Low Back & Hip Unit 2



Welcome to Beyond Trigger Points Seminars Low Back & Hip Unit Module 2 on the quadratus lumborum and gluteus minimus. This lecture will introduce you to one of the most common source

of low back pain, trigger points in the quadratus lumborum. If you haven't been routinely checking for trigger points in this muscle, you're not alone. The majority of health care practitioners don’t either. This muscle is practically non-palpable and hence commonly over looked unless the client is positioned on their side. I think you'll agree, the pain pattern for the quadratus lumborum is readily recognized because you have so frequently seen it. The gluteus minimus’ pain pattern will seem surprisingly familiar to you as well. It's estimated, of the massage clients presenting to a massage office with pain, 80% of them have hurt their low back. We will speculate that the majority of them have trigger points in the quadratus lumborum and the gluteus minimus. By the end of this lecture, you will have all the necessary information to check this assumption yourself.

We're starting with the actions of the gluteus minimus.

On page 7 of the study guide, there is room for you to write its three actions. The first is abduction of the thigh. ABduction. The second action is medial rotation. The third, like the gluteus medius we learned about in the last module is hip stabilization.

Take out your coloring tool now and turn to page 169 of the textbook, volume 2. Or you will see the pain pattern of the documented trigger points on the next page of the study guide. Go ahead and draw those X's onto the body scan on page 7. Then draw in the pain pattern as well. As you're drawing this picture, I think you’ll appreciate why this muscle has been nicknamed, Pseudo Sciatica. Are you drawing the pain pattern down the lateral leg? Make sure you extend that pain pattern inferiorly onto the lateral malleolus. The pattern into the ankle is interesting. When I ask my first question during an intake, “How can I help you, where do you hurt?” people often fail to mention the lateral ankle sensation. Unless you ask, they think it’s unrelated. Do you see how the primary pain pattern skips the knee? So now you’ve drawn a solid line representing both pain and tenderness down the lateral aspect of the thigh and leg as far as the ankle. Your client may also take their hand and reach behind to grab their lower lateral portion of the buttock. Having your client touch their own body gives you the most precise information on where they’re hurting.

Do you see the hornets’ nest of trigger points in the posterior fibers of the gluteus minimus? The pattern of pain and tenderness includes most of the buttock and the posterior side of the thigh and calf. The spillover pattern behind the knee may or may not be present. Remember; draw the spillover pattern more lightly or as a stippled area. The primary pain complaint you are memorizing as you’re drawing now is represented with the darker colored areas.

Moving to page 9 of our student study guide I’ll answer the question, A doctor may need to rule out what two differential diagnoses when leg pain is associated with hip or low back pain?

The first is a motor root compression at the spine potentially causing radiculopathy, a disturbing sensation down a limb. Quite often a patient will have seen their physician about this bothersome and for some, a scary sensation. An S1, L5, L4 peripheral nerve as it’s exiting the spinal cord through the foramen of the lumbar spine, can develop problems causing referred pain down the leg. On an aside, you may be wondering how you could distinguish neurogenic from trigger point referred pain. Beyond Trigger Point Seminars offers a Neuromuscular Evaluation workshop to help therapists determine when referring to another health care provider is appropriate and how we can help with our soft tissue approach. Muscle strength assessment, dermatome testing with a pinwheel and checking reflexes with rubber mallet are a few ways to determine a motor root compression. Don’t forget to ask your client the obvious like have you had an EMG study or an X-ray? I hope from these courses you will develop the good habit of asking what other health providers have ruled out. I used to wonder what an X-ray would reveal about a nerve. The neurologist I worked for explained how a peripheral nerve occupies only a third of the foramen. A foramen, coming from the Latin root for window, is the opening in the vertebrae through which the nerve exists. A trained eye can see if any boney obstruction inside the foramen might be compromising the space through which a nerve passes. Isn’t the interrelatedness of all our parts amazing? So again, one diagnosis to have ruled out is motor root compression.

