Pain in the lumbar spine and pelvic region 302
7.1.1 Low-back pain due to muscle and ligament overload 303
7.1.2 Painful or tender coccyx 303
7.1.3 Painful hip joint (coxalgia) 305
7.1.4 Restrictions in the lumbar spine and sacroiliac joints 306
7.1.5 Low-back pain due to disk herniation 309
7.1.6 Pelvic distortion 311
7.1.7 Forward-drawn posture 311
7.1.8 Inflare and outflare (Greenman) 313
7.1.9 The coccygeus and pelvic floor 314
7.1.10 Low-back pain due to restricted trunk rotation 315
7.1.11 Combined lesions 316
7.9 Vertebrovisceral inter-relationships 348
7.9.1 General principles 348
7.9.2 Tonsillitis 349
7.9.3 The lungs and pleura 349
7.9.4 The heart 350
7.9.5 The stomach and duodenum 351
7.9.6 The liver and gall bladder 352
7.9.7 The kidneys 352
7.9.8 Importance of the psoas major and rectus abdominis 352
7.11 The clinical picture of dysfunctions in individual motion segments 357
7.11.1 The temporomandibular joint (TMJ) 358
7.11.2 Atlanto-occipital segment 358
7.11.3 Atlantoaxial segment 358
7.11.4 Segment C2/C3 358
7.11.5 Segments C3/C4–C5/C6 358
7.11.6 The cervicothoracic junction (C6/C7–T2/T3) 359
7.11.7 Thoracic segments T3/T4–T9/T10 359
7.11.8 Restricted trunk rotation (segments T10/T11–L1/L2) 359
7.11.9 Segment L2/L3 359
7.11.10 Segment L3/L4 359
7.11.11 Segment L4/L5 360
7.11.12 Segment L5/S1 360
7.11.13 The sacroiliac joint 360
7.11.14 The coccyx 360
7.11.15 The diaphragm and pelvic floor 360
7.11.16 The hip joint 360
7.11.17 The foot and fibular head 361
This chapter will illustrate how the theoretical principles and the diagnostic and therapeutic methods set out in previous chapters are applied to specific clinical entities and symptoms involving the locomotor system. It should be remembered that familiar clinical pictures such as back pain, shoulder pain, and headache have rarely been considered systematically from this point of view and consequently there is little on the subject to be found in the literature (Brügger, Cyriax, Gutmann, Mennell, Simons, Travell, etc.). All the more reason therefore to demonstrate the importance of what has been discussed in earlier chapters as it ‘touches down’ in everyday clinical practice. It is of great consequence for medical theory that this new approach has yielded major and unsuspected new insights into these seemingly familiar clinical entities. This has been made possible because of the efficacy and specificity of the new therapeutic measures we use. Nevertheless, they can only be called upon and applied to best advantage if the functional diagnosis is as accurate and comprehensive as possible. And as the number of practitioners working with these methods is increasing rapidly, the body of clinical data is also growing apace.
In back pain, the significant role played by the spinal column is established beyond all reasonable doubt. However, the problem is traditionally treated mainly or even exclusively as a morphological issue, which creates the impression that all we have to do is to find the underlying inflammatory, degenerative, or metabolic disease or gross mechanical lesion, such as a herniated disk. We first have to satisfy ourselves that such a disease or lesion is indeed present and to what extent it is of key relevance. Once patients have been ‘pigeon-holed,’ the largest group left over cannot be assigned to any category, that is these are patients ‘without any specific diagnosis’ whose symptoms are produced by locomotor system dysfunctions.
Because the field of pathomorphological diagnosis is amply covered in textbooks of orthopedics, rheumatology, and neurology, we will deal here only with issues relating to differential diagnosis. For a discussion of how to take the patient’s history, readers are referred back to Section 4.1.
The present chapter will consider not only the mechanical aspects of the problem, but also the impact on the autonomic nervous system of factors such as menstruation, infection, meteorological changes, hormonal disturbances, or psychological stress. Because the term ‘back pain’ is altogether inadequate for a proper clinical understanding, it will be imperative to focus close attention on each individual section of the spinal column.
7.1. Pain in the lumbar spine and pelvic region
The majority of lumbar and sacral dermatomes converge in the lumbar region, which comprises the lower lumbar spine and sacrum (see Figure 4.3). Furthermore, the most powerful muscles have their attachments at the pelvis: this is the site of greatest mobility and is where the movements of the lower extremities are transferred to the trunk. All of this explains the great vulnerability of this region, harboring as it does a vast number of potentially pathogenic factors that have to be assessed for relevance in every case. The most important dysfunctions causing different types of low-back pain will now be reviewed, together with their respective specific therapies. The term ‘low-back pain’ also includes pain radiating laterally toward the hips or groin, and referred pain that is felt in the lower extremities.
7.1.1. Low-back pain due to muscle and ligament overload
In this type of low-back pain, morphological lesions may be absent and the spinal column as such may not necessarily be altered, at least at the outset. However, since this first pain category is not homogeneous, some further definition is required.
The cause may be exogenous, for example heavy physical labor. More frequently, however, pain is the result of faulty posture and excessive static strain caused either by external factors or by faulty movement patterns. Poor posture may be attributable to adverse static development, for example leg length inequality, or to juvenile osteochondrosis. In most cases, however, postural abnormalities are due to muscle imbalance arising in the context of adverse movement patterns, hypermobility, or obesity. All these sets of circumstances are characterized by signs of excessive strain on locomotor system structures.
Fatigue sets in, usually in the form of trigger points (TrPs) with attachment point pain, and this increases to become pain during postural and/or dynamic loading. Often the symptoms are more the result of postural strain than of movement per se. Thus, any posture or position that the patient is required to hold for any length of time is registered as unpleasant strain. Patients therefore feel the need to change their position, even in bed. In this context morning stiffness is often reported, and while this is gradually overcome, it can manifest itself later as pain associated with fatigue and excessive strain.
The typical imbalance in the lumbosacral region is characterized by weakness of the abdominal and gluteal musculature on the one hand, and by hyperactivity of the hip flexors and erector spinae on the other. The individuals most commonly affected are constitutionally hypermobile patients who experience ‘ligament pain’ involving the iliolumbar and sacroiliac ligaments (see Section 6.7.1). An extremely common finding in these patients is insufficiency of the deep stabilizer system, which is linked with the compensatory development of large numbers of TrPs, principally in the long muscles (e.g. erector spinae, quadratus lumborum, or rectus abdominis). Tender pain points are also frequently found at the inferior lumbar spinous processes and the posterior superior iliac spines (PSISs). If there is marked postural asymmetry, pain points may be detected on the iliac crests and the lowest ribs on the same side, especially where there are TrPs in the quadratus lumborum. Baastrup’s phenomenon (osteochondrosis of the spinous processes) is commonly regarded as a cause of tenderness involving the spinous processes. In practice, tender spinous processes are encountered in hypermobile adolescents without radiological evidence of degenerative changes. And in cases where Baastrup’s phenomenon yields typical radiological signs suggestive of a pseudarthrosis between the spinous processes, the patient usually feels no pain at all.
Where pain is due primarily to external factors producing excessive strain, the first-line approach is to correct posture and dynamic overexertion patterns (see Section 8.3). However, if the underlying cause is faulty statics and muscle imbalance, the guidelines set out in Sections 5.4 and 5.5 should be followed (correction of statics and use of a remedial exercise program). In hypermobile patients exposed to situations of excessive static loading, attention should focus on the deep stabilizer system, with recommendations for appropriate supports (see Section 6.9) to be used especially during road or rail travel. Acute pain should be relieved by treating TrPs (with post-isometric relaxation (PIR) and reciprocal inhibition (RI)) and soft tissue, especially the fascia. If necessary, needling or local anesthesia can be used.
7.1.2. Painful or tender coccyx
A painful or tender coccyx is the result of muscle dysfunction involving the gluteus maximus and levator ani and their points of attachment to the coccyx.
