My Sacrum is Out!

My Sacrum is Out!

A fresh look at medical terminology and the effect of language and words

There has been a lot of media attention on Tiger Woods, his injuries and more recently, the language and terminology that is used to describe his injuries. His sacrum “went out” has been a widely used term or description of his injuries, with USA today publishing these details in August for the general population to read and digest. Read the full article here

My back has “gone out” is a common phrase I have heard on many occasions, with the hopeful patient placing all their trust in me to please-would-you-be-so-kind-as-to “put it back in”.

The medical community at large has been in despair and uproar since this publication, with the British Journal of Sports Medicine even posting a reply in attempt to accurately educate the community and eradicate the terminology of a bone ‘being out”. Read the BMJ article here:

So why the uproar? Why does the medical profession have such a problem with the words a bone ‘being out. It’s just words? Does it really matter? If I tell you with conviction that you back ‘is out’, even if the terminology isn’t an entirely accurate description of your problem, why do these words cause such concern for the health profession?
I will explore two reasons why the medical profession is so concerned about this inaccurate terminology and why we are working hard and have a responsibility to educate the community about their health including the language we use to describe their health.
Firstly, your bones do not go ‘out of place’, unless you have dislocated something. If I fall and sprain my ankle, the ligaments might tear a little which might cause swelling. This swelling might need some ice, my ligaments might need taping or strapping to prevent excessive movement in the first period of time to optimise healing. I might limp for a few days with protective muscles spasm and guarding. I may perhaps see a physiotherapist to assist in optimising my recovery. I will be given some advice on optimising healing, which might include a series of stretches, strengthening exercises and education on restoring normal walking pattern or function.
Nowhere in this time line, has my ankle ‘popped out’, requiring someone else to ‘put it back in’ for me. When we think of our peripheral joints (such as our knees, our ankles, our elbows, our hands and feet) we know and understand that nothing needs to be ‘popped back in place’. If we have a joint injury, then part of the recovery process is allowing time for swelling to reduce, optimising healing with advice, preventing excessive muscle spasm or guarding, restoring joint motion, strength and function.
For some strange reason, when we think of our spinal joints, the common feature that I hear is that instead of having an injury (like a sprained ankle) that needs optimal recovery, we suddenly have something that is ‘out of place’ and needs to be ‘popped back in’. It is anyone’s guess as to why we suddenly feel that our spines ‘need to be put back in’, yet our ankles, elbows or knees do not.
Well here’s the news: all of the bones and joints in our body (knees, ankles, low back, neck, and elbows) are connected by firm tissue called ligaments. These bones cannot ‘go out’ unless those ligaments are ruptured to the point of bony dislocation.
If you bend over too far and perhaps twist, you might overstretch some of the lower back ligaments and fibres of disc. Like an ankle sprain, if you go to far for your capacity, you may have microtears to those structures. Like an ankle sprain, there may be some swelling involved and perhaps some protective muscle spasm to try and guard the area. That muscle spasm might restrict your movement or cause you to develop habitual postures that cause more pain in other joints. If you are frightened that your back’ has gone out’, you may even release some stress induced chemicals into your blood stream, which causes nerves to be more sensitive, muscles to tighten further and for the brain to go on ‘high alert’.
Nowhere in this time line, has your back ‘popped out’ requiring someone else to ‘pop it back in’. That’s not to say some manual therapy won’t help. Yes, certain techniques can help reduce your protective muscle spasm and possibly help your joints move with more freedom and ease. But it is physically not possible for someone to ‘pop your spine back in’, (especially if it’s not ‘out’ in the first place). The last time I witnessed a true ‘popping back in’ was when a colleague relocated a friend’s dislocated shoulder. Yes that shoulder was definitely out, and definitely needed someone else’s assistance in putting it back in. But if you have neck pain after using the computer, then your C2 is not ‘out’. If your C2 was ‘out’ then you would be in hospital on a ventilator unable to breath unassisted due to lack of neural communication to your diaphragm. An unlikely ergonomic injury.
So, as a starting point, the medical community would like the general community to know and understand that the term ‘my bone is out’ is far from accurate and it not supported by any research literature anywhere. Yes that includes X-Rays. As fancy as that X-Ray looks your spine is not out. It is connected by ligaments and muscles and tissue that generally prevent that. X-Rays are useful for detecting broken bones or joint wear and tear. That’s about it.
An analogy that I like to use is this: If you can imagine your body like a puppet on strings. Bones are the puppet, strings are the muscles that make the bones move. If you have some tight or overactive strings, this may pull the puppet into a slightly twisted or asymmetrical position. Is the puppet ‘out’? If you have some weak muscles or strings it may not support the bones very well, contributing to more asymmetry. If you hold habitual postures all day long, then some of those strings may get ‘habitually’ tight- causing more pulling on the puppet. If you are stressed, have a ‘high alert’ nervous wiring system this might also contribute to some problems. So your ‘puppet body’ may indeed appear to be very twisted or asymmetric.
Nowhere in this time line, has anything ‘gone out’ requiring someone else to ‘put it back’. What is needed here is an analysis of habitual postures, an analysis on what muscles may be weak and which ones may be overworking, an analysis of the brain and its function with some answer as to why it may have developed these habits, and some education on how to address all of this.
There is a second reason the medical community cries in despair when the term ‘my bone is out’ is advertised and spread throughout the general community. And it’s not simply because it’s an inaccurate term. It is because it reflects a language that can be disempowering to patients.
Language and the words we use and the images they invoke for people is an interest of mine. There is a lot written and studied on the power of words! If I tell you “your back is out”, I am implying, through my choice of words, that you can do nothing for yourself about this, and you need me to fix it for you. And once I put it ‘back in’, you will be cured. Because putting a bone ‘back in’ is surely a skilled and dangerous task, not something you can accomplish yourself. My choice of words ‘your bone is out’ implies you have no power or ability to fix yourself and that you are possibly forever chained to my services in order to function. ‘Your bone is out’ is also quite a dramatic choice of words. Can even be scary for some.
If an architect told me my house had a supporting truss “out”, there would be a few alarm bells ringing for me! Is my house about to collapse? Invoking fear is a method that, for some, will guarantee your adherence and dependence, and will have the added effect of ramping up your neural system into overdrive which can increase neural sensitivity and increase pain perception. The words chosen can disempower you and can create a feeling you cannot possibly help yourself and that the situation needs urgent and immediate attention to avoid potential collapse.
Yes, joints can tighten, muscles can spasm and sometimes manual therapy of some sort will assist with this. But this needs to be described accurately! Your muscle is tight (you can stretch it) contributing to a restricted joint (you can move it) and this might be due to your habitual posture (you can change it), muscle weakness (you can strengthen it), or a sensitive nervous system (you can help yourself desensitise). This is a far more empowering and accurate description of an injury than ‘your bone has popped out!’.
So the medical profession would love for this term ‘your bone is out’ to finally be put in its place. Out to pasture. You are a very connected being with bones, ligaments and muscles holding you together. Your electrical nervous system is the wiring from the brain that can control and perceive all of that. You have all of the skill and power to understand and help your own injuries and optimise your own health with accurate education and resources.
I hope this helps clarify and educate the community on accurate medical terminology and why you will never see ‘bones out of place’ in any medical dictionary. I also hope it helps the general community understand that the power, capacity and ability to recover from injury can lie in your own hands with education and support from health professionals.

Nichole Hamilton

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