A second one is degenerative joint disease. How many times have you heard that diagnosis? Oh I'm just getting old; my parts are wearing out, your clients might say. Keep in mind the diagnosis of degenerative joint disease does not establish the source of pain. As a soft tissue expert your job is to rule out the soft tissue component of the problem. Specifically, you and your client will know after one treatment if they have trigger points reproducing their pain complaint. Through just simple palpation and know how of the trigger points, you will either reproduce a familiar pain complaint or not. To repeat the answers again, one was motor root compression and two is degenerative joint disease.

Sacroiliac joint dysfunction is another reason a person may be experiencing radiculopathy. On page 9 of the study guide two different ways of determining sacroiliac joint dysfunction are listed. Find your own sacroiliac joint by palpating in the dimpled area of your low back region where the sacrum intersects with the iliac crest. By flexing and extending at your hips, you can feel its movement. The SI joint functions as a shock absorber and is one of 3 joints in the body not directly leveraged by a muscle. Because no muscle directly crosses it, the SI joint can become displaced by many different muscular imbalances and insults resulting in an irritated gluteus minimus. The injurious movement pattern frequently occurs during the combined movements of bending and twisting the trunk. For example, as a person gets up from a soft chair or picks an object off the floor, the SI joint can slip and/or the quadratus lumborum muscle can be strained. Other actions displacing the sacroiliac joint are being pregnant, shoveling, a short golf swing such as when chipping from out of a sand trap. The symptoms of a displaced SI joint are pain down the posterior or lateral leg, which can mimic the pain of the gluteus minimus trigger point pattern. An SI joint displacement is rarely shown with an x-ray. To test for SI joint tenderness, palpate the SI joint and simply ask your client if it’s tender. The Patrick’s test is another method shown in the study guide. Your client tests positive when rocking the leg of a bent knee up and down creates discomfort on the opposite SI joint. In class we learn a protocol to work on all the muscles affecting this joint.

Along with an SI misalignment, there are three other mechanical factors causing compensatory tightening of the quadratus lumbar and the gluteus minimus. On page 10 of the study guide or page 45 of the text, there is an illustration of a small hemipelvis. In the same way a person can be born with one foot or leg or hand smaller on one side, a difference in the hip bones can also be a birth anomaly. Letter A at the top of the page shows the affect of having one hemipelvis smaller than the other. When the ischial tuberosities are placed on a hard surface, you can see on the picture how the iliac crest is high on the left and low on the bottom. Also shown in the picture is a smooth compensatory scoliosis that results from sitting on an uneven base. By placing a knife edged hand on both sides of their iliac crest and standing either in front or in back, you can measure for any disparity in seated hip height. Visually you will observe how the small side seems to dip down into a chair or when prone, as shown on picture D, onto your table. With a small hemipelvis there is the tendency to cross their legs. The question I like to ask when I notice my clients crossing their legs during the intake interview is, “Do you always cross that leg? Or with your more flexible client, do you always tuck that foot under your hip?” These are compensatory behaviors of a small hemipelvis. Crossing one leg over the other leverages the small hip down. Letter B shows another correction for a small hemipelvis. Dr. Travell, this is not my terminology, calls this a butt book. I’ve collected Reader's Digests and TV Guides to use. Placing the magazine with an appropriate amount of page thickness under the smaller hip will feel comfortable to the patient and will cause the iliac crest to measure even. As picture C shows, when the butt book is placed under the side of the larger hip side, an even greater compensatory curve of the spine occurs. The patient will instantly feel the imbalance and be impressed with the importance of using the ischial correction whenever seated. A few more considerations: a soft couch or chair will require doubling up on the thickness measured on a hard surface. Also, it’s been my observation that as car seats wear, particularly the right side of the driver’s seat, a butt book may be a beneficial aid in maintaining the evenness of the seat surface.

