Sunday, November 24, 2013

Uneven pelvis and sciatic pain in endo

I found this interesting as before I had excision of endo on my uterosacral and round ligaments (and other areas!), my hips were consistently uneven despite constant work with physical therapy. After I had surgery, they have, so far, been in alignment every time I've been to therapy! Also, many ladies with endo have expressed sciatic type pain in relation to their endo.


"A common site for endometriosis is on or below the ligaments that support the uterus from behind, at the level of the cervix, and which lie just below the ovaries. These ligaments are the uterosacral ligaments, running from the sacrum (the lowest part of the back-bone) to the uterus, and endometriosis affecting them is one reason why dysmenorrhea is often felt in the back.
Because these ligaments are located behind and to the sides of the uppermost part of the vagina, pain with sex (dyspareunia), is another symptom of endometriosis; it's characteristically felt deep inside the vagina, sometimes particularly after a period, when the endometriosis will have become congested. The dyspareunia might be felt from the time of first intercourse or it can develop in sexually active women who previously had no symptoms with sex.
If scarring occurs in the uterosacral ligaments from the repeated irritation and bleeding each month, the uterus can be pulled backwards -- a producing a retroverted uterus -- which can make dyspareunia worse."

"If the rectovaginal septum or uterosacral ligaments are involved
with disease, pain may radiate to the rectum or lower back.
Alternatively, pain radiating down the leg and causing cyclic
sciatica may reflect posterior peritoneal endometriosis or direct
sciatic nerve involvement."
"When endometriosis is present on the uterosacral ligaments, vaginal examination may reveal thickening or nodularity. There is often tenderness around the ligaments just before or during menstruation."

"Low back pain is a very common syptom of endometriosis. It often is caused by endo on the uterosacral ligaments. The uterosacrals, along with the cul-de-sac, are the most common site in the body to find endo. These ligaments are at the bottom of the uterus and help support it. Nerves that run through these ligaments supply the lower back (the sacral area).  Hence, endo lesions or adhesions, or both, can irritate the nerves and cause you to experience pain in your lower back. Sometimes the pain can radiate through the buttocks and down the leg. The best way to relieve this pain is to remove the endo from the body."

"Common symptoms of endometriosis include abdominal, hip, and pelvic pain, cramping, irregular bleeding, painful menstruation, low back pain, sacroiliac joint pain, bladder pain or painful urination, digestive problems, abdominal bloating, painful bowel movements, painful intercourse (dyspareunia), and can lead to infertility. Endometriosis can also be a cause of or related to pelvic floor muscle dysfunction. Endometriosis can lead to trigger points in the abdominal muscles and pelvic floor muscles causing even more pelvic pain."

"Endometriosis can compress the sciatic nerve within the pelvis, at the sciatic notch, in the gluteal region distal to the notch, or within the sheath of the sciatic nerve [, ]. The commonest site is the sciatic notch where fibrosis, organised haematoma and endometrial tissue involving the muscles envelop the sciatic and sometimes the gluteal nerves []. Hip pain due to endometriosis in a lumbar foramen has been described []. Typically, patients present with pain in the hip and the buttock radiating in the leg and foot that has its onset few days before menstruation and becomes progressively more severe, subsiding 2 or 3 days to 2 weeks after cessation of menstruation; hence, the term cyclical or catamenial sciatica. As time goes on, the duration of sciatic discomfort may increase until it is constantly present with excruciating exacerbation during menses [, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ]. Diagnosis is usually late. Vercellini et al. [] found that two-thirds of patients with sciatic nerve endometriosis had right-side lesions."

"Sciatic pain in a young woman was not relieved by orthopedic treatment. The gynecologist found a large hard tumor-like mass in the uterosacral ligament extending to the pelvic wall. Cytologic examination of fine needle aspirate indicated an endometriotic lesion. The large tumor-like mass was extirpated by an extraperitoneal technique and the pain disappeared."

Anatomy of the Misaligned Hips:
(not to be confused with "Anatomy of a Murder" by the way)
(courtesy of

"I have found that the two sides of their pelvis are not even relative to one another. Usually one side of their pelvis has an anterior rotation relative to the other. An anterior tilt is where one side has rotated down and forward. It is usually (there are always exceptions) the one that has the stronger anterior tilt that complains. There are a number of muscles that can contribute to this such as:
  • Iliopsoas
  • Rectus femoris (a quadricep)
  • The adductors
  • Or even Tensor fasciae latae
I am starting to think that this difference between the sides of the pelvis may be the common factor in the pattern that I’m seeing regardless of the symptoms that may be appearing. As of late, the symptom has just seemed to revolve mostly around tight gluteals and a tight iliopsoas.

How Does the Pelvis Get Like This?

