Treating Trigger Points - Paul Townley PT MSc MACP BSc (Hons)
Most cases of lower back pain are associated with myofascial trigger points
In reality, these kinds of problems are often just minor factors in back pain. In fact, most acute and chronic back pain may be associated with trigger points.
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.
Depending on how long the symptoms have persisted, we see certain “classic” trigger points when dealing with Lower back Pain (LBP).
For example - the erector spinae, multifidus, iliopsoas, quadratus lumborum, piriformis, rectus abdominus and hamstring muscles tend to manifest trigger points in patients with disc problems, whilst the gluteus medius muscle ‘switches-off’ by developing trigger points in response to sacroiliac problems.
Here's an overview of the main muscles that tend to be involved ...
The multifidus muscle has a deeper and more superficial arrangement and 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.
Pain is typically reported at the spinous processes of L1–L5 and anterior to the abdomen. S1 projects pain down to the coccyx; this referral radiates laterally from the level of T4–T5 to the inferior angle of the scapula.
Trigger points located in the cervical region of the multifidus refer pain from the suboccipital region, down the posterior neck to the approximate segmental level of T3 and laterally to the rhomboids.
There is also often referred pain to the base of the neck and upper back region.
Common Multifidi / Rotatores 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 in fact 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.
Common Erector Spinae Trigger Points
The piriformis eccentrically contracts to decelerate internal rotation and hip adduction when the hip is flexed.
A short piriformis can cause the sacrum to tilt, giving the appearance of a short-leg discrepancy, and result in a rotation or twisting of the sacrum in the sacroiliac joint, setting up additional sacroiliac stress. (Note: If not corrected in a timely fashion, this is a recipe for shoulder injury).
Piriformis often gets involved with the protective "holding" 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 abdominis has two distinct pain patterns: one at the level of the xiphoid process, spreading bilaterally across the middle back, and the other at the level between the umbilicus and the inguinal ligament, spreading pain into the sacroiliac joint and lower back.
Note that rectus abdominis trigger points can also cause chest pain, heartburn, belching, diarrhea, and dysmenorrhea.
Psoas / Iliacus
Bilateral contraction of this fleshy triangular muscle provides stability to the lumbar spine. These muscles are rich in muscle spindles and are therefore prone to shorten under stress. This in turn can cause inhibition in the gluteus maximus.
Prolonged sitting has been identified as a significant precursor to the formation of trigger points. Trigger points form in the psoas major as a result of primary trigger points in related muscles of the psoas functional unit.
These muscles include the rectus femoris, pectineus, sartorius, tensor fascia latae, adductors (longus, brevis, magnus), and gracilis.
Pain is typically felt as a vertical pattern ipsilaterally along the lumbar spine, and downward over the sacroiliac joint and gluteal region.
Psoas Major (Left) and Iliacus (Right) Trigger Points
The gluteus maximus plays a significant role in stabilizing both the sacroiliac joint and the knee joint. It does so by means of superior fibers, which attach to the aponeurosis of the sacrotuberous ligament, and inferior fibers, which attach anteriorly to the iliotibial band, providing tension down to the knee.
It is hypothesized that gluteal trigger points could be a result of inhibition in the gluteal muscles caused by spasm in the psoas muscles, gluteus medius, and gluteus minimus. The formation of these trigger points provides much-needed tension for sacroiliac support.
Pain is often felt in the lower back and mimics bursitis of the hip, with pain experienced at the site of the coccygeal bone and of the gluteal crease.
This muscle is a major generator of lower back and hip pain, as well as being responsible for complaints of a burning sensation along the posterior superior iliac spine (PSIS) and sacroiliac joint.
Pain is often mistaken for lumbago- type pain, with discomfort (such as tenderness) into the buttocks and superior thigh.
Typically, pain is referred up toward the gluteal muscles, with some residual pain spreading down just below and behind the knee into the medial gaster of
the gastrocnemius. This pain can also often be mistaken for sciatic pain.
Weak inhibited gluteal muscles, including the gluteus medius, can lead to trigger points forming in the hamstrings and lumbar erector muscles, including the quadratus lumborum.
Ultimately, the hamstrings are trying to be gluteal muscles, while the lumbar muscles are trying to be hamstrings.
Quadratus Lumborum (Q/L)
A short quadratus lumborum leads to a functional short leg on the same side. This in turn leads to muscle adaptations, whereby the contralateral adductors may shorten in an effort to pull the femur more posteriorly into the acetabulum.
This can create the look of a short leg on the contralateral side and cause subluxation at the pubic symphysis and sacroiliac joint.
Pain from QL trigger points is experienced at the sacroiliac joint and into the gluteal muscles and the hip. Referred pain in the anterior thigh and groin can be very painful. Fear of coughing or sneezing because of intolerable pain in the lower back is common.
Common Quadratus Lumborum (QL) Trigger Points
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 can be implicated in low back pain syndromes.
From a dynamic postural viewpoint, the soleus prevents the body falling forward at the ankle joint during standing.
In gait, the muscle eccentrically decelerates subtalar joint pronation and internal rotation of the lower leg at heel-strike. It also decelerates dorsi flexion of the foot.
Surprisingly to many, trigger points in the soleus can be the origin of tight hamstrings and lower back pain.
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