A third biomechanical perpetuating factor is short upper arms. On page 11 of the study guide and page 46 of the text, there are examples of short upper arms. When your shoulders are relaxed and dropped and your forearms are parallel to the floor, a normal arm to torso ratio is having the elbows resting on top of the iliac crest. If there is a gap between the iliac crest and where the elbows rest, than you test positive for short upper arms. If your arms come below your iliac crest, than you have long upper arms. The short upper arms create the problem. Do you see why on picture D? I have short upper arms and like picture D & E shows, I use to do a lot of leaning when seated. The armrests on chairs are designed for folks who have a normal torso to arm ratio. This can create a problem in the quadratus lumborum as well as the shoulder elevator muscles.

A lower limb length inequality or an LLLI, is a forth factor to consider. An LLLI could be functional as when a tight quadratus lumborum hikes the hip. Or it can be genetic. You can be born with a short leg; a femur bone or a tibia bone could be smaller on one side. An x-ray would confirm this.

According to a meta- analysis study sited in the journal Chiropractic and Osteopathy, 90% of the population has some degree of a leg length disparity; on average a 3/16th or 5.2mm difference. The most common effect of a LLLI is to cause a pelvic torsion, which rotates the pelvis and/or the innominate bone. A person can go through life without any affect from an LLLI. However, in the same way that small degrees of imbalance off the central axis of a see-saw causes large movement at its ends, so too will a small disparity of a quarter of an inch at the hip joint cause a larger disparity at the shoulders. On page 12 picture C, do you see how an exaggerated lower limb length inequality commonly causes a smooth compensatory S curve of the spine and a large shoulder height difference? We’ll consider the muscular implications for this shortly.

An individual may self correct for a LLLI by throwing their long out and bearing the body weight on the short leg. Or they may widen their stance like a sailor on a rocky sea. When I lived up north, where people still wear long slacks, I use to ask this question, do you have the leg lengths of your pants hemmed differently? People will know if a tailor has measured one pant leg higher than the other. I share these four mechanical perpetuating factors with you because, starting tomorrow, you could begin observing these factors with any of your clients.

Now, I've saved the discussion of measuring a short leg till now because errors can be made in manual measuring. I know because I've made them all. The most accurate way to measure a lower limb length inequality is by taking a standing x-ray. For more details see chapter 4, volume 2 of the textbook. However the method we practice in class is, according to one study, 95% accurate. It involves the three observations listed at the bottom of page 9.

First let me digress for a moment. Remember, it makes little difference to the body why one leg is shorter than the other. To the body’s inherent wisdom, the “why” isn’t important. Our soft tissue will adapt holding patterns in order to keep the eyes even with the horizon. Keeping both eyes level is a reflex. If the eyes were uneven, you would be walking around feeling dizzy and nauseous. One way the body compensates for uneven platforms, like a leg length disparity, is by creating the smooth compensatory S curve seen on page 12 picture A and C. Each vertebral body rotates a little to create this alignment. So the first thing to determine is whether the spine appears curved. If you can’t see this easily when standing behind your client, have them bend forward like when the school nurse checked your back for scoliosis in grade school. Now there are other spinal compensatory variations, but the smooth S curve is commonly seen with a lower leg length inequality.

Here’s a piece I want you to remember: on the concave side of the S curve, trigger point development is more frequent because of the increased muscular activity. For example on picture C, page 12, since the left lumbar spine is the concave side you would expect to see trigger point formation in the left quadratus lumborum and lumbar paraspinals.

The next factor to measure is the relative heights of the iliac crest while the client is standing on an even surface. Placing a knife edged hand on both sides of their iliac crest and eye-balling this at hip height is fairly accurate.

And the last factor you could begin measuring is the relative heights of one greater trocanter over the other. If there are problems finding this boney landmark, have your client jut one hip out to the side while you feel for the boney protuberance.

All three factors must be present in a standing patient in order for you to know with assurance that you're dealing with a lower limb length inequality. However, inactivating trigger points in the quadratus lumborum should precede any evaluation of leg length disparities. Usually within one treatment you can tell if the leg length changes. If it does then you’re probably dealing with a functional compensation. If leg length doesn’t change, give it another two or three treatments. Then if the hip height is still imbalanced after all your great muscular work, consider you may be dealing with a genetic disparity.