In the majority of cases where the coccyx is tender to palpation, patients report pain not in the coccyx itself but in the lower back. In low-back pain, on the other hand, about one-fifth of patients experience coccygeal tenderness on palpation. The opposite is also true: reports of coccygeal pain may in fact be attributable to painful lower sacroiliac joint dysfunction, a painful ischial tuberosity, a TrP in the coccygeus muscle (pelvic floor), or exceptionally even pain referred from the hip. In such cases, however, tenderness does not involve the tip of the coccyx itself but rather one side of the coccyx only. Falls on to the coccyx play a negligible role in chronic coccygeal pain. History taking in our patients revealed that only about one-fifth had experienced any previous falls on to their coccyx. In particular, patients complain of low-back pain when seated. There may sometimes be constipation and patients may report dyspareunia.
In obese patients, in particular, examination discloses a hyperalgesic zone (HAZ) in the form of a small fat pad on the sacrum. Another important sign is hypertonus of the gluteal muscles, and sometimes a TrP in the iliacus or piriformis. Most characteristically, however, there are TrPs in the levator ani but these can only be detected on examination per rectum. Patrick’s sign and the straight-leg raising test may also be mildly positive. However, the pathognomonic sign is an exquisitely tender (painful) tip of the coccyx, in response to even the slightest touch. Palpation must include the ventrally curved end of the sacrum. The true pain point will never be located if palpation covers only the dorsal surface of the coccyx. Sacral palpation may be difficult not only due to hypertonus of the gluteus maximus but also because the patient resists by clenching the buttocks. A painful coccyx is always curved ventrally; a coccyx that is straight and points caudally is never painful.
The treatment of choice is PIR of the gluteus maximus, during which the levator ani also contracts and relaxes at the same time. The conventional approach per rectum is used only exceptionally if there is no hypertonus of the gluteal muscles but instead hypotonus with the patient, so to speak, sitting on the coccyx without the ‘cushioning’ of the buttocks. The patient can practice PIR of the gluteus maximus regularly at home, several times daily (see Figure 6.124).
Based on clinical experience and on therapeutic results it can be assumed that tension in the gluteus maximus and the levator ani is the main cause of a tender coccyx, that is it represents a tendomyopathy of these muscles. Contraction and relaxation of the gluteus maximus (PIR) are coupled with PIR of the levator ani. Increased tension in these muscles is associated with psychological tension, and relaxation of these muscles leads not only to a reduction in coccygeal pain but also to psychological relaxation. Finally, in the patient with low-back pain, it is important never to miss a tender coccyx, otherwise any treatment given may be doomed to failure.
R J; male; born 1922; civil servant.
Pain in lower back and buttocks since 1977, permanently troublesome since Spring 1982. Pain worst on getting up in the morning or after sitting for lengthy periods. Coughing sometimes provoked stabbing discomfort. The patient’s medical record showed that he often suffered from tonsillitis in boyhood (tonsillectomy performed at age 10 years). He had also had typhoid fever and pneumonia. Sports activities: skiing, ice-skating, tennis, horse-riding. No record of accidents.
Examination on 11 June 1983 revealed some limitation of retroflexion, atlanto-occipital movement restriction on both sides, and a painful coccyx.
Mobilization of C0/C1 into anteflexion, and traction manipulation. PIR of gluteus maximus muscles. Home exercise for self-treatment: gluteus maximus relaxation.
At the follow-up examination on 4 July 1983 the patient’s low-back pain had improved, occurring now with reduced frequency and intensity. If he stood for longer periods, he noticed pain in the region of his sacrum. On examination his coccyx was no longer painful; the key finding now was extreme weakness of the abdominal muscles, with separation of the rectus abdominis. He was advised to wear a lumbar belt.
7.1.3. Painful hip joint (coxalgia)
In a series of 59 patients with a painful hip joint with no or very slight osteoarthritis of the hip, low-back pain was the most frequent complaint (Lewit 1977). Conversely, signs of a painful hip are common in patients with low-back pain. It is therefore justifiable to discuss the painful hip in this section because the hip also needs to be considered in the setting of low-back pain.
Patients complain of pain on prolonged walking, especially when climbing hills and stairs or on hard paved surfaces, when standing for long periods, and when lying on the painful hip. However, pain is relieved by lying down for extended periods. The pain is usually felt in the low back, hip, and groin and it may radiate in segment L4 toward the knee, causing patients often to complain of knee pain. Sometimes pain localized at the knee is the first and only sign of (incipient) osteoarthritis of the hip: the pain is experienced on climbing stairs but not when descending.
On examination, Patrick’s sign is strongly positive, and when passive mobility is tested, the extreme limits of movement, especially internal rotation, are painful, particularly if a light springing force is applied in the extreme position. In osteoarthritis of the hip there is movement restriction consistent with the capsular pattern described by Cyriax, 1977 and Cyriax, 1978 (internal rotation is most severely limited, see Section 4.10.5). Active abduction is also painful. The characteristic pain points are found at the femoral head palpated in the groin, at the insertion points of the adductors at the pubic symphysis, and at the pes anserinus of the tibia (which is also interpreted as knee pain). Further pain points include the greater trochanter (which provides attachment for the abductors) and the iliac crest. Increased tension of the hip flexors is responsible not only for pain at their attachment point, the lesser trochanter, and for TrPs in the tensed muscles, but also for flexion at the knee and hip in osteoarthritis of the hip. This results in the characteristic posture typified by excessive lumbar lordosis. The PSIS is also frequently painful.
The choice of treatment depends largely on the stage of osteoarthritis of the hip and to what extent any anatomical changes permit functional improvement. It is beyond the remit of this volume to discuss the full range of therapeutic options available in the fields of physical medicine and surgery. The most important form of conservative therapy is traction. Where anatomical changes are not (yet) detectable, traction with a high-velocity, low-amplitude (HVLA) thrust can be instantly effective. Otherwise, traction with PIR constitutes the treatment of choice in this setting (see Section 6.1.2). The effect can be further enhanced by shaking. The efficacy of this technique is probably attributable to the relaxation of all the muscles that place the hip joint under pressure. It is evidently the most effective form of conservative treatment and it should be performed daily, as far as possible.
Because self-treatment is not really practicable, the following procedure can be adopted: once the patient has learned how to relax during therapy, then anyone in regular contact with the patient (family member, friend, colleague) can perform resistance by placing their hands in the patient’s groin. The patient then does the rest.
If there is a muscle imbalance, it is usually the abductors that are weak and the hip flexors and adductors that are hyperactive. This is often apparent in the Trendelenburg test (the hip drops during standing on one leg); more usually, however, it is lifted, causing the center of gravity to shift over the standing leg, thus relieving the weakened abductors. In this case the hyperactive, shortened muscles should be relaxed and also possibly stretched, and the weakened muscles should be strengthened.
Lifestyle advice is particularly important. Patients should avoid prolonged periods of walking (especially on hard pavements or asphalt) and standing. Soft heels and soles should be encouraged, and in severe cases the use of a walking stick (on the healthy side) is recommended. Weight loss is imperative in patients who are obese.
S Z; male; born 1922; university professor.
At the initial examination on 7 May 2002 the patient complained of pain in his right thigh that woke him at night; he had no pain on walking, and no back pain, only slight stiffness in the neck.
Clinical findings and therapy
On examination the patient was found to have reduced fascial mobility in the cervical region, restricted movement of the fibular head, and restricted movement in Lisfranc’s joint on the right side. He received treatment for these.
At the follow-up examination on 22 May 2002 the patient reported that he was free from pain at night, his neck was not as stiff, and he had only minimal pain intermittently in his thigh.
The patient was seen again on 27 April 2004. While he had no recurrence of his original discomfort, he now had pain at the back of his thigh and sometimes a stabbing pain on walking.
He was now found to have reduced spinal anteflexion, retroflexion, and side-bending without pain, increased tonus in the thoracolumbar erector spinae, and a positive femoral nerve stretch test on the right side, consistent with a movement restriction between L3/L4. L3/L4 were mobilized, after which the femoral nerve stretch test was negative, and the patient practiced the McKenzie technique in the prone position for self-mobilization into extension.
