out’ is complete and utter nonsense, let alone the sacrum of a fit athletic professional male golfer without any history of trauma, previous pelvic issues or any other risk factors such as joint hypermobility, to put it simply…

SACRUMS DON’T JUST POP IN AND OUT…

I’m not alone in thinking this is nonsense and pseudo science at its worse, many have voiced their concern and dismay at this debacle, including the British Journal Of Sports Medicine, who voice their concerns extremely eloquently here.

So lets look at why this ‘story’ of Tigers sacrum popping out has happened. But first lets look at why the sacrum simply can not pop out!

For starters the pelvis is an incredibly strong and stable structure with many, many strong ligaments and muscles across it. The sacroiliac joint does have some small amount of movement, no question about that, and yes some have more or less than others, but the variation is minimal and the belief that many have in thinking that they can 1) feel this joint move 2) decide if it’s in the right or wrong position and 3) adjust it with manipulations is just complete and utter tosh based in cloud cuckoo land and is nothing more than palpation pareidolia, a phenomenon I have discussed before in a previous blog here and on the assessment of the painful SIJ here and its management here.

Now that’s not to say the SIJ doesn’t cause some people pain, or more accurately can be a source of nociception which can produce pain, and yes there are pathologies and conditions that can cause this such as sacroiliitis etc. 

But despite the common belief there is no evidence that instability or lack of it, or mal alignments cause issues around the SIJ, rather it is usually simply irritated due to overload.

So next question is why did Tiger think his sacrum had ‘popped out’ well there are two possible reasons

  1. He got the wrong end of the stick from his medical team
  2. He was given the wrong information from his medical team

So did Tiger get the wrong end of the stick? Did he misinterpret what his doctors told him?

Well its very possible! It is well known and documented that patients often misinterpret what medical professionals tell them. There are many stories of miscommunication and misunderstandings that unfortunately happen, like the one Kieran O’Sullivan talks about in this podcast about a patient who was concerned that her back pain was caused by some things called ‘vertebrae’ in her back after her doctor showed them to her on an xray! 

Miscommunication like this does happen often, I had a patient who was convinced she had an extra bone in her shoulder after a doctor told her she had some calcification in her rotator cuff!

So yes its very possible Tiger got the wrong end of the stick. However, this is inexcusable in my opinion, that the medical team of one of the worlds most influential and recognised sports personalities do not FULLY brief and inform him about his condition simply, honestly and correctly, they will be well aware that he will be interviewed and asked questions about his injury and so must prepare him for such.

Now it may also be possible that Tiger didn’t get the wrong end of the stick and that maybe he was actually informed by his medical team that his sacrum had ‘popped out’! It seems that there are some doctors in the US that work with professional golfers that unbelievably think that this nonsense can happen.

For example a specialist golf MD called Dr Ara was seen discussing Tigers sacrum here on TV shortly after the incident and he seems to concur that the sacrum can dislocate and a quick 20 minute fix of popping it back in, together with some anti inflammatory’s equals ‘job done’.

He also goes on to offer some other rather dubious advice on hydration during the interview as well but that’s by the by!

Now when you look at Dr Ara’s website here we can see that he is a MD who has worked hard to rise to his current position as a golf specialist and this all sounds highly admirable, but the question still begs, why would a doctor who works with professional golfers choose to believe in some pseudo science such as dislocating sacrum’s?

Well in my opinion the answer is either pressure or ego!

The pressure can be from having to be seen to be doing something! Something proactive, something advanced or high tech or cutting edge by the player, or their management and even the public when really there isn’t anything more to do with a professional athlete than there is with any other patient in the early stages of injury. That is simply to give good, clear, sensible, well reasoned and evidenced based advice and education on the injury, recommend the most appropriate management, loading and if suitable, and maybe, just maybe a little bit of light manual therapy as well.

In my experience the best physios/doctors I know simply don’t offer or promise quick fixes or miraculous cures as they know they don’t exist!

I come across this a lot in professional sport, a desire by physios and medical professionals to promise things they simply cant do or that can be done just to be seen to be ‘doing’ something, whether its prolotherapy or PRP injections, horse placenta or stem cell massages, silly electrotherapy machines, manipulations, quacupuncture, stretchy tape etc etc the list can be endless, all in an effort to be seen as getting the athlete better, quicker, faster, sooner, I have a saying when I worked in professional football that I still use today….

the hardest thing for a physio or doctor to do at times is…. NOTHING!

Now, when I say ‘nothing’ I mean apart from giving good, honest, advice, education and optimal loading/movement stratagies for the essentail mechanotherapy effects, which really isn’t nothing, in fact it can be a bloody lot more hard work for a physio to do this, taking more gumption and guts to apply this than taking the easy pseudo scientific route and giving a muscle rub, joint pop or a bit of sticky tape!

Now, if it’s not pressure making medical professionals believe in pseudo science then its thier ego!