To summarize, a small leg, small hemipelvis or short upper arms makes selected muscles work harder to compensate for the asymmetry. Muscles can generally tolerate the extra work until a trigger point is introduced. So the asymmetry may not have been the causative factor, but it can perpetuate it. If after three treatments you're finding a little bit of improvement but the treatments aren’t holding- they take one step forward but two baby steps back- then generally, you need to correct the biomechanical factors. Let me say that differently; if the muscular relieve experienced from your treatment is only temporary, then an assessment of the perpetuating factors is absolutely necessary to ensure more permanent relief. Assure your client that getting rid of the pain is the easy part; keeping it away is trickier.

Keep these pictures of asymmetries for your treatment rooms. Then you can visually show how these factors are related to your client’s low back complaint and why their pain has persisted without improving on its own.

Turn now to page 13 of our student study guide. Here we will answer the question: What are some findings for the gluteus minimus?

One finding is pain when crossing the legs. Another common finding is the client or somebody they know will have self diagnosed them with sciatica. Keep in mind that sciatica is a symptom not a diagnosis. In one study, 55 of 70 patients with a sciatic presentation had soft tissue problems arising from the gluteus minimus. It’s a very common source of pain down the leg.

Now I’ll list some of the corrective actions. As tactfully as possible suggest a weight reduction program. We talked about the gluteus minimus as being a hip stabilizer. Increased load from weight can perpetuate the problem. Another corrective action would be to sit more than stand. Another would be to keep the hips warm. All muscles appreciate warmth. Another corrective would be to stop sitting on the wallet. Remove the wallet. At night, if they are side sleepers, sleep with a pillow between the legs so they maintain anatomical neutral. Correcting the structural asymmetry is another factor.

The gluteus minimus responds really well to self treatment with tennis balls. Place them in a sock and then roll on them. I give tennis balls out as treatment favors at the end of my sessions. The client can take them home and stick them in the freezer before they roll their hip on them. Self stretches for the gluteus minimus are shown in the study guide here. Picture A shows the start position for a contract-relax stretching technique. First the individual gently contracts the muscle by pressing upward against the resistance of the other foot, holding for five seconds and then relaxing or pushing the leg downward to pick up the slack. Picture B shows how the leg progressively adducts after several cycles. I highly recommend this wonderful stretch. It feels really nice and it’s easy to do. You can teach it to your clients on your massage table. Then they can go home and perform it on the edge of their bed or couch. Self-stretching this muscle while standing is counterproductive. The muscle attempts to do its job of postural stability and won’t be able to relax fully.

Our textbook summarizes this best and I quote, “When active trigger points fail to respond to treatment, with few exceptions one or more perpetuating factors need to be identified and resolved.” In order to maintain and enhance the effects they receive from your treatments careful adherence to a home program is necessary.

Let’s move on to the big daddy of all the low back muscles, the quadratus lumborum. When the pelvis is fixed, contraction causes lateral flexion. When the ribs and spine are fixed, it acts as a hip hiker. The muscles also stabilize and extend the lumbar spine and assist in forced exhalation, such as when coughing.

On page 15 of the study guide or page 30 of the text, the documented trigger points for the superficial and deep layer are shown. The overlying latissimus dorsi and the erector spinae have been removed in this picture. Draw the trigger point locations and their pain patterns now on page 14. Trigger points in the superficial fibers shown on picture A are likely to refer pain along the iliac crest and the lateral hip. The pain over the greater trocanter can be so sore that the client cannot lie on the involved side. Sometimes the pain can extend into the lower abdomen and groin. Picture B shows the deep fibers and the pain referral zones over the SI joint and into the lower buttock. The client might show you this pain pattern by taking their hand and drawing a pattern from the sacrum diagonally to the side of their hip. To help you remember a common injury to this muscle, we can nickname it, Lumbar Whip Lash muscle. In a study of one hundred folks in a motor vehicle accident who had no prior complaint, 81% developed a trigger point in their quadratus lumborum, with the right side being the most likely.

