Chapter 4 / Quadratus Lumborum 83 Figure 4.33. Supine Self-stretch Exercise for the thigh medially and downward, which rotates and pulls right quadratus lumborum muscle. A, starting position, the right half of the pelvis caudad; this takes up slack supine with the hips and knees bent. The hands are in the quadratus lumborum and abductor fibers of the placed behind the head to elevate the rib cage. S, pre- gluteal muscles (dashed lines). Large arrow indicates paratory position with the controlling left leg crossed the direction of applied pressure. Steps 8 and C may over the right thigh, the side to be stretched. After the be repeated until no further increase in range of mo- right thigh has been adducted as far as it will go with- tion is achieved. D, release of stretch by slipping the out resistance, during slow deep inhalation, the left leg controlling (left) leg off the right knee, releasing ten- is used to resist a gentle isometric abductive effort of sion and at the same time supporting the treated side. the right thigh. C, as the patient slowly exhales and Hips and knees are then returned to the relaxed posi- relaxes the right side, the left leg gently pulls the right tion, as in A.
84 Part 1 / Lower Torso Pain Figure 4.34. Hip-hike Exercise in the supine position right hip-hike position, stretching the left quadratus to maintain active range of motion of the quadratus lumborum. The patient then pauses, breathes, re- lumborum muscles. A, resting position. S, left hip-hike laxes, and repeats the series. position, stretching the right quadratus lumborum. C, ing the hip on the other side toward that should follow a flexion exercise such as shoulder, and then reversing sides. This the sit-up with extension to protect the tilting motion of the pelvis alternately intervertebral disc.103 stretches the quadratus lumborum on one side and then on the other side. This is References more effective if done synchronously with slow respiration, breathing in while 1. Baker BA: The muscle trigger: evidence of elevating the hip on the involved side and overload injury. J Neurol Orthop Med Surg 7 : 3 5 - breathing out while lowering it. Addi- 44, 1986. tional active stretch of the quadratus lum- borum occurs if the hips and knees are 2. Baker BA: Myofascial pain syndromes: Ten flexed as this exercise is performed. single muscle cases. J Neurol Orthop Med Surg 10:129-131, 1989. A popular flexion exercise is the sit-up. However, patients frequently have weak 3. Bardeen CR: The musculature, Sect. 5. In Mor- abdominal muscles that require consider- ris's Human Anatomy, edited by C. M. Jackson, ation. Since muscles exert more force Ed. 6. Blakiston's Son & Co., Philadelphia, with less effort during lengthening con- 1921 (p. 469). tractions than during shortening contrac- tions, one starts with sit-backs, proceeds 4. Basmajian JV, Deluca CJ: Muscles Alive, Ed. 5. to abdominal curls, and finally to partial Williams & Wilkins, Baltimore, 1985 (pp. 3 8 5 - sit-ups with the knees bent to unload the 387, 423). iliopsoas muscle if it, too, is involved. These exercises are described and illus- 5. Beal MC: A review of the short-leg problem. J trated in Figure 49.11 of Volume l . 1 8 1 One Am Osteopath Assoc 5 0 : 1 0 9 - 1 2 1 , 1950. 6. Beal MC: The short-leg problem. J Am Osteo- path Assoc 7 6 : 7 4 5 - 7 5 1 , 1977. 7. Beattie P, Isaacson K, Riddle DL, et al.: Validity of derived measurements of leg-length differ- ences obtained by use of a tape measure. Phys Ther 7 0 : 1 5 0 - 1 5 7 , 1990. 8. Bengert O: uber die Bedeutung der Beinlangen- differenz. Z Orthop 7 0 8 : 4 3 5 - 4 4 5 , 1970.
Chapter 4 / Quadratus Lumborum 85 9. Bopp HM: Periarthrosis coxae oder Trochan- 36. Friberg O: Clinical symptoms and biomechan- terschmerz bei Beinlangedifferenzen? Orthop ics of lumbar spine and hip joint in leg length Praxis 7 0 : 2 6 1 - 2 6 3 , 1 9 7 1 . inequality. Spine 8 : 6 4 3 - 6 5 1 , 1 9 8 3 . 10. Botte RR: An interpretation of the pronation 37. Friberg O: Biomechanical significance of the syndrome and foot types of patients with low correct length of lower limb prostheses: a clini- back pain. J Am Podiatr Assoc 7 7 : 2 4 3 - 2 5 3 , cal and radiological study. Prosthet Orthot Int 8: 1981. 124-129, 1984. 11. Bourdillon JF, Day EA: Spinal Manipulation, Ed. 38. Friberg O: The statics of postural pelvic tilt 4. Appleton & Lange, Norwalk, 1987 (pp. 1 8 - scoliosis; a radiographic study on 288 consecu- 19, Fig. 2.2). tive chronic LBP patients. Clin Biomechanics 2: 211-219, 1987. 12. Ibid. (pp. 50, 5 2 - 5 3 , Fig. 3.12). 13. Brash JC, Jamieson EB: Cunningham's Manual of 39. Friberg O: Lumbar instability: a dynamic ap- proach by traction-compression radiography. Practical Anatomy, Ed. 10, Vol. 2. Oxford Uni- Spine 7 2 : 1 1 9 - 1 2 9 , 1987. versity Press, New York, 1942 (p. 389). 14. Callen PW, Filly RA, Marks WM: The quad- 40. Friberg O: Hip-spine syndrome. Manual Med 3: ratus lumborum muscle: a possible source of 144-147, 1988. confusion in sonographic evaluation of the re- troperitoneum. J Clin Ultrasound 7 : 3 4 9 - 5 2 , 41. Friberg O: Personal communication, 1989. 1979. 42. Friberg O, Koivisto E, Wegelius C: A radio- 15. Carter BL, Morehead J, Wolpert SM, et al: graphic method for measurement of leg length Cross-Sectional Anatomy. Appleton-Century- inequality. Diagn Imag Clin Med 5 4 : 7 8 - 8 1 , 1 9 8 5 . Crofts, New York, 1977 (Sections 29, 31-34). 43. Friberg O, Nurminen M, Korhonen K, et al.: Ac- 16. Clarke GR: Unequal leg length: an accurate curacy and precision of clinical estimation of method of detection and some clinical results. leg length inequality and lumbar scoliosis: Rheum Phys Med 7 7 : 3 8 5 - 3 9 0 , 1972. comparison of clinical and radiological meas- urements. International Disability Studies 7 0 : 4 9 - 17. Clemente CD: Gray's Anatomy of the Human 53, 1988. Body, American Ed. 30. Lea & Febiger, Phila- delphia, 1985 (Fig. 6 - 1 9 , p. 498). 44. Giles LGF: Leg length inequality: Its measure- ment, prevalence and its effects on the lumbar 18. Delacerda FG, Wikoff OD: Effect of lower ex- spine. Master's preliminary thesis. Department of tremity asymmetry on the kinematics of gait. J Anatomy, University of Western Australia, Orthop Sports Phys Ther 3 : 1 0 5 - 1 0 7 , 1982. 1979. 19. Denslow JS, Chace JA, Gardner DL, Banner KB: 45. Giles LGF, Taylor JR: Low-back pain associated Mechanical stresses in the human lumbar with leg length inequality. Spine 6 : 5 1 0 - 5 2 1 , spine and pelvis. J Am Osteopath Assoc 6 1 : 7 0 5 - 1981. 712, 1962. 46. Giles LGF, Taylor JR: Lumbar spine structural 20. Dixon A St J, Campbell-Smith S: Long leg ar- changes associated with leg length inequality. thropathy. Ann Rheum Dis 2 8 : 3 5 9 - 3 6 5 , 1969. Spine 7 : 1 5 9 - 1 6 2 , 1982. 21. Duchenne GB: Physiology of Motion, translated 47. Gilsanz V, Miranda J, Cleveland R, et a/.: Scoli- by E.B. Kaplan. J. B. Lippincott, Philadelphia, osis secondary to fractures of the transverse 1949 (p. 504). processes of lumbar vertebrae. Radiology 134: 627-629, 1980. 22. Edinger Von A, Biedermann F: Kurzes Bein— schiefes Becken. Forschr Rdntgenstr 8 6 : 7 5 4 - 48. Gitelman R: A chiropractic approach to bio- 762, 1957. mechanical disorders of the lumbar spine and pelvis, Chapter 14. In Modern Developments in 23. Eisler P: Die Muskeln des Stammes. Gustav the Principles and Practice of Chiropractic, edited Fischer, Jena, 1912 (Fig. 105, p. 654). by S. Haldeman. Appleton-Century-Crofts, New York, 1980 (pp. 297-330, see pp. 2 9 9 - 24. Ibid. (Fig. 106, p. 6 5 5 ) . 306). 25. Ibid. (pp. 6 5 3 - 6 5 6 ) . 26. Elze C: Hermann Braus Anatomie des Menschen, 49. Gofton JP: Studies in osteoarthritis of the hip: Part IV. Biomechanics and clinical considera- Ed. 3, Vol. 1, Springer-Verlag, Berlin, 1954 tions. Can Med Assoc J 7 0 4 : 1 0 0 7 - 1 0 1 1 , 1 9 7 1 . (Fig. 100, p. 165). 27. Ibid. (Fig. 274, p. 5 2 2 ) . 50. Gofton JP, Trueman GE: Studies in osteoarthri- 28. Ferner H, Staubesand J: Sobotta Atlas of Human tis of the hip: Part II. Osteoarthritis of the hip Anatomy, Ed. 10, Vol. 2. Urban & Schwarzen- and leg-length disparity. Can Med Assoc J 104: berg, Baltimore, 1983 (Fig. 102). 791-799, 1971. 29. Ibid. (Fig. 136). 30. Ibid. (p. 137). 51. Good MG: Diagnosis and treatment of sciatic 31. Ibid. (Fig. 351). pain. Lancet 2 : 5 9 7 - 5 9 8 , 1942. 32. Fisk JW: Medical Treatment of Neck and Back Pain. Charles C Thomas, Springfield, 1987. 52. Good MG: What is \"fibrositis\"? Rheumatism 5: 117-123, 1949. 33. Fisk JW, Baigent ML: Clinical and radiological assessment of leg length. NZ Med J 8 7 : 4 7 7 - 4 8 0 , 53. Gould N: Back-pocket sciatica. N Engl J Med 1975. 290:633, 1974. 34. Ford LT, Goodman FG: X-ray studies of the 54. Grant JCB: An Atlas of Human Anatomy, Ed. 7. lumbosacral spine. South Med J 5 9 : 1 1 2 3 - 1 1 2 8 , Williams & Wilkins, Baltimore, 1978 (Fig. 2- 1966. 119). 35. Friberg O: Leg length asymmetry in stress frac- 55. Ibid. (Fig. 5-28). tures. J Sports Med 2 2 : 4 8 5 ^ 8 8 , 1982. 56. Ibid. (Fig. 5-29). 57. Greenman PE: Lift therapy: use and abuse. J Am Osteopath Assoc 7 9 : 2 3 8 - 2 5 0 , 1 9 7 9 .
86 Part 1 / Lower Torso Pain 5 8 . Greenman PE: Principles of Manual Medicine. 79. Kidd R: Pain localization with the innominate Williams & Wilkins, Baltimore, 1989 (p. 234, upslip dysfunction. Manual Med 3 : 1 0 3 - 1 0 5 , 236). 1988. 59. Grice AS: Radiographic, biomechanical and 80. Knapp ME: Function of the quadratus lum- clinical factors in lumbar lateral flexion: Part I. borum. Arch Phys Med Rehabil 3 2 : 5 0 5 - 5 0 7 , J Manipulative Physiol Ther 2 : 2 6 - 3 4 , 1979. 1951. 60. Gross RH: Leg length discrepancy in marathon 81. Knapp ME: Exercises for lower motor neuron runners. Am J Sports Med 7 7 : 1 2 1 - 1 2 4 , 1 9 8 3 . lesions, Chap 16. In Therapeutic Exercise, edited by J. V. Basmajian, Ed. 3. Williams & Wilkins, 61. Grundy PF, Roberts CJ: Does unequal leg Baltimore, 1978 (p. 369). length cause back pain? Lancet 2 : 2 5 6 - 2 5 8 , 1984. 82. Krakovits G: Uber die Auswirkung einer Beinverkurzung auf die Statik und Dynamik 62. Gutstein-Good M: Idiopathic myalgia simulat- des Huftgelenkes. Z Orthop 7 0 2 : 4 1 8 - 4 2 3 , 1967. ing visceral and other diseases. Lancet 2 : 3 2 6 - 328, 1940. 8 3 . Lange M: Die Muskelharten (Myogelosen). J.F. Lehmanns, Miinchen, 1931 (pp. 90, 91 [Fig. 63. Hagen DP: A continuing roentgenographic 31], 92 [Case 2], 113 [Case 10] 118 [Case 13]). study of rural school children over a 15-year period. J Am Osteopath Assoc 6 3 : 5 4 6 - 5 5 7 , 84. Langman J, Woerdeman MW: Atlas of Medical 1964. Anatomy. W.B. Saunders, Philadelphia, 1978 (p. 143, A, B & C). 64. Hallin RP: Sciatic pain and the piriformis mus- cle. Postgrad Med 7 4 : 6 9 - 7 2 , 1 9 8 3 . 85. Last RJ: Anatomy, Regional and Applied, Ed. 5. Williams & Wilkins, Baltimore, 1972 (pp. 3 3 1 - 6 5 . Heilig D: Principles of lift therapy. J Am Osteo- 332). path Assoc 7 7 : 4 6 6 - 4 7 2 , 1 9 7 8 . 86. Lawrence D, Pugh J, Tasharski C, Heinze W: 66. Henrard J-Cl, Bismuth V, deMolmont C, Gaux Evaluation of a radiographic method determin- J-C: Unequal length of the lower limbs: Meas- ing short leg mensuration. ACA J Chiropractic urement by a simple radiological method: Ap- 78:57-59, 1984. plication to epidemiological studies. Rev Rheum Mai Osteoartic 4 1 : 7 7 3 - 7 7 9 , 1 9 7 4 . 87. Lawrence DJ: Chiropractic concepts of the short leg: a critical review. J Manipulative 67. Heufelder P: Die Beinlangendifferenz aus der Physiol Ther 8 : 1 5 7 - 1 6 1 , 1 9 8 5 . Sicht des Allgemeinarztes. Z Orthop 1 1 8 : 3 4 5 - 354, 1979. 88. Leeson CR, Leeson T S : Human Structure. W.B. Saunders, Philadelphia, 1972 (p. 269). 6 8 . Hollinshead WH: Functional Anatomy of the Limbs and Back, Ed. 4. W.B. Saunders, Philadel- 89. Leong JCY, Luk KDK, Chow DHK, Woo CW: phia, 1976 (p. 400). The biomechanical functions of the iliolumbar ligament in maintaining stability of the lumbo- 6 9 . Hollinshead WH: Anatomy for Surgeons, Ed. 3. sacral junction. Spine 7 2 : 6 6 9 - 6 7 4 , 1987. Vol. 3, The Back and Limbs. Harper & Row, New York, 1982 (pp. 164-165, Fig. 2-74). 90. Lewinnek GE: Management of low back pain and sciatica. Int Anesthesiol Clin 2 7 : 6 1 - 7 8 , 1983. 70. Hoskins ER: The development of posture and its importance: III Short leg. J Am Osteopath 91. Lewit K: Rontgenologische Kriterien statischer ASSOC 3 4 : 1 2 5 - 6 , 1934. Storungen der Wirbelsaule. Manuelle Med 20: 26-35, 1982. 71. Hudson OC, Hettesheimer CA, Robin PA: Causalgic backache. Am J Surg 5 2 : 2 9 7 - 3 0 3 , 92. Lewit K: Manipulative Therapy in Rehabilitation of 1941. the Motor System. Butterworths, London, 1985 (p. 106, Fig. 4.1; pp. 167-8, Fig. 4.65; p. 291). 72. Inglemark BE, Lindstrom J: Asymmetries of the lower extremities and pelvis and their rela- 9 3 . Ibid. (pp. 1 5 4 - 5 , Fig. 4.44) tions to lumbar scoliosis. Acta Morphol Neerl 94. Ibid. (pp. 2 7 5 - 6 , Fig. 6.94) Scand 5 : 2 2 1 - 2 3 4 , 1 9 6 3 . 95. Lewit K: Postisometric relaxation in combina- 73. Institute of Medicine: Pain and Disability: Clini- tion with other methods of muscular facilita- tion and inhibition. Manual Med 2 : 1 0 1 - 1 0 4 , cal, Behavioral, and Public Policy Perspectives. 1986. Washington, D.C., National Academy Press, 96. Lewit K: Muscular pattern in thoraco-lumbar May 1987. lesions. Manual Med 2 : 1 0 5 - 1 0 7 , 1986. 74. Janda J: T h e pelvis, Chapter 6. In Muscle Func- 97. Lewit K: Disturbed balance due to lesions of tion Testing. Butterworths, London, 1983 (pp. the cranio-cervical junction. J Orthop Med:58- 41-43). 59, (No. 3) 1988. 75. Jull GA, Janda V: Muscles and motor control in 98. Llewellyn LJ, Jones AB: Fibrositis. Rebman, low back pain: assessment and management, New York, 1915 (Fig. 53 facing p. 280). Chapter 10. In Physical Therapy of the Low Back, edited by L.T. Twomey and J.R. Taylor. 99. Lockhart RD, Hamilton GF, Fyfe FW: Anatomy Churchill Livingstone, New York, 1987 (pp. of the Human Body, Ed. 2. J.B. Lippincott, Phila- 253-278). delphia, 1969 (p. 181). 76. Kelly M: Some rules for the employment of lo- 100. Luk KDK, Ho HC, Leong JCY: The iliolumbar cal analgesic in the treatment of somatic pain. ligament. J Bone Joint Surg [Br] 6 8 : 1 9 7 - 2 0 0 , Med J Austral 7 : 2 3 5 - 2 3 9 , 1947 (p. 236). 1986. 77. Kendall FP, McCreary EK: Muscles, Testing and 101. Mahar RK, Kirby RL, MacLeod DA: Simulated Function, Ed. 3. Williams & Wilkins, Baltimore, leg-length discrepancy: its effect on mean 1983 (pp. 222, 230). center-of-pressure position and postural sway. Arch Phys Med Rehabil 66:822, 1 9 8 5 . 78. Ibid. (p. 2 2 7 ) . 102. Maloney M, PT: Personal communication, 1990.