Ego to be seen as the smartest, cleverist or most cutting edge clinican! To be seen as being able to detect and cure things that other mere mortals cannot! Again I have seen this a lot, a hell of a lot in my time in both professional sport and day to day practice, guru’s, specialists or experts and thier influential charismatic personas who believe they have some extra skill or ability that no other in their field has, that only they can fix this athlete based on some mumbo jumbo clap trap that usually costs a lot of money!

Anyway, what now for Tiger? Well I wish him all the best for his recovery, but I do sincerely hope he hasn’t been affected by this episode of terrible, shockingly bad medical advice, and I hope he hasn’t been left with any negative thoughts or beliefs that his sacrum is now vulnerable to ‘popping out’ and that he doesn’t rely on the use of regular manipulations in a belief that it is putting it back in.

Instead I would suggest Tigers needs some simple, good, honest advice from a medical professional that his back pain isnt due to popping sacrums, that in fact its more than likley due to his recent disc surgey and the true cause of the structure to blame can really never be found, and that to manage this episode, it needs some time, regular movement and perhaps some good strength and conditioning from the many excellent golf specialist physios I know!

So Tiger if you need any recommendations, I know you’re a subscriber to ‘The Sports Physio’, drop me a line and I’ll hook you up with a sports physio who doesn’t feed you bull shit about sacrums popping out!

As always thanks for reading

Adam

95 thoughts on “A Tiger’s Tale… or rather its Sacrum!

  1. hi patti, can you provide me with the cases where the removal of hypermobility of the SIJ results in the ceasing of muscular dysfunction, imbalance and neuromuscular problems? For your claim to hold water researchers need to demonstrate the following:

    1. that we know of a way to reliably assess for and identify hypermobility of the SIJ
    2. if SIJ hypermobility is reliably identifiable, that we can reliably attribute pain in the SIJ region, in a causal manner to this hypermobility
    3. that removal of this hypermobility (presumably by surgical fusion or stability exercises- multifidus/TA, deep hip mm etc) is measurable
    4. that the removal of hypermobility via said interventions (above) affects “muscular dysfunction” or “neuromuscular problems” in such a way that pain is reduced or eliminated.

    note: i’m assuming that what you refer to as “muscular dysfunction” and “neuromuscular problems” = what i referred to as “defensive motor output”?

    Can you demonstrate any of these points?

    If we agree that defensive motor output is a primary driver of symptoms, wouldn’t it make sense to direct treatment towards those interventions that best stand the chance of reducing such defensive motor output? What factors might lead to the persistence of defensive motor output at the SIJ? Dont you think its possible that when a physio tells a patient that his SIJ is hypermobile/unstable, that this might plant some unhelpful cognitions with regards to the patient’s own opinion about the durability, tolerance to loading of the SIJ and influence (non consciously or consciously) their confidence and approach to occupational, recreational and sporting movement? What then might help reduce defensive motor output and sensitization? Is it necessary to move the SIJ itself in order to achieve this end? I dont think it’s necessary, but it does seem to help to provide non threatening sensory input from the SIJ region.

    Why would i, as a physio, hang my hat on a “the pain you have in the region of your SIJ is the result of hypermobility of the SIJ” explanatory narrative?? I’d have to be able to answer points 1-4 above first, which i cant do ( no one can). And I’d also have to account for other variables that arent accounted for in such a narrative.

    None of this is to suggest that an unstable SIJ is never a primary nociceptive contributor to the CNS’s assessment of threat state and projection of pain to the SIJ region… but its not fair on the patient for me to provide such a narrowly framed explanatory narrative. Pain is never that simple, its always multifactorial and its a shame that even with all his money tiger hasn’t been exposed to a balanced and reasonable explanatory narrative for his pain. I also think its a shame that you appear to have been exposed to, and now adhere to a similarly narrowly framed explanation for your symptoms and any relief you have gained.

  2. I’d just like to add that when I say pain is always multi-factorial, I don’t want that to be interpreted as me saying “pain is all in your head”. All It means is that pain is ALWAYS more complex than a linearly arranged sequence of thermo/mechano/chemo-reception>>>>> afferent flow along nerves>>>> pain… so we owe it to patients to ALWAYS provide them with information that is inclusive of this complexity. Much of the language used to categorize clinical presentations of pain have connotations attached that deny the patient an understanding of the complexity of their pain problem. This denial could be insignificant for an individual patient who responds well to whatever treatment they receive for whatever specific, narrowly framed diagnosis they have received. But such a denial can be a disaster for the non responding patient, who then begins a trial and error journey across multiple professionals, each one lumping a different narrowly framed diagnostic label, with a concomitant treatment plan. And the multitude of various diagnostic labels and treatment regimes that exist out there simply add to the overall confusion and misinformation with regards to persistent pain problems at a societal level, thus perpetuating a cyclical generation of erroneous cultural ideas about pain, why it exists, what it means, and how it might be treated without having to become a “patient”, or have surgery, or blow $1000s on conservative treatment regimes that a conceptually blinkered..