At a follow-up examination on 18 May 2004 the patient reported considerable improvement, but climbing stairs was still painful. Patrick’s sign was now positive on the right side, internal hip rotation was largely restricted on the right side and was possible only up to 20° on the left side. Dorsiflexion at the hips was also limited. Internal rotation of the right hip improved to 20° following isometric traction with shaking. X-rays revealed narrowing of the joint space in the right hip and a translucent area at the right acetabulum. The patient and his wife were trained so that they could perform self-treatment regularly.
This patient presented initially with quite uncharacteristic symptoms. Then in 2004 important findings were made in the lumbar spine at L3/L4 for the first time; when these were treated, improvement ensued. It was not until after this disorder was treated that the first signs of osteoarthritis of the hip were diagnosed; these typically responded to traction. This case also illustrates the close connection between the L3/L4 segment and the hip.
7.1.4. Restrictions in the lumbar spine and sacroiliac joints
These conditions share common ground in terms of their etiology, clinical features, and therapy. Mobilizing therapy constitutes the first-line approach for movement restrictions in the lumbar motion segments.
In the acute stage mobility is severely restricted, and straightening up (extension) usually presents more difficulty than flexion. Often there is pain on coughing and sneezing. In more chronic cases there is usually stiffness after longer periods of sitting and/or bed rest, and this improves on movement. Retroflexion is generally more restricted than anteflexion, and the most characteristic complaint is pain on straightening up after anteflexion. Side-bending is also often painful and as an early sign there is no rotational synkinesis during this movement (normally, the upright pelvis rotates in the direction opposite to side-bending). Pain is usually asymmetrical and may radiate to the hips, buttocks, lower abdomen, groin, and lower extremities, and cranially toward the thoracic spine (referred pain).
Clinical signs and therapy
Typical signs of movement restriction are found. One early sign is the absence of rotational synkinesis of the pelvis during side-bending. The specific symptoms in the individual motion segments are listed in Table 7.1. What used to be designated as ‘movement restriction of the thoracolumbar junction’ is now termed ‘movement restriction on trunk rotation’ (see Section 3.4.1). Movement restriction of L2/L3 is a rarity.
|Clinical sign||Trunk rotation||L3/L4||L4/L5||L5/S1||Sacroiliac joints|
|Absence of rotational synkinesis||−||+||+||+||++|
|Straight-leg raising test: ischiocrural muscle spasm (TrPs)||−||−||+||+||+|
|Femoral nerve stretch test: rectus femoris spasm (TrPs)||−||+||−||−||−|
|Patrick’s sign: adductor spasm (TrPs)||−||+||+||+||+|
|Spasm (TrPs) of thoracolumbar erector spinae||++||−||−||−||−|
|Spasm (TrPs) of lumbar erector spinae||−||+||+||+||−|
|Spasm (TrPs) of quadratus lumborum||++||−||−||−||−|
|Spasm (TrPs) of psoas major||++||−||−||−||−|
|Spasm (TrPs) of piriformis||−||−||+||−||−|
|Spasm (TrPs) of iliacus||−||−||−||+||−|
|Painful iliac crest||+||+||−||−||−|
|Painful greater trochanter||+||+||+||−||−|
|Pain at PSIS||−||+||+||+||+|
|Referred pain in L4 segment||−||+||−||−||−|
|Referred pain in L5 segment||−||−||+||−||−|
|Referred pain in S1 segment||−||−||−||+||+|
|Pain at pubic symphysis||+||−||−||−||+|
|Pain in upper part of sacroiliac joint||−||−||−||+||++|
|Pain in lower part of sacroiliac joint||−||−||−||−||++|
It should be noted that a positive straight-leg raising test is caused by spasm (TrP) of the ischiocrural muscles while a positive femoral nerve stretch test is caused by spasm of the rectus femoris. Patrick’s sign is positive when there are TrPs in the adductors. The characteristic TrPs for the individual motion segments are very important for the clinical diagnosis: TrPs of the psoas major, quadratus lumborum, and erector spinae for rotational restriction, and TrPs of the rectus femoris for segment L4, of the piriformis for L5, and of the iliacus for S1. The TrPs in the psoas major are responsible for pseudovisceral pain on restricted trunk rotation, and TrPs in the rectus femoris for thigh and knee pain that mimics a painful hip (‘pseudo-hip’). In the case of TrPs in the piriformis, pain occurs laterally in the buttocks, making side-lying painful and causing patients to report hip pain. A TrP in the iliacus muscle is experienced as pain in the lower abdomen, or sometimes in the groin, possibly simulating some gynecological complaints and, when it occurs on the right-hand side, appendicitis. The typical pain emanating from the lumbosacral and sacroiliac joints cannot be differentiated. TrPs in the iliacus muscle are more likely to indicate a dysfunction at L5/S1.
Sacroiliac joint restriction occurs far more often as a secondary phenomenon than was previously assumed. It commonly reflects muscle fixation due to movement restriction of the fibular head with TrPs in the biceps femoris, or due to restrictions of L4/L5 as a result of TrPs in the piriformis and in the pelvic floor. When these disorders are treated, normal function of the sacroiliac joints is restored. However, since none of these muscles directly connects the ilium with the sacrum, this restriction is not strong; consequently, minimal force is always sufficient when mobilizing the sacroiliac joints, and HVLA thrust techniques are superfluous. There is one condition, however, in which sacroiliac joint restriction plays a major role: namely osteoarthritis of the hip, and even as a sequel to hip replacement surgery. In such cases sacroiliac joint mobilization can greatly relieve the patient’s pain. Indeed, sacroiliac joint restriction after hip replacement surgery may be the frequently unrecognized cause of persistent symptoms.
V M; male; born 1979; professional dancer.
The patient sustained a lifting injury while dancing in March 2004, producing ‘a cracking sound’ in his lower back. The intense pain subsided after a few hours but returned in June 2004. By then the pain was very severe and could only be relieved if the patient was supine with knees flexed; in the mornings he had difficulty getting up and dressing, and he also experienced considerable pain when seated. However, he had no pain when he coughed or sneezed.
Clinical findings and therapy
When he was examined standing on 11 August 2004, anteflexion, retroflexion, and side-bending were possible to only a minimal extent, and even seated anteflexion was restricted. When he was prone, however, retroflexion in a straight-arm press-up position was possible. Therefore counterstrain was applied in the press-up position in lordosis for 90seconds. Afterward, seated anteflexion was possible to some extent. Next, a flexion restriction at L4/L5 was diagnosed and carefully mobilized. Furthermore, there were still active TrPs in the erector spinae and these were found alongside TrPs in the coccygeus (pelvic floor). The deep stabilizers were activated to encourage diaphragm breathing instead of clavicular breathing. Self-mobilization of the lumbar spine (McKenzie method) and correction of the faulty breathing pattern were assigned as home exercises.
At the follow-up examination on 24 August 2004 the ranges of movement on standing were completely normal, just slightly uncomfortable, and the restriction at L4/L5 was mobilized without difficulty and with an HVLA thrust into flexion, after which the patient was pain-free and required no further treatment.
Jones’ counterstrain technique in the pain-free direction was helpful as an initial step, and then careful mobilization into flexion was possible. The deep stabilizers were also exercised as breathing was corrected. About 14 days later a minor residual restriction was released easily. The possible role of an intervertebral disk lesion was considered.
M J; male; born 1967.
The patient had been experiencing low-back pain and subscapular pain since 2002. The pain was worse at night. A general medical assessment was inconclusive.
At examination on 2 August 2005 there were TrPs on the right side in the thoracolumbar erector spinae, psoas major, and quadratus lumborum. Trunk rotation to the left was restricted. Retroflexion was also painfully restricted.
