Thread by @BadgleyLaurence

DYSPAREUNIA:
Many years ago, I encountered a young woman who had pelvic pain and dyspareunia. “Jane” suffered from chronic low back pain & with pelvic pain during intercourse, “dyspareunia”.

https://twitter.com/BadgleyLaurence/status/1164580742359212037

Jane consulted a Gynecologist who told her that vaginal prolapse was cause of her dyspareunia. Many visits were taken in attempt to deal with her problem: pessaries, creams, etc. Nothing helped.

Finally, the Gynecologist wrote a consultative note that she now considered that Jane was experiencing pain originating from a “musculoskeletal” disorder. Jane came to my office.

What I found was that Jane was hypermobile. One of her sacroiliac joints (SIJ) subluxed & this SIJ was on the same side where she experienced sciatica (the sciatic nerve tracts just inferior to the SIJ). AXIOM: a common thread of chronic low back pain & sciatica is injured SIJ.

The academic medical literature identifies a disordered SIJ to be the major pain generator in 13-30% of people with chronic low back pain; a concept surprisingly unfamiliar to the vast majority of professionals licensed to touch & study the human bodies of patients in pain.

Jane was lean & her body habitus enabled me to make some important observations. By this time in my decades long study of SIJ subluxation & chronic low back pain, I had developed the most dependable way to examine for SIJ subluxation: the “Badgley Book Sign” & Maneuver.

I have provided discussions and descriptions of the Badgley Book Sign several times within my Twitter feed and at Quora.com. I first described this Sign in “Practical Pain Management” (September 2009; on-line & entitled “Sacroiliac Joint Disorder”).

Scientific characteristics of the Badgley Book Sign are that it is measurable, reproducible, & teachable. Another characteristic is that SIJ deformity is function of & proportional to each individual’s body mass. The Maneuver is scaled to patient body size; as it should be.

With proper positioning, as Jane sat on a firm chair, I was able to place my hand, palm up, under her ischial prominences & make direct observations of excursions of the ischial prominence associated with her injured SIJ & ...

... as I tilted her upper body from side to side with a 1” ischial bolster (Guideon Bible). I use a Guideon Bible as a standardized medical instrument because it is ubiquitous and enables others to replicate my research.

As I placed the bolster under the ischial prominence on the injured SIJ side, the ischial prominence shifted anterior, (nutated) & Jane’s associated upper leg lengthened (monitored at anterior tibial plateaus) relative to the other leg & by about 2”. Why did this happen?

Apparently, ground force of chair seat/1” bolster shifted the ischial prominence forward, but that was not all. During forward excursion, the ischial prominence shifted slightly lateral. This is an observation of profound importance:

When anterior aspect of Ilium cants slightly medial, as ischial prominence shifts anterior during nutation, distal polar axis of acetabulum cants anterior. Net effect is slight femur internal rotation, which shifts long axis of foot into a more true anterior-posterior direction.

Of course we are talking about minuscule deviations measured in mm & 1+ degrees; phenomena too subtle to be viewed grossly. A consideration is that the long radius of the leg magnifies small spatial changes occurring at loci of the SIJ & acetabulum.

These observations of Jane’s ischial prominence during bio-mechanical stress, while tilting her body from side to side, lead me to better understand anatomy of nutation & participation of an injured Sacrotuberous ligament within the real time phenomenon of SIJ nutation.

My subsequent clinical observations led me to understand that nutation is prevented by an intact (fully tethering Sacrum to Ilium) Sacrotuberous ligament system.

In trying to understand these complex SIJ shifts of nutation & counter-nutation it is important to keep in mind that the SIJ has a virtual axis of rotation that transcends the body in the coronal plane & through the mid part or waist of the SIJ.

These observations of ischial shift with hemi-pelvis mechanical stress also taught me how SIJ nutation shifts the spacial orientation of the hemi-pelvis & axis of the contained acetabulum.

People with Sacrotuberous ligament system injury/laxity have a characteristic gait. When they ambulate, axis of the ipsilateral foot becomes abnormally anterior-posterior & absent slight forefoot lateral cant, as is seen in normal-gait foot posture.