There are many ways in which this can happen, too many to list them all, but sometimes it’s an anatomical difference in size between the right and left side of the pelvis, or an anatomically longer leg. We’ve already mentioned that the tension of various muscles can create this. A fall onto your bottom, or more specifically onto your sit bone can be the culprit. As I mentioned in a recent article, scoliosis can create an imbalance in the pelvis as well.
muscles - anterior tilters of the pelvis
I would suggest that the practice of yoga by itself is unlikely to cause this to happen. I say this because the practice of postures is usually balanced in terms of stretching and strengthening tissues as well as in terms of front/back and left/right. Some practices however could lead to furthering an imbalance if it already exists.
It is also possible that an injury sustained while practicing could over a period of time lead to an imbalance. For instance a torn hamstring could either create compensations, or a change in balance between the front and the back of the pelvis that other muscles then tighten around.

How To Check Your Pelvis

If you do have any of the mentioned issues going on then it might be worth having someone check your pelvis to see if an imbalance might be part of your problem. If you’re curious whether or not there is a difference between the sides of someone’s pelvis here’s how you would check someone else’s pelvis.
Have them stand in front of you while you kneel down and place your thumbs on their ASIS. That’s the bump on the front of your pelvis, sometimes known in yoga as hip points. They can be difficult to find on some people so it may be helpful to have them fold just slightly at their waist to soften some of the hip flexors. Just make sure you have them stand up straight after you’ve located them. Another way would be to have them find their ASIS for you.
You’ll also want to slide your finger up from just below the ASIS so that you hit the bottom of it on both sides with both thumbs. This helps you to feel that you’re in the same spot on both sides.
Most people will have at least a very slight difference in the height of these relative to one another. If it’s a significant difference then it’s more likely to be a component of the problem.
To confirm that one side is actually rotated, you should also check the PSIS, which can be even more difficult to find. This one is the bump you feel on the back of your pelvis on either side of your sacrum. It may be helpful to have the person you’re checking find them for you so you can then place your thumbs on them once again while you note if one is higher or lower than the other. The best way to find it yourself is to make slide all of your fingertips over the approximate area where you think it should be. Make circular motion and see if you can find it.
PSIS_YogaanatomyIf you found that their left ASIS was lower than the right and then when you checked the PSIS and found that the left one was higher this might lead us to conclude that the left side is tilted forward in an anterior tilt. In other words lower ASIS and higher PSIS on the same side could be indicating that.
There are certainly more sophisticated ways of confirming these imbalances; this is just the simplest way of doing it. More importantly than me trying to teach you how to interpret these differences in a newsletter is noting the differences between right and left side. Then note any differences you find in the student’s postures around the pelvis. Also the “symptoms” that you find in the student. Is there a correlation?

Understanding the Implications

Since I went with the more simple and common one side tilted down and forward a couple of things go along with this. It’s hard to say which comes first. If the pelvis is tilted down and forward (anterior tilt) on one side, we would expect to find that muscles that attach to the front of the pelvis, such as the adductors, rectus femoris (a quadriceps), and the iliopsoas might be short and tight.
This could mean that at the back of the pelvis we find that the hamstrings are longer than they should be, maybe even complaining with some pain at the sit bone. We often think long is good but what we really mean is that there is flexibility to get long when needed, not in a constant state of being stretched.
In addition to the hamstring getting long, it also means the area above the pelvis on this same side is usually short and compressed. The quadratus lumborum is the typical muscle people would suspect to be short here and it very well could be, but even the more simple paraspinal muscles or “erector spinae” muscles may also complain and feel tight, or painful due to their constant state of being short.
ql yoga anatomy david keilWith this pelvic difference it wouldn’t be unreasonable that the gluteals are also not particularly happy. If this is also the case then we might see that the student has a hard time externally rotating their thigh at the hip joint. Perhaps not an issue for students trying to do a simple janu sirsasana, but maybe it shows itself as knee pain in a lotus or as a restriction for some students trying to get a leg behind their head.
What we want to do is factor in what we’ve found in terms of the balance of the pelvis. Then we want to mix in what the student describes, or rather what areas of their body are feeling tension or even pain. Based on the coming together of these there are a number of things we might try to change in the practice or even add specific poses to help bring length to some of those shortened tissues.

On the Mat

Continuing to assume an anterior tilt on one side we will almost always want to bring length into the front of the hip and lengthen the hip flexors. This can be anything from a simple lunge to a supta virasana. Feel free to use any other postures that you know put length into these tissues.
If the gluteals and lower back are involved then make sure the student isn’t over tightening their buttocks in their up dog or other back bending type postures which may lead to more tension in these tissues. Maybe also encourage postures that lengthen these tissues such as pigeon or us the lotus preps that I describe in my youtube video."