PIR of the quadratus lumborum on the right side while side-bending to the left with the patient standing: the patient performed side-bending to the left to take up the slack, then looked up and breathed in deeply, straightening up a little in the process. He then looked down, breathed out, and relaxed into side-bending. He repeated this three times and then actively and energetically performed side-bending to the left side. Afterward, not only were the TrPs in the quadratus lumborum released, but also those in the psoas major and erector spinae in the chain reaction pattern on the right side. Trunk rotation was symmetrical on both sides. The patient’s home exercise was therefore to perform PIR-RI of the quadratus lumborum on the right side on a daily basis.
At the follow-up examination on 16 August 2005 the patient stressed that he was pain-free for the first time since 2002, but on closer questioning he admitted that slight pain was still present at the level of the lumbosacral junction. The extent of trunk rotation and retroflexion were normal, but retroflexion was still rather painful. TrPs were detected in the rectus abdominis on the left side and its attachment at the pubic symphysis was slightly tender; the left fibular head was restricted with a TrP in the biceps femoris; there was also a TrP deep in the left sole with movement restriction of the second tarsometatarsal joint. After shaking mobilization of the foot, all TrPs disappeared, including the TrP in the rectus abdominis. Retroflexion was now also completely pain-free and we recommended the patient to use a foot roller for his left foot.
Typical low-back pain due to restricted trunk rotation with TrPs in the psoas major, quadratus lumborum, and erector spinae muscles. As a secondary finding, there was a TrP in the rectus abdominis on the left side with a tender attachment at the pubic symphysis, rendering retroflexion painful (due to stretching of the rectus abdominis), and this is always interpreted as low-back pain (!). This TrP forms a chain reaction pattern with TrPs in the biceps femoris and sole of the foot, with the foot being the dominant point.
7.1.5. Low-back pain due to disk herniation
The subject of this section is disk herniation without radicular compression. It is essential to know when disk herniation should be suspected in simple low-back pain. The conditions described thus far have been functional disorders. Here, however, we are faced with a defined pathological lesion with a correspondingly serious prognosis. It must be remembered that many instances of disk herniation are completely devoid of clinical relevance, and for this reason the prognosis is favorable even with conservative therapy. At the same time, dysfunctions play an important role here.
If we discount acute attacks, the clinical course as a rule is more severe than in straightforward functional disorders, that is to say attacks last longer and the condition has a greater tendency to relapse. Coughing and sneezing are generally very painful. The posture that is particularly difficult for patients to manage is bending forward (even slightly), as over a wash basin, because in this position contraction of the erector spinae is maximal and therefore the pressure on the disk is at its greatest. The ‘painful arc’ described by Cyriax, 1977 and Cyriax, 1978 also generally manifests itself in this position. Pain when turning over in bed and when getting up is also highly characteristic.
In acute cases there is a characteristic antalgic (or relieving) posture that is also adopted in response to radicular pain. The most typical antalgic pattern is lumbar kyphosis with the pelvis displaced toward the side of the lesion (and deviation of the trunk to the opposite side; see Figure 7.1). Anteflexion while standing is generally severely limited and the straight-leg raising test is positive (except in lesions at L3/L4 where the femoral nerve stretch test is positive). All movement that is at odds with the antalgic posture is painful. There need not be any movement restriction in the segment affected by disk herniation. When movement restriction is present simultaneously, springing of the lumbar spine continues to elicit pain even after the restriction has been released. Conversely, an (experimental) traction test may bring marked pain relief.
In the more chronic stage, anteflexion is limited while standing, but normal when the patient is seated (with knees flexed). Another very typical sign is the painful arc described by Cyriax, 1977 and Cyriax, 1978 (see Section 4.6.1). Here, too, the straight-leg raising test and the femoral nerve stretch test in segment L3/L4 are positive, much more so than when there is only joint restriction. A most valuable diagnostic sign is pain on springing the lumbar spine, irrespective of whether restriction is present or not.
Manual traction taking account of antalgic posture may be attempted in the acute stage. In other words, if the antalgic posture is in kyphosis, then traction is performed with the patient supine over the practitioner’s knee, but if the antalgic posture is in lordosis, then traction is performed with the patient lying prone. If traction is well tolerated it may procure immediate relief. Counterstrain to exaggerate the antalgic posture is also highly effective. This might be termed ‘manipulative first aid.’
If these techniques fail to bring immediate relief, epidural anesthesia and bed rest in the antalgic posture should be considered, as should analgesic medication. However, bed rest should be kept as brief as possible because energetic (‘aggressive’) therapy in the acute stage is the most important step in preventing chronicity.
Traction may also be helpful in the chronic stage, provided that the patient finds it agreeable and improvement is detected afterward. In every instance it is important to proceed in a manner that is consistent with the clinical findings, and this approach presupposes a fresh examination at every follow-up visit. In this process, chain reaction patterns should be sought in order to shed light on the pathogenesis. Current knowledge indicates that the commonest causes are to be found in the deep stabilizer system (in conjunction with faulty breathing), the feet, faulty movement patterns, active scars, movement restrictions, and TrPs in the key region as well as the fascia.
No less important are general measures: these include avoiding situations that routinely trigger recurrences, and protecting the lumbar region against chill after perspiring.
B J; male; born 1930; professor of clinical medicine.
The patient was seen on 11 March 2004 complaining of low-back pain radiating primarily to his left thigh. The pain was worse at night and the patient had difficulty getting up in the mornings. He also reported pain on coughing and sneezing. His low-back pain had started after a hiking tour in the mountains. For two years he had also had pain in his right arm, the mobility of which was limited. When he was younger he had no history of pain whatsoever. In February 2004 he sustained a fall on to his coccyx. A tonsillectomy had been performed when he was 11 years old.
Examination revealed pes planus on both sides, but more pronounced on the right. When standing, the patient’s right knee was slightly flexed. He had a kyphotic posture and retroflexion was extremely limited. In relative terms, extension in his right knee was more limited than flexion. Joint play in the knee was restricted. A TrP was present in the iliacus muscle on the left side. There was also a hard restriction in segment L5/S1 and the springing test was extremely painful. There was limited mobility of the deep lumbar fascia.
We first performed mobilization for the fascia, followed by rhythmic traction, and then mobilization of L5/S1 into rotation to the right, followed by mobilization into flexion to the left. After this the TrP in the iliacus could no longer be palpated and the patient was assigned a home exercise to practice extension (McKenzie technique) while supine. A lumbar belt was prescribed for rectus abdominis diastasis.
At the follow-up examination on 20 April 2004 the patient felt that his condition had improved. He sometimes had pain radiating to his legs but this improved on walking (despite osteoarthritis of the knee). Even then the springing test was painful. On this occasion the patient was trained how to practice retroflexion while standing.
On 28 June 2006 the patient was symptom-free.
The repeatedly painful springing test, the relief of pain after traction, the pain on coughing and sneezing, the only moderate improvement, and the difficulty experienced with the McKenzie exercise in the supine position are suggestive of disk herniation in the setting of simple low-back pain with referred pain – but without neurological abnormalities.
7.1.6. Pelvic distortion
Pelvic distortion is always a secondary symptom (see Section 4.5.3). The clinical picture is therefore dependent entirely on the condition in which pelvic distortion is (also) detected and which is also the object of therapy. If treatment is correct, pelvic distortion also disappears. It is encountered far more frequently in children and adolescents than in adults, and it is generally a consequence of a restriction at the craniocervical junction. Adolescent girls with pelvic distortion also frequently present with dysmenorrhea. Here, too, the true cause is probably a dysfunction at the lumbosacral junction with a TrP in the iliacus. In the final analysis the Rosina test (see Section 4.5.5) also indicates that pelvic distortion in patients with normal sacroiliac joints can be provoked by head rotation and that this is a palpatory illusion, as has been confirmed radiologically.
7.1.7. Forward-drawn posture
Because this disorder affects posture as a whole, symptoms may occur at every level of the locomotor system, although they are strikingly common in the cervical region.