Chapter 4 / Quadratus Lumborum 87 103. McKenzie RA: The Lumbar Spine: Mechanical Di- Medicine, edited by J.Goodgold. C.V. Mosby agnosis and Therapy. Spinal Publications, Ltd., Co., St. Louis, 1988 (pp. 6 8 6 - 7 2 3 ) . New Zealand, 1981. 127. Simons DG, Simons LS: Chronic myofascial pain syndrome, Chapter 42. In Handbook of 104. McMinn RMH, Hutchings RT: Color Atlas of Chronic Pain Management, edited by C. David Human Anatomy. Year Book Medical Publishers, Tollison. Williams & Wilkins, Baltimore, 1989 Chicago, 1977 (p. 243B-6). (pp. 509-529). 105. Morscher E: Etiology and pathophysiology of 128. Simons DG, Travell JG: Myofascial origins of leg length discrepancies. Progr Orthop Surg 1: low back pain. 2. Torso muscles. Postgrad Med 9-19, 1977. 73:81-92, 1983. 106. Mortensen OA, Pettersen JC: The musculature, 129. Simons DG, Travell JG: Myofascial pain syn- Section VI. In Morris' Human Anatomy, edited by dromes, Chapter 25. In Textbook of Pain, edited B.J. Anson, Ed. 12. McGraw-Hill, New York, by P.D. Wall and R. Melzack, Ed 2. Churchill 1966 (p. 542). Livingstone, London, 1989 (pp. 368-385). 107. Netter FH: The Ciba Collection of Medical Illustra- 130. Snook SH, Jensen RC: Cost, Chapter 5. In Occu- tions, Vol. 8, Musculoskeletal System. Part I: pational Low Back Pain, edited by M.H. Pope, Anatomy, Physiology and Metabolic Disorders. J.W. Frymoyer and G. Andersson. Praeger, New Ciba-Geigy Corporation, Summit, 1987 (p. 4). York, 1984 (pp. 115-121, see p. 116). 108. Ibid. (p. 5). 131. Snook SH, White AH: Education and training, 109. Ibid. (p. 77). Chapter 12. In Occupational Low Back Pain, ed- 110. Nichols PJR, Bailey NTJ: The accuracy of mea- ited by M.H. Pope, J.W. Frymoyer and G.Andersson. Praeger, New York, 1984 (p. suring leg-length differences. Br Med J 2 : 1 2 4 7 - 234). 1248, 1955. 132. Sola AE: Trigger point therapy, Chapter 47. In 111. Nielsen AJ: Spray and stretch for myofascial Clinical Procedures in Emergency Medicine, ed- pain. Phys Ther 5 8 : 5 6 7 - 5 6 9 , 1978. ited by J.R. Roberts and J.R. Hedges. W.B. Saunders, Philadelphia, 1985 (pp. 674-686, 112. Northup GW: Osteopathic lesions. J Am Osteo- see pp. 682, 684). path Assoc 7 7 : 8 5 4 - 8 6 5 , 1972. 133. Sola AE, Kuitert JH: Quadratus lumborum my- 113. Norton JL: Pelvic side shift in standing roent- ofasciitis. Northwest Med 5 3 : 1 0 0 3 - 1 0 0 5 , 1 9 5 4 . genologic postural studies. J Am Osteopath As- soc 5 7 : 4 8 2 - 4 8 4 , 1952. 134. Sola AE, Williams RL: Myofascial pain syn- dromes. Neurology 6 : 9 1 - 9 5 , 1 9 5 6 . 114. Pansky B: Review of Gross Anatomy, Ed. 4. Mac- millan Publishing Co., Inc., New York, 1979 135. Spalteholz W: Handatlas der Anatomie des Men- (pp. 306, 316-317). schen, Ed. 11, Vol. 2. S. Hirzel, Leipzig, 1922 (p. 306). 115. Ibid. (p. 355). 136. Ibid. (p. 3 4 4 ) . 116. Proverbs, Chapter 26, Verse 7. Holy Bible, New 137. Steindler A: Diseases of Spine and Thorax. C.V. Testament. Mosby, St. Louis, 1929. 117. Rab GT, Chao EYS, Stauffer RN: Muscle force 138. Stoddard A: Manual of Osteopathic Technique. analysis of the lumbar spine. Orthop Clin North Am 8:193-199, 1977. Hutchinson Medical Publications, London, 1959 (p. 212). 118. Rasch PJ, Burke RK: Kinesiology and Applied 139. Strong R, Thomas PE: Patterns of muscle activ- Anatomy, Ed. 6. Lea & Febiger, Philadelphia, ity in the leg, hip, and torso associated with 1978 (p. 228). anomalous fifth lumbar conditions. J Am Osteo- path Assoc 6 7 : 1 0 3 9 - 1 0 4 1 , 1 9 6 8 . 119. Reynolds MD: Myofascial trigger point syn- 140. Strong R, Thomas PE, Earl WD: Patterns of dromes in the practice of rheumatology. Arch muscle activity in leg, hip, and torso during Phys Med Rehabil 6 2 : 1 1 1 - 1 1 4 , 1981 (Table 1, p. quiet standing. J Am Osteopath Assoc 6 6 : 1 0 3 5 - 112). 1038, 1967. 141. Sutton SE: Postural imbalance: examination 120. Rush WA, Steiner HA: A study of lower ex- and treatment utilizing flexion tests. J Am Oste- tremity length inequality. Am J Roentgen Rad opath Assoc 7 7 : 4 5 6 - 4 6 5 , 1 9 7 8 . Ther 5 6 : 6 1 6 - 6 2 3 , 1946. 142. Taillard W, Morscher E: Die Beinlangenunter- schiede. S. Karger, Basel, New York, 1 9 6 5 (pp. 121. Saudek C: C'mon let's twist. Orthop Phys Ther 26-42). Prac 7:24-27, 1989. 143. Tanz SS: Motion of the lumbar spine, a roent- genologic study. AJR 6 9 : 3 9 9 - 4 1 2 , 1 9 5 3 (see 122. Schuit D, Adrian M, Pidcoe P: Effect of heel Fig. 6). lifts on ground reaction force patterns in sub- 144. Thompson CW: Manual of Structural Kinesiology, jects with structural leg-length discrepancies. Ed. 9. C.V. Mosby, St. Louis, 1981 (p. 110). Phys Ther 6 9 : 6 6 3 - 6 7 0 , 1989. 145. Toldt C: An Atlas of Human Anatomy, translated by M.E. Paul, Ed. 2, Vol. 1. Macmillan, New 123. Simons DG: Functions of the quadratus lum- York, 1919 (p. 339). borum muscle and relation of its myofascial 146. Ibid. (p. 3 4 4 ) . trigger points to low back pain. Pain Abstracts, 147. Travell JG: The quadratus lumborum muscle: Vol. 1. Second World Congress on Pain, Inter- an overlooked cause of low back pain. Arch national Assn for the Study of Pain, Montreal, Phys Med Rehabil 57:566, 1 9 7 6 . Canada, August 27-September 1, 1978 (p. 245). 124. Simons DG: Myofascial pain syndromes due to trigger points: 2. Treatment and single-muscle syndromes. Manual Med 1:72-77, 1985. 125. Simons DG: Muskulofasziale Schmerzsyn- drome infolge Triggerpunkten. Manuelle Med 23:134-142, 1985. 126. Simons DG: Myofascial pain syndrome due to trigger points, Chapter 4 5 . In Rehabilitation
88 Part 1 / Lower Torso Pain 148. Travell JG, Simons DG: Myofascial Pain and Dys- 165. Waters RL, Morris JM: Electrical activity of muscles of function: The Trigger Point Manual. Williams & the trunk during walking. J Anat 111:191-199, 1972. Wilkins, Baltimore, 1983. 166. West HG Jr: Physical and spinal examination 149. Ibid. (pp. 82-85). procedures utilized in the practice of chiropractic, 150. Ibid. (pp. 104-109). Chapter 13. In Modern Developments in the Principles 151. Ibid. (pp. 104-156). and Practice of Chiropractic, edited by S. Haldeman. 152. Ibid. (pp. 106-110, 651-653, Fig. 48.10A). Appleton-Century-Crofts, New York, 1980 (Fig. 13, p. 153. Ibid. (pp. 108-109). 294). 154. Ibid. (pp. 112-190, 196-197, Fig. 6.10). 155. Ibid. (pp. 114-156). 167. Winter Z: Referred pain in fibrositis. Med Rec 156. Ibid. (p. 209). 757:34-37, 1944. 157. Ibid. (pp. 398-491). 168. Woerdeman MW: Atlas of Human Anatomy, Vol. 1. 158. Ibid. (pp. 638, 639). Williams & Wilkins, Baltimore, 1948 (Fig. 345). 159. Ibid. (p. 645). 160. Ibid. (p. 664). 169. Woodburne RT: Essentials of Human Anatomy, Ed. 4. 161. Ibid. (pp. 680-681). Oxford University Press, London, 1969 (p. 369). 162. Ibid. (Chapter 48). 163. Turula KB, Friberg O, Lindholm TS, et al.: Leg length 170. Zohn DA: The quadratus lumborum: an unrecognized source of back pain, clinical and thermographic inequality after total hip arthroplasty. Clin Orthop aspects. Orthop Rev 74:163-168, 1985. 202:163-168, 1986. 171. Zohn DA: Musculoskeletal Pain: Diagnosis and 164. Venn EK, Wakefield KA, Thompson PR: A Physical Treatment, Ed. 2. Little, Brown and comparative study of leg-length checks. Eur J Company, Boston, 1988 (pp. 204, 206). Chiropractic 37:68-80, 1983.
CHAPTER 5 Iliopsoas Muscle \"Hidden Prankster\" HIGHLIGHTS: The iliopsoas is a \"hidden prank- taneous or associated with anticoagulation ther- ster\" in the sense that it serves many critically apy, can cause a painful compression syndrome important functions, often causes pain, and is of the femoral nerve. ACTIVATION of iliopsoas relatively inaccessible. Unidentified iliopsoas TrPs can result from acute overload stress or and/or quadratus lumborum trigger points (TrPs) from prolonged sitting with the hips acutely are frequently responsible for a failed low back flexed, although they are usually activated sec- postsurgical syndrome. REFERRED PAIN from ondarily to TrPs in other muscles of the func- myofascial TrPs in the psoas major muscle ex- tional unit. PATIENT EXAMINATION for a tight tends along the spine ipsilaterally from the tho- iliopsoas muscle entails tests for restriction of racic region to the sacroiliac area, and some- extension of the thigh at the hip. TRIGGER times to the upper buttock. Pain is referred simi- POINT EXAMINATION of the iliopsoas muscle larly from the iliacus and often also to the requires examination at three locations, (a) Digi- anterior thigh and groin. ANATOMICAL AT- tal pressure exerted deep on the lateral border TACHMENTS of the psoas major, above, are of the femoral triangle over the lesser trochanter along the sides of the lumbar vertebrae and in- elicits tenderness of distal iliacus fibers and usu- tervertebral discs. Below, its tendon anchors to ally from psoas musculotendinous junctions at the lesser trochanter of the femur. The iliacus that level, (b) Palpation over the inner border of muscle attaches, above, to the upper two-thirds the ilium behind the anterior superior iliac spine of the iliac fossa. Below, it joins the psoas major permits examination of taut bands and TrPs in tendon and, in addition, some fibers attach di- the uppermost iliacus fibers, (c) Pressure ex- rectly to the femur near the lesser trochanter. erted first downward on the abdomen lateral to The primary FUNCTION of the iliacus and psoas the rectus abdominis muscle and then beneath major muscles is flexion of the thigh at the hip. the rectus abdominis, medially, elicits tender- The psoas can assist extension of the lumbar ness of the psoas muscles by compression spine (increase lumbar lordosis) when one is against the lumbar spine. ENTRAPMENTS of standing with a normal lordosis, and it plays a the femoral, lateral femoral cutaneous, and the significant role in maintaining upright posture. femoral branch of the genitofemoral nerves may Both the iliacus and psoas may assist abduction occur in the lacuna musculorum beneath the in- of the thigh and probably contribute slightly to guinal ligament, as the nerves exit the pelvis lateral rotation. The psoas and sometimes the through a narrow lacuna in the company of the iliacus are active during sitting and standing. iliopsoas muscle. The genitofemoral nerve regu- Both may be continuously active during ambula- larly penetrates, and the iliohypogastric and ilio- tion. During jogging, running, or sprinting, the inguinal nerves occasionally penetrate the iliacus is active while the thigh is being flexed at psoas major muscle as they emerge from the the hip. It is vigorously active through the last lumbar plexus. For INTERMITTENT COLD 60° of a sit-up. The painful SYMPTOMS from WITH STRETCH of the iliopsoas muscle, the iliopsoas TrPS are aggravated by weight-bear- patient lies on the opposite side, and the ice or ing activities and relieved by recumbency; relief vapocoolant is applied in downward parallel is greater when the hip is flexed. The psoas mi- sweeps over the abdomen and anterior upper nor syndrome is easily mistaken for appendici- part of the thigh as the thigh is extended. Finally, tis. Hemorrhage within the psoas muscle, spon- parallel, distalward sweeps of intermittent cold 89
90 Part 1 / Lower Torso Pain cover the referred pain pattern on the back and ated TrPs and correction of systemic perpetuat- buttock. Intermittent cold with stretch is followed ing factors. Restricted or locked thoracolumbar, by rewarming with moist heat and by full active lumbosacral, or sacroiliac articulations can pre- range of motion. INJECTION AND STRETCH vent lasting relief and need to be treated. Other begin by injecting iliopsoas TrPs in the femoral mechanical approaches include correcting a triangle, while carefully avoiding the adjacent lower limb-length inequality; avoiding sitting im- femoral nerve and artery. One can inject proxi- mobile for long periods, especially with an acute mal iliacus fibers inside the iliac fossa just below angle at the hip joints; normalizing paradoxical the crest of the ilium through the lower abdomi- breathing; and maintaining proper positioning nal wall. After application of a moist heating pad, during sleep. An optimal management program the patient actively moves the iliopsoas through begins with appropriate gentle hip extension ex- its full range of motion several times. CORREC- ercise followed by a balanced, progressive rec- TIVE ACTIONS start with inactivation of associ- tus abdominis-iliopsoas strengthening program. 1. REFERRED PAIN tern usually also includes the groin and (Fig. 5.1) upper anteromedial aspect of the thigh on the same side. Pressure applied by ab- Pain referred from trigger points (TrPs) in dominal palpation of either psoas or the iliopsoas muscle forms a distinctive iliacus TrPs causes pain referred chiefly v e r t i c a l pattern ipsilaterally along the to the back. Palpation of TrPs near the at- lumbar spine. It extends downward to the tachment of the iliopsoas muscle (mostly sacroiliac region and may spill over to in- iliacus fibers) on the lesser trochanter of clude the sacrum and proximal medial the femur may refer pain both to the back buttock (Fig. 5.1).81 The referred pain pat- and anteriorly to the thigh. Figure 5 . 1 . Pattern of pain (bright red) referred from erence zone is solid red; the spill-over pattern is stip- palpable myofascial trigger points (Xs) in the right pled. iliopsoas muscle (darker red). The essential pain ref-
Chapter 5 / Iliopsoas Muscle 91 Figure 5.2. Attachments of the right psoas major, psoas minor and iliacus muscles (red). The psoas major crosses many articulations including those of the lumbar spine and the lumbosacral, sa- croiliac, and hip joints. The psoas minor does the same, except that it does not cross the hip joint. The iliacus, on the other hand, crosses only the hip joint. The senior author observed a patient sides of the 12th thoracic and all lumbar who had severe pain in the hip joint and vertebral bodies, to the corresponding in- anterior thigh when walking, but could tervertebral discs, and by more slender walk without pain as long as she hyper- fasciculi to the anterior surfaces and extended her lumbar spine and pressed lower borders of the lumbar transverse down against the greater trochanter on processes.7,17 This muscle occupies the the painful side. space beside the vertebral bodies anterior to the transverse processes along the Pain in the scrotum has been intensi- lower lumbar spine.2 The psoas lies adja- fied by stretching the iliopsoas muscle.47 cent, anterior, and medial to the quad- Psoas muscle pain in the back has been ratus lumborum muscle in the lumbar re- reported to extend as high as the inter- gion.28 More distally, the psoas major scapular region.24 passes anterior to the sacroiliac joint, then follows the border of the pelvic brim 2. ANATOMICAL ATTACHMENTS AND and proceeds anteriorly in front of the CONSIDERATIONS roof of the hip joint.29 Inside the pelvis, it (Fig. 5.2) is joined by the iliacus muscle to become the iliopsoas. The psoas portion becomes The psoas major muscle (Fig. 5.2) at- largely tendinous as it passes deep to the taches above by thick fasciculi to the
92 Part 1 / Lower Torso Pain inguinal ligament and exits the pelvis tendon from the femur at its attachment (Fig. 5.2). There it helps to form the lat- to the lesser trochanter. eral floor of the femoral triangle. The ilio- psoas tendon anchors below to the lesser At each segmental level, the psoas major attaches trochanter on the posteromedial aspect of to the medial half or so of the anterior surface of the the femur.17 transverse process, to the intervertebral disc, to the margins of the vertebral bodies adjacent to the disc, The psoas minor muscle is variable and and to a fibrous arch that connects the upper and is absent bilaterally in from 4 1 % 7 to over lower margins of each lumbar vertebral body. The 50%17 of bodies. When present, it lies an- fibers of this muscle are systematically overlapped terior to the psoas major in the lumbar re- by fibers from the above attachments at succes- gion. It attaches above to the anterolateral sively higher segmental levels. As a result, the mus- aspect of the 12th thoracic and one or two cle is layered, with fibers from the higher levels of the upper lumbar vertebrae. The psoas forming the outer surface of the muscle and those minor attaches below to the pectineal from lower levels buried sequentially more deeply line on the superior ramus of the pubic within its substance.12 Since all fibers of a muscle bone, to the iliopectineal eminence, and are nearly the same length, this structure is re- to the iliac fascia.17 flected in the distribution of distal myotendinous junctions (Fig. 5.2). The iliacus muscle attaches above to the upper two-thirds of the inner surface In an X-ray computed tomography study of 44 of the iliac fossa, completely lining the men and 52 women ranging in age from 9 to 86 lateral wall of the greater pelvis. It also years,46 the psoas major muscle reached maximum anchors to the internal lip of the iliac cross-sectional area in men at age 30, declined crest. Below, many of the iliacus fibers rapidly to about two-thirds of that value by age 40, join the psoas major tendon; the remain- and was only one-half as large by age 60. Women der attach directly to the lesser trochanter showed only a slight decline in the size of this anteriorly and to the adjacent femur.17,77 muscle with age. In both sexes, the relative den- sity gradually declined by about 25% between the The psoas major crosses the lumbar in- ages of 20 and 80 years. tervertebral, lumbosacral, sacroiliac, and hip joints; the psoas minor crosses all of Supplemental References these except the hip joint. The iliacus crosses only the hip joint. All three muscles, the psoas major, psoas minor, and iliacus, are depicted from in front with ves- The iliacus muscle and iliopsoas tendon sels or nerves removed.28, 77 The three muscles re- exit the pelvis through the lacuna mus- late to nerves in the abdomen1, 27, 30 and the ilio- culorum in company with the femoral psoas muscle relates to nerves and vessels in the nerve17 and often together with the lateral femoral triangle.3,72 femoral cutaneous nerve. This lacuna is a firmly constricted space bounded anteri- Markings on the bones identify attachments of orly by the inguinal ligament, posteriorly the iliacus muscle.4,35,69 and laterally by the pelvic bone, and medi- ally by a thickened band of fascia, the Cross sections show all three muscles through- iliopectineal arch. This restricted outlet out their length,14 the psoas muscle at the L2-L3 creates a potential for nerve entrapment level,2 the psoas muscle at a lower lumbar level,31 caused by an enlarged or shortened (thick- and the iliopsoas just above its femoral attach- ened) iliopsoas muscle. (This entrapment ment.71 All three muscles appear in side view in a is comparable to that of the sciatic and ac- sagittal section,32 and the iliopsoas in a frontal companying nerves by the piriformis mus- section through the hip joint that shows its rela- cle as they pass through the greater sciatic tionship to the pelvic fascia.29 foramen, see Chapter 10.) Illustrations portray the locations of the iliopec- The large iliopectineal bursa34 lies be- tineal bursa34 and the subtendinous iliac bursa.18 tween the iliopsoas muscle anteriorly, and the capsule of the hip joint and the 3. INNERVATION iliopectineal eminence of the pubis on the other side, posteriorly. This bursa Branches of the lumbar plexus, which may communicate with the synovial cav- contain fibers from spinal nerves L2, L3, ity of the hip joint.17 The small, subtendi- and L4, innervate the psoas major muscle. nous iliac bursa18 separates the iliopsoas A branch of the first lumbar spinal nerve
innervates the psoas minor. Spinal nerves Chapter 5 / Iliopsoas Muscle 93 L2 and L3 supply the iliacus muscle.17 and, therefore, should exert a marked flexion 4. FUNCTION force between the ilium and the sacrum. All allusions to the psoas muscle apply to In the standing subject, strong attempts to in- the psoas major muscle unless otherwise crease lumbar lordosis (to extend the lumbar stated. spine) generally recruited the psoas muscle; ef- forts to straighten the lumbar spine did not.9,11 Actions Both Rasch and Burke76 and Janda49 noted clini- cally that patients with weak abdominal muscles Without question, the primary action of who attempted a sit-up developed spinal hyper- the iliacus and psoas major muscles is extension. This is the effect one expects as the flexion at the hip.79, 17, 22, 37 Beyond that, psoas hyperextends the lumbar spine when it and there has been little general agreement the iliacus tilt the pelvis forward without restraint through the years.9 It now appears that by the rectus abdominis during a sit-up. This ef- the psoas major extends the lumbar spine fect is sometimes called the psoas paradox.78 when the individual is standing with nor- mal lumbar lordosis but assists flexion of Rotation of the Thigh. Basmajian and Deluca9 the lumbar spine when one bends for- concluded that, from a functional point of view, ward.9 The small effect that the iliopsoas the question of whether the iliopsoas rotates the exerts on rotation of the thigh is usually thigh is not worth pursuing. After careful mechan- to assist lateral rotation.9,11,22 The ilio- ical analysis of the axis of rotation in 11 speci- psoas sometimes assists abduction at the mens, Hooper45 substantiated their conclusion hip but not adduction.39 The optimal with the finding that the iliopsoas does not play a stretch position is extension of the thigh significant role in rotation of the normal femur be- at the hip with medial or neutral rotation cause its tendon is aligned with the axis of rota- of the thigh and with neutral positioning tion in most cases. or adduction of the thigh.39 However, the effect of rotation on the muscle Flexion at the Hip. Hip flexion activated could influence the optimal stretch position. Elec- the iliacus and psoas muscles regardless trophysiological studies revealed that neither the of position and in proportion to the effort iliacus nor the psoas was activated during medial expended. Both muscles were inactive rotation of the thigh at the hip, but both muscles during hip extension effort.89 Electrical often were active during lateral rotation.9,11 Elec- stimulation of the iliopsoas muscle or of trical stimulation of either muscle while the sub- only the iliacus produced primarily hip ject was standing or supine produced a slight lat- flexion.22 Extension effort only at the knee eral rotation.22 recruited the iliacus as a s t a b i l i z i n g mus- cle.37 The iliopsoas is primarily a hip Based on these results, the optimal stretch posi- flexor that requires extension at the hip to tion would avoid lateral rotation and would place lengthen it. the limb either in neutral or in medial rotation. Evjenth and Hamberg26 recommend stretching by Flexion or Extension of the Spine and Pelvis. The extension with medial rotation of the thigh. In the psoatic gait of a shortened iliopsoas, the thigh is direct effect of the psoas muscle on flexion or ex- laterally rotated.6667 tension of the lumbar spine is not immediately ob- vious anatomically. Abduction or Adduction of the Thigh. In one study of 13 subjects,11 abduction of the thigh in Sophisticated analysis of mechanical moments the standing position generally recruited activity about the L4-L5 interspace led to the conclusion in the psoas muscle; although it, too, was moni- that the psoas contributes to extension of the tored with fine-wire electrodes, no mention was spine in the low lumbar region but adds only 4% made of activity in the iliacus muscle.11 Close20 re- to the total extension force; the erector spinae, ro- ported EMG activity of the psoas during abduc- tatores, and quadratus lumborum, in that order, tion, but not until other muscles had initiated ab- provide the primary extensor force.75 As would be duction against gravity. However, in Greenlaw's expected and as confirmed experimentally,68 con- study of 10 subjects,39 neither abduction nor ad- traction of the psoas increases loading on the in- duction activated the psoas muscle; only abduc- tervertebral discs. This muscle passes anterior to tion activated the iliacus muscle. It appears that the axes of movement of the sacroiliac (SI) joint the optimum stretch position avoids abduction. Psoas Minor. The psoas minor, when present, ordinarily should have little or no effect on move- ment of the thigh but should assist the psoas ma-
