Core Stabilization

Core stabilization is a concept discussed commonly in chiropractic, but until recently I had not come across one source that compiled research and presented conclusions, based on logical and quantatative studies, in a clear and precise manner. There are two general theories on core stabilization; core stiffening and hollowing. I will not go into detail about these theories so as not to influence you in one direction, but I recommend reading up on both. Recently, I finished a book Dr. Morgan recommended and I would STRONGLY SUGGEST every chiropractic student read at least the last few chapters. Stuart McGill’s “Low Back Disorders: Evidence Based Prevention and Rehabilitation” gives a nice review of back anatomy and biomechanics as well as discussing common injuries found in a sedentary lifestyle. Current research on the biomechanics of the low back is presented and interpreted eliminating hours of tedious research. McGill explains how to analyze patients’ physical characteristics in order to more effectively help patients learn preventative measures. Most importantly, you will learn rehabilitation techniques, including core stabilization exercises, and treatments specific to the various stages of rehabilitation: corrective exercise, stability, endurance, and strength. This text is relatively inexpensive ($40 at half.com) and I have already seen significant improvement in many of my patients, and noticed a difference in my own core strength, from using techniques learned from this book.

Cluneal Nerve

I saw a 33 yo male patient recently who presented with left hip pain which he has had since Nov of 2007. The patient also reported a leg length discrepancy which was confirmed to be 2.5 cm short on the right. He had been to various other doctors and had multiple imaging studies and was diagnosed with trochanteric bursitis. The ortho surgeons wanted to operate but the patient wanted to investigate conservative treatment options.

After taking the history I found a couple of factors which made explore other options besides the bursitis diagnosis.  First, the patient has stopped running, the major provocative action, and although the pain has decreased, he is still having constant 3/10 pain. Second, point tenderness was found at the middle portion of the iliac crest and, even though pain extended about ten inches down the lateral thigh which is consistent with trochanteric bursitis, side lying on the both the left and right sides did not provoke pain.

While trochanteric bursitis was a viable option I wanted to explore other possible causative factors. After initially thinking of lateral femoral cutaneous nerve involvement due to the pain distribution down the lateral thigh Dr. Morgan, suggested investigating the cluneal nerve.  After some research, the superior cluneal nerve, as seen in the image below, passes over the exact portion of the iliac crest where the patient reported point tenderness.  The superior cluneal nerves are more commonly associated with lower lumbar and sacroiliac pain since the distribution pattern normally involves the superior buttock. This classic entrapment occurs when a branch of the superior cluneal nerve becomes restricted in the tunnel of thoracolumbar fascia through which it crosses over the iliac crest. 

Picture from www.thebarrow.org

Although it is uncertain whether cluneal nerve involvement is a part of this patient’s condition, a treatment plan involving myofascial release of the tissue surrounding the its passage over the iliac crest will be utilized. For more information on how cluneal nerve entrapment is related to low back pain check out Dr. Warren Hammer’s article from Dynamic Chiropractic in 1998 which can be found at the following link (http://www.chiroweb.com/mpacms/dc/article.php?id=37220).