The following pathological mechanism in particular is responsible for low-back pain: TrPs in the rectus abdominis produce attachment point pain at the pubic symphysis and prevent retroflexion of the trunk. This is perceived as low-back pain and can be eliminated directly by relaxing the abdominal muscles or by local anesthesia of the pubic symphysis.
In this dysfunction an (apparent) asymmetry is palpated at the pubic symphysis and at the ischial tuberosities. Inspection from the side reveals a forward shift of the pelvis relative to the patient’s feet, of the shoulder girdle relative to the pelvis, and of the head relative to the shoulders (see Figure 7.2). TrPs in the rectus abdominis are a typical finding, with the abdomen often drawn in and not participating in respiration. The attachments of this muscle at the pubic symphysis and at the inferior costal arch with the xiphoid process are tender. Hypertonus of the gluteal region is also found, with increased resistance of its soft tissue against shifting in a cranial direction. Further TrPs are located in the biceps femoris with restricted mobility of the fibular head and, when the chain reaction pattern is complete, there are TrPs and restrictions at the feet, often with asymmetric tactile perception on the soles of the feet. A forward-drawn posture is also always associated with increased tension (hypertonus) of the erector spinae throughout the back and neck.
The most important clinical test is to sit the patient down. If hypertonus disappears, especially in the neck, then we know that the disorder originates not from above but from the feet (in cases where the chain reaction pattern is complete). The underlying pathological mechanism is as follows: where TrPs are present in the biceps femoris, the postural fixation of the pelvis via the ischial tuberosity and the sacrotuberal ligament is impaired, and it is held in place by compensatory tension of the abdominal and gluteal muscles.
On the side where the rectus abdominis has its insertion and hypertonus exists, palpation reveals that the symphysis is higher, and on the side of the tensed biceps femoris it is found that the ischial tuberosity is lower. Interestingly, these differences are only ever detected with the patient in the prone position, and never standing. There are numerous osteopathic techniques by which this asymmetry can be corrected, but nothing in the radiological appearance is altered. What does change is the position of the palpating fingers (‘palpatory illusion’; see Figure 4.11). In our experience this finding has nothing to do with the sacroiliac joints.
If increased tension in the dorsal muscles disappears on sitting down, treatment of the most caudal lesion is indicated, where possible at the feet (key region), or in the event of negative findings there, at the fibular head. Forward rocking (see Section 6.8.8 and Figure 6.157) causing reflex toe flexion is currently the most effective and indeed the simplest form of (self-)treatment. Findings at the buttocks and abdomen are almost always secondary, and they may have their origin in the deep stabilization system, especially in the pelvic floor.
It must be stressed that forward-drawn posture is a very common disorder: we saw 90 cases over a two-year period. Treatment in patients with forward-drawn posture is so effective that restricted mobility at the craniocervical junction, for example, is also released.
If a patient with headache and restricted mobility in the cervical region is found to have a forward-drawn posture, and if the neck muscles are tensed on standing but become relaxed on sitting, then any treatment that is limited to the cervical region alone is bound to be unsuccessful.
B K; female; born 1985.
The patient was seen on 22 February 2005 complaining of headache. In December 2004 she had been struck by an automobile and knocked to the ground. She had landed on her back and occiput, was briefly unconscious, and was admitted to hospital. Her headaches did not start until a few days later and were now constant. The patient also reported flickering in front of her eyes and dizziness when performing certain movements; when this occurred she had a tendency to stagger to the right. Since 2003 she had also experienced low-back pain occasionally in the mornings and during her menstrual periods. She underwent surgery for an umbilical hernia at the age of 11 years and she suffers from bronchial asthma.
Examination disclosed hypermobility; the patient had a typical movement restriction at C0/C1 with TrPs in the sternocleidomastoid muscle and the short extensors of the upper cervical spine, a restriction at T1/T2 on the left side with a restriction of the first rib on the left side, TrPs in the diaphragm and the pectoralis major (right side), quadratus lumborum (right side), erector spinae, gluteus medius, and in the pelvic floor (right side), in the thigh adductors (right side), at the right fibula with TrPs in the biceps femoris, TrPs in the soleus, and restricted movement in Lisfranc’s joint with TrPs in the sole and on the dorsum of the right foot.
Activation of the deep stabilizers, first in the supine position, then by lifting the knees while seated; the patient palpated contraction of the lateral abdominal wall with her own hands. Then clavicular breathing was corrected in front of a mirror: during inhalation she palpated for contraction of the lateral abdominal wall and the lower abdomen while simultaneously checking in the mirror to see whether her thorax was lifting. After repeated exercise, all TrPs and restrictions were eliminated. Her home exercise was to practice breathing correctly in front of the mirror.
At the follow-up examination on 15 March 2005 the patient was virtually pain-free. Correct fixation of the thorax during breathing was verified and she was recommended to continue with regular exercises to activate the deep fixators.
The case of this patient illustrates how dysfunctions of the deep stabilizers provoke chain reaction patterns in all sections of the locomotor system and how all TrPs and restrictions can be eliminated by activating (exercising) this system. The umbilical hernia, for which the patient underwent surgery at the age of 11 years, is a further indicator of a major weakness in this system.
7.1.8. Inflare and outflare (Greenman)
In our experience these conditions frequently take the form of low-back pain and radicular pain with a severe clinical course, and they are also encountered in patients with residual discomfort following intervertebral disk surgery. In the vast majority of cases the patient’s history contains evidence of a fall on to the buttocks and/or coccyx. This fact, coupled with the often very favorable effect of ‘repositioning,’ awakens the suspicion that trauma in the history is a factor here. Our experience indicates that this disorder is highly relevant although the true pathological mechanism is far less clear. Nevertheless we know today that movement restriction of the hip is a routine finding on the side of inflare and that this disappears immediately after therapy.
Inflare and outflare are in fact characterized by pelvic asymmetry (as described by Greenman & Tait 1988): on one side (usually the right) the anterior superior iliac spine (ASIS) appears to be more lateral and flattened, while on the other side (usually the left) the ASIS appears to be more medial and ventral. As a result the triangle formed by the right and left ASIS and the umbilicus is pulled out of shape (see Figure 7.3). These findings create the impression that one half of the pelvis is tilted outward and the other half inward. Hypotonus (reduced muscle tone) is palpated on the side of the flattened ASIS, while relative hypertonus is palpated in the lower abdomen on the opposite side. It appears to be important that internal rotation at the hip on the side of the prominent ASIS is routinely found to be clearly restricted compared with the other side (Lewit & Olšanská 2005). This asymmetry is readily visible in slim patients; in obese patients, however, this possibility must be remembered and palpated for. Unlike Greenman, we are of the opinion that there is generally no sacroiliac joint dysfunction.
For specific therapy, on the side where the ASIS appears flattened (outflare) and with the patient’s knee and hip flexed at right angles, the practitioner adducts the patient’s thigh (as when testing the iliolumbar ligament, see Figure 4.13) until the slack is taken up. He then tells the patient to resist adduction for 5–10seconds and breathe in, then to relax and breathe out. PIR is repeated two or three times, and then the patient adducts the thigh flexed at the knee and hip against repetitive resistance (RI).
On the other side (inflare), the practitioner takes up the slack on the thigh abducted at the knee and hip (as when testing for Patrick’s sign, see Figure 4.43). The patient resists abduction for about 5–10seconds and breathes in, and then relaxes into abduction while breathing out. PIR is repeated two or three times, and then the patient performs abduction against repetitive resistance or else abducts the thigh maximally (RI). Afterward, the practitioner checks whether the ASISs are symmetrical, whether muscle tone in the lower abdomen is now balanced, and whether internal rotation at both hip joints is now identical.
R D; male; born 1946.
The patient was first seen on 14 June 2005. He had been involved in a road traffic accident in August 2004, following which he had been unconscious for almost a week. On his left side he sustained several fractured ribs and a fractured lower leg. He was a professional downhill skier and recalled having fallen on to his coccyx on numerous occasions. He had experienced back pain for the past 18 years related to his sporting activity, and had suffered one or two headaches every week since adolescence. The symptom that actually prompted him to consult us was pain in the left groin that radiated into his thigh and on account of which he had to remain standing in order to get moving again.