94 Part 1 / Lower Torso Pain jor in extending the normal lordotic curve of the that psoas muscle activity began shortly before lumbar spine while flexing the lumbosacral artic- toe-off and persisted only during the initial 40% ulation. The latter movement would have the ef- of swing phase. This activity occurred exactly fect of elevating the front of the pelvis on the same when it would be needed to accelerate forward side. No functional studies of this muscle have movement of the limb.51 been found. During jogging, running, or sprinting, vigorous In summary, the optimal stretch posi- activity appeared in the iliacus while the thigh tion for the iliopsoas muscle is extension was being flexed at the hip. This movement was of the thigh, most likely without abduc- forceful and imparted the major force for forward tion and with either neutral or medial ro- propulsion.62 The psoas was not monitored in this tation. study. Functions Sit Ups. There is general agreement that, after the first 30° of upward movement of a sit-up, the When a person is standing or sitting, the iliacus is vigorously active.9, 36, 56 LaBan and co- psoas muscle may be continuously active workers56 saw no activity in five subjects through and plays a significant role in maintain- the first 30° when the legs were straight, but did ing upright posture. The iliacus shows observe activity when the knees were bent. Flint38 minimal activity during standing. During found mild to moderate activity in three subjects walking, the iliacus is continuously ac- throughout that 30° angle. Apparently, some indi- tive, but the psoas is active only shortly viduals depend on the rectus femoris muscle preceding and during early swing phase, without help from the iliacus and others use both when it would accelerate forward move- muscles when initiating a sit-up. ment of the limb. Running induced vigor- ous iliacus activity during flexion of the Scoliosis. Among the nearly 1500 subjects ex- thigh. Some individuals showed vigorous amined radiographically for back pain or prior to iliacus activity throughout a sit-up, job placement, 80% of those who had 5° or more whereas the iliacus muscles of others be- of scoliosis showed a visible psoas shadow on the came active only after the first 30° of the convex side, but only 30% showed a visible sit-up. Testing of patients without an shadow on the concave side, and none had a visi- iliacus muscle and some sit-up data indi- ble shadow only on the concave side.13 This raises cate that the muscle is most effective as a a question as to how important a role asymmetri- hip flexor after the first 30° of hip flexion. cal psoas development and activity play in scolio- sis. Standing or Sitting. In electromyographic (EMG) studies during quiet standing, the iliacus showed Extirpation. Removal of the iliopsoas muscle in only intermittent short bursts of marked activity two patients produced only slight loss of either at irregular intervals,9 or no activity,56 whereas isometric or isokinetic strength of hip flexion at the psoas showed continuous slight activity.9 30°.63 Isometric strength dropped sharply as the Nachemson68 inserted wire electrodes directly angle increased to 90°. Isokinetic strength de- into the lumbar psoas muscle from a posterior ap- creased only slightly to moderately beyond 30°. proach and reported that it was continuously ac- This observation, in conjunction with the data on tive during standing and sitting. Activity was in- reduced or no electrical activity of the iliacus creased by holding 10-kg weights in each hand through the first 30° of flexion, as noted previ- during sitting or standing and was decreased ously, suggests that the iliacus becomes signifi- when the subject leaned forward. He68 concluded cantly more effective as the prime flexor at the hip that the lumbar psoas plays a significant role in after the first 30° of hip flexion. maintaining upright posture. 5. FUNCTIONAL (MYOTATIC) UNIT Locomotion. During the walking cycle, the il- iacus acts continuously with two peaks of activ- Synergists to the iliopsoas for flexion of ity, the greatest during the swing phase and the the thigh at the hip are the rectus femoris other in midstance. The psoas has two peaks of and pectineus muscles assisted by the EMG activity that correspond with those of the sartorius, tensor fasciae latae, gracilis, iliacus and a third peak midway through the cycle and by the three adductors—longus, (during stance phase).10 An earlier study found brevis, and middle part of the magnus. The antagonists to these hip flexors are primarily the gluteus maximus, the ham-
Chapter 5 / Iliopsoas Muscle 95 string muscles, and the posterior part of The psoas minor syndrome86 is caused the adductor magnus. by a tense psoas minor muscle and ten- don. This syndrome was described by a Bilaterally, the two iliopsoas muscles surgeon, who observed it most often on work as a team, synchronizing their activ- the right side in 15- to 17-year-old girls ity for some functions and alternating it with a diagnosis of suspected appendici- for others. tis. The author attributed the tension of the muscle to its failure to keep pace with During a sit-up, additional agonists in- the growth of the pelvis. He could palpate clude the rectus abdominis and psoas mi- a \"strand\" of psoas minor (that he inter- nor muscles. preted as tendon) through the abdominal wall in most patients. In almost all cases, 6. SYMPTOMS the patients complained of pain in the lower right quadrant of the abdomen and Patients who have unilateral iliopsoas the pain was aggravated by palpation of TrPs complain primarily of low back the taut \"tendon.\" Consistently, the ap- pain; when describing the pain, they run pendix was normal and tenotomy of the the hand vertically up and down the psoas minor relieved the symptoms. The spine rather than horizontally. When bi- tenotomy also relieved scoliosis of the lateral iliopsoas muscles have active lumbar spine (convex to the side opposite TrPs, the patient may perceive the pain as the taut psoas minor muscle) in several running across the low back, as also felt patients. with bilateral quadratus lumborum TrPs. Pain is worse when the patient stands up- Disproportionate growth would be an excep- right, but may remain as a slight nagging tional cause of symptoms from a muscle. The pre- backache when the patient is recumbent. viously described findings suggest that myofascial A frequent additional complaint is pain TrPs in the psoas minor may have contributed to in the front of the thigh. the pain, tenderness, and muscle shortening. If so, they demonstrate that pain is referred from this Patients are likely to have difficulty get- muscle locally to the corresponding lower abdom- ting up from a deep-seated chair and are inal quadrant. The predominance of right-sided unable to do sit-ups. In severe cases, mo- symptoms may have resulted from the fact that bility may be reduced to crawling on the patients with similar pain and tenderness on the hands and knees. left side usually would not be seen by a surgeon for suspected appendicitis. Constipated patients with tender psoas TrPs may experience referred pain In the psoas minor syndrome, limited extension evoked by the passage of a bolus of hard at the hip frequently impaired ambulation. Since feces that presses against the TrPs. A hy- the psoas minor normally extends only to the pel- pertrophied psoas muscle can compress vis and not to the femur, the reason for this limita- the neighboring large bowel, as demon- tion is not immediately obvious. Several possibili- strated by a barium study of the colon in a ties deserve consideration: (a) V o s 8 6 noted that the sportswoman.23 lateral fibers of the psoas minor tendon that join the iliac fascia can sometimes be followed as far In a review of six patients with ilio- as the lesser trochanter. In this case, the corre- psoas myofascial dysfunction, Ingber47 sponding muscle fibers, which act across the hip also found that they experienced aggrava- joint, would be particularly vulnerable to stress tion of their low back pain during an- overload. The tightness of the muscle would in- tigravity activity and alleviation of the crease with extension of the thigh, (b) The short- pain when recumbent. The most comfort- ened muscle, by producing abnormal lumbar cur- able recumbent positions were side-lying vature,86 would limit pelvic motion, (c) The psoas in a nearly fetal position or lying supine minor TrPs may activate secondary TrPs in the ili- with hips and knees flexed. opsoas, which, in turn, limit hip extension. Ap- propriately directed physical examination should Tightness (loss of full extension range determine which of these mechanisms is respon- of motion) of the iliopsoas muscle initi- sible. ated a chain of catastrophic effects in some ballet dancers as they tried to com- pensate for the loss of that muscle's func- tion. Performing the arabesque was pain- ful and the dancers were plagued by re- duced turnout.6
96 Part 1 / Lower Torso Pain Differential Diagnosis A patient with pyogenic iliopsoas my- ositis showed no evidence of femoral TrPs in a number of muscles other than nerve compression, but had local pain, lo- the iliopsoas refer pain in patterns that cal tenderness, and a limp.55 Other abnor- may be confused with the pain arising malities of the iliopsoas muscle visual- from iliopsoas TrPs. Low back pain can ized by computed tomography included also be referred from TrPs in the quad- atrophy, hypertrophy, neurofibroma, met- ratus lumborum, lowest section of the astatic cancer, primary tumor, lym- rectus abdominis, longissimus thoracis, phoma,46,73 and abscess.42,73 rotatores, gluteus maximus, and gluteus medius muscles. Iliopsoas TrPs do not Iliopsoas bursitis is unusual, but it can cause pain on coughing and deep breath- cause a tender mass in the groin area with ing as do those in the quadratus lum- persistent diffuse pain in the lateral hip borum muscle,81 described in Chapter 4 of region that may extend to the knee. It is this volume. When the patient indicates usually, but not always, seen in conjunc- that pain spreads horizontally across the tion with underlying rheumatoid arthri- low back, the pain is much more likely to tis.43 be referred from TrPs bilaterally in the quadratus lumborum muscles or from the A patient with a posteriorly displaced lowest portion of the rectus abdominis lesser trochanter on one side developed a (Volume 1, Fig. 49.2A, p. 664).83 These painfully disabling snapping iliopsoas rectus abdominis TrPs are often associ- tendon syndrome. The tendon snapped ated with TrPs in the iliopsoas muscle. across the iliopectineal eminence. Tenot- omy gave relief.80 Thigh and groin pain may also be due to TrPs in the tensor fascia latae, pec- 7. ACTIVATION AND PERPETUATION tineus, vastus intermedius, adductores OF TRIGGER POINTS longus and brevis, or the distal parts of the adductor magnus muscle. Of these Activation muscles, only the pectineus and tensor fasciae latae should restrict extension at The TrPs in the iliopsoas muscle are gen- the hip. Physical examination readily dis- erally activated secondarily to TrPs in tinguishes the more superficial TrP ten- other muscles of the functional unit. They derness of the last two muscles from the may be activated simultaneously with deep tenderness of the iliopsoas muscle. TrPs in these other muscles by sudden overload in a fall. Iliopsoas TrPs also may Ingber47 reported on several patients be activated and are perpetuated by pro- with persistent backache following lami- longed sitting with the hips in the jack- nectomy for lumbar discopathy, and one knifed position (acutely flexed), which suffering discopathy who had not under- shortens the muscle. This position is as- gone surgery. Injecting their iliopsoas sumed often while riding in an automo- TrPs and instituting extension exercises bile, but problems can develop whenever relieved them of their symptoms. one sits with the buttocks pushed back- ward so that the torso must lean forward, The psoas major muscle seems pecu- placing the knees higher than the hips. liarly vulnerable to developing hema- Truck drivers, in particular, are vulnera- toma in association with anticoagulation ble to backache because of this shortened t h e r a p y , and2 5 , 3 8 , 53, 64,65,73 sometimes fol- position of the iliopsoas. They should lowing minor trauma in teenagers.41 The routinely perform a hip extension exer- hematoma causes local pain and swell- cise at every stop on the road. ing, difficulty in walking, and often seri- ously compromises femoral nerve func- Patients often report that their first tion. Hematoma in the iliacus muscle in- awareness of pain referred from these duced by anticoagulation therapy can TrPs is when they get out of bed in the also produce femoral neuropathy.85 The morning. Sleeping in the fetal position, diagnosis of hematoma can be made by with the knees drawn up to the chest, can computed tomography73 or by ultra- activate latent iliopsoas TrPs. sound scanning.38,41 Lewit57,59 associates TrP tenderness of the psoas with articular dysfunction in the thoracolumbar region, T10-L1 The dys-
Chapter 5 / Iliopsoas Muscle 97 function is identified clinically by im- tolerant of the eccentric contraction of paired trunk rotation and side bending in slow let-backs or sit-backs (see Volume 1, this region. He associates TrP tenderness Chapter 49, Fig. 49.11).83 of the iliacus with dysfunction of the lumbosacral junction.57 Tightness of the rectus femoris muscle that prevents full hip extension can per- Back pain caused by iliopsoas TrPs is petuate TrPs in the iliopsoas muscle. common in pregnancy. Dobrik21 believed that a viscerosomatic reflex was probably TrPs in this muscle group can be per- responsible for the close association that petuated by a lower limb-length inequal- he observed between painful dysfunc- ity or by a small hemipelvis. The sympto- tions of the internal female genitalia and matic muscles most commonly occur on increased tension of the iliopsoas muscle. the longer side, but not always. He21 did not clarify how important he considered the reverse process: somato- 8. PATIENT EXAMINATION visceral reflex aggravation of gynecologi- (Fig. 5.3) cal symptoms by iliopsoas TrPs. Patients with active TrPs that shorten the Klawunde and Zeller54 reported in 12 men and iliopsoas muscle significantly are likely nine women that a marked relationship existed to stand with the weight on the unin- between the voluntarily recruitable electrical ac- volved limb and the foot of the involved tivity of the iliacus muscle and blocked move- limb forward with the knee bent slightly ment of the ipsilateral sacroiliac and upper cervi- to lessen iliopsoas tension. They are also cal joints. The iliacus muscle clinically showed likely to stand with the torso leaning increased tonus on the same side as the sacroiliac slightly toward the involved side. When blockage, but maximum voluntary activation of asked to bend forward while standing, the muscle was inhibited whereas the recruitable they lean farther to the involved side activity of the iliacus on the contralateral side was through approximately the first 20° of increased. Manipulation of blocked joints in the trunk flexion and then become centered high cervical spine on the ipsilateral side reduced as they continue to flex.40 this difference to 25% and manipulation of the blocked sacroiliac joint reduced it further. Follow- Patients with active or latent ilio- ing treatment, the restoration of activity on the in- psoas TrPs tend to walk with a stooped volved side nearly equaled the reduction of elec- posture, have a forward tilt of the pel- trical hyperactivity on the uninvolved side. vis, and exhibit hyperlordosis of the lumbar spine. Together, these factors Increased tension and inhibition of maximal can reduce the standing height several contraction are typically found in muscles with centimeters (an inch or more). These myofascial TrPs.83 It is unfortunate that the iliacus patients must extend the head and neck muscles of the patients in the study were not ex- to see where they are going and may be amined specifically for TrP phenomena. It is not forced to use a cane because of the clear whether the relation observed was due to an stooped forward posture and low back arthromuscular reflex that caused the effects di- pain. Michelle66, 67 characterizes the pa- rectly or whether the joint restriction perpetuated tient with a psoatic limp (or gait), TrPs that were secondarily inactivated by the ma- which minimizes loading by shortening nipulative procedure. However, it is difficult to the iliopsoas muscle, as holding the understand why a reflexly inhibited muscle would thigh in flexion, abduction, and lateral show increased tension unless an additional rotation (the foot toes out). mechanism for non-electrogenic muscular con- traction, such as that produced by TrPs, was pres- The supine patient can be checked for ent. shortening of the iliopsoas by simply test- ing the hip for extension range of motion Perpetuation with the thigh positioned over the end of the examining table, as illustrated and de- Overloading the psoas muscle by the re- scribed in Figure 5.3. The patient grasps petitive vigorous concentric contraction the thigh of the limb not being tested and required to perform sit-ups can perpetu- pulls it toward the chest to flatten the ate its active TrPs. The muscle is more back and stabilize the pelvis, preventing an increase in lumbar lordosis. In Figure 5.3A, the fully rendered right lower limb
98 Part 1 / Lower Torso Pain Figure 5.3. Testing the right iliopsoas muscle for effect of a shortened rectus femoris is neutralized in tightness. A, the fully rendered right lower limb shows the fully rendered limb. When the ankle is raised to the normal stretch position without excessive tension. straighten the knee, the hip becomes more extended, The red limb depicts the effect of a severely shortened but not fully extended as in A. A tight rectus femoris iliopsoas muscle with an apparently normal-length rec- may have contributed to the original hip flexion, but ili- tus femoris. The hip remains flexed against gravity, opsoas tightness probably causes the hip flexion re- the thigh is elevated, and the leg hangs freely, without maining after the rectus femoris is relaxed. This test the extension that would be seen from a tight rectus does not distinguish tightness of the iliopsoas from femoris muscle. S, the red right limb indicates both that of the tensor fascia latae muscle; such a test is hip flexor and knee extensor tightness that could be described in the text. (Adapted from Kendall and Mc- due to shortening of both the iliopsoas and rectus fem- Creary.52) oris muscles, or of the rectus femoris only. The shows the normal stretch position with- would be seen if there were a tight rectus out muscle tightness. The hip is extended femoris muscle. and the leg hangs freely with normal knee flexion. The red limb depicts the effect of When the limb being tested remains in a severely shortened iliopsoas muscle (in excessive hip flexion and excessive knee the presence of a rectus femoris of appar- extension (red right limb in Fig. 5.36), the ently normal length). In this figure, the position could be due to shortening of hip remains flexed against gravity, so the both the iliopsoas and rectus femoris thigh is elevated. The leg hangs freely, muscles, or of the rectus femoris only. without the excessive knee extension that The effect of a shortened rectus femoris can be neutralized by putting the limb in
Chapter 5 / Iliopsoas Muscle 99 the position shown in the fully rendered population, and that there are usually other im- limb in Figure 5 . 3 6 . When elevating the ankle to straighten the knee allows the portant causes of backache in addition to an ilio- hip to become more extended, but not completely extended, it suggests that a psoas source. If the iliopsoas tightness were due to tight rectus femoris contributes to some limitation of hip extension while ilio- latent TrPs, the tightness would not cause back- psoas tightness causes the remainder. Conversely, if there is no change in hip ache unless the TrPs were aggravated by examina- flexion in response to passive knee exten- sion, there is probably no component of tion of the muscle. rectus femoris tightness.58 9. TRIGGER POINT EXAMINATION This test (Fig. 5.36) does not distin- (Fig. 5.4) guish tightness of the iliopsoas from tight- ness of the tensor fascia latae muscle. Pas- The spot tenderness of iliopsoas TrPs can sively straightening the knee with the be detected by palpation in three loca- thigh abducted and medially rotated re- tions (Fig 5.4). In two of the three loca- leases tightness in the tensor fasciae latae. tions, the muscle fibers can be palpated Iliopsoas tightness then probably causes directly beneath the skin without other any remaining restriction of extension at muscle intervening. The nails of the pal- the hip. pating fingers and thumb must be clipped short for these examinations to avoid Increasing the stretch on an iliopsoas causing cutaneous pain. muscle that has tightness due to TrPs is likely to cause referred pain in the sacro- In the supine patient, pressure can be iliac region. exerted on the psoas musculotendinous junction and on iliacus muscle fibers by Muscle balance is necessary for good pressing against the lateral wall of the body mechanics. The iliopsoas works in femoral triangle, as depicted in Figure harmony with the rectus abdominis; if 5.4A (see also Fig. 13.4). Pain from TrPs this abdominal muscle is weak, the psoas in this part of the muscle is referred to the is likely to develop problems trying to low back and usually to the anteromedial compensate. Full function of the abdomi- aspect of the thigh and to the groin. Since nal musculature is confirmed if the pa- the femoral nerve is on the medial side of tient can do a curl-up with the knees bent the muscle,33 one is less likely to apply and without foot support.50 pressure to that nerve when palpating the muscle if the thigh is abducted (Fig. Porterfield points out that the pelvic 5.4A). If the iliacus is very tight, it may be stress added by a shortened iliopsoas necessary to flex the thigh slightly by sup- muscle during hip extension while walk- porting it with a pillow for patient com- ing can cause an anterior torsion of either fort and to avoid excessive tension on the ilium.74 The iliacus and psoas attach- muscle. A local twitch response is evoked ments suggest that a shortened iliacus only rarely by digital examination at this could provoke anterior torsion of the ipsi- site, and even less frequently at the other lateral ilium and a shortened psoas major two sites. could induce anterior torsion of the con- tralateral ilium via the contralateral SI At the second location, one palpates joint. the proximal fibers of the iliacus muscle inside the iliac crest of the pelvis (Fig. By examining 547 unselected young military re- 5.46), through the aponeurosis of the ex- ternal abdominal oblique muscle. The pa- cruits for hamstring and iliopsoas tightness three tient must relax the abdominal muscles, and be positioned so that the skin of the times over a period of 4 years, Hellsing44 found abdominal wall becomes slackened. The fingers reach inside the crest of the ilium that 21% had restricted stretch range of motion starting in the region behind the anterior superior iliac spine and slide back and throughout their 4-year enlistment. No significant forth parallel to the iliac crest while pressing against the bone, palpating correlation was found between this iliopsoas across the fibers of the iliacus muscle. Oc- casionally, palpation reveals taut bands tightness and any back pain these recruits had and their associated spot tenderness. Pain before or during enlistment. The author inter- preted this as showing that iliopsoas tightness does not consistently produce backache in this
