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7. Lumbar spine pathology Definition: Direct mechanical irritation of the facet joints or indi- rect irritation of the lumbar nerve roots by the intervertebral discs creating referred pain into the posterior thigh Cause: Referral to the posterior thigh can be caused by direct com- pression of the nerve root by disc pathology. Spondylolisthesis (a forward displacement of one vertebra on another) could cause altered stresses on local neural tissue, or alternately altered load- ing of the facet joints. Facet joint irritation can cause increased EMG activity in the hamstrings, the increased tension in the mus- cle may lead to local damage. Trauma to the facet joints can also result in direct referral to the posterior thigh Presentation: Patients will generally present with a degree of low back pain or stiffness. The pain in the posterior thigh is brought on by prolonged activities such as sitting or standing, or repetitive activities such as bending. Changes in posture or activity often relieve the symptoms immediately Assessment: Stiffness and/or pain on spinal movements, restricted straight leg raise with neural involvement, decreased strength on testing (but should not be painful) Treatment/rehabilitation: Correction of posture, spinal hyper/hypo-mobility through manipulation, mobilisation and pos- tural muscle strengthening. In cases of severe disc protrusion surgery may be required.

8. Sacroiliac joint pathology Definition: Mechanical irritation of the sacroiliac joint, creating referred pain into the posterior thigh

Cause: An anterior tilt of the ilium elongates the hamstring muscle producing functional tightness, the pelvic tilt resulting in a decreased straight leg raise and increased tension within the mus- cle. Another cause may be direct referral of pain from the sacroili- ac joint as a result of mechanical irritation of that joint Presentation: Dull ache in the buttock (posterior superior iliac spine (PSIS) area), with radiating pain into the posterior thigh. This pain may have a traumatic onset, usually involving flexion and rota- tion of the trunk on a fixed limb or alternatively there may be a gradual insidious onset related to altered loading to the joint Assessment: There is usually local joint tenderness, tests of sacro- iliac joint motion eg. Pedillieus tests, will display abnormal motion at the joint. Straight leg raise will often be limited with pain often occurring in the first 30o or on limb lowering (especially active low- ering). In carrying out Pedillieus test the heights of the PSIS are monitored during forward flexion of the trunk, both PSISs should move in a upward direction equally as the pelvis rotates during trunk flexion, any asymmetry is indicative of a hypomobile sacro- iliac joint Treatment/rehabilitation: Mobilisation/manipulation of the sacro- iliac joint, correction of muscle control of joint motion.

Lee Herrington is a chartered physiotherapist and lecturer in sports physiotherapy on the Manchester Metropolitan University MSc Sports Physiotherapy course. He is a clinical specialist in sports injuries at BUPA Murrayfield Hospital, Wirral, and has a specific interest in lower limb injuries.

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