  3. Patti, the term “SIJ dysfunction”, as distinct from “SIJ or low back pain” also requires some deconstructing. The concept of mechanical dysfunction distinct from pain is popular with followers of diane lee’s paradigm for treating pelvic pain. The aberrant mechanics are argued to arise either from trauma, or insidiously from inherent or lifestyle acquired flaws in the motor control system’s capacity to provide optimal joint compression for tasks of every day living. The idea being that an optimally firing motor control system will always provide just the right amount of joint compression at the SIJ (or any joint) to match the load requirements of any given task the body is performing. If the motor control system is not providing optimal stability for daily activities, the SIJ is said to be dysfunctional… even though it might not be painful.

    I think there is merit to the idea that there exists an optimal degree of joint compression for various physical tasks… i need more myofascial force to stabilize my lower back and SIJs when I bend to lift 100lbs than when i bend to lift up a pencil. However, the clinical utility of this conceptual framework is limited by our inability to do two things

    1. to (for a given individual) measure or even guess at the range of NORMAL compressive forces (generated by muscular force) across an SIJ that effectively facilitate load transfer such that there is no excessive tissue strain or nociception generated from within or nearby the SIJ. If the dysfunction is not related to pain, how does the dysfunction manifest, and how is it identifiable? Is it only detectable via palpatory motion tests that have been shown to be unreliable? I suspect, given the range of symmetry and shape of SIJ joint surfaces across individuals, that the range of NORMAL forces for which there is no significant strain to the tissues in and around the SIJ is greater than the range of forces that the average patient subjects their SIJs to from day to day. Even if we could identify a range of forces outside of which the biomechanics of the pelvis are so affected that tissue strain to the point of nociception begins to arise (we… to point 2)

    2. dont tend to see patients who arent experiencing pain. So by the time they see us, we cant rule out the influence of the presence of pain on ongoing cyclical processing of defensive motor output, sensitization and pain. Therefore, there is no way to make judgment about how “dysfunctional” the SIJ is because the degree to which the motor control system that act on the SIJ is behaving “non optimally” as a result of “trauma” or “non traumatically” from lifestyle behaviours cannot be distinguished from the extent to which the motor control system acting across the SIJ is behaving “non optimally” because of the presence of nociception, and the cylical processing of defensive motor output, sensitization and pain by the CNS.

    So while there probably exists an optimal degree of motor output for optimal joint function (to conserve compression/shear at joints surfaces)… it exists as a moving target, that varies from moment to moment as the demands of a physical task shift from moment to moment. Its not something we can hope to parcel up in a neat package of clinical tests with a view to making discrete diagnoses such as SIJD. As I said, the neurophysiology accompanying these biomechanical issues is simply too relevant and complex to leave out of the explanatory narrative.

    We need to provide info that accounts for those variables that we know have an influence on our clinical outcomes. A narrowly framed diagnosis that considers the problem to be centred around “dysfunctional mechanics” without being inclusive of the full range of factors that can affect said mechanics is inadequate.

    • Bisco

      Thank you so much for your time and attention to detail and your expertise in these replies, you have essentially just given a consultation for free and I for one appreciate it, I just sincerely hope other do to and take heed and listen to the message, but I will reiterate one point as I think its key for patients in persistent pain such as those with SIJ

      Pain just isn’t as simple as structure gone wrong!

      Kindest Regards

      Adam

    • Bisco, thank you very much for your response. Very wise words that all SIJD patients should read and contemplate!

  4. Excellent, excellent blog as usual Adam. Please don’t let the ad hominem attacks stop you from continuing to push evidence/ science based medicine. You are doing a great job. Keep it up

  5. Hi Adam,

    excellent blog, i’ve just started to follow your opinions, ideas, clinical and scientifical knowledge. I totally agree you with Tigers problem. Pain is coming from the lumbar spine, and my opinion for manual therapy (SIJ or any joint, soft tissue etc…) is that if you just touch patients, it leads pain decreasing due to several hormonal and neurophysiological effects. But how long this will last?? You can create optimal surroundings for tissue healing process with manual therapy but main question is: How patient can avoid recurrency? My answer for this is well planned exercise therapy, which sould include always after manual therapy (if MT is even needed…).

    • Hi Marko

      Thanks for your comments, the theories and reasoning for reduced pain with manual therapy are wide and varied, but in my opinion they are predominately non specific neuromodulation with a big touch of placebo and not to forget regression to the mean, people get better on their own without any help, rubbing poking etc etc

      Reoccurrence is a tricky one and one NO ONE has any clear answers too, we can never prevent reoccurrence only try to reduce, people will always get injured, its a fact of life.

      But yes a good quality strength and conditioning program is important but can we say this will prevent reoccurrence unfortunately not

      Cheers

      Adam

Please leave your comments here...

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s