100 Part 1 / Lower Torso Pain Figure 5.4. Palpation of trigger points in the right iliopsoas muscle at three lo- cations. The arrows indicate the direc- tion of pressure. The solid circle covers the anterior superior iliac spine; the open circle marks the pubic tubercle. The solid line marks the iliac crest; the dashed line locates the inguinal liga- ment; the dotted line follows the course of the femoral artery. A, palpation of the distal iliopsoas trigger-point region deep along the lateral wall of the femoral trian- gle, just above the distal attachment of the muscle to the lesser trochanter. S, palpation of iliacus trigger points inside the brim of the pelvis behind the anterior superior iliac spine. C, digital pressure on proximal psoas trigger points applied first downward beside, and then medi- ally, beneath, the rectus abdominis mus- cle toward the psoas muscle. This sec- ond direction of pressure compresses the psoas fibers against the lumbar spine. evoked from these TrPs is more likely to it can usually be elicited at approximately refer to the low back and sacroiliac region the level of the umbilicus or slightly than to the thigh. lower. The palpating fingers are placed on the abdominal wall with the fingertips Indirect palpation of the psoas major just lateral to the lateral border of the rec- muscle at the third location, through the tus abdominis muscle. Downward pres- abdominal wall (Fig. 5.4C), is remarkably sure is slowly, gradually, gently exerted effective when properly done. The patient to depress the fingers below the level of must be comfortable and the abdominal the rectus abdominis muscle. If the pres- wall relaxed. The psoas major is palpable sure is exerted directly downward with for tenderness along the entire length of no medial component, it elicits only ten- the lumbar spine. If tenderness is present,
Chapter 5 / Iliopsoas Muscle 101 derness of other abdominal contents. At pass through this foraminal space.70 Since this point, therefore, the examiner exerts at this level the psoas is mostly tendon slowly increasing pressure medially to- and the iliacus is still largely fleshy, it is ward the spinal column. The intervening more likely that such an entrapment abdominal contents transmit the pressure would be caused by TrP shortening or re- to the psoas muscle against the lumbar flex spasm of the iliacus than of the psoas spine. It is amazing how a little pressure muscle. Some enigmatic femoral nerve elicits so much pain when the psoas entrapments may arise in this way. harbors active TrPs. One usually cannot palpate the tension of the muscle itself A number of space-occupying lesions but, in thin patients with loose skin, one in and around the psoas muscle also can may be able to palpate its tension. Pain cause symptoms of lumbosacral plex- elicited from this part of the psoas refers opathy. Such lesions were diagnosed by chiefly to the low back. computed tomography and included in- trapsoas hemorrhage in a patient receiv- When the clinician finds active TrPs in ing anticoagulant therapy, a retroperito- one iliopsoas muscle, the contralateral ili- neal hematoma, an abscess involving the opsoas needs to be examined, since they left psoas muscle, and multiple enlarged function together. This contralateral mus- abdominal nodes due to lymphoma.64 cle frequently also requires treatment. Usually, TrPs are more active in one ilio- 11. ASSOCIATED TRIGGER POINTS psoas muscle than in the other. This \"Hidden Prankster\" can cause dis- 10. ENTRAPMENTS torted posture that overloads back and neck muscles, perpetuating TrPs in them. The iliohypogastric, ilioinguinal, lateral The victimized muscles may include the femoral cutaneous, and femoral nerves hamstring, gluteal, thoracolumbar para- all emerge from the lateral border of spinal, and posterior cervical muscles. the psoas major muscle.19 The obturator nerve emerges from its medial border.17 Iliopsoas TrPs are usually associated The genitofemoral nerve passes anteri- with TrPs in other muscles and rarely orly through the center of the belly of present as a single-muscle myofascial the muscle, emerging on its anterior syndrome. The iliopsoas and the quad- surface.1,15-17,27,30,72,78 Sometimes, the il- ratus lumborum muscles are usually in- iohypogastric nerve16 and the ilioingui- volved together through their stabilizing nal nerve1,78 also pass through the belly action on the lumbar spine and the occa- of this muscle. sional extensor action of the psoas mus- cle. Therefore, for lasting relief of an ilio- Although symptoms of entrapment of psoas syndrome, TrPs in both the quad- these sensory lumbosacral nerves have ratus lumborum and iliopsoas muscles not been specifically related to TrPs in must be inactivated. Bilateral involve- the psoas major, this possibility should be ment of the psoas leads to bilateral in- considered when a patient suffers enig- volvement of the quadratus lumborum, matic pain and disturbance of sensation but one side is usually more severely af- in the distribution of one or more of these fected than the other. The quadratus lum- nerves. For example, entrapment of the borum and the posterior portion of the genitofemoral nerve by taut TrP bands in iliacus muscle may form a continuous the psoas muscle could cause pain and sheet of fibers where both attach along the paresthesias in the groin, scrotum or la- crest of the ilium.77 bia, and proximal anterior thigh.47 Synergistic muscles likely to exhibit Lewit57 suggests the possibility that the myofascial TrPs in association with ilio- lateral femoral cutaneous nerve may be psoas involvement include the rectus entrapped by an iliopsoas muscle that is abdominis,47 quadratus lumborum,47 rec- enlarged (in spasm) as it passes through tus femoris, tensor fasciae latae,47 pec- the lacuna musculorum where nerve and tineus, lumbar paraspinal muscles, and muscle exit the pelvis together (see Sec- the contralateral iliopsoas. When the rec- tion 2). The femoral nerve and the femo- tus femoris is shortened because of TrPs, ral branch of the genitofemoral nerve also the iliopsoas also remains in a shortened
102 Part 1 / Lower Torso Pain position, making it more susceptible to initial sweeps of ice or vapocoolant spray TrPs. The reverse is also true; patients over the muscle, the operator gradually with patellofemoral dysfunction from a extends the thigh and rotates it medially tight rectus femoris are sometimes greatly (Fig. 5.5B) while continuing to apply uni- benefitted by a concomitant iliopsoas directional parallel sweeps of cold. Each stretch program.48 sweep successively covers the abdomen, groin, and anterior thigh on the affected Antagonists to the iliopsoas include the side. Sweeps of coolant are then applied gluteus maximus and hamstring muscles. to the back and buttock, as shown in Fig- Tightness of the latter is generally of key ure 5.5C, to cover the posterior pain refer- importance to most low back pain pa- ral pattern. tients. Functional shortening of the ham- strings causes an unnatural posterior tilt Immediately following intermittent cold of the pelvis that tends to overload the with stretch, a moist heating pad is ap- psoas muscle, thus facilitating the devel- plied to the cooled skin. When the skin opment and perpetuation of TrPs in that has been thoroughly rewarmed, the pa- muscle. tient actively moves the thigh slowly through full flexion and extension at the 12. INTERMITTENT COLD WITH hip several times. STRETCH (Fig. 5.5) When re-examined following this bilat- eral procedure, the patient stands taller. Iliopsoas muscles should not be treated The stooped posture induced by hip flex- for myofascial TrPs by stretching until ion has been replaced by a more erect one identifies any coexisting lumbar posture. Remarkably, older individuals spine articular dysfunction. If present, who have no pain complaint, but stand both must be treated since each can pre- bent forward due to latent iliopsoas TrPs vent recovery of the other. accumulated during many years, can gain several centimeters (an inch or more) of It is important to apply intermittent stature. They may appear to be a decade cold with stretch to the iliopsoas bilater- younger simply by the release of their ili- ally; the muscle on one side rarely devel- opsoas TrP tension. ops TrPs without the other also doing so. In the early 1950s, when ethyl chloride was the The hamstrings are so important in myofascial pain syndromes of the low only vapocoolant spray available, the senior au- back that it is wise to always start with bilateral release of the hamstrings [see thor observed no release of iliopsoas tension with Chapter 16, pages 315-338) even though the iliopsoas seems to be the muscle that the spray-and-stretch technique by applying the is primarily involved. The remarkable in- crease in straight-leg raising that usually spray to the skin over the back where pain was follows this hamstring release procedure removes a source of stress on the ilio- felt.84 Later, she suspected that the skin represen- psoas muscle. tation of this muscle might be over the abdomen, The technique for using ice to apply in- termittent cold is described in Chapter 2 rather than over the low back. Spray and stretch of this volume, page 9; the technique for using vapocoolant spray is on pages 6 7 - then proved remarkably effective when she di- 74 of Volume l ; 8 3 and techniques to aug- ment relaxation and stretch are in Chap- rected sweeps of the spray downward over the ab- ter 2 of this volume, on page 11. domen parallel to the midline. This emphasizes For intermittent cold with stretch of the iliopsoas muscle (Fig. 5.5) the patient lies the critical importance of cooling specifically the on the side opposite to the limb to be treated, with the low back close to the skin area where the cutaneomuscular reflexes re- edge of the treatment table. The thigh of the limb to be treated is gently extended late to the muscle being passively stretched, at the hip (Fig. 5.5A). After two or three rather than cooling only where the patient com- plains of pain. Postisometric relaxation60,61 was found effective for release of iliopsoas muscle tightness associated with low lumbar dis- copathy82 and is very useful for inactivat- ing myofascial TrPs in this muscle. Deep massage and hip extension exercises may also be helpful in relieving the pain re- ferred from iliopsoas TrPs.47,79
Chapter 5 / Iliopsoas Muscle 103 Figure 5.5. Stretch positions and inter- mittent-cold patterns (thin arrows) for distal trigger points (Xs) in the right ilio- psoas muscle. The dashed line identifies the inguinal ligament, and the solid cir- cle covers the anterior superior iliac spine. The dotted line marks the femoral artery. The thick arrow shows the direc- tion of pull applied to stretch the muscle. A, initial stretch position of extension of the thigh at the hip. B, full stretch posi- tion with the addition of medial rotation of the thigh at the hip. C, final application of vapocoolant spray (or ice) to the pain reference zone in the low back and up- per buttock. Before leaving the clinician's office, the associated TrPs in the quadratus lum- patient should be trained in a stretching borum, rectus abdominis, rectus femoris, exercise for use at home, as described in hamstring, and gluteal muscles. Then, the Section 14 of this chapter. iliopsoas TrPs can usually be inactivated by applying intermittent cold with stretch 13. INJECTION AND STRETCH combined with Lewit's postisometric re- (Fig. 5.6) laxation (see Chapter 2, pages 10-11). Oc- casionally, TrPs remain that require injec- Only the distal end of the psoas major tion. muscle is accessible by ordinary injection techniques. Generally, injection of this If injection of TrPs in the psoas muscle muscle should await the inactivation of is attempted before the associated TrPs in the functionally related muscles have
104 Part 1 / Lower Torso Pain Figure 5.6. Injection of distal trigger points in the right iliopsoas muscle. The solid circles cover the anterior superior iliac spine and the pubic tubercle. Be- tween them, the inguinal ligament lies beneath the dashed line. The femoral artery is red. The thigh is abducted and laterally rotated to separate the iliopsoas muscle and the femoral artery. The nee- dle is directed toward the trigger point tenderness close to the lesser trochan- ter, laterally, away from the femoral ar- tery. The pulsation of the artery is usu- ally palpable. The femoral nerve lies close and lateral to the artery. been eliminated, patients are prone to ex- For this injection, the thigh is extended perience severe local soreness and in- and then abducted and laterally rotated to creased disability for several days after- separate the iliopsoas muscle as far as ward. They complain of increased diffi- possible from the femoral nerve and ar- culty in standing and walking. The tery (Fig. 5.6). Usually, the thigh should associated TrPs should be identified and lie flat against the examining table or else inactivated before injecting the iliopsoas the iliopsoas muscle is likely to be unde- TrPs, because tautness of the involved ili- sirably slack. The pulsating femoral artery opsoas fibers provides protective splint- is identified by palpation medial to the ing for the other muscles of its functional TrP tenderness in the muscle fibers. How- unit. Removal of protective splinting sup- ever, the clinician must be aware that the plied by the iliopsoas muscle, without femoral nerve lies between the iliopsoas first inactivating TrPs in the muscles that muscle and the femoral artery. it is protecting, frequently aggravates their myofascial pain syndromes. In this While injecting these iliopsoas TrPs, situation, the increased severity of symp- one finger (the index finger of the left hand toms due to TrPs in the other muscles in Fig. 5.6) is held just lateral to the femo- overshadows the relief obtained from the ral artery, over the femoral nerve. A needle pain that had been referred from TrPs in usually 50 mm (2 in) long is directed into the iliopsoas muscle. This paradoxical re- the tender area and angled to avoid the sponse to treatment also occurs in other femoral nerve and artery. Because the functional units. muscle lies so deep, only occasionally is a local twitch perceptible when the needle The distal iliacus fibers and fibers of penetrates a TrP. The pain response of the the psoas muscle at its musculotendinous patient (jump sign), however, is unmistak- junction are accessible to injection in the able. If the patient is asked before injection femoral triangle. The position of the mus- to note the location of pain elicited by the cle with regard to the femoral nerve and needle, he or she can report the specific artery must be taken into account; it has pattern of referred pain evoked by the in- been well illustrated.3,72 The tender areas jection of that active TrP. to be injected are located by palpation just proximal to the attachment of the Performing intermittent cold with muscle on the lesser trochanter, as de- stretch after injection helps to ensure in- scribed under Section 9, Trigger Point Ex- activation of any residual TrPs. amination. This attachment is located on the medial aspect of the femur (Fig. 5.2). Application of a moist heating pad to both the abdomen and upper anterior thigh follows the intermittent cold with stretch. When the skin has been re-
Chapter 5 / Iliopsoas Muscle 105 warmed, the patient performs full active perpetuating factors (see Volume 1, Chap- range of motion in flexion and extension ter 4).83 of the hip slowly through several cycles. When iliopsoas TrPs are causing pain Dry needling of iliopsoas TrPs in this that demands emergency relief, the pa- femoral triangle area was also reported to tient should be instructed to apply moist be effective. When the needle reached the heat to the abdomen over the entire TrP it induced a \"fasciculation\" (local length of the muscle from the rib cage to twitch response) that could be felt by the the lesser trochanter. Patients need an ex- patient and by the examiner's hand as it planation as to why this positioning of rested gently on the area.47 hot packs is used for a muscle that is lo- cated beside the backbone and causes Inactivation of these distal iliopsoas pain in the back. Its musculocutaneous TrPs may occasionally eliminate the more reflex area is the skin of the abdomen, not proximal psoas TrPs. of the back. Iliacus TrPs close to the iliac crest may If upright ambulation is prohibitively be injected, with special care, via a lower painful, a degree of mobility may be abdominal approach. The upper iliac fossa achieved temporarily by suggesting that is palpated for taut bands and TrP tender- the patient try to move around on the ness, as described in Section 9, Trigger hands and knees. This position relieves Point Examination. A spinal needle 67-87 the iliopsoas of its erect postural respon- mm (2 1/2-3 /1 2 in) long is inserted inside the sibilities. crest of the ilium and directed to the taut bands with TrP tenderness. The needle Body Asymmetry must travel close to the inner surface of the ilium to avoid penetrating abdominal A lower limb-length inequality and/or a contents. Occasional contact with bone small hemipelvis should be corrected by ensures that the needle is still within the appropriate lifts (Chapter 4, pages 77-78). muscle. A pain response by the patient usually indicates that the needle encoun- A locked sacroiliac joint is likely to ag- tered a TrP. Local twitch responses rarely gravate TrPs in the iliacus muscle54 and reveal themselves here. Again, application may be corrected by appropriate manipu- of moist heat and active range of motion lation (Chapter 2, pages 16-17). Lewit as- follows intermittent cold with stretch to sociates iliacus TrPs with dysfunction at complete the procedure. the lumbosacral junction,57 while thora- columbar restriction aggravates TrPs in Although no report was found that de- the psoas muscle.57,59 scribed a posterior approach for injecting psoas TrPs beside the lumbar spine, nee- Postural and Activity Stress dles have been placed in that muscle from behind for other reasons. Awad5 described A position on the hands and knees can and illustrated this approach to perform provide at least temporary relief of pain, motor point blocks of the lumbar psoas often greater than can be obtained in any muscle and Nachemson68 described it for recumbent position. This observation is intramuscular EMG monitoring of its ac- useful diagnostically and therapeutically. tivity. For those accustomed to performing On awakening from sleep, it may be the lumbar sympathetic blocks, this should only way a person who is alone and ex- not be especially difficult. Normally, the periencing an acute attack of pain can aorta lies anterior to the iliopsoas muscle reach the bathroom. and is shielded by the vertebral bodies from needles introduced posteriorly. When sitting, the patient should main- tain an open angle at the hips by avoid- 14. CORRECTIVE ACTIONS ing the jackknifed position, at least 10° (Figs. 5.7 and 5.8) beyond a right angle. Raising the back of the seat so that the thigh slopes down- The initial corrective actions are to inacti- ward toward the front of the seat pro- vate associated TrPs (see Section 11) and duces this desirable effect. Leaning back to correct any mechanical and systemic against a slightly reclining backrest is also helpful.
106 Part 1 / Lower Torso Pain pede recovery from iliopsoas TrPs. Pa- tients who exhibit paradoxical breathing should practice abdominal breathing un- til they habitually breathe in the normal pattern of coordinated chest and abdomi- nal movements during inhalation and ex- halation. For sleeping, the patient may place a small pillow under the knees when lying on the back, or under the hips when sleeping prone. This produces some hip flexion that lessens tension on the ilio- psoas muscles sufficiently to improve sleep. The patient should avoid side lying in a tight fetal position that excessively shortens the iliopsoas muscles. A bed that sags like a hammock may place the iliopsoas in too shortened a po- sition and aggravate pain. In this situa- tion, moving the mattress to the floor for the night can temporarily solve the prob- lem. A bed board offers a more permanent solution (see Chapter 4, page 79). Exercise Therapy (Figs. 5.7 and 5.8) Figure 5.7. Exercise for mobilizing extension of the A hip extension exercise to stretch the ili- lumbar spine and for stretching the hip flexor muscles. opsoas muscle passively is illustrated in This exercise is applicable only to selected patients Figure 5.7. Patients are reminded to keep who have no neck and shoulder-girdle problems. A, the thighs and pelvis solidly against the starting position. S, correct extension position with table (or floor) as they hyperextend the hips flat against the table. C, incorrect position (red X) lumbar spine and hips. For maximum that fails to extend the lumbar spine and tends to over- stretch of the iliopsoas, it is helpful for load the extensor musculature. some patients also to medially rotate the thigh at the hip on the involved side. If the jackknifed seated position is una- voidable, then standing up frequently to Another exercise for relieving tension extend the hips and stretch the iliopsoas of the iliopsoas muscle employs the post- muscles avoids immobility in the short- isometric relaxation technique, which ened position for too long a period. was described and illustrated for this muscle by Lewit.57 This technique is re- Sustained immobility in any seated posi- markably effective and is easy for the pa- tion is likely to impair circulation and ag- tient to do. It is performed in the position gravate iliopsoas TrPs. On long automobile for examination that is illustrated in Fig- trips, cruise control provides an opportu- ure 5.3A The lower limb on the side of nity for the driver to change positions and the iliopsoas muscle to be stretched is al- improve the mobility of the muscles. lowed to hang freely with the knee bent. If the thigh needs more support, the pa- The habit of paradoxical breathing (see tient moves up on the examining table. Volume 1, Fig. 20.13)83 can seriously im- Tension is increased by pulling the other knee to the chest. This position also loads a sufficiently shortened rectus femoris muscle. A variation of the Lewit relaxation-and- stretch method has the patient lie supine on a stair landing and gradually \"walk\"
Chapter 5 / Iliopsoas Muscle 107 Figure 5.8. Slow Sit-back Exercise to improve strength and coordination of the abdominal and hip flexor muscles as the spine \"rolls down\" on the table. This ex- ercise requires a less demanding length- ening contraction, rather than the short- ening contraction of a sit-up. A, pushing the torso up (arrow) with the arms from the supine to the seated position. This avoids loading the flexor muscles of the trunk and hips. B, beginning of the slow sit-back, lumbar spine flexed. C, rolling the back down onto the table, maintain- ing spinal flexion so that each spinal segment reaches the table in succes- sion. D, completion of slow sit-back. E, period of full relaxation with abdominal (diaphragmatic) breathing. Three cycles of this slow sit-back exercise should be performed daily to provide full benefit. the foot of the involved limb downstairs knee of the rear leg straight emphasizes while holding the knee of the uninvolved hip extension. limb close to the chest (Personal commu- nication, Mary Maloney, PT, 1990). In the office, another effective stretch of the iliopsoas is to grasp a file cabinet with The In-doorway Stretch Exercise (see one hand for stability, then place one foot Volume 1, Fig. 42.10)83 also provides ef- well behind and extend that thigh at the fective stretch of the iliopsoas muscle, if hip while bending the opposite knee the patient makes a point of swinging the placed in front. The office worker can hips forward, alternately. Keeping the also provide a hip flexor stretch by sim-