Patients with Sacrotuberous ligament system laxity walk with foot on that side positioned abnormally internally shifted & straight ahead; absent forefoot lateral cant.

When the book bolster was placed under Jane’s non-injured SIJ, her upper body weight was shifted so as to position her upper body mass over & above the injured SIJ. This bio-mechanical force had a different displacement effect on her injured hemi-pelvis.

In this instance, I felt the ischial prominence on the injured side shift posteriorly & slightly medial (counter-nutation) & the upper leg on the injured side became shorter than on the normal side, & by about an inch. This was a manifestation of SIJ counter-nutation.

Counter-nutation expresses secondary to laxity of the Iliolumbar ligament system of the SIJ. In persons with a pure Iliolumbar ligament system injury the shift in hemi-pelvis anatomy causes a shift of the upper Ilium, the iliac crest, laterally & anterior Ilium (ASIS) laterally.

These shifts change central axis of acetabulum so that distal pole cants posterior. This shifted acetabulum axis manifests as “duck waddle” posture of foot during ambulation & forefoot everts abnormally. These are people who wear out posterior-lateral aspect of their shoe heel.

I believe these shifts in the iliac crest, during nutation & counter-nutation, are the biomechanical shifts that cause the Gillette Sign (sometimes called the Stork Sign/Test) & the Forward Flexion Test/Sign; Signs elicited during pelvic girdle exam with “Provocation Maneuvers”.

Exam of Jane lead me to another observation. She was so lean that I could directly palpate her Symphysis pubis. Remember, pelvic girdle is a bony ring with 3 joints (2 SIJs & 1 SP).

Torsion in one SIJ places torque on the SP. in Jane’s case, I could palpate a step off from one pubic ramus to the other within her SP.

The SP is a small joint held together by ligaments. Twisted ligaments hurt. SP pain is sensed in the mid-pelvis region. People with this problem think there is something wrong with their vagina & dyspareunia is experienced.

Explanation for Jane’s low back pain & dyspareunia was pelvic girdle instability from ligament laxity. She was predisposed to ligament laxity by hypermobility (#HSD). She had one child, probable etiology of pelvic disorder & from an epidural anesthesia, but that’s another story.

So what is the cause of pain, dyspareunia, during intercourse, in Jane’s case? AXIOM: Loose ligaments potentiate ligament injury. Injured ligaments are loose. Stretched loose ligaments hurt.

The perfect posture to cause SIJ torque is the Trendelenberg Maneuver: supine with knees draw up and rotated laterally; the birthing position & the position of women having sex in the “missionary” position.

Women with injured SIJs have pain dying intercourses because weight of the man forces the SIJ to sublux if it is injured; so that SIJ ligament pain is aroused & radiates into the pelvis. The woman experiences dyspareunia.

It is a common characteristic of pain generated by a dysfunctional & subluxing SIJ that pain oft radiates into the groin. This is distinctive for SIJ pain. This never occurs with sciatica generated at level of the lumbar spine. Groin radiation seems to be more common in men.

Women with SIJ subluxation causal of chronic low back pain & dyspareunia should try having sex in spooning position; while laying on non-injured (SIJ) side....

... They also like Spanx & yoga pants, which relatively bind their loose SIJ in a “form closed” & relatively anatomically neutral & fixed position; with less ligament stretch & pain when ambulating.

A loose and subluxing SIJ is also why women with hypermobility have such painful menses (dysmenorrhea), but that is another story.

I am aware that the bio-mechanical actions I related are complex. They are novel discoveries I have made & reported. I present them here so that students of human bio-mechanics can study my ideas & replicate them.

The detail I have included should be adequate for those with anatomical knowledge & to see for themselves.

The ideas I have espoused are not taught in schools of Medicine, Osteopathy, Chiropractic, or Physiotherapy. Whenever I tried to dialogue with practitioners from these schools, I have found little interest....

... They never attempt to even replicate my findings, which take only minutes to demonstrate in the clinic.

I am not surprised by this impoverished reception. I have been in the medical arena long enough to know that the vast majority of practitioners are steeped in dogma they learned in school, and reflexly turn deaf ear to ideas they did not hear within those walls.