Treating Trigger Points for Back Pain - Dr. Jonathan Kuttner
Lower Back Pain has reached epidemic proportions. Here we look at the part played by trigger points.
It has been suggested that low back pain is an inevitable result of walking upright (Harari).
As the force of gravity acts upon the skeleton and its muscular and ligamentous armature, it is distributed via the fascia into three dimensions.
Myers (2013) talks of an internal cohesion-compression of the body where it is both collapsing in on itself and pushing out from itself in a constant state of equilibrium, a concept called ‘tensegrity’. Tensegrity is seen nowhere better than in the spine.
If the spine were a straight, rigid stick it wouldn’t be able to compensate for the multiple forces acting upon it.
Therefore it is specifically arranged in a series of curves (cervical and lumbar lordosis and thoracic kyphosis).
Along with the spinal discs, these curves are essential for shock absorption and are maintained by an interblend of muscles and ligaments that fire up in cyclical sequences.
If the spine were a straight, rigid stick it wouldn’t be able to compensate for the multiple forces acting upon it.
Even though all of the spinal vertebrae are designed to move, the spine also demonstrates specialization in its movement patterns, allowing us to exploit our three dimensions.
The direction of movement is mainly determined by the orientation of the spinal “facet joints”.
These are the forward and backwards movements (flexion and extension) from the low back, sideways from the neck (side bending) and rotation from the thoracic spine (although this is limited by the ribs).
The other important movement is a type of nodding backwards and forwards which is translated through the sacroiliac joints (nutation and counter-nutation).
Layered on top of the vertebrae are a series of ligaments that are strong and specialized to resist directional forces.
They again can be a source of pain and may develop “trigger points”.
On top of the ligaments is a complex but beautiful system of muscles.
The deepest spinal muscles are used to make minute adjustments in vertebral orientation (rotatores, interspinalis and intertransversalis).
Then the multifidus with its large and strong fibers bridging several vertebrae at once and helping to maintain posture.
The next layer of muscles connects the vertebrae to another from one to six segments upwards.
This is the erector spinae and it is divided into three columns.
Moving outwards from the center it forms a “wing like” structure - spinalis, longissimus and iliocostalis.
The erector spinae don’t really keep the spine erect (that’s the job of the psoas and the multifidus) but they do extend the spine from a flexed position.
Side-bending is mainly performed by the quadratus lumborum muscles.
Arranged over these muscles we have broader, flatter and more superficial muscles such as the latissimus dorsi.
Added to all this hardware is the software that the brain uses to co-ordinate and sequence movement.
All of the above structures feed information to the brain in a constant stream affording it orientation (proprioception), as well as force and direction (velocity).
The brain responds by organizing movement sequences hierarchically in functional units.
These functional units mainly consist of a prime mover (agonist), an opposing muscle force (antagonist) and other muscles that either fix the local joint (fixators) or help the prime mover (synergists).
The body tends to shut down around pain to avoid further noxious stimuli.
Part of the way it does this is by using trigger points.
For example, the erector spinae, multifidus, iliopsoas, quadratus lumborum, piriformis, rectus abdominus and hamstring muscles often manifest trigger points in patients with disc problems.
Similarly, the gluteus medius muscle often ‘switches-off’ and develops trigger points around sacroiliac problems.
Implicated Muscles - Overview
So here's a brief overview of how, why and where trigger points develop in the above structures and their connection to lower back pain:
The multifidus muscle has a deeper and more superficial arrangement.
It is intimately involved with most types of LBP and often manifests trigger points.
Because the muscles are so deep you need to use firm pressure to work on these trigger points.
Interestingly and contrary to what some of us have been taught the erector spinae don’t hold the spine erect!
Most fibers are electrically silent during postural work (Kippers 1984).
This muscle group is designed to activate during extension from flexion, i.e. standing upright from bending forward.
The erector spinae has three divisions each of which may manifest a trigger point.
According to Travell, and Simons, individual pain patterns of several trigger points that refer pain to the Lumbosacral region may blend into each other.
The piriformis takes its origin from the lower part of the sacrum but it also often gets involved with the protective patterns.
It has been suggested that when the piriformis muscle gets tight, it can compress the sciatic nerve, or even the blood vessels to the nerve, (vaso nervorum) which can lead to (pseudo) sciatica.
Remember that around 17% of people have a sciatic nerve that runs through the piriformis muscle.
The rectus is an antagonist to the multifidus muscle and may either get involved with LBP due to reciprocal inhibition or it may be a source of LBP itself.
It is also interesting to note that trigger points in the lower rectus may also cause diarrhea and symptoms mimicking diverticulosis or gynecological disease.
We have often found that treating trigger points in the rectus adds the finishing touch in some patients.
Often it can also be the reason why the lower back trigger points don’t stay released.
Mechanically, the iliopsoas has an intimate relationship with maintaining the lumbar spinal lordosis and is often involved in mechanical LBP, but that is not the whole story.
In her book The Vital Psoas, Jo Ann Staugaard- Jones also describes the physical, emotional and spiritual aspects of the iliopsoas. Staugaard-Jones talks of the iliopsoas as two distinct muscles: the psoas major (one of the deepest core muscles) and the ilaicus.
The psoas, she maintains, is the only muscle that connects the upper body to the lower (spine to legs) and integrates deeply with the nerve and energy systems: “It is enervated by the lumbar nerve complex (lower back) and when released, helps energize subtle body systems!”
Glutes, Piriformis and Hamstrings
Along with the tight glutes and piriformis the lower back muscles tend to form a triangle of tight, spastic and fatigued tissues.
Postural changes also cause tension in the hamstring muscles, which also often manifests trigger points and can ache after exercise.
We often find trigger points in the hamstring muscles associated with LBP. Sometimes this is a cause-and-effect relationship, from a trapped nerve (radiculopathy) in the spine (sciatica).
In these cases not all of the information/trophic input reaches the muscle fibers and the muscles may become tight and full of trigger points.
The corollary is also true. Sometimes a tight hamstring will have a negative mechanical effect on the lower back.
Quadratus Lumborum (Q/L)
The myofacial pain maps for the Q/L tend to radiate into the pelvis even though the trigger points are higher in the spine. Taut bands in the quadratus lumborum muscle can contribute to scoliosis.
The Q/L is often involved in any disc pathology literally bending the patient to one side (especially in the morning).
Levator Ani – Sacral Pain
The levator ani muscle consists of the pubococcygeus and the iliococcygeus muscles.
Together with the coccygeus muscle, these muscles form the pelvic diaphragm (the muscular floor of the pelvis).
Trigger points in the levator ani muscle are often implicated in low back pain syndromes.
Soleus – Sacral Pain
The soleus is a “classic” example of a trigger point whose myofascial pain map is remote from the origin.
The soleus is deep in the calf, yet in some cases a trigger point in the soleus can refer pain to the coccyx area.
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