108 Part 1 / Lower Torso Pain ply sitting on the side edge of the chair 11. Basmajian JV, Greenlaw RK: Electromyography seat (without armrests), with one buttock off the edge and the knee flexed, then of iliacus and psoas with inserted fine-wire sliding that leg posteriorly to extend the electrodes. Anat Rec 1 6 0 : 3 1 0 - 3 1 1 , 1968. hip. 12. Bogduk N, Twomey LT: Clinical Anatomy of the Lumbar Spine. Churchill Livingstone, New York, Following a program of muscle length- ening, the iliopsoas and rectus abdominis 1987 (pp. 72-73). muscles should be conditioned together in a coordinated strengthening exercise. 13. Bloom RA, Gheorghiu D, Verstandig A, et al.: This program should start with slow sit- backs (Fig. 5.8, and Volume l , 8 3 Fig. The psoas sign in normal subjects without 49.11). Then, as the muscles gain strength, the patient can reverse the bowel preparation: the influence of scoliosis on process and start doing a few sit-ups visualisation. Clin Radiol 4 1 : 2 0 4 - 2 0 5 , 1990. safely and comfortably. This exercise pro- 14. Carter BL, Morehead J, Wolpert SM, et al.: Cross- gram can, however, aggravate TrPs in the Sectional Anatomy. Appleton-Century-Crofts, sternocleidomastoid and scalene muscles by overloading them in the shortened po- New York, 1977 (Sects. 30-42, and 44-48). sition. 15. Clemente CD: Anatomy. A Regional Atlas of the It is also important to warn patients Human Body. Lea & Febiger, Philadelphia, 1975 what not to do. Some patients aggravate iliopsoas TrPs in the long-sitting position (pp. 231, 235). while performing the In-bathtub Stretch 16. Ibid. (p. 232). Exercise that is illustrated in Volume 1, 17. Clemente CD: Gray's Anatomy of the Human Body, Figure 48.13.83 Leaning forward, they strongly contract the iliopsoas muscles in American Ed. 30. Lea & Febiger, Philadelphia, the fully shortened position in an effort to reach their toes, which can seriously ag- 1985 (pp. 557-558). gravate iliopsoas TrPs and induce severe 18. Ibid. (p. 564, Fig. 6 - 7 0 ) . pain. The patient should learn to perform 19. Ibid. (pp. 1 2 2 7 - 1 2 3 2 ) . this stretch by leaning forward and al- 20. Close JR: Motor Function in the Lower Extremity. lowing gravity to pull the head, torso, and arms forward without vigorous muscular Charles C Thomas, Springfield, 1964 (p. 128). effort. Patients who are unable to learn to relax in this way should be discouraged 21. Dobrik I: Disorders of the iliopsoas muscle and from doing the In-bathtub Stretch Exer- its role in gynecological diseases. J Man Med 4: cise. 130-133, 1989. References 22. Duchenne GB: Physiology of Motion, translated by 1. Anderson JE: Grant's Atlas of Anatomy, Ed. 8. Wil- E.B. Kaplan. J. B. Lippincott, Philadelphia, 1949 liams & Wilkins, Baltimore, 1983 (Fig. 2-119). (pp. 259-260). 2. Ibid. (Fig. 2 - 1 2 5 ) . 3. Ibid. (Fig. 4 - 2 2 ) . 23. Duprat G Jr., Levesque HP, Seguin R, et al.: 4. Ibid. (Figs. 4 - 2 3 , 4 - 2 4 ) . 5. Awad EA: Phenol block for control of hip flexor Bowel displacement due to psoas muscle hyper- trophy. J Can Assoc Radiol 3 4 : 6 4 - 6 5 , 1983. and adductor spasticity. Arch Phys Med Rehabil 53:554-557, 1972. 24. Durianova: [Spasm of the m. psoas in the differ- 6. Bachrach RM: The relationship of low back/pel- vic somatic dysfunctions to dance injuries. ential diagnosis of pain in the lumbosacral re- Orthop Rev 7 7 : 1 0 3 7 - 1 0 4 3 , 1988. gion.] Fysiatr Reumatol Vestn 5 2 : 1 9 9 - 2 0 3 , 1974. 7. Bardeen CR: The musculature, Sect. 5. In Mor- ris's Human Anatomy, edited by C. M. Jackson, 25. Ekelund L, Jonsson G, Riinow A: [Compartment Ed. 6. Blakiston's Son & Co., Philadelphia, 1921 (p.489). syndrome in the iliopsoas region with compres- 8. Basmajian JV, Deluca CJ: Muscles Alive, Ed. 5. sion of the femoral nerve. J Lakartidningen 77: Williams & Wilkins, Baltimore, 1985 (pp. 2 3 4 - 235). 4539-4540, 1980. 9. Ibid. (pp. 3 1 0 - 3 1 3 ) . 26. Evjenth O, Hamberg J: Muscle Stretching in Man- 10. Ibid. (p. 380). ual Therapy, A Clinical Manual. Alfta Rehab Ferlag, Alfta, Sweden, 1984 (p. 102). 27. Ferner H, Staubesand J: Sobotta Atlas of Human Anatomy, Ed. 10, Vol. 2. Urban & Schwarzen- berg, Baltimore, 1983 (Fig. 91). 28. Ibid. (Fig. 137). 29. Ibid. (Fig. 152). 30. Ibid. (Fig. 261). 31. Ibid. (Fig. 351). 32. Ibid. (Fig. 4 0 4 ) . 33. Ibid. (Fig. 410). 34. Ibid. (Figs. 4 1 6 , 4 1 7 ) . 35. Ibid. (Fig. 4 2 1 ) . 36. Flint MM: An electromyographic comparison of the function of the iliacus and the rectus abdominis muscles. J Am Phys Therap Assoc 45: 248-253, 1965. 37. Fujiwara M, Basmajian JV: Electromyographic study of two-joint muscles. Am J Phys Med 54: 234-242, 1975. 38. Graif M, Olchovsky D, Frankl O, et al.: Ul- trasonic demonstration of iliopsoas hematoma causing femoral neuropathy. Isr J Med Sci 18: 967-968, 1982. 39. Greenlaw RK: Function of Muscles About the Hip During Normal Level Walking. Queen's University,
Chapter 5 / Iliopsoas Muscle 109 Kingston, Ontario, (thesis) 1973 (see pp. 1 0 8 - jogging, running, and sprinting. Am J Sports Med 111). 14:501-510, 1986. 40. Grice A: Personal communication, 1991. 63. Markhede G, Stener B: Function after removal of 4 1 . Giuliani G, Poppi M, Acciarri N, et al.: CT scan various hip and thigh muscles for extirpation of and surgical treatment of traumatic iliacus he- tumors. Acta Orthop Scand 5 2 : 3 7 3 - 3 9 5 , 1 9 8 1 . matoma with femoral neuropathy: case report. J Trauma 3 0 : 2 2 9 - 2 3 1 , 1990. 64. Massey EW: CT evaluation of lumbosacral plexus disorders. Postgrad Med 6 9 : 1 1 6 - 1 1 8 , 42. Haines JD, Chop WM Jr, Towsley DK: Primary psoas abscess: an often insidious infection. Posf- 1981. grad Med 8 7 : 2 8 7 - 2 8 8 , 1 9 9 0 . 65. Mastroianni PP, Roberts MP: Femoral neuropa- 43. Helfgott SM: Unusual features of iliopsoas bur- thy and retroperitoneal hemorrhage. Neurosur- sitis. Arthritis Rheum 3 7 : 1 3 3 1 - 1 3 3 3 , 1988. gery 13:44-47, 1983. 44. Hellsing A-L: Tightness of hamstring and psoas 66. Michele AA: The iliopsoas muscle. Clin Symp 12: major muscles. Ups J Med Sci 9 3 : 2 6 7 - 2 7 6 , 1988. 6 7 - 1 0 1 , 1 9 6 0 (Plates I, III, VI, pp. 67, 70, 87, 8 9 ) . 45. Hooper ACB: The role of the iliopsoas muscle in 67. Michele AA: Iliopsoas. Charles C Thomas, femoral rotation. Irish J Med Sci 7 4 6 : 1 0 8 - 1 1 2 , Springfield, 1962 (pp. 195, 282, 489-491). 1977. 46. Imamura K, Ashida H, Ishikawa T. et al.: Human 68. Nachemson A: Electromyographic studies on the vertebral portion of the psoas muscle. Acfa major psoas muscle and sacrospinalis muscle in Orthop Scand 3 7 : 1 7 7 - 1 9 0 , 1 9 6 6 . relation to age: a study by computed tomogra- 69. Netter FH: The Ciba Collection of Medical Illustra- phy. J Gerontol 3 8 : 6 7 8 - 6 8 1 , 1983. tions, Vol.8, Musculoskeletal System. Part I: 47. Ingber RS: Iliopsoas myofascial dysfunction: a Anatomy, Physiology and Metabolic Disorders. treatable cause of \"failed\" low back syndrome. Ciba-Geigy Corporation, Summit, 1987 (p. 86). Arch Phys Med Rehabil 7 0 : 3 8 2 - 3 8 6 , 1 9 8 9 . 70. Ibid. (pp. 77, 89). 71. Ibid. (p. 87). 48. Ingber RS: Personal communication. 1989. 72. Ibid. (p. 89). 49. Janda V: Muscle Function Testing. Butterworths, 73. Nino-Murcia M, Wechsler RJ, Brennan RE: Com- London, 1983 (p. 29). puted tomography of the iliopsoas muscle. Skel Radiol 7 0 : 1 0 7 - 1 1 2 , 1983. 50. Jull GA, Janda V: Muscles and motor control in 74. Porterfield JA: The sacroiliac joint, Chapter 23. low back pain: assessment and management, In Orthopaedic and Sports Physical Therapy, ed- Chapter 10. In Physical Therapy of the Low Back, ited by J.A. Gould III and G.J. Davies, Vol. II. CV edited by L. T. Twomey and J. R. Taylor, Mosby, St. Louis, 1985 (p. 553). Churchill Livingstone, New York, 1987 (pp. 2 5 3 - 2 7 8 see p. 271). 75. Rab GT, Chao EYS, Stauffer RN: Muscle force analysis of the lumbar spine. Orthop Clin North 51. Keagy RD, Brumlik J, Bergan JJ: Direct electro- Am 8:193-199, 1977. myography of psoas major muscle in man. J Bone Joint Surg [Am] 48:1377-1382, 1966. 76. Rasch PJ, Burke RK: Kinesiology and Applied Anat- omy, Ed. 6. Lea & Febiger, Philadelphia, 1 9 7 8 52. Kendall FP, McCreary EK: Muscles, Testing and Function, Ed. 3. Williams & Wilkins, Baltimore, (pp. 243-244). 77. Rohen JW, Yokochi C: Color Atlas of Anatomy, Ed. 1983 (pp. 160-163). 2. Igaku-Shoin, New York, 1988 (p. 417). 53. Klammer A: [Fascia compartment syndrome of 78. Ibid. (p. 308). the iliacus-psoas compartment.] Z Orthop 121: 79. Saudek CE: The hip, Chapter 17. In Orthopaedic 298-304,1983. and Sports Physical Therapy, edited by J.A. Gould 54. Klawunde G, Zeller H-J: Elektromyographische III and G.J. Davies, Vol. II. CV Mosby, St. Louis, 1985 (pp. 3 6 5 - 4 0 7 , see p. 4 0 6 , Fig. 1 7 - 4 8 ) . Untersuchungen zum Hartspann des M. iliacus 80. Silver SF, Connell DG, Duncan CP: Case report (Sagittale Blockierungen im lumbo-iliosakralen 550. Skel Radiol 7 8 : 3 2 7 - 3 2 8 , 1 9 8 9 . Bereich). Beitr Orthop Traumatol 2 2 : 4 2 0 - 4 3 0 , 81. Simons DG, Travell JG: Myofascial origins of 1975. low back pain. 2. Torso muscles. Postgrad Med 7 3 : 8 1 - 9 2 , 1983 (see pp. 91, 92). 55. Kvernebo K, Stiris G, Haaland M: CT in idio- 82. Stodolny J, Mazur T: Effect of post-isometric re- pathic pyogenic myositis of the iliopsoas mus- cle: a report of 2 cases. Eur J Radiol 3 : 1 - 2 , 1983. laxation exercises on the ilio-psoas muscles in patients with lumbar discopathy. J Manual Med 56. LaBan MM, Raptou AD, Johnson EW: Electro- 4:52-54, 1989. myographic study of function of iliopsoas mus- 83. Travell JG, Simons DG: Myofascial Pain and Dys- cle. Arch Phys Med Rehabil 4 6 : 6 7 6 - 6 7 9 , 1965. 57. Lewit K: Manipulative Therapy in Rehabilitation of function: The Trigger Point Manual. Williams & the Motor System. Butterworths, London, 1985 Wilkins, Baltimore, 1983. (pp. 138, 276, 315). 58. Ibid. (p. 153, Fig. 4.42). 84. Travell J: Ethyl chloride spray for painful mus- cle spasm. Arch Phys Med Rehabil 3 3 : 2 9 1 - 2 9 8 , 59. Lewit K: Muscular pattern in thoraco-lumbar le- sions. Manual Med 2 : 1 0 5 - 1 0 7 , 1986. 1952. 60. Lewit K: Postisometric relaxation in combina- 8 5 . Uncini A, Tonali P, Falappa P, et al.: Femoral tion with other methods of muscular facilitation neuropathy from iliac muscle hematoma in- and inhibition. Manual Med 2 : 1 0 1 - 1 0 4 , 1986. duced by oral anticoagulation therapy. J Neurol 61. Lewit K, Simons DG: Myofascial pain: relief by 226:137-141, 1981. post-isometric relaxation. Arch Phys Med Rehabil 86. Vos PA: The psoas minor syndrome. J Int Coll 65:452-456, 1984. Surg 4 4 : 3 0 - 3 6 , 1 9 6 5 . 62. Mann RA, Moran GT, Dougherty SE: Compara- tive electromyography of the lower extremity in
CHAPTER 6 Pelvic Floor Muscles Bulbospongiosus, Ischiocavernosus, Transversus Perinei, Sphincter Ani, Levator Ani, Coccygeus, and Obturator Internus \"Pain in the Rear\" HIGHLIGHTS: The levator ani and coccygeus body and the last two segments of the coccyx. muscles afford a unique opportunity to palpate The coccygeus muscle usually covers the inner directly with minimal intervening tissue the taut surface of the sacrospinous ligament. Together, band and tender attachment phenomena asso- these two muscles span the space between the ciated with trigger points (TrPs). REFERRED spine of the ischium laterally and the coccyx and PAIN from TrPs in the bulbospongiosus and is- sacrum medially. The obturator internus covers, chiocavernosus muscles usually projects to the and is attached to, the anterolateral wall of the perineum and adjacent urogenital structures. pelvis including the obturator foramen. It exits Sphincter ani TrPs induce pain in the posterior the pelvis through the lesser sciatic foramen to pelvic floor. The levator ani and coccygeus mus- end on the greater trochanter of the femur. IN- cles refer pain and tenderness to the sacrococ- NERVATION of these muscles is supplied by cygeal region. The levator ani may also refer spinal nerves from L5 to S5. The FUNCTION of pain to the vagina. The TrPs of the obturator in- the anal sphincter is to serve as gate keeper of ternus cause pain in the anococcygeal region the rectum. The bulbospongiosus in the female and in the vagina, with a spillover pattern to constricts the vagina. Both the bulbospongiosus the thigh posteriorly. ANATOMICAL ATTACH- and ischiocavernosus muscles enhance tumes- MENTS of the bulbospongiosus muscle in the cence of the penis in the male and of the clitoris male are to the perineal body, below, and to the in the female. The levator ani supports the pelvic corpus spongiosus and corpus cavernosus, floor and assists the anal and urethral sphinc- which they enclose, above. In the female, this ters. It helps to constrict the vagina in the fe- muscle also attaches to the perineal body and male. The coccygeus flexes the coccyx inward then surrounds the vagina on its way to the cor- toward the pelvis and exerts rotatory tension on pora cavernosa clitoridis. The ischiocavernosus the sacroiliac joint. The obturator internus later- muscle anchors laterally to the ischial tuberosity ally rotates the extended thigh and abducts the in both men and women. Medially in the male, it thigh when it is in 90° of flexion. SYMPTOMS of blends with the crura of the penis and in the fe- patients with myofascial TrPs in one or several male with the crus clitoridis. The more anterior of these pelvic muscles are remarkably similar and medial pubococcygeus muscle of the leva- to the symptoms of many patients categorized tor ani forms a sling around the rectum and uro- by other authors as having coccygodynia, leva- genital structures; it anchors in front to the pubis tor ani syndrome, proctalgia fugax, and tension and behind to the anococcygeal and perineal myalgia of the pelvic floor. PATIENT EXAMINA- bodies. The deeper iliococcygeus muscle of the TION, when low back or pelvic floor pain sug- levator ani forms a hammock across the pelvic gests the possibility of intrapelvic TrPs, should floor and is anchored laterally to the tendinous include examination of the coccyx for tender- arch of the levator ani muscle along the wall of ness and mobility. The thigh should be tested for the pelvis and centrally to the anococcygeal restriction of medial rotation caused by obturator 110
Chapter 6 / Pelvic Floor Muscles 111 internus TrP tension. TRIGGER POINT EXAMI- isometric relaxation, high voltage pulsed gal- NATION of all of these intrapelvic muscles re- vanic stimulation, ultrasound, and correction of quires either a rectal or vaginal approach. Some seated posture. INJECTION of TrPs in the peri- muscles are more effectively examined by one neal muscles employs surface techniques, but of these routes, other muscles by the other. The injection of myofascial TrPs of other muscles examiner identifies each muscle by locating ap- within the pelvis requires a bimanual approach. propriate bony and ligamentous landmarks and CORRECTIVE ACTIONS include consideration carefully relates the direction of palpation to the of mechanical and systemic perpetuating fac- direction of the muscle fibers. The INTERMIT- tors, seated posture, dysfunction of pelvic articu- TENT COLD WITH STRETCH procedure is not lations, internal hemorrhoids, and chronic pelvic applicable to these muscles, but other methods inflammatory conditions. of treatment include massage, stretch, post- 1. REFERRED PAIN the ipsilateral thigh.56 This additional thigh (Fig. 6.1) pain can be caused also by piriformis mus- cle involvement (see Fig. 10.1), so that Trigger points (TrPs) in muscles of the muscle too should be examined for TrPs. posterior half of the pelvic floor, including the sphincter ani, superficial transverse 2. ANATOMICAL ATTACHMENTS AND perinei, levator ani, and coccygeus mus- CONSIDERATIONS cles refer poorly localized pain. Patients (Figs. 6.2 and 6.3) are often uncertain whether to call it tail- bone, hip, or back pain.77 The pain centers As the previous descriptions of referred in the region of the coccyx but often in- pain show, knowing only the patient's re- cludes the anal area and the lower part of ferred pain pattern in the pelvic region is the sacrum (Fig. 6.1A). Both the levator ani not sufficient to identify which muscle and coccygeus muscles typically refer harbors TrPs that are responsible for the pain to the region of the coccyx.88 This re- pain. Therefore, a thorough knowledge of ferred pain pattern is often called coc- the anatomy of the muscles and their rela- cygodynia, although the coccyx itself is tionships is essential if one is to identify usually normal and not tender.33,62,94,95 by palpation which muscle is responsi- Since the levator ani is the muscle most ble. This knowledge is valuable also for commonly involved, pain in the region of massaging TrPs in these muscles, and the coccyx is also called the levator ani critically important if one wishes to inject syndrome.62 the TrPs to inactivate them. The TrPs in the anterior half of the pel- This section first presents the major in- vic floor muscles, the ischiocavernosus trapelvic muscles in the sequence of the and bulbospongiosus, are likely to refer physical examination. Then, it reviews pain to genital structures, the vagina and the less commonly involved superficial the base of the penis beneath the scrotum. perineal muscles, and, lastly, considers Vaginal pain can also arise from TrPs in variable, but occasionally clinically im- the levator ani and has been reproduced portant, intrapelvic muscles. by pressure on the tender sites in that muscle.94 Sphincter Ani Muscles (Fig. 6.2) In addition, Goldstein found that injec- tion of obturator internus TrPs relieved The sphincter ani internus and externus pain in the vagina.45 Obturator internus consist, in all, of four concentric layers or TrPs also refer pain to the anococcygeal re- rings of muscle. The innermost ring, the gion and may have a spillover pattern to sphincter ani internus, comprises autonom- the upper portion of the posterior thigh ically innervated involuntary muscle fibers (Fig. 6 1 B ) . 8 8 of the anal wall.39 The remaining three lay- ers are the deep, superficial, and subcuta- The obturator internus syndrome causes neous laminae of the sphincter ani ex- pain and a feeling of fullness in the rectum ternus. The external sphincter is under vol- and some pain referred down the back of
112 Part 1 / Lower Torso Pain Sphincter ani, levator ani, and coccygeus (view from below) Obturator internus (oblique front view) Figure 6 . 1 . Referred pain patterns (solid red and muscles and B, in the right obturator internus muscle. red stippling) generated by trigger points (Xs), A, in Pain referred from this muscle sometimes spills over the right sphincter ani, levator ani, and coccygeus to include the posterior proximal region of the thigh. untary control. This sphincter is elliptical cles (Fig. 6.2). The deep layer of the exter- in shape, extending three or four times as nal sphincter ani is closely associated with far anteroposteriorly as it does laterally, the slinglike puborectalis portion of the le- and surrounds the last 2 cm of the anal ca- vator ani, which is the most posterior, lat- nal. The superficial (middle) lamina of the eral, and deepest section of the pubococ- external sphincter ani contains the bulk of cygeal part of the levator ani (Fig. 6.2).73 the muscle. This superficial lamina is anchored posteriorly to the tendinous Levator Ani Muscle anococcygeal body and anteriorly to the (Fig. 6.3) tendinous perineal body—where it is joined by the levator ani, bulbospongiosus, The paired levator ani muscles meet in and transversus perinei superficialis mus- the midline to form a muscular sheet, the pelvic diaphragm, across most of the floor
Chapter 6 / Pelvic Floor Muscles 113 Right Left Anterior superior Urethra Pubis Ischiocavernosus iliac spine Bulbospongiosus Vagina Ilium Acetabulum (hip socket) Perineal body Transversus perinei Tuberosity of ischium profundus Obturator fascia Coccygeal fascia Inferior layer Sacrotuberous of urogenital ligament diaphragm (cut) Transversus perinei Levator ani, pubic part superficialis (pubococcygeus) Sphincter ani externus Anus Levator ani, iliac part Anococcygeal body (iliococcygeus) Coccygeus (ischiococcygeus) Figure 6.2. Pelvic floor muscles as seen from below the deep fascia of the urogenital diaphragm has been in the supine female subject. The muscles of the pelvic cut and removed to reveal the transversus perinei diaphragm are dark red and the associated pelvic profundus muscle. muscles are light red. On the subject's left side, part of of the lesser pelvis. This diaphragm is around the rectum. The closest that any of perforated by the urogenital hiatus and the pubococcygeus fibers come to the coc- the anal hiatus (Fig. 6.3). The levator ani cyx is usually their attachment to the is composed of two distinct muscles: the anococcygeal body.26 more anterior (lower in the pelvis) pubococcygeus and the more posterior Tichy97 illustrates well how embryolog- (higher in the pelvis) iliococcygeus. ically the levator ani develops as a series of telescoping rings and slings. The pubococcygeus muscle attaches along the dorsal surface of the pubic bone The posterior section of the levator ani, from the symphysis to the obturator canal the iliococcygeus muscle, anchors above (Fig. 6.3). It forms a sling around the to the tendinous arch of the levator ani anus, prostate gland or vagina, and the muscle and to the spine of the ischium. urethra. The two halves of the pubococ- The tendinous arch of the levator ani cygeus meet in the midline, some at the anchors to the spine of the ischium poste- perineal body, and most at the anococ- riorly and attaches anteriorly either to the cygeal body26 (Figs. 6.2 and 6.3). anterior margin of the obturator mem- brane or to the pubic bone just medial The most anterior (medial) fibers of the (farther anterior) to the margin of the pubococcygeus that meet bilaterally at the membrane. This tendinous arch is firmly perineal body in front of the anus are attached to the fascia covering the obtura- called the levator prostatae in the male. In tor internus muscle.27 As seen from inside the female, these anterior fibers are called the pelvis, the levator ani covers the the pubovaginalis muscle and serve as an lower one-half to two-thirds of the obtura- important sphincter of the vagina. The tor internus muscle and essentially all of more posterior fibers of the pubococ- the obturator foramen. cygeus (the puborectalis part) form a sling
114 Part 1 / Lower Torso Pain Greater Sacrum Sacrotuberous ligament sciatic foramen Left iliac crest Ischial spine Location of Right anterior lesser superior iliac sciatic foramen spine Sacrospinous Obturator internus ligament Coccygeus Tendinous arch of the muscle levator ani muscle Sacrococcygeal Obturator canal joint Iliococcygeal part of levator ani muscle Pubis Urogenital Anal hiatus hiatus Pubococcygeal part of levator ani muscle Figure 6.3. Pelvic floor muscles palpable on the right looking down inside the pelvis. The levator ani muscle side of the pelvis by intrapelvic examination with the is dark red. The coccygeus muscle is medium red and patient lying on the right side. The muscles are seen the obturator internus muscle is light red. obliquely from above and diagonally from the left side Below, the iliococcygeus attaches to the the levator ani. The two muscles often anococcygeal body and to the last two form a continuous plane (Fig. 6.3). The segments of the coccyx.2 coccygeus muscle covers (internally) the sturdy sacrospinous ligament (Fig. 6.3). The adjacent margins of the pubococ- Laterally the apex of this triangular mus- cygeus and iliococcygeus muscles may be cle is anchored to the spine of the is- separated or may overlap. The iliococ- chium and to fibers of the sacrospinous cygeus may be replaced by fibrous tissue. ligament. Medially it fans out to end on Its upper border lies adjacent to the the margin of the coccyx and on the side sacrospinous ligament and the overlying of the lowest piece of the sacrum.26 coccygeus muscle (Fig. 6.3).26 Coccygeus Muscle Obturator Internus Muscle (Fig. 6.3) The anatomy of the part of the obturator The coccygeus muscle, sometimes called internus that lies outside of the pelvis and the ischiococcygeus, lies cephalad and attaches to the greater trochanter of the fe- adjacent to the iliococcygeus muscle of mur is considered in Chapter 10 of this