On examination, lumbar spinal mobility with the patient standing was normal, head rotation was limited in both directions, there was restricted mobility of C1/C2, restricted mobility of the fibular head with a TrP in the left biceps femoris, outflare on the right side and inflare on the left, and the femoral nerve stretch test was positive on the left side. Internal rotation at the hip joint was 25° on the left and 45° on the right. Dorsiflexion in the right talocrural joint was restricted (80° compared with 100° on the left side).
Treatment involved ‘repositioning’ the pelvis. After this treatment all findings became normal, apart from the right talocrural joint, which was also mobilized.
At follow-up examination on 12 July 2005 the patient was able to walk normally, but he felt slight pain in his left lower leg on running. Over the intervening four-week period the patient had had only two headaches. The findings now comprised a movement restriction at C1/C2. The fascia on his left lower leg showed poor mobility relative to the underlying bone, a sign of an active scar following the accident, and there was a TrP in the adductors on the left side. After treating the fascia of the left lower leg, there was no longer a TrP in the adductors, and the movement restriction at C1/C2 was also released. The findings at the pelvis and hips were symmetrical.
The principal symptoms associated with claudication were abolished following treatment of outflare and inflare, and the findings in the cervical region were also improved immediately after treatment, as reflected in the reduced frequency of headaches. The pain in the patient’s left lower leg was a residue from a comminuted fracture with an active scar; after these were treated there was normalization of the TrPs in the adductors and of the movement restriction in the upper cervical spine. The movement restriction in the right talocrural joint was not linked with the other dysfunctions; it may have been the result of excessive strain caused by an antalgic posture adopted by the left lower leg after fracture.
7.1.9. The coccygeus and pelvic floor
The coccygeus forms part of the deep stabilization system and can be understood only in the context of the locomotor system as a whole. We should further recall the role of the levator ani in conjunction with the sphincters and the gluteus maximus. Here we are dealing with an entirely different function of the pelvic floor, which contributes to erect posture and respiration; disturbances of this function are announced by a TrP in the coccygeus. The palpatory technique for this TrP is described in Section 4.5.8 (see Figure 4.12).
The numerous chain reaction patterns originating in the deep stabilizers, and in the pelvic floor in particular, are described in Section 4.20. One especially characteristic finding is a usually very clear TrP in the thoracic erector spinae; mechanical stimulation of this TrP produces not only an observable, local twitch response but also contraction of the lumbar erector spinae with brusque dorsiflexion of the pelvis. This phenomenon was described by Silverstolpe (1989) and Skoglund (1989) who termed it the ‘S reflex.’
Relaxation of this TrP can be obtained by release achieved using simple sustained pressure (as for diagnosis). However, this is felt to be painful by the patient and, what is worse, relapses usually develop quickly. We have therefore elaborated a relaxation technique that the patient can practice on a daily basis (see Figure 6.143).
However, the process begins with activation of the entire deep stabilizer system and involves exercising the concerted action of the diaphragm, the deep abdominal muscles, and the pelvic floor. This has been described for the rehabilitation of breathing in Section 6.7.7 (see 6.155 and 6.156). Interestingly, this activation relaxes not only the TrPs in the pelvic floor and diaphragm, but also generally all other TrPs linked with them. The patient is then instructed to exercise actively with the aim of normalizing respiratory movement patterns and the deep stabilizer functions of the trunk. However, if the TrP in the coccygeus persists, the patient needs to practice its relaxation.
7.1.10. Low-back pain due to restricted trunk rotation
Patients complain of low-back pain, apparently due to painful attachment points of the erector spinae and quadratus lumborum dorsally on the iliac crest. TrPs in the psoas major may cause pseudovisceral pain. TrPs in the erector spinae may also be responsible for pain felt underneath the shoulder blades. The pain here may have an acute onset, particularly on picking up an object placed to one side of the patient, causing lifting to occur with a rotating movement. This mechanism is also important in evolutionary terms: only humans generate maximum forces by trunk rotation, for example as when throwing the discus. Farfan et al (1996) have emphasized that the intervertebral disks in particular are not well adapted to powerful rotational movements.
Trunk rotation is widely regarded as a function of the thoracolumbar junction because, on anatomical grounds, it has been claimed that the joints of the lumbar spine do not permit rotation and that the ribs pose an obstacle to rotation, at least of the upper and middle thoracic spine. It has already been shown in Section 3.4.1 (see Figure 3.19) that this is an erroneous view and that coupled movement associated with scoliosis and rotation can be regularly observed in the lumbar and thoracic spine: side-bending (scoliosis) produces rotation, and rotation produces side-bending. On clinical examination, patients with restricted trunk rotation are found to have TrPs in the thoracolumbar erector spinae, the psoas major, and the quadratus lumborum on the side opposite to the lesion. In this context it is sufficient to treat one of the three muscles in this chain to restore trunk rotation. Compared with these three powerful muscles, the joints do not appear to play a major role here.
It should also be recalled that vertebral fractures are most commonly encountered at T12 and L1, especially in osteoporosis. In such patients trunk rotation is indeed considerably restricted, at least on one side. Careful neuromuscular mobilization (using only visual and respiratory synkinesis) achieves instantaneous pain relief here in a very gentle way.
Treatment takes the form of PIR and RI of one of the three muscles in the chain, namely, the erector spinae (see Figure 6.115), the quadratus lumborum (see Figure 6.120), or the iliopsoas (see Figure 6.122).
As a relatively recent phylogenetic function, trunk rotation is very commonly restricted and often occurs in a chain along with many other dysfunctions. The link with restricted rotation of the cervical spine appears particularly important. In such cases, restricted trunk rotation should be treated first. Usually it is then no longer necessary to treat the cervical spine.
H K; female; born 1919; professional translator.
The patient came to us on 1 July 2003 complaining of pain in her cervical and lumbosacral regions. Cervical pain had been present since 1998, and low-back pain since the onset of puberty at the age of 13 years. She had experienced low-back pain both during menstruation and during three pregnancies. Her most recent episode of low-back pain had occurred in May 2003, but by early July it was cervical pain that was dominant. Her occupation as a translator involves keyboard work at a computer. She reported having undergone a hysterectomy and ovarectomy in 2000.
Clinical findings and therapy
Examination revealed a slight movement restriction to the left at C4/C5, TrPs in the diaphragm on the right, and in the psoas major, quadratus lumborum, and erector spinae on the left. Trunk rotation was 30° to the right and 45° to the left. Therefore the quadratus lumborum was treated using gravity-induced PIR coupled with visual and respiratory synkinesis. After this, not only trunk rotation but also head rotation was completely normal; moreover, the TrP in the diaphragm on the right side was no longer palpable. The patient’s home exercise consisted of PIR and RI for the quadratus lumborum.
At the follow-up examination on 30 July 2003 the patient made a point of saying how much the exercise program was helping, but she still had low-back pain and right shoulder pain as a legacy from tidying up on the previous day. The principal finding on examination was a painful subscapularis on the right side, which was treated using PIR and RI; otherwise the examination yielded no abnormalities.
In elderly patients, in particular, low-back pain is frequently associated with restricted trunk rotation and is also typically coupled with slight restriction of head rotation. The latter resolves immediately following treatment of trunk rotation. The focus therefore simply needs to be on correcting trunk rotation. This was reflected in the exercise prescribed for the patient at home. The subscapularis muscle is a common source of shoulder/arm pain, especially after exertion.
7.1.11. Combined lesions
Needless to say, the individual forms of back pain described above rarely occur in isolation. Usually they present as mixed or combined lesions, with the clinical picture being dominated by a different factor in each case. And this does not happen by chance. All the structures involved in the etiology of low-back pain are somehow interconnected, and many are closely linked in a chain reaction pattern. Movement restriction at L4/L5 often fixes the sacroiliac joint via the piriformis, the sacroiliac joint itself is closely connected to the hip, and this in turn to segment L3/L4, while the pelvic floor has a special relationship with the adductors, and also with the biceps femoris and fibular head.