So the first factor to list on page 16 under activation and perpetuation is lumbar whiplashes. Surfing, skiing and other sports that cause severe onset because of sudden injury, can also create lumbar whip lash action. The morning after the accident, a person may have to crawl on their hands and knees in order to unload the lumbar stabilization action of the quadratus lumborum. Lifting something while bending and twisting is another factor. Prolonged leaning over desks or sinks or massage tables is another factor potentially activating and or perpetuating trigger points in the QL. Dental hygienists are also leaning forward and twisting over their clients. Shoveling and pitching hay is another repetitive factor involving a forward bend and twist. Soft beds; with a soft bed one hip can rest lower than the other causing a compensatory strain on one of the QLs. A golf swing with a divot shot. I know many of you work with golfers. Ask your golfer if they are picking up a lot of dirt or grass in their golf swing, because they may have injured their muscle impacting with the ground. Slanted surfaces; walking on beaches for example with one leg lower than the other, or walking on the side of a road that’s been cambered. I had a brick layer who always stood with one leg up higher than the other while he laid bricks. His QL and spine were whacky because of this. Another injurious action occurs when mothers carry their babies by hiking up one hip. I am sure you can think of a number of other occupations and recreational hazards that create QL problems as well, but hopefully this gives you a picture. Let’s move on.

What signs or symptoms would your client present with when the QL is injured? A question I like to ask is, “Do you have difficulty turning over in bed at night?” In fact when the QL is fired up it can wake them from a sound sleep. Just rolling over can cause pain. So rolling over in bed is one sign. Climbing stairs can be painful. They might feel increased pain when standing. When someone tells you the story of crawling to the bathroom the morning after a gross trauma, the quadratus lumborum might be involved. Range of motion restriction is measured on side bending. It's restricted to the contralateral side, meaning if you have a trigger point in your left quadratus lumborum then side bending to the right side is restricted. We take measurements in class.

What are the corrective actions?

Number one is stretching. It’s the best thing we can teach our clients when they have just been injured. Pictures A-D on page 16 shows a simple non-weight bearing stretch from our textbook. The leg can be returned to the start position as shown on picture D by using the other leg to push it back to neutral. Side bending and spinal twisting are two other ways to stretch the quadratus lumborum. You may not feel qualified or knowledgeable enough at this point in your career to design a home exercise program, so referring your client out to an appropriate provider may be helpful.

Another corrective would be to sleep with a pillow between the legs or under the knees if supine, and on a firm mattress. A Canadian I worked the other day knew his QL was involved when he felt the need to sleep on the floor. He has been dealing with his QL for some time and he knew all the tricks. Avoid curling up in the fetal position while sleeping because that can aggravate the QL too.

I often teach keeping the spine straight while moving from a standing to sitting position. Strategize with your clients on ways to maintain proper alignment of their spine. Encourage them to keep a straight back when they are brushing their teeth for example. I know these things may seem tiny but they are huge to a client who has low back pain. It also gives them something to do to help them selves.

Consider too the chairs they sit in frequently. Again the principle is keeping the back in a neutral position while seated and to move frequently. Dr Travell designed the seats for Air Force One during her years as White House Physician. She had successfully treated President Kennedy for his war injury to his low back. The airplane seat she designed was more comfortable. She also encouraged him to sit in a Boston rocker which had a firm straight back and allowed for movement. You can find postural awareness exercises on the resource page of the site. Feel free to download those for you and your clients.

So in closing, perhaps the positive spin for low back injury to either the gluteus minimus or quadratus lumborum is the potential for developing better body mechanics. If you take the time to educate your clients on any of these correctives, they may use your suggestions to take care of themselves in ways they may have never thought about before. In our next module, we will be studying the role of the piriformis and iliopsoas muscles and their relationship to posture and low back pain. Until then, stay in touch.

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