Chapter 6 / Pelvic Floor Muscles 115 volume. Here we are concerned with the superficialis muscles on each side of the intrapelvic portion that covers the antero- body form a triangle (Fig. 6.2). The medial lateral wall of the lesser pelvis, where it leg of the triangle, the bulbospongiosus surrounds and covers the greater part of (also known as the bulbocavernosus or the obturator foramen (Fig. 6.3). The obtu- the sphincter vaginae), surrounds the ori- rator internus is fan shaped and the direc- fice of the vagina. The muscle attaches tion of its fibers spans an arc of roughly anteriorly to the corpora cavernosa clito- 135°. Its muscle fibers form an anterior ridis with a muscular fasciculus that also and posterior mass, one in front of and the crosses over the body of the clitoris and other behind the obturator canal. That ca- compresses its deep dorsal vein. Posteri- nal allows nerves and vessels to penetrate orly the bulbospongiosus anchors to the the obturator membrane along the anterior perineal body where it blends with the margin of the obturator foramen, on the external anal sphincter and the transver- side opposite to the lesser sciatic foramen. sus perinei superficialis (Fig 6.2).28 Inside the pelvis, the obturator internus The ischiocavernosus of the female muscle attaches to the inner pelvic brim, to (formerly called the erector clitoridis) the margin of the obturator foramen, and to forms the lateral side of the triangle (Fig. much of the obturator membrane stretched 6.2). The muscle is located along the lat- across that bony foramen. The fibers of the eral boundary of the perineum next to the muscle converge toward the lesser sciatic bony ridge of the anterior pubic ramus, foramen and end in four or five tendinous extending between the symphysis pubis bands. As the muscle exits the pelvis and the ischial tuberosity. Above and an- through the lesser sciatic foramen, it makes teriorly the ischiocavernosus ends in an a right angle bend around the grooved sur- aponeurosis that blends with the sides face between the spine and tuberosity of and undersurface of the crus clitoridis. the ischium. This bony pulley is covered Below and posteriorly it is anchored to with cartilage; the passage of the tendon is the surface of the cms clitoridis and to also assisted by the ischiadic bursa of the the ischial tuberosity.28 obturator internus.10 As the tendon crosses the capsule of the hip joint, it is cushioned The transversus perinei superficialis by the subtendinous bursa of the obturator muscle forms the base of the triangle. The internus (see also Chapter 10, Section 2 ) . 3 2 two muscles together span the perineum The exit of the obturator internus from the laterally between the ischial tuberosities, pelvis through the lesser sciatic foramen is joining the sphincter ani and bulbo- marked by palpable ligaments that form spongiosi in the midline at the perineal two borders of that foramen: the sacro- body (Fig. 6.2). The transversus perinei tuberous ligament posteriorly and the profundus lies deep to the superficialis; it sacrospinous ligament above.25 Since the is a broader muscle that courses between fibers of the two ligaments intermingle as the ischial tuberosity and the vagina (Fig. they cross at the upper end of the fora- 6.2).28 men,25 the foramen is a tightly enclosed space that leaves no room for expansion of Male Anatomy the muscle. The structures forming the lesser sciatic foramen are illustrated in Fig- In the male, the bulbospongiosus is more ure 10.5. That figure serves as a valuable complex than in the female and essen- reference throughout this chapter because tially wraps around the corpus spongi- it clarifies relations of intrapelvic muscles osum of the penis, which is the central and ligaments. erectile structure through which the ure- thra passes. As illustrated,4,29, 39 the two Bulbospongiosus, Ischiocavernosus, symmetrical parts of this muscle begin and Transversus Perinei Muscles below at the perineal body and along the median raphe. The fibers extend outward Female Anatomy and upward in a pennate fashion to en- close the bulk of the corpus spongiosum In the female, the bulbospongiosus, is- penis posteriorly and the corpus caverno- chiocavernosus, and transversus perinei sum penis anteriorly. Above, some of the fibers end in a tendinous expansion that
116 Part 1 / Lower Torso Pain covers the dorsal blood vessels of the pe- divisions: the pubococcygeus, iliococcygeus, and nis.28 After 5 months of fetal gestation, the (ischio)coccygeus. The levator ani is presented this muscle wraps around the bulb of the in cross section,21 in sagittal section,1 and in fron- penis.73 tal section.27, 3 8 , 8 3 Its bony attachments are de- picted.44 The ischiocavernosus muscle in the male is similar to that in the female, but is Coccygeus Muscle usually larger. On each side, the muscle attaches posteriorly to the ischial tuberos- Midline sagittal sections provide a medial view of ity and angles across the perineum anteri- the coccygeus muscle from inside the pel- orly toward the penis. After coursing lat- vis.7,43,66,68 It is shown in cross section22 and its eral to the bulbospongiosus, it ends in an bony attachments are marked.44, 65 aponeurosis that blends with the sides and undersurface of the crura as they be- The sacrospinous ligament, which is useful for come the body of the penis.4,28,39 orientation when palpating muscles deep within the pelvis, is described and illustrated.8,25 The transversus perinei profundus at- taches laterally to the ischial tuberosity Obturator Internus Muscle as in the female, but in the male, the mus- cles interlace in the midline at a tendi- The usual anatomical view of this muscle is a nous raphe deep to the bulbospongiosus midline sagittal section seen from inside the pel- muscle.28,29,39 vis.7,43,66,68 This view also includes the coccygeus muscle. It is presented in one cross section Sacrococcygeus Ventralis Muscle through the hip joints,11 in a cross section through the prostate and ischial tuberosities,82 in a series The sacrococcygeus ventralis (anterior) of cross sections that includes all of the muscle,18 muscle is variable and was found in 102 and in frontal sections.27, 38, 83 The bony attach- of 110 adult bodies. It often is vestigial, ments of the obturator internus muscle are identi- consisting mainly of tendinous bands fied9,44,70,72 and the ischiadic bursa of the obturator with only short muscle fibers.37 When internus is illustrated.10 well developed, it extends vertically from the sides of the fourth and fifth sacral ver- Bulbospongiosus, Ischiocavernosus, and Transversus tebrae, from the front of the first coccyg- Perinei Muscles eal vertebra, and from the sacrospinous ligament to the second to fourth coccyg- The bulbospongiosus, ischiocavernosus, and trans- eal vertebrae and to the anterior sacrococ- versus perinei superficialis muscles are presented cygeal ligament.1 3 , 3 7 , 4 3 , 8 0 schematically in relation to other layers of the per- ineum for both men and women,3 and bony at- The sacrococcygeus ventralis muscle tachments are identified.70 The three muscles are may divide into medial and lateral fiber illustrated from below without nerves or vessels bundles. When this has happened, the for m e n 4 , 2 9 , 4 1 (except for the superficial transverse lateral fibers have been identified as the perinei muscle84) and for w o m e n . 6 , 3 0 , 4 1 , 8 6 They are sacrococcygeus ventralis (depressor cau- shown from below with nerves and vessels for dae lateralis) muscle and the medial fi- men40,89 except for the superficial transverse per- bers as the infracoccygeus (depressor inei muscle.85 The ischiocavernosus is shown in caudae medialis) muscle.37 These fibers cross section for men and women19 and the bulbo- are probably phylogenetic remnants of spongiosus in cross section for a male.20 The bul- tail-wagging muscles. bospongiosus is illustrated in midline sagittal sec- tions of males.167 Supplemental References Sacrococcygeus Ventralis Muscle Sphincter Ani Muscles The vestigial sacrococcygeus ventralis muscle (an anterior remnant of tail-wagging muscles) may be The sphincter ani is depicted from below,4,5, ',29 39 in seen looking down into the pelvis in cross sec- tion,80 in sagittal section,43 and in frontal sec- cross section,23 in sagittal section,1,42,81 and in cor- tion.13,37 onal section.27,83 3. INNERVATION Levator Ani Muscle The external anal sphincter is innervated by a branch of the fourth sacral nerve and The levator ani is shown schematically by layers by twigs from the inferior rectal branch of the pudendal nerve. The internal sphinc- in relation to other perineal muscles for both men and women.3 It is illustrated from below5, 29,39 and from above,2 where it is presented as having three
Chapter 6 / Pelvic Floor Muscles 117 ter is innervated by fibers of the auto- floor, resisting increased intra-abdominal nomic nervous system.31 pressure.26 In the male, the more anterior (medial) pubococcygeal portion, some- The obturator internus muscle is sup- times called the levator prostatae muscle, plied by its own nerve, which carries fi- forms a sling around the prostate and spe- bers from the L 5 , S1, and S2 segments.32 cifically applies upward pressure on it. The corresponding fibers in the female, The levator ani muscle is innervated by also known as the pubovaginal muscle, fibers of the S4 segment and sometimes of constrict the vaginal orifice. The more the S3 or S5 segments via the pudendal posterior puborectalis fibers of the pubo- plexus.26 Stimulation of the S3 ventral coccygeus form a sling around the anus root produced nearly 70% of closure pres- that is structurally continuous with the sure by the external sphincter urethrae sphincter ani and constricts the anus and the remaining 30% was provided by when contracted.34 Strong contraction of stimulating the S2 and S4 spinal nerve this part of the levator ani can help to roots.50 eject a bolus of feces. Contraction of the more anterior periurethral fibers helps The coccygeus muscle derives its inner- empty the urethra at the end of urination vation from fibers of the S4 and S5 seg- and is thought to prevent incontinence ments via the pudendal plexus.26 during coughing or sneezing. All of the perineal muscles (including Histological comparison of the perianal and the bulbospongiosus, the ischiocaverno- periurethral regions of the pubococcygeus muscle sus, and both the superficial and deep revealed that, although most fibers were type 1 transverse perinei) are innervated by the (oxidative metabolism) fibers, in the periurethral second, third, and fourth sacral nerves via region, only 4% were type 2 (glycolytic) fibers, the perineal branch of the pudendal while in the perianal region, 23% were type 2 fi- nerve.28 bers. This higher percentage of type 2 fibers in the perianal region suggests that it is used for occa- Fibers from the S4 and S5 segments usu- sional forceful contractions, as compared to more ally innervate the sacrococcygeus ven- sustained contractions in the periurethral re- tralis muscle.37 gion.34 A later study by this same group46 reported only type 1 fibers in the external (voluntary) 4. FUNCTION sphincter urethrae muscle. The only references found that concerned In a more recent study,53 a greater proportion of electromyographic (EMG) studies applied type 1 (slow-twitch) fibers was associated with to the more superficial pelvic floor mus- improved support of the pelvic viscera, especially cles and the sphincters. Understandably, under conditions contributing to increased intra- no references to motor electrical stimula- abdominal pressure. A greater proportion of type tion experiments were located. 2 (fast-twitch) fibers improved the periurethral continence mechanism, providing increased ure- Sphincter Ani thral closure during mechanical pressure stress. Clinical experience shows and EMG stud- In an EMG study of 24 normal women, about ies15 confirm that the sphincter ani is in a half of whom had delivered babies, none was able state of constant tonic contraction, which to relax the pubococcygeal part of the levator ani is increased by straining, speaking, muscle in the lithotomy position, whereas some coughing, laughing, or weight-lifting. The were able to relax the sphincter urethrae com- tonic contraction falls to a very low level pletely.16 during sleep and is strongly inhibited during defecation. It is strongly recruited Coccygeus Muscle by voluntary effort, which is accompa- nied by general contraction of the peri- neal muscles, especially the sphincter urethrae.15,16 Levator Ani Muscle Anatomically, the coccygeus muscle pulls the coccyx forward and is said to In general, both the pubococcygeus and support the pelvic floor against intra-ab- iliococcygeus muscles of the levator ani dominal pressure.26 It also stabilizes the support and slightly elevate the pelvic sacroiliac joint64 and has powerful lever-
118 Part 1 / Lower Torso Pain age for rotating that joint. Therefore, ab- the midline between the anus and genita- normal tension of the coccygeus muscle lia and to support the pelvic floor. In both could easily hold the sacroiliac joint in a men and women, all of these perineal displaced position. muscles are generally contracted as a unit. EMG studies indicate that selective Obturator Internus Muscle contraction of individual perineal mus- cles is difficult, if not impossible.15,16 The obturator internus is a lower-limb muscle that serves no motor function in 5. FUNCTIONAL (MYOTATIC) UNIT the pelvis. As noted in Chapter 10 of this volume, the obturator internus is most The pelvic floor muscles, especially the strongly a lateral rotator of the thigh when anal and urethral sphincters and the le- the thigh is extended; the muscle be- vator ani, function closely together. Con- comes increasingly an abductor at the hip tractions of the genital bulbospongio- as the thigh is flexed.32 sus and ischiocavernosus muscles are scarcely, if at all, voluntarily separable Bulbospongiosus, Ischiocavernosus, from sphincter activation. and Transversus Perinei Muscles The iliococcygeus and upper pubococ- Contraction of the bulbospongiosus in the cygeus muscles of the levator ani are male serves to empty the urethra at the strong flexors of the coccyx. The equally end of urination.28 Erection of the penis is powerful antagonist to this movement is primarily a vascular response under auto- the gluteus maximus; it attaches to the nomic control,12,75 but the anterior and dorsolateral surface of the coccyx65 with middle fibers of the bulbospongiosus and fibers that are directed laterally and form the ischiocavernous muscles contribute the gluteal cleft. Working together, the le- to erection by reflex and voluntary con- vator ani and gluteus maximus provide traction that compresses the erectile tis- more powerful elevation (closure) of the sue of the bulb of the penis and also its anus than the levator ani could provide dorsal vein.17, 28, 51 In the female, contrac- alone. When maximum voluntary effort is tion of this voluntary muscle constricts required to close the anal aperture, the the orifice of the vagina and contributes gluteus maximus is powerfully recruited. to erection of the clitoris by compression of its deep dorsal vein.28 The obturator internus muscle func- tions in concert with other lateral rotators In the male, contraction of the ischio- of the thigh, as described in Chapter 10 of cavernosus serves to maintain and en- this volume. hance penile erection by retarding the re- turn of blood through the cms penis. Dur- 6. SYMPTOMS ing erection, intracavernous pressure correlated strongly with the duration of Patients with TrPs in the sphincter ani voluntary EMG activity in the ischio- muscle complain primarily of poorly lo- cavernosus muscle.54 Change of pressure calized aching pain in the anal region and on the glans reflexly activates the ischio- may experience painful bowel move- cavernosus muscle. This substantiates the ments. clinical impression that pressure stimula- tion of the glans penis during coitus con- In women, TrPs in the bulbospongiosus tributes to the erectile process.55 muscle cause dyspareunia, particularly during entry, and aching pain in the peri- In the female, the ischiocavernosus acts neal region. In men, these TrPs cause pain similarly to maintain erection of the clito- in the retroscrotal region, discomfort ris by retarding return flow from the cms when sitting erect, and sometimes a de- clitoridis.28 gree of impotence. The two pairs of transverse perinei Ischiocavernosus TrPs likewise cause form a muscular sling that cradles the perineal pain but are less likely to inter- perineal body between the two ischial tu- fere with intercourse. berosities. Bilateral contraction of the su- perficial and deep transversus perinei Involvement of the obturator internus muscles serves to fix the perineal body in can cause pain and a feeling of fullness in the rectum, with occasional extension of pain down the back of the thigh.56 This
Chapter 6 / Pelvic Floor Muscles 119 muscle may also refer pain into the va- elsewhere that refer pain or tenderness to the coccygeal region. One such condition gina.53 is a myofascial pain syndrome. The levator ani muscle is the most Authors have associated pain in the re- widely recognized source of referred pain gion of a non-tender coccyx (dorsal sur- face) with abnormal tension and marked in the perineal region. Its referred pain tenderness of the levator ani,59,77,87,94 coc- cygeus,64,77,94 and gluteus maximus mus- may be described as pain in the sacrum,62 cles.59 Pace77 and Long63 explicitly recog- nized that coccygeal pain is referred from c o c c y x , r e c t u m ,6 2 , 7 7 , 9 4 , 9 5 62, 71, 87 pelvic floor myofascial TrPs in the pelvic muscles. or perirectal area,62,71 vagina,95 or low Levator Ani Syndromes back.77 Referred pain from this muscle Several of the conditions causing pelvic pain are specifically identified with the makes sitting uncomfortable.71,77, 87 The levator ani muscle: levator spasm syn- drome,91 levator ani spasm syndrome,62,103 pain may be aggravated by lying on the levator syndrome,47, 87 and pelvic floor syn- dromes.63 back,94 and by defecation.87 For example, the levator ani spasm syn- Myofascial TrPs in the coccygeus mus- drome62 causes pain in the sacrum, coc- cyx, rectum, and pelvic diaphragm. It is cle were identified as the cause of pain diagnosed by finding on rectal examina- similar to that ascribed to TrPs in the le- tion \"spastic,\" tender muscles in the pel- vic floor (puborectalis, iliococcygeus, and vator ani, and referred to the coccyx, hip, coccygeus). The piriformis muscle is not included in this group; it refers pain in or back. This pain also limited sitting.77 the buttock and down the thigh.33,62,63, 9 1 , 9 5 TrPs in this muscle are likely to cause This levator ani syndrome62 was identi- fied in 31 patients on a Physical Medicine myofascial backache late in pregnancy Service. As in other studies, most of the patients with this syndrome were women and early in labor. Tenderness and (90%). The pain was located in the sa- crum (100% of patients), pelvic dia- \"spasm\" (tension) of the coccygeus mus- phragm (90%), anal region (68%), and in the gluteal region (only 13%). The levator cle were usually the key factors responsi- ani was tender and \"spastic;\" these signs were bilateral in 55%. All patients expe- ble for low back pain suffered by 1350 rienced sharp pain in the sacral area last- ing 5-10 minutes after digital examina- women seen for infertility.64 tion. Of the women who attempted inter- course during the illness, 43% suffered Differential Diagnosis dyspareunia. Forty percent of all patients reported disturbed bowel function (con- The following deals with causes of coc- stipation or frequency) but none ex- cygodynia and intrapelvic pain that are perienced painful bowel movements. not explained by the findings obtained Twenty percent complained of pain when with the usual examination and diagnos- sitting. Only 10% of the patients failed to tic procedures. respond to massage therapy of the levator ani muscle and 74% became symptom- The muscle outside the pelvis most free or had only very slight residual likely to refer pain within the pelvis is the symptoms. adductor magnus (Chapter 15, Fig. 15.2). Patients with pelvic floor syndromes63 Numerous authors have used a variety experienced pain referred in various com- of names to describe what would appear, binations to the buttock, underneath the on thoughtful consideration, to be largely myofascial pain syndromes of the pelvic musculature: tender coccyx,57 coccygo- dynia,33,35,77,94,95,100 coccygeal spasm,64 le- vator syndrome,47,74,76,87,92 levator ani syn- drome,71 levator spasm syndrome,91 leva- tor ani spasm syndrome,62 1 0 3 tension myalgia of the pelvic floor,89 pelvic floor syndromes,63 pelvic pain syndrome,90 proctalgia fugax,36,49,79,93,96 1 0 1 and obturator internus spasm.56 Coccygodynia Although the dictionary definition of coc- cygodynia is \"pain in the coccygeal re- gion,\"14 several authors57,59, 77 draw a sharp distinction between what they consider \"true\" coccygodynia resulting from trau- matic injury to the coccyx and conditions
120 Part 1 / Lower Torso Pain sacrum, in the hip laterally, and the thigh TrPs stimulated by tension may exist in posteriorly, from the piriformis, coc- smooth muscle, interstitial connective tis- cygeus, or levator ani muscles. The pa- sue, or the lining of the bowel wall. It is tients complained of pain when seated on also possible that increased intraluminal hard surfaces and when sitting down on pressure aggravates TrPs located in the or standing up from a chair. Digital exam- bowel mucosa when there is something ination of an involved muscle revealed within the gut that can press against trigger areas with local soreness and a them. This may be an example of intesti- tight, fibrous, nodular feel of the involved nal TrPs that are amenable to experimen- muscle. tal study. Proctalgia Fugax In the other study, Douthwaite36 re- ported 10 physicians who examined Proctalgia fugax is defined as \"painful themselves during attacks of proctalgia spasm of the muscle about the anus with- fugax. None detected spasm of the anal out known cause.\"14 It is characterized by sphincter. They did palpate a tense, ten- paroxysms of anorectal pain in the ab- der band on one or the other side of the sence of identifiable local lesions.79 It is rectum, which they located in the levator not a rare condition; 13-19% of appar- ani. These findings are consistent with ently healthy persons surveyed have TrPs in the levator ani. symptoms of proctalgia fugax, although most experience fewer than seven epi- A few patients experience attacks of sodes per year.79 The pain usually occurs proctalgia following coitus. Peery79 postu- irregularly in bouts that generally show lates that the pain derives from exagger- no correlation to activity or to the condi- ated or prolonged contraction of the rectal tion of the patient.79 Proctalgia can begin sphincter after orgasm. This pain might as early as 13 years of age.101 A physician also derive from TrPs in the sphincter with this condition wrote an eloquent ani, bulbospongiosus, or ischiocaverno- description of it.93 sus muscles. As we have learned more about most Oral clonidine was helpful93 and in- \"idiopathic\" diseases, they have turned haled salbutamol has also been recom- out to represent a number of conditions mended.102 lumped together under one rubric. Proc- talgia fugax appears to be no exception. Tension Myalgia Of The Pelvic Floor The levator ani syndromes, noted previ- ously, and coccygodynia, as described by Sinaki and associates89 consolidated the Thiele,94,95 bear a remarkable resemblance various syndromes of the pelvic muscula- to proctalgia fugax. ture (piriformis syndrome, coccygodynia, levator ani spasm syndrome, and proctal- Two studies found evidence of specific gia fugax) under one umbrella, tension causes for proctalgia fugax. One study49 myalgia of the pelvic floor. They saw the reported pressures in the rectum and sig- patients in the Department of Physical moid colon measured by inserting instru- Medicine and Rehabilitation at the Mayo mented balloons while two patients were Clinic. Nearly all of the 94 patients were experiencing recurrent pain. The small between 30 and 70 years of age; most changes in pressure observed in the rec- were between 40 and 50 years. Women tum did not correlate with the episodes of constituted 83% of the group, which is pain, but the intermittent peaks of pres- about the usual percentage of women pa- sure observed in the sigmoid colon did. tients with a levator ani syndrome.91 Pain The greater the pressure peaks, the more in the coccygeal area and a heavy feeling likely the subject was to identify pain, in the rectal or vaginal region were the which began a short time before a peak. most prominent symptoms occurring in This study strongly suggested that the 82% and 62%, respectively. Defecation pain resulted from muscular contraction caused pain in 33%. All patients had ten- of the wall of the sigmoid colon, not from derness of the pelvic floor muscles on rec- pressure within the lumen. tal examination. This examination elic- ited localized tenderness of the piri- formis, coccygeus, levator ani muscles,
Chapter 6 / Pelvic Floor Muscles 121 sacrococcygeal ligaments, and of muscu- joint.57 Lewit59 found that only one-fifth lar attachments to the sacrum and coccyx, of the patients who had tenderness on or some combination of these. It is likely palpation of the ventral surface of the coc- that many of these patients had myofas- cyx complained of coccygeal pain. The cial TrPs in the tender muscles, but no majority suffered primarily from low back mention was made of the presence or ab- pain. sence of taut bands or referral of pain when pressure was applied to a tender Upslip, or innominate shear dysfunc- spot. tion,48 (upward displacement of an in- nominate bone in relation to the sacrum) Integumentary Trigger Points is an important source of low back and groin pain. Among 63 patients in a pri- Although TrPs in the scar tissue pro- vate orthopaedic medicine practice who duced by a surgical incision are well were examined because of pain and known,\" those occurring in the vaginal found to have an innominate upslip dys- cuff following hysterectomy apparently function, the most common site of the are particularly troublesome.90 These chief pain complaint was the low back TrPs are usually associated with addi- and groin (50%).52 tional TrPs in the vaginal wall. Vaginal wall TrPs were reported as referring The pain characteristic of dysfunc- pain to the lower abdomen and uterine tional low lumbar facet joints is discussed paracervical area. The pain was usually and illustrated in Chapter 3, page 26 and described by the patient in terms of a may be similar to the pain referred from familiar condition, such as \"ovarian intrapelvic muscles. pain,\" \"menstrual cramps,\" or \"bladder spasms.\" Pressure applied to these TrPs 7. ACTIVATION AND PERPETUATION reproduced the presenting symptom.90 OF TRIGGER POINTS Vaginal wall TrPs may be analogous to cutaneous TrPs or to colon TrPs (consid- TrPs in these pelvic floor muscles are ered previously in this section under sometimes activated by a severe fall, an Proctalgia Fugax). automobile accident, or by surgery in the pelvic region. Often, the patients cannot Non-myofascial TrPs in subcutaneous identify a specific initiating event. In only adipose tissue have been described.57 Dit- one-fifth of the patients with low back trich35 identified TrPs in the fat pads pain and a tender coccyx ventrally was an overlying the sacrum that referred pain to injury identified as the cause of the the coccygeal region (coccygodynia). Pace pain.59 and Henning78 described episacral \"li- pomas\" that were identifiable as tender, Levator ani TrPs are certainly perpetu- palpable nodules; they referred pain ated, and perhaps activated, by sitting in down the lateral aspect of the thigh. a slumped posture for prolonged periods Slocumb90 reported that TrPs in the tis- of time. Thiele95 demonstrated radio- sues over the sacrum responded to injec- graphically the acute angulation of the tion therapy, especially if pressure on coccygeal joints caused by sitting on a them reproduced the same pain caused hard surface in a slumped posture. Ap- by stimulation of abdominal wall and parently the compressed gluteus max- vaginal TrPs. imus muscle transmits the pressure to the coccyx. Thiele attributed coccygodynia to Articular Dysfunction this posture in 32% of 324 patients. Cooper33 considered prolonged sitting in Muscle spasm and tenderness secondary a slouched position watching television to articular dysfunction at the sacroiliac as the factor responsible for coccygodynia joint are likely to be associated with coc- in 14% of 100 patients. Lilius and cygeal and low back pain. Conversely, Valtonen62 regarded this posture as an im- tension of the muscles attached to the portant cause of levator ani spasm syn- coccyx can destabilize the sacroiliac drome. joint.84 Ventral coccygeal tenderness is of- ten associated with a blocked sacroiliac In those patients with no known initiat- ing event, possible causes for the muscle hyperirritability and TrPs are nutritional
122 Part 1 / Lower Torso Pain inadequacies and/or other systemic per- Lewit57,59 emphasizes how frequently petuating factors (Chapter 4, Volume l ) . 9 8 patients who complain of low back pain have marked tenderness inside the tip of Articular dysfunctions of the sacroiliac the coccyx. In such cases, the coccyx is joints,57 sacrococcygeal articulation, and kyphotic (pulled in toward the pelvis) but the lumbosacral junction may be potent is not tender to pressure on its dorsal sur- aggravating sources of TrPs in these pel- face and movement at the sacrococcygeal vic floor muscles. joint is not painful. Because of this ky- photic curvature and the hypertonus of Chronic hemorrhoids can aggravate the adjacent gluteus maximus muscles, it symptoms in the related muscles.62 is difficult for the examiner to reach be- Chronic inflammatory conditions within neath the tip of the coccyx to where the the pelvis, such as endometritis, chronic ventral surface is so tender;57 therefore, salpingo-oophoritis, chronic prostatove- this tenderness is easily overlooked. siculitis,62 and interstitial cystitis61 may However, when present, it is a strong in- evoke referred pain and tenderness of the dication for the need to determine the pelvic floor, and have been associated cause by doing an intrapelvic examina- with the levator ani spasm syndrome.82 tion, as described in the next section. However, other coexistent pelvic disease, including ovarian cysts, pelvic adhesions, It is helpful to screen for a tilted pelvis and fibroids, did not prevent a successful and for pelvic asymmetries, as described response to local injection of TrPs in the in Chapter 4 of this volume, and to screen levator ani and coccygeus muscles and in for pelvic articular dysfunctions.48 posthysterectomy vaginal cuff scars.90 8. PATIENT EXAMINATION 9. TRIGGER POINT EXAMINATION Patients with TrPs in the pelvic floor For the purpose of locating myofascial musculature are likely to walk somewhat TrPs within the pelvis, the pelvic muscles stiffly and sit down cautiously, often on can be considered in three categories: per- one buttock close to the edge of the chair ineal muscles, pelvic floor muscles, and seat.94,95 The patient shifts sitting position pelvic wall muscles. The intrapelvic mus- frequently and, after prolonged sitting, cles are examined through the rectum. the act of arising from the chair often Unfortunately, the conventional rectal ex- causes obvious pain and requires in- amination does not include the identifica- creased effort.95 tion of muscles.24 The special features of the vaginal examination are considered If the obturator internus muscle harbors subsequently. For the rectal examination, active TrPs, the stretch range of motion the patient may lie supine in the lithot- will show some restriction. The clinician omy position, or, if footrests are not avail- tests this in the supine patient by looking able, semiprone in Sims's position. It is for restricted medial rotation of the thigh best to begin examination with the hand with the hip straight. A considerably that supinates toward the symptomatic greater stretch of the obturator internus is side. If TrPs are found on that side, it is obtained by flexing the thigh 90° and then wise to examine the opposite side of the adducting it. This maneuver, however, pelvis for comparison, which is most ef- also exerts tension on the piriformis, fectively done with the other hand. It is gemelli, and obturator externus muscles. difficult and awkward to perform an ade- quate rectal examination of the muscles Normally, the sacrococcygeal joint is on both sides of the pelvis with one hand. freely movable. The coccyx normally ex- tends through an arc of about 30°, and Pelvic Floor Muscles bends laterally to bring the tip about 1 cm from the midline. Mobility is greater in The pelvic floor muscles commonly af- women than in men.95 Bilateral tension of flicted with TrPs, and the ones to become the coccygeus muscles tends to flex the well acquainted with first, are the sphinc- sacrococcygeal joint. Unilateral coccygeus ter ani, levator ani, and coccygeus mus- muscle tension pulls the coccyx toward cles. Although the levator ani and coc- one side.95 cygeus muscles cover most of the pelvic
Chapter 6 / Pelvic Floor Muscles 123 floor, the intrapelvic rectal digital exami- erwise, the anal sphincter TrPs must be nation begins with the sphincter ani. inactivated before the patient can be ex- amined for intrapelvic TrPs. Sphincter Ani Orientation Inside the Pelvis If the patient has TrPs in the anal sphinc- ter, insertion of the finger can be distress- Establishing relevant bony and ligamen- ing even when done very carefully. First, tous landmarks for reference helps greatly the clinician should examine the anal ori- in identifying the intrapelvic muscles by fice for internal hemorrhoids, which can palpation. For orientation purposes, it is perpetuate TrPs of the anal sphincter. Lu- helpful to identify the structures that bor- bricant is liberally applied to the examin- der the levator ani muscle (Figs. 6.2, 6.3, ing gloved finger and the anal orifice. Or- and 10.5).2 dinarily, as the examiner inserts the fin- ger, he or she would gently apply pressure Usually, no muscles are found in the toward one side of the anus to help relax midline on the ventral surface of the the sphincter. However, if one inadvert- coccyx and sacrum. When the patient is ently presses on TrPs in the muscle, this examined rectally, only the rectal wall aggravates the pain. In the presence of ex- lies between the examining finger and cessive sphincter tension or tenderness, these bones. In the midline below (distal instead of the clinician applying side to) the tip of the coccyx, the anococ- pressure, the patient may bear down on cygeal body (which usually is not distin- the rectum to enhance relaxation of the guishable by palpation) extends to the sphincter ani as the clinician slowly in- sphincter ani and serves as the attach- serts the examining finger directly into ment for much of the pubococcygeus the anal orifice. muscle of the levator ani. Just anterior to the rectum is an analogous structure, the By gently flexing the tip of the finger, perineal body, to which the bulbospon- the examiner can feel when it has passed giosus, transverse perinei, and sphincter the sphincters. The finger first encounters ani muscles anchor. the external and then the internal sphinc- ter ani. The finger should be withdrawn It is relatively easy to examine the to halfway along the sphincters and pres- range of motion of the coccyx. One grasps sure gently applied to the muscle at every the coccyx between the finger inside the one-eighth of a circle (positions at 12:00, rectum and the thumb outside to flex, ex- 1:30, 3:00, etc.) to find any TrP tender- tend, and bend it laterally, testing for ten- ness. When the finger locates tenderness derness at its articulations. All of the coc- in one direction, the muscle is explored cygeal joints may be mobile. The most to determine where the spot of maximum proximal joint that exhibits mobility is tenderness occurs. An associated taut usually the sacrococcygeal joint. band may be identified, if the TrP is not too tender and the patient can tolerate the A firm, tendinous edge crossing the additional pressure. If the muscle is pelvis at about the level of the sacrococ- strongly contracted, the patient can relax cygeal joint (Fig. 6.3) identifies the lower it by bearing down, making the contrast border of the sacrospinous ligament. This between the taut band and relaxed fibers border nearly always is sharply deline- more clearly evident. A taut band, when ated. It lies close to the sometimes over- present, usually extends from one-quarter lapping borders of the iliococcygeal mus- to halfway around the anus. These bands cle of the levator ani, below, and the coc- are often multiple. cygeus muscle, above. Laterally, the ligament ends at a palpable, hard, bony When an anal sphincter harbors very prominence, the spine of the ischium, to active TrPs, their tenderness may pre- which the tendinous arch of the levator clude further rectal examination of the in- ani also anchors.2 At least the posterior trapelvic muscles. The movement and half of this tendinous arch is palpable as additional pressure of the finger may be it swings around the pelvis to attach ante- intolerable. In a woman, the vaginal ex- riorly to the body of the pubis. The arch amination may then be substituted. Oth- may become indistinguishable near the anterior margin of the obturator mem-
124 Part 1 / Lower Torso Pain brane. This arch serves as the lateral at- anatomical landmarks. Pressure on leva- tachment of the iliococcygeal part of the tor ani TrPs nearly always reproduces the levator ani muscle; therefore, this part of patient's pain complaint, usually in the the levator ani lies below it. The obturator region of the coccyx. internus muscle extends above and below the arch of the levator ani. The obturator When the examiner finds tender spots internus muscle can be palpated directly that seem to be in the lateral portions of anywhere above the arch, but below the the levator ani below this muscle's tendi- arch, it can be palpated only through the nous arch, care must be exercised to be levator ani. sure that the tenderness is not due to TrPs in the underlying obturator internus. The Just caudal to the tip of the ischial two muscles can be distinguished by pal- spine, a soft spot felt through the levator pating while asking the patient to squeeze ani muscle locates the opening of the the finger in the rectum (levator ani acti- lesser sciatic foramen. vation), relax, and then abduct the flexed thigh or laterally rotate the extended Levator Ani thigh on that side against resistance (ob- turator internus activation). The increase The most medial and anterior portion of in muscle tension identifies the con- the pubococcygeus muscle loops around tracting muscle. the urogenital tract and serves to constrict the vagina in women (pubovaginal mus- Coccygeus cle) and to elevate the prostate in men (le- vator prostatae). The most posterior por- The coccygeus muscle is palpable mainly tion of the pubococcygeus (the puborec- at the level of the sacrococcygeal joint talis) loops around the rectum at the level (Fig. 6.3).2 Much of the muscle lies be- of the external anal sphincter; it elevates tween the examining finger and the un- and helps constrict the anus. Bilaterally, derlying sacrospinous ligament. In some the iliococcygeus part of the levator ani persons the muscle is intertwined with forms a sling between the ilium and coc- the ligament, the caudal border of which cyx that supports the pelvic floor and is usually distinctly palpable. Against pulls the coccyx inward. Contraction of this firm ligamentous foundation, taut the muscle can be palpated during the bands and their TrPs are usually readily rectal or vaginal examination. identified by palpation across the muscle fibers. Palpation of the levator ani starts by feeling the ends of the muscle fibers for Occasionally, a thick band of coccygeus tenderness. The examiner then moves the muscle fibers crosses the midline; here it finger across the midbelly of the muscle is readily palpable against the lowest part from the region of the perineal body to of the sacrum or uppermost region of the the middle of the sacrospinous ligament, coccyx. feeling for local tenderness and taut bands indicative of TrPs. By sweeping the The gluteus maximus attachment to the finger from side to side through an arc of outer margins of the sacrum and coccyx 180° at successively higher levels, the ex- corresponds closely to the coccygeus aminer can palpate all of the fibers of the muscle's attachment on the inner margins levator ani and of the coccygeus muscle of these bones.65 as well.95 Thiele95 illustrated this exami- nation technique. He commented on how Malbohan and associates64 found that, frequently individual fascicles stood out among 1500 patients examined for low like tight cords with areas of relaxed mus- back pain, only a small percentage did cle between them and reported that some- not experience pain during internal ex- times the entire levator ani was tense and tension pressure against the coccyx. The felt like a firm sheet of muscle stretched authors attributed this discomfort to the from its tendinous arch to the sacrum, increased tension placed on the coc- coccyx, and anococcygeal body.95 A simi- cygeus muscle. However, this maneuver lar examination of the piriformis muscle simultaneously stretches the iliococ- is illustrated in Figure 10.5 with useful cygeal portion of the levator ani, which also attaches to the coccyx. Tenderness along the margin of the coccyx suggests
Chapter 6 / Pelvic Floor Muscles 125 tenderness of either levator ani mus- termine if TrPs are likely to be present culotendinous junctions, coccygeus mus- anywhere in the muscle. Tenderness at culotendinous junctions (Fig. 6.3), or of this location is comparable to that in the a sacrococcygeus ventralis muscle13,37 region of the musculotendinous junction (when present). of the psoas major muscle just above its attachment to the lesser trochanter (see Pelvic Wall Muscles Chapter 5). One pelvic wall muscle, the obturator in- Piriformis ternus, covers the anterolateral wall of the lesser pelvis. Looking into the pelvis from See Chapter 10 in this volume for a above, one sees that much of this muscle description of the intrapelvic examina- is covered by the levator ani (see Fig. tion of the piriformis muscle. Its rectal ex- 10.5). The obturator internus exits the amination is illustrated in Figure 10.5. pelvis through the lesser sciatic foramen, which is bounded on two sides by the Sacrococcygeus Ventralis sacrospinous and sacrotuberous liga- ments. The sacrotuberous ligament at- If the sacrococcygeus ventralis (when taches to the externally identifiable is- present) has TrPs, the examiner will find chial tuberosity. The other major in- spot tenderness along the lower sacrum trapelvic muscle, the piriformis, is found or the coccyx in a taut band running par- cephalad to the sacrospinous ligament allel to the axis of the spine. The fibers of and is considered in Chapter 10 of this the levator ani and coccygeus also can volume. The sacrococcygeus ventralis cause tenderness at the edge of the coc- muscle, when present, is palpable as lon- cyx, but lie more nearly at right angles to gitudinal fibers along the margins of the the spine. Pressure on an active sacrococ- lower sacrum and coccyx. cygeus TrP is likely to reproduce the pain in the coccyx. Obturator Internus Vaginal Examination A view of the pelvis from above shows that the posterior portion of the obturator In the female, the bulbospongiosus mus- internus must be palpated through the le- cle can be satisfactorily examined for vator ani muscle2 (see Fig. 10.5). A frontal TrPs only by vaginal examination. The section through the anus27 likewise illus- patient should be placed in the lithotomy trates this and shows the relation of these position for this approach. The bulbo- muscles to the tendinous arch. A frontal spongiosus and levator vaginae portions section82 and a cross section83 through the of the levator ani muscle enclose the in- prostate depict how one must palpate the troitus. They can be located and their thick posterior part of the obturator in- strength assessed by having the patient ternus through a thin layer of the levator squeeze the examining finger. Myofascial ani muscle on either side of the prostate TrPs weaken them. These muscles are ex- (or vagina). amined for TrPs by gentle pincer palpa- tion at about the middle of each lateral When running the finger around the wall of the introitus. When present, the lateral wall of the pelvis above the tendi- taut bands are clearly delineated, are ten- nous arch of the levator ani from the is- der, and contain TrPs that, when com- chial spine to the pubis, any observed pressed, usually refer an ache to the vagi- tender spots or taut bands are in the obtu- nal and perineal regions, reproducing the rator internus. The obturator internus patient's pain complaint. muscle exits the pelvis through the lesser sciatic foramen. This point of exit lies be- The clinician examines the ischio- low (caudal to) the tip of the ischial spine cavernosus muscle by pressing directly beneath the tendinous arch. Since this is laterally from within the distal vagina an area of musculotendinous junction against the edge of the pubic arch. This where most of the obturator internus muscle and the crus clitoridis that it cov- muscle fibers are represented, it is a criti- ers are normally not tender. When com- cal point to examine for tenderness to de-
126 Part 1 / Lower Torso Pain pressed, active TrPs in this muscle refer The bulb of the penis is palpable in the pain to the perineal region. midline, between the anus and the base of the shaft of the penis, through the skin of Vaginal examination has the advantage the scrotum between the testicles. The that one can reach farther into the pelvis bulbospongiosus muscle fibers angle to examine the coccygeus and piriformis around the bulb in a pennate fashion, muscles than one can reach rectally. If the more circumferential than longitudinal. examiner places two fingers against the Taut bands and TrP tenderness are most lateral wall of the pelvis just beyond the readily detectable if the bulb is at least inside margin of the pubic arch over the partially tumescent so there is a firmer obturator membrane, the upper finger base against which to perform flat palpa- overlies the anterior portion of the obtura- tion. The ischiocavernosus muscles angle tor internus while the lower finger pal- in and upward on either side of the bulb. pates the levator ani. These muscles can be identified as described previously in The transversus perinei superficialis is the discussion of the levator ani in this not usually distinguishable by palpation section. Furthermore, one can distinguish unless it contains taut bands. The muscle the backward angulation of the anterior fibers extend from the ischial tuberosity obturator internus fibers from the trans- on each side to the fibrous perineal body verse orientation of the levator ani fibers; that lies between the anus and the bulb of this is more difficult to do by rectal exam- the penis. To feel these taut bands and lo- ination. Higher in the pelvis, the exam- calize the TrP spot tenderness, it some- iner palpates the bulky posterior portion times helps to provide counterpressure of the obturator internus muscle anterior against the external palpating finger by to the ischial spine. one finger in the rectum. The coccygeal region and coccygeus External Examination, Female muscle are more difficult to palpate from the vagina than from the rectum because In a woman, the lithotomy position with one must palpate through two layers of the feet in stirrups is likewise the most rectal mucosa and one of vaginal mucosa. satisfactory for examining the superficial An optimum localization of all the in- pelvic floor muscles. Usually, only the is- trapelvic musculoskeletal structures re- chiocavernosus and transversus perinei quires both rectal and vaginal examina- superficialis muscles are identifiable by tions. external palpation, and then only if they have taut bands and tender TrPs. The re- Perineal Muscles lationships of these muscles are clearly drawn30,41 and realistically depicted.6 The perineal muscles—the transverse perinei, bulbospongiosus, and ischioca- The ischiocavernosus muscle and its vernosus—are the most superficial and TrPs are more readily located by vaginal contribute some support to the pelvic examination. The ischiocavernosus lies floor. None of these muscles is likely to close to, and along most of the length of, be identifiable unless it has taut bands, the perineal margin of the pubic bone be- which lie parallel to the direction of the low the pubic symphysis. On vaginal ex- muscle fibers. In both sexes, the bilateral amination, taut bands become evident ischiocavernosus muscle frames the pu- when compressed by flat palpation a- bic arch that borders the perineum be- gainst the margin of the pubic bone at the neath the symphysis pubis. midvaginal level and at right angles to the direction of the muscle fibers. External Examination, Male As in the male, the transversus perinei Ideally, the patient should be placed in superficialis on each side spans the dis- the lithotomy position with the feet in tance between the perineal body centrally stirrups. If that is not practical, then he and the ischial tuberosity laterally. Palpa- can lie supine, pulling his knees up to- tion must be at right angles to the direc- ward the armpits. The testicles are lifted tion of the fibers and the muscle must be out of the way with a towel used as a under slight tension to identify taut bands sling.4,39 most effectively.
Chapter 6 / Pelvic Floor Muscles 127 10. ENTRAPMENTS trapelvic TrPs. However, other therapeu- tic techniques have been found effective No nerve entrapments by these pelvic in these muscle syndromes: massage, muscles have been demonstrated. How- stretch, postisometric relaxation, high ever, the situation at the lesser sciatic fo- voltage pulsed galvanic stimulation, ul- ramen with regard to potential entrap- trasound, and posture correction. ment of a nerve appears analogous to sci- atic nerve compression at the greater Massage sciatic foramen, as discussed in Chapter 10 of this volume. The lesser sciatic fora- Thiele95 presented the classic illustrated men has firm, unyielding boundaries: the description for the examination and treat- bony ischium on one side and heavy liga- ment by massage of the levator ani and ments, the sacrotuberous and the sacro- coccygeus muscles via the rectum. He rec- spinous, on the other sides. Since these ommended rubbing the muscle fibers two ligaments fuse as they pass one an- along their length, from origin to insertion, other,25 there is no space available for with a stripping motion (as when sharpen- pressure relief if the foramen becomes ing a straight razor), applying as much completely filled. The pudendal nerve, pressure as the patient could tolerate with the internal pudendal vessels, and the ob- moderate pain. The patient was instructed turator internus muscle with its tendon to \"bear down\" during massage to relax pass through the foramen. At this point, these muscles. The massage motion was the obturator muscle usually has become repeated 10 to 15 times on each side of the mainly tendinous, but there may be a suf- pelvis, and this treatment was repeated ficient number of muscle fibers passing daily for 5 or 6 days. Massage only once or through the foramen to compress the pu- twice a week was found to be ineffective. dendal nerve and vessels if the muscle Of the 223 patients with coccygodynia develops TrPs, shortens, and bulges. This who were treated in this way, 64% were is a possibility that deserves investigation \"cured\" and 27% improved.95 when perineal pain or dysesthesia is un- explained. Malbohan and associates also reported successful use of massage of these two 11. ASSOCIATED TRIGGER POINTS muscles in the treatment of nearly 1500 patients with low back pain attributed to Myofascial TrPs in the perineal muscles coccygeal spasm.64 Cooper33 reported that (namely, the bulbospongiosus, ischio- 81% of 62 coccygodynia patients were re- cavernosus, and transverse perinei) are lieved of pain by the Thiele type of mas- likely to present as single muscle syn- sage, but careful instruction about proper dromes. On the other hand, pelvic floor sitting posture relieved an even higher muscles (for instance, the sphincter ani, percentage of 28 other patients. Grant and levator ani, and coccygeus) are much associates47 found that two or three leva- more likely to exhibit multiple muscle in- tor ani massages spaced 2-3 weeks apart, volvement. Increased tension of the leva- in conjunction with heat and diazepam, tor ani often occurs in conjunction with provided good results in 63% of patients increased tension of the gluteus maximus with the levator syndrome. muscle.58, 60 Stripping massage is a powerful tool for The obturator internus and piriformis the inactivation of these accessible myo- are lower-limb muscles and, as such, are fascial TrPs. Massage is painful but it can prone to develop TrPs together, and in as- be effective when other modalities have sociation with other lateral rotators of the failed. One is able to identify the taut hip (i.e., the gemelli, obturator externus, bands and TrPs requiring attention and and quadratus femoris muscles). literally to put one's finger on the source of the pain, treating its source until the 12. INTERMITTENT COLD WITH problem is resolved. STRETCH Stretch Intermittent cold with stretch is not ap- plicable for the management of in- Two authors referred to treatment by stretching the levator ani muscle in terms
128 Part 1 / Lower Torso Pain of \"stretching the spastic muscles,\"62 and ation. This technique passively stretches \"retropulsion of the coccyx.\"64 Dorsal mo- the parts of the levator ani that attach to bilization of the coccyx to stretch the le- the coccyx and anococcygeal body. vator ani can be included as part of the massage procedure. High Voltage Pulsed Galvanic Stimulation Postisometric relaxation is a more so- phisticated stretch technique that is con- Several reports on the levator ani syn- sidered next. drome describe the effectiveness of high voltage pulsed galvanic stimulation ap- Postisometric relaxation plied through an electrode inserted into the rectum. Stimulation frequency was The principles of postisometric relaxation set between 80 and 120 Hz with the maxi- (or contract-relax only at mild effort) are mum patient-acceptable voltage ranging discussed in Chapter 2, pages 10-11 of between 100 and 400 V. Most authors re- this volume. Lewit58 describes and illus- ported a treatment time of 1 hour re- trates a valuable application for patients peated every day or every few days for who have pain in the coccygeal region three to eight times. The details of these with a tender coccyx and who exhibit in- studies were summarized by Morris and creased tension of both the levator ani Newton.71 Either good or excellent thera- and gluteus maximus muscles. The pa- peutic results were reported for 4 3 - 9 0 % tient lies prone with the heels rotated out- of patients.92 Consistently, those patients ward, which places the gluteus maximus who proved not to have the levator ani on partial stretch. The clinician stands syndrome or in whom it was a secondary beside the patient's thigh, crosses the diagnosis responded poorly. None of forearms and places one palm on each these studies was controlled. buttock at the level of the anus to provide isometric resistance. The patient is in- The reason why this form of electrical structed to press the buttocks together stimulation should inactivate myofascial with very little force, to maintain this TrPs is cloudy. The rhythmical contrac- pressure for about 10 seconds, and then to tions may increase local blood flow and \"let go.\" During relaxation, the clinician help equalize sarcomere lengths. The feels the initial tension in the gluteus stimulation of muscle afferent nerve fi- maximus muscles diminish. After this cy- bers may help disrupt feedback loops that cle has been repeated three to five times, sustain the local TrP mechanism. These external palpation of the ventral surface factors need to be investigated. of the coccyx is then usually accom- plished more easily and has become pain- Ultrasound less. The patient can apply this isometric contraction technique as self-treatment in Lilius and Valtonen62 reported that 75% a home program. The portion of the glu- of 24 patients treated for levator ani teus maximus that attaches to the coccyx spasm syndrome with ultrasound became is embryologically separate from the rest symptomless or had only mild continuing of the gluteus maximus;97 this fact may re- symptoms. They applied 1-2.5 W/cm2 of late to the effectiveness of postisometric ultrasound to the perineum around the therapy for this part of the muscle. anus for 5-10 minutes on 15-30 succes- sive days. Malbohan and associates64 outline a combined program for coccygeal pain. In Seated Posture addition to the postisometric relaxation described previously and massage of the Because he could demonstrate acute an- levator ani and coccygeus muscles, they gulation of the coccyx radiographically employ isometric relaxation of the mus- when the patient was seated in the cles attached to the coccyx. This is per- slumped posture, and because his pa- formed by contraction of the muscles tients responded so well to correction of forming the pelvic diaphragm followed this poor posture, Thiele95 strongly em- by manually assisted retropulsion (dorsal phasized the therapeutic importance of displacement) of the coccyx during relax- sitting posture in patients with coc-
Chapter 6 / Pelvic Floor Muscles 129 cygodynia. He considered it the cause of and these should be injected before the the patients' symptoms in 3 1 % of 324 needle is withdrawn. cases. Cooper33 found that slumping pos- ture was responsible for the pain in 14% Long63 recommended injection of in- of his 100 cases with coccygodynia. Other trapelvic TrPs located in the levator ani or authors have made a point of teaching coccygeus muscles close to the coccyx their coccygodynia patients who slump when they were refractory to massage and while sitting to sit up straight.62 involved a small area. He, too, used a bi- manual method, palpating rectally to 13. INJECTION check the position of the needle tip. Wa- ters100 injected 2-10 ml of 2.0% procaine Generally, only the perineal muscles and solution into tender spots in the peri- sphincter ani are accessible for injection neum for coccygodynia. therapy. It should be employed only if the TrP and its taut band are unmistakably 14. CORRECTIVE ACTIONS palpable and precisely located. The prin- ciples of TrP injection are covered in Vol- When patients with myofascial TrPs fail ume 1, pages 7 4 - 8 6 . 9 8 For injection of the to respond to specific local treatment or ischiocavernosus in either sex and of the when the beneficial results are only tran- bulbospongiosus in the male, the clini- sient, the clinician should aggressively cian uses flat palpation to localize the investigate the possibility of nutritional TrP. In a female patient, a taut band and inadequacies or other systemic perpetuat- TrP in the bulbospongiosus muscle are lo- ing factors for myofascial TrPs, which are calized and held between the fingertip in discussed in detail in Chapter 4 of Vol- the vagina and the tip of the thumb on the ume l . 9 8 labium majorus and then injected through the labium using the other hand. For the patient with TrPs in the coc- cygeus and levator ani muscles, the clini- Massage of TrPs in the sphincter ani cian should identify and, if possible, cor- muscle is rarely satisfactory by itself, but rect any articular dysfunctions of the these TrPs may be responsive to pulsed sacroiliac joints and sacrococcygeal or electrical stimulation or ultrasound, as lumbosacral articulations. Also in such described previously. Injection is painful cases, resolution of any chronic inflam- but may be quickly effective. matory condition within the pelvis, such as endometritis, chronic salpingo-oopho- Injection of the sphincter ani is per- ritis, chronic prostatovesiculitis, intersti- formed bimanually. A 10-mL syringe with tial cystitis, and urinary tract infections a 63-mm (21/2-in) 21-gauge needle is may be critical to pain relief. A slumped loaded and gloves donned. A palpating seated posture must be corrected, as finger localizes the taut band and its TrP noted previously in Section 12. in the anal sphincter. Before the needle is inserted, the skin area to be penetrated Sphincter ani TrPs are likely to be re- is cleansed with antiseptic and then fractory when painful internal hemor- sprayed for 6 seconds or less (just short of rhoids are present. Conservative ap- frosting) with vapocoolant applied for proaches to relief of hemorrhoidal pain brief local anesthesia; the mucous mem- include increased liquid intake and/or a brane of the anal opening should be pro- stool softener, a diet with more fiber, tected from the spray, since here the va- local application of an analgesic hemor- pocoolant can produce burning pain. rhoid preparation, restoration of the inter- Before the skin can rewarm, the needle is nal hemorrhoids to their protected posi- inserted parallel to and at one side of the tion within the anal sphincter after def- anus. When the needle approaches the ecation, and an enema of 30-60 gm (1/2-1 sphincter ani muscle, its tip is felt by the oz) of pediatric liquid petrolatum given finger in the rectum; that finger then di- the last thing before retiring at night to rects the needle precisely to the TrP. Fre- help lubricate passage of the stool. If con- quently there is a cluster of TrPs to be in- servative measures fail, banding or surgi- activated. The muscle should be thor- cal removal of internal hemorrhoids oughly palpated for any remaining TrPs, needs to be considered.
130 Part 1 / Lower Torso Pain References 38. Ferner H, Staubesand J: Sobotta Atlas of Human Anatomy, Ed. 10, Vol. 2. Urban & Schwarzen- 1. Anderson JE: Grant's Atlas of Anatomy, Ed. 8. berg, Baltimore, 1983 (Fig. 152). Williams & Wilkins Baltimore, 1983 (Figs. 3- 3 9 . Ibid. (Fig. 292). 40. Ibid. (Fig. 295). 10, 3-39). 4 1 . Ibid. (Figs. 320, 328, 329). 2. Ibid. (Fig. 3 - 1 2 ) . 42. Ibid. (Fig. 325). 3. Ibid. (Fig. 3 - 1 6 ) . 4 3 . Ibid. (Fig. 4 0 4 ) . 4. Ibid. (Fig. 3 - 1 7 ) . 44. Ibid. (Fig. 4 2 0 ) . 5. Ibid. (Fig. 3 - 1 9 ) . 6. Ibid. (Fig. 3 - 3 3 ) . 45. Goldstein J: Personal communication, 1990. 7. Ibid. (Fig. 3 - 5 5 ) . 46. Gosling JA, Dixon JS, Critchley HOD, et al.: A 8. Ibid. (Fig. 3 - 5 7 ) . 9. Ibid. (Fig. 4 - 4 0 ) . comparative study of the human external 10. Ibid. (Fig. 4 - 4 3 ) . 11. Ibid. (Fig. 4 - 1 6 ) . sphincter and periurethral levator ani muscles. Br J Urol 5 3 : 3 5 - 4 1 , 1981. 12. Bard P: Control of systemic blood vessels, Chapter 10. In Medical Physiology, Ed. 12, Vol. 47. Grant SR, Salvati EP, Rubin RJ: Levator syn- drome: an analysis of 316 cases. Dis Colon Rec- 1, edited by V.B. Mountcastle. C. V. Mosby tum 7 8 : 1 6 1 - 1 6 3 , 1975. Company, St. Louis, 1968 (pp. 1 5 0 - 1 7 7 , See 4 8 . Greenman PE: Principles of Manual Medicine. 168-169). 13. Bardeen CR: The musculature, Sect. 5. In Mor- Williams & Wilkins, Baltimore, 1989 (pp. 234, ris's Human Anatomy, edited by C. M. Jackson, 236). Ed. 6. Blakiston's Son & Co., Philadelphia, 49. Harvey RF: Colonic motility in proctalgia fugax. Lancet 2 : 7 1 3 - 7 1 4 , 1979. 1921 (p. 481, Fig. 424). 14. Basmajian JV, Burke MD, Burnett GW, et al, 50. Juenemann KP, Lue TF, Schmidt RA, et al.: (eds.): Stedman's Medical Dictionary, 24th ed. Clinical significance of sacral and pudendal nerve anatomy. J Urol 7 3 9 : 7 4 - 8 0 , 1988. Williams & Wilkins, Baltimore, 1982 (pp. 293, 51. Karacan I, Hirshkowitz M, Salis PJ, et al.: Pe- 1143). nile blood flow and musculovascular events 15. Basmajian JV, Deluca CJ: Muscles Alive, Ed. 5. during sleep-related erections of middle-aged Williams & Wilkins, Baltimore, 1985 (pp. 3 9 9 - men. J Urol 738:177-181, 1987. 400). 52. Kidd R: Pain localization with the innominate 16. Ibid. (pp. 4 0 2 - 4 0 3 ) . upslip dysfunction. Manual Med 3 : 1 0 3 - 1 0 5 , 17. Benoit G, Delmas V, Gillot C, et al: The anat- 1988. omy of erection. Surg Radiol Anat 9 : 2 6 3 - 2 7 2 , 53. Koelbl H, Strassegger H, Riss PA, et al.: Mor- 1987. phologic and functional aspects of pelvic floor 18. Carter BL, Morehead J, Wolpert SM, et al.: muscles in patients with pelvic relaxation and Cross-Sectional Anatomy. Appleton-Century- genuine stress incontinence. Obsfef Gynecol 74: Crofts, New York, 1977 (Sects. 38-41, 44-46). 789-795, 1989. 19. Ibid. (Sects. 4 1 - 4 2 - m a l e , Sect. 47-female). 20. Ibid. (Sect. 42). 54. Lavoisier P, Courtois F, Barres D, et al.: Correla- 2 1 . Ibid. (Sects. 40-42, 4 6 ) . 22. Ibid. (Sects. 40, 4 4 ) . tion between intracavernous pressure and con- 23. Ibid. (Sects. 42, 4 7 - 4 8 ) . 24. Clemente CD: Gray's Anatomy of the Human traction of the ischiocavernosus muscle in man. J Urol 736:936-939, 1986. Body, American Ed. 30. Lea & Febiger, Phila- 55. Lavoisier P, Proulx J, Courtois F: Reflex con- delphia, 1985 (p. 96). 2 5 . Ibid. (pp. 3 6 1 - 3 6 3 ) . tractions of the ischiocavernosus muscles fol- 26. Ibid. (pp. 4 9 8 - 5 0 0 ) . lowing electrical and pressure stimulations. J 27. Ibid. (pp. 5 0 0 , 501, Fig. 6 - 3 6 ) . Urol 739:396-399, 1988. 28. Ibid. (pp. 5 0 8 - 5 1 1 ) . 29. Ibid. (p. 5 0 9 , Fig. 6 - 4 0 ) . 56. Leigh RE: Obturator internus spasm as a cause 30. Ibid. (p. 510, Fig. 6 - 4 1 ) . of pelvic and sciatic distress. Lancet 1 : 2 8 6 - 2 8 7 , 31. Ibid. (pp. 5 1 1 - 5 1 2 ) . 32. Ibid. (pp. 5 6 8 - 5 7 0 ) . 1952. 57. Lewit K: Manipulative Therapy in Rehabilitation of 33. Cooper WL: Coccygodynia: an analysis of one hundred cases. J Internat Coll Surg 3 3 : 3 0 6 - 3 1 1 , the Motor System. Butterworths, London, 1985 1960. (pp. 113, 174, 311). 58. Ibid. (pp. 2 2 3 ; 278, Fig. 6.97). 34. Critchley HOD, Dixon JS, Gosling JA: Compar- 59. Ibid. (pp. 3 0 6 - 3 0 7 ) . ative study of the periurethral and perianal 60. Lewit K: Postisometric relaxation in combina- parts of the human levator ani muscle. Urol Int tion with other methods of muscular facilita- 35:226-232, 1980. tion and inhibition. Manual Med 2 : 1 0 1 - 1 0 4 , 35. Dittrich RJ: Coccygodynia as referred pain. J 1986. Bone Joint Surg [Am] 3 3 : 7 1 5 - 7 1 8 , 1 9 5 1 . 36. Douthwaite AH: Proctalgia fugax. Br Med J 2: 61. Lilius HG, Oravisto KJ, Valtonen EJ: Origin of pain in interstitial cystitis. Scand J Urol Nephrol 164-165, 1962. 37. Eisler P: Die Muskeln des Stammes. Gustav 7:150-152, 1973. Fischer, Jena, 1912 (pp. 447, 4 4 9 - 4 5 1 , Fig. 65). 62. Lilius HG, Valtonen EJ: The levator ani spasm syndrome: a clinical analysis of 31 cases. Ann Chir Gynaecol Fenn 6 2 : 9 3 - 9 7 , 1973. 63. Long C, II: Myofascial pain syndromes: Part Ill—Some syndromes of trunk and thigh. Henry Ford Hosp Med Bull 4 : 1 0 2 - 1 0 6 , 1956.
Chapter 6 / Pelvic Floor Muscles 131 64. Malbohan IM, Mojisova L, Tichy M: The role 8 5 . Ibid. (p. 323). of coccygeal spasm in low back pain. J Man 86. Ibid. (p. 332). Med 4 : 1 4 0 - 1 4 1 , 1 9 8 9 . 87. Salvati EP: The levator syndrome and its vari- 65. McMinn RMH, Hutchings RT: Color Atlas of ant. Gastroenterol Clin North Am 7 6 : 7 1 - 7 8 , 1987. Human Anatomy. Year Book Medical Publishers, 88. Simons DG, Travell JG: Myofascial origins of Chicago, 1977 (p. 81). 66. Ibid. (p. 245). low back pain. 3. Pelvic and lower extremity 67. Ibid. (p. 248). muscles. Postgrad Med 7 3 : 9 9 - 1 0 8 , 1 9 8 3 . 68. Ibid. (p. 252A). 69. Ibid. (p. 256). 89. Sinaki M, Merritt JL, Stillwell GK: Tension my- 70. Ibid. (pp. 266, 273). algia of the pelvic floor. Mayo Clin Proc 5 2 : 7 1 7 - 71. Morris L, Newton RA: Use of high voltage 722, 1977. pulsed galvanic stimulation for patients with 90. Slocumb JC: Neurological factors in chronic levator ani syndrome. Phys Ther 6 7 : 1 5 2 2 - 1 5 2 5 , pelvic pain: trigger points and the abdominal 1987. pelvic pain syndrome. Am J Obstet Gynecol 149: 72. Netter FH: The Ciba Collection of Medical Illustra- 536-543,1984. tions, Vol. 8, Musculoskeletal System. Part I: 9 1 . Smith WT: Levator spasm syndrome. Minn Med Anatomy, Physiology and Metabolic Disorders. 42:1076-1079, 1959. Ciba-Geigy Corporation, Summit, 1987 (p. 86). 92. Sohn N, Weinstein MA, Robbins RD: The leva- 73. Ibid. (pp. 1 4 2 - 1 4 3 ) . tor syndrome and its treatment with high-volt- 74. Nicosia JF, Abcarian H: Levator syndrome: a age electrogalvanic stimulation. Am J Surg 144: treatment that works. Dis Colon Rectum 2 8 : 4 0 6 - 580-582,1982. 408, 1985. 93. Swain R: Oral clonidine for proctalgia fugax. 75. Nocenti MR: Reproduction, Chapter 48. In Medical Physiology, Ed. 12, Vol. 1, edited by Guf 2 8 : 1 0 3 9 - 1 0 4 0 , 1987. V.B. Mountcastle. CV. Mosby Company, St. 94. Thiele GH: Coccygodynia and pain in the su- Louis, 1968 (pp. 9 9 2 - 1 0 2 8 , see 1 0 2 4 - 1 0 2 5 ) . perior gluteal region. JAMA 7 0 9 : 1 2 7 1 - 1 2 7 5 , 76. Oliver GC, Rubin RJ, Salvati EP, et al.: Electro- 1937. galvanic stimulation in the treatment of levator 95. Thiele GH: Coccygodynia: cause and treat- syndrome. Dis Colon Rectum 2 8 : 6 6 2 - 6 6 3 , 1985. ment. Dis Colon Rectum 6 : 4 2 2 - 4 3 6 , 1 9 6 3 . 77. Pace JB: Commonly overlooked pain syn- 96. Thompson WG, Heaton KW: Proctalgia fugax. J dromes responsive to simple therapy. Postgrad R Coll Physicians Lond 7 4 : 2 4 7 - 2 4 8 , 1 9 8 0 . Med 5 8 : 1 0 7 - 1 1 3 , 1975. 97. Tichy M: Anatomical basis for relaxation of the 78. Pace JB, Henning C: Episacroiliac lipoma. Am muscles attached to the coccyx. Manual Med 4: Fam Phys 6 : 7 0 - 7 3 , 1 9 7 2 . 147-148, 1989. 79. Peery WH: Proctalgia fugax: a clinical enigma. 98. Travell JG and Simons DG: Myofascial Pain and South Med J 8 7 : 6 2 1 - 6 2 3 , 1988. Dysfunction: The Trigger Point Manual. Williams 80. Pernkopf E: Atlas of Topographical and Applied Human Anatomy, Vol. 2. W.B. Saunders, Phila- & Wilkins, Baltimore, 1983. 9 9 . Ibid. (p. 19). delphia, 1964 (Fig. 306). 81. Rohen JW, Yokochi C: Color Atlas of Anatomy, 100. Waters EG: A consideration of the types and treatment of coccygodynia. Am J Obstet Ed. 2. Igaku-Shoin, New York, 1988 (p. 311). Gyncecol 3 3 : 5 3 1 - 5 3 5 , 1937. 82. Ibid. (p. 316). 83. Ibid. (p. 317). 101. Weizman Z, Binsztok M: Proctalgia fugax in 84. Ibid. (p. 322). teenagers. J Pediatr 7 7 4 : 8 1 3 - 8 1 4 , 1 9 8 9 . 102. Wright JF: Inhaled solbutamol for proctalgia fugax. Lancef 2:659-660, 1985. 103. Wright RR: The levator ani spasm syndrome. Am J Proctol 6:477, 1 9 6 9 .
CHAPTER 7 Gluteus Maximus Muscle \"Swimmer's Nemesis\" HIGHLIGHTS: The gluteus maximus is a large tant referred pain patterns. ACTIVATION AND muscle composed predominantly of the \"work- PERPETUATION OF TRIGGER POINTS may horse\" type 1 (slow-twitch) muscle fibers. These result from a direct blow on the muscle, from fibers depend primarily on oxidative metabolism walking uphill, from sleeping in an incorrect posi- and are suited for continuous use, but at a small tion, or from sudden overload during a fall or percentage of maximal strength. The weight of near-fall that induces a vigorous lengthening the gluteus maximus is several times that of the contraction. PATIENT EXAMINATION usually gluteus medius and gluteus minimus together. reveals an antalgic gait, impaired sitting toler- The large size and the anatomic orientation of ance, and restricted flexion of the thigh at the the gluteus maximus of humans are unique and hip. TRIGGER POINT EXAMINATION is per- are an important anatomic basis of upright pos- formed with the involved thigh of the side-lying ture. The evolutionary changes in this muscle patient flexed about 90°. The TrPs may be found have been associated with the distinctive intelli- in three areas and their vigorous local twitch re- gence and manual dexterity of humans among sponses are clearly visible. INTERMITTENT primates. REFERRED PAIN from trigger points COLD WITH STRETCH is accomplished with (TrPs) in the gluteus maximus projects to the the patient side lying by gently bringing the knee buttock region, rarely to a considerable dis- of the affected side toward the opposite axilla tance. The proximal ANATOMICAL ATTACH- while parallel sweeps of the ice or vapocoolant MENTS of this muscle are to the posterior iliac are applied downward from the waist over the crest, lateral sacrum, and coccyx. Distally, the fi- buttock to midthigh. During passive stretch, re- bers are secured to the iliotibial band of the fas- laxation is enhanced by rhythmic slow exhala- cia lata and to the femur. INNERVATION derives tion. Application of moist heat and slow, active, from the L5, S1, and S2 spinal roots via the infe- full range of motion must follow. For INJECTION rior gluteal nerve. FUNCTION of the gluteus AND STRETCH, the more cephalad TrPs are maximus includes powerful extension of the identified and pinned down for injection by flat thigh at the hip during strenuous activities: run- palpation; the most caudal TrPs are fixed by pin- ning, jumping, climbing stairs, and arising from cer palpation. Injection is followed by intermit- the seated position. During the stance phase of tent cold and muscle lengthening, moist heat, ambulation, the gluteus maximus restrains the and active