J F; female; born 1906.
Our patient since 1962, she was obese with a slouched posture consistent with lumbar hyperlordosis and weak abdominal muscles. Low-back pain started in 1957, often occurring when the patient bent forward.
Clinical findings and therapy
Initial examination revealed movement restriction in segment L5/S1 and pelvic distortion, and subsequent examination showed a painful coccyx (this relapsed twice). Later the clinical picture came to be dominated by hip pain (without osteoarthritis), then again by lumbosacral movement restriction and a painful coccyx, followed by pain at the L5 spinous process, and (since 1968) sacroiliac restriction. The patient’s condition improved slowly in response to remedial exercise and weight reduction, but she continued to require treatment periodically.
It is certainly uncommon to encounter such a wide range of pelvic lesions in an individual, not concurrently but occurring in alternating sequence over a number of years. Despite the often close anatomical relationships, it is important to differentiate the individual dysfunctions precisely so that they can be treated in a targeted manner and so that remedial exercises can be prescribed as specifically as possible.
7.2. Pain in the thoracic spine and thorax
The thoracic spine is the least mobile section of the spinal column. Because of this stability it is only relatively rarely the site of the primary lesion in dysfunctions. On the other hand, pain in the thoracic region is often referred pain from the viscera, and it is here that vertebrovisceral inter-relationships are most clearly apparent. A special warning against diagnostic error is particularly apposite in this region. One important condition that manifests itself primarily in the thoracic spine is juvenile osteochondrosis, the commonest cause of kyphosis in adolescents. Stiffness of the kyphosed thoracic spine has to be compensated for by lumbar hyperlordosis, and it is there that pain is most commonly felt.
Patients complain mostly of pain between or below the shoulder blades. Here, again, pain in the dorsal region may be the result of excessive strain due to external factors or to muscle imbalance and excessive static loading. One particularly common culprit is a kyphotic sitting position associated with working at the computer. The typical muscle imbalance is shortening of the pectoralis major and weakness of the interscapular muscles and of the lower fixators of the shoulder blade. Major stiffness is detected especially at the point where the kyphosis peaks. On the other hand, hypermobility can also be linked with pain, generally in a flat back in the upper thoracic region.
Movement restrictions may be present not only in the apophyseal joints between the individual vertebrae but also at the joints between vertebrae and ribs, and they produce very similar symptoms. Deep breathing can be painful in both scenarios. Of course, this is particularly the case with rib lesions, where it is useful to distinguish between pain on inhalation and pain on exhalation. It is essential for the differential diagnosis to exclude pleural disease.
The techniques for diagnosis and therapy have been discussed in the appropriate sections in 4 and 6, with regard to both movement restrictions and TrPs. The deep stabilization system with TrPs in the diaphragm and pelvic floor also plays an important role here. Patients with restricted trunk rotation suffer not only from low-back pain but also from pain between or beneath the shoulder blades (attachment points of the iliocostal muscle).
Therapy and self-mobilization (see Figure 6.74) simultaneously serve to strengthen the interscapular component of the erector spinae. Where painful tender points are present at the sternocostal joints, specific relaxation of the bundles of the pectoralis major with insertion there has proved effective (see Figure 6.109). While highly effective, self-mobilization (see Figure 6.38) is indicated only if lordosis in the thoracolumbar region does not occur in the process.
Less frequently than in the lumbar and cervical spine (where acute low-back pain and acute wry neck are common conditions), acute episodes of pain may occur in the thoracic spine, due especially to rib dysfunction. Such episodes can be even more dramatic than acute low-back pain or neck pain, because patients are unable not only to move but also even to breathe without pain. Manipulation and mobilization are complicated by the fact that mere contact at the rib is excessively painful; on the other hand, local anesthesia at the transversocostal joint is easy to perform because the structure is superficial. However, a similar acute pain on respiration may also be produced in the very early stage of pneumonia (before the typical rise in temperature).
7.2.1. Slipping rib
Here attention will be drawn to a clinical condition that is by no means rare but is only seldom recognized. Slipping rib presents as intense pain localized in the lower thorax and upper abdomen, sometimes associated with pain on respiration and coughing (or sneezing). Large, forceful movements of the upper extremity on the side of the lesion may also be painful. Generally, suspicion falls on a wide variety of diseases of the thoracic and upper abdominal organs, and these patients usually undergo a great many visceral examinations (which all prove negative).
A simple maneuver can be valuable in confirming the diagnosis. With the patient seated or supine, the practitioner hooks her fingers under the last ribs at the upper end of the patient’s abdominal cavity (similar to the situation shown in Figure 6.112) and exerts pressure on the ribs with her fingers underneath against her thenar eminence above. At that moment the patient experiences sharp pain. This response clinches the diagnosis of slipping rib (Heinz & Zavala 1977). Interestingly, we have encountered slipping ribs relatively frequently in women with pain following breast cancer surgery.
Therapy consists of mobilization using the fingers hooked beneath the inferior costal arch to exert repetitive springing pressure ventrally and laterally. This mobilization is always painful but generally brings instantaneous relief. Only in exceptional cases is local anesthesia necessary at the inner margin of the tenth rib, while surgical removal of the painful rib may be considered as a last resort. Treatment of the spinal column or of the costovertebral joints is ineffective in this condition and the true pathogenesis is unknown.
C M; female; born 1929.
First seen by us on 4 June 2002 complaining of burning pains in the thorax, usually occurring at rest and apparently without any provoking factors. Onset of pain just one month previously. The patient had undergone surgery in 1992 to remove her left breast, after which she experienced transient swelling of the feet; no symptoms at all prior to surgery.
Clinical findings and therapy
Restricted movement at C3/C4 to the left side, TrPs in the diaphragm on the left side, the thoracic fascia on the left side showed reduced mobility relative to the underlying structures, and the fifth sternocostal joint was painfully tender. The fascia was treated and the attachment point of the pectoralis at the fifth costotransversal joint was released. The restriction at C3/C4 was also treated, after which the TrP in the diaphragm could no longer be palpated.
At follow-up examination on 25 June 2002 the patient reported no major improvement. She also still complained of ‘spasm-like back pain.’ On this occasion a slipping rib (left side) was diagnosed and treated. Following further examination on 4 July 2002 the patient’s condition was considerably improved, and she reported feeling only slight tension in the axilla. The serratus anterior was found to be shortened; this was relaxed and stretched. Relaxation of the serratus anterior was then assigned as her home exercise.
The slipping rib was found to be crucially important for the symptoms experienced by this patient. The far more typical findings made at the initial examination proved to have little relevance.
7.3. Pain in the cervical spine
The clinical features of neck pain per se are relatively straightforward by comparison with low-back pain. By contrast, the clinical features of vertebrogenic disorders in the cervical region, the so-called ‘cervical syndrome,’ are far more complex than those of lesions of the lumbar spine and pelvis.
7.3.1. Muscle imbalance
Pain may result from excessive strain due to external factors or from muscle imbalance. Most commonly, static overload due to long periods of working with the head bent forward plays a prominent role. A similar effect is produced by a forward-drawn posture as a result of faulty statics (see Figure 3.39). The typical signs of muscle imbalance have been described in Section 4.20.3.
Initially, signs of fatigue occur, followed by pain, most frequently after working at the computer with head bent forward or in a fixed position. Jolting in automobiles and other types of vehicle may elicit similar pain.
Wherever possible, long periods spent with the head bent forward should be avoided and fixed positions should be corrected. Remedial exercises should be employed to correct any muscle imbalance. Clavicular breathing, a faulty respiratory pattern characterized by thoracic lifting (without widening) during inhalation, is a particularly common expression of a disorder of the deep stabilization system, and this requires treatment.
Any TrPs and movement restrictions found should be treated. Later, during the rehabilitation phase, muscle imbalance is corrected, paying particular attention to clavicular breathing as the most common manifestation of this.
In terms of lifestyle advice, correct positioning in bed at night is especially important (see Section 8.3.1).
7.3.2. Acute wry neck
The pain often has its onset after rest in bed (in an unsuitable position), after a sudden jerk of the head, or after an automobile journey with the window open. The patient complains of neck pain, frequently on the right side and radiating toward the shoulder and/or occiput, and of stiffness. Autonomic symptoms such as nausea or drowsiness may also be present.
The patient’s head is rotated to one side, more usually to the left. Rotation to the right and inclination to the left are restricted, but anteflexion and retroflexion also suffer. Segment C2/C3 is most commonly involved, and in exceptional cases C1/C2 or C3/C4. However, in the acute stage it can be difficult to localize the dysfunction precisely. Further, it is important to realize that another segment is usually restricted, for example C5/C6, as well as a segment at the cervicothoracic junction. Simultaneously, numerous TrPs are present in the area of the short extensors at the craniocervical junction, and in the sternocleidomastoid, levator scapulae, and trapezius. A very characteristic finding is a pain point on the lateral aspect of the spinous process of the axis (during the examination the practitioner should not forget to bend the patient’s head to one side!). A pain point in the horizontal part of the trapezius close to the shoulder blade is an important prognostic indicator: finding this TrP suggests that a cervicobrachial syndrome or even a radicular syndrome may be imminent.
The first step is post-isometric traction (see Figure 6.52): this must be performed in the direction that is most agreeable to the patient and in which the patient also finds it easiest to relax. One alternative is a simplified version of Jirout’s maneuver (2000): for this, the patient is supine with the cervical spine precisely in a neutral position. If rotation to the right is restricted (as is usually the case), the practitioner’s thumb takes up contact with the patient’s left acromion, which must not be elevated, stimulates this a little with the thumb and instructs the patient to offer (isometric) resistance against this pressure and then to let go again. This procedure is repeated two or three times. In those exceptional cases where head rotation to the left is restricted, resistance is offered on the right-hand side. This technique has the advantage that no contact at all is made with the painful neck region. The acute muscle spasm is usually corrected after this maneuver, as after post-isometric traction.
Only after this step is complete can the remaining restrictions or TrPs then be treated specifically; possible chain reaction patterns from other areas of the locomotor system can also be diagnosed and treatment can be continued as appropriate.
It is important not to confuse the common form of wry neck with spasmodic torticollis, a mistake that can be easily made because in the initial attack pain is the dominant clinical feature of both. However, although pain diminishes with each relapse, the fixed position in spasmodic torticollis continues to deteriorate. The powerful spasm of the sternocleidomastoid on one side and of the splenius capitis on the other will then be noted, but without the typical signs of true movement restriction.
Meningeal bleeding must also be considered in the differential diagnosis. This may also begin with acute neck pain radiating to the head, and here too the patient will avoid movement and jolting. However, the movement that is primarily restricted is anteflexion, although here it is a meningeal sign. Side-bending and rotation are not affected.
If the pain is not acute, then neck pain is just one of many signs of what is termed the ‘cervical syndrome.’ It is unusual for neck pain not to be combined with either headache or shoulder pain, that is pain in dermatome C4. Among other sources, pain is also referred to this segment from the diaphragm. There is often also a HAZ posterior to and below the mastoid process, which is suggestive of restriction at the craniocervical junction.
7.4. Referred pain and other pain types
The lower extremities (see 7.4.1–7.4.5)
It will be useful at this point to review the material on the subject of referred pain presented in Section 2.11. Table 7.1 lists those spinal segments where individual movement restrictions produce referred pain. As in true radicular syndromes, in the pseudoradicular (or reflex) syndromes provoked by movement restrictions we encounter referred (or radiating) pain exclusively in segments L4, L5, and S1.
In the L4 pseudoradicular (reflex) syndrome, pain radiates down the ventral aspect of the thigh toward and even below the knee; in the L5 syndrome, pain radiates down the lateral aspect of the thigh and lower leg to the lateral malleolus; and in the S1 syndrome, pain radiates down the dorsolateral aspect of the lower extremity toward the heel. In the L4 syndrome, the femoral nerve stretch test is positive (TrP in the rectus femoris), while in the L5 and S1 syndromes, the straight-leg raising test is positive (TrPs in the ischiocrural muscles). Besides the referred pain, there may also be paresthesia. The TrPs in the key muscles were listed in Table 7.1.
It may also be helpful to consider which other structures are also capable of triggering the same patterns of referred pain. The referred pain in L4 may stem not only from a lesion in the motion segment L3/L4 but also from the hip joint, and for this reason it may be difficult to distinguish a painful hip with (minimal or) no osteoarthritis from an L3/L4 lesion. Pain at the knee may even be caused by both these lesions, especially where TrPs in the adductors produce pain at the pes anserinus on the tibia.
A mildly positive Patrick’s sign may also be elicited in the L4 pseudoradicular syndrome if there are TrPs in the adductors. The femoral nerve stretch test is probably the most useful tool for differentiating between the two lesions.
In the L5 pseudoradicular (reflex) syndrome, a TrP in the piriformis plays a major role and this may even persist after the movement restriction at L4/L5 has been released. The piriformis may also cause fixation of the sacroiliac joint, and for this reason restrictions at the sacroiliac joint are quite often found concurrently with restrictions at L4/L5. Where a TrP is simultaneously present in the biceps femoris, a restricted and sometimes painful fibular head may also be encountered.
The S1 pseudoradicular (reflex) syndrome is caused not only by lesions of the L5/S1 motion segment but also by lesions of the sacroiliac joint. The sacroiliac ligaments and the ischial tuberosity may also give rise to pain in this segment. The TrP in the iliacus is generally consistent with the movement restriction at L5/S1. Further findings in this segment may include TrPs in the ischiocrural muscles and movement restriction at the fibular head.
The structure that may complicate all three pseudoradicular (reflex) syndromes is the coccyx. A painful coccyx may be associated with a positive Patrick’s sign, a mildly positive straight-leg raising test, and TrPs in the iliacus and even in the piriformis and gluteus maximus. In exceptional cases a painful coccyx may even simulate hip pain.
The upper extremities (see 7.4.6–7.4.8)
Referred pain is not the exclusive preserve of the lower extremities. Dysfunctions are often found that have their origin in the upper extremities; they may be complications of vertebrogenic and even of radicular syndromes.
In the upper extremities, too, it is common to find pain that is referred from lesioned structures in the cervical spine. Here, however, unlike the lower extremities, referred pain does not exactly follow the individual segments/dermatomes. Instead, the pattern is consistent with that produced by TrPs in the individual muscles close to the cervical spine and cervicothoracic junction, with pain characteristically referred to the shoulders, elbows, and hands.
7.4.1. Fibular head restriction
Movement restriction involving the fibular head is closely linked with faulty statics (see Figure 6.25). Locally, it may give rise to lateral pain at the knee and cramping in the calf. Often it is a secondary finding in dysfunctions involving the foot. Fibular head restriction is regularly associated with TrPs in the biceps femoris, a muscle that plays a critical role in the anatomical fixation of the pelvis. Where pelvic fixation by the biceps femoris is inadequate, there is a compensatory response by the rectus abdominis together with the gluteal muscles, and then TrPs are found principally in the rectus abdominis, causing a forward-drawn posture.
7.4.2. Painful patella
In true knee pain (not pain that is referred to the knee) it is most important not to overlook a painful patella. A healthy patella should move freely on the articular surfaces of the femur and tibia. It should therefore be checked whether the patella is freely mobile in all directions and whether gentle pressure on the patella during mobility testing produces grinding resistance and pain. The technique for this is described on page 198 and can often bring instantaneous relief. Attachment point pain at the upper margin of the patella may be caused by TrPs in the rectus femoris, but also by increased tension in the tensor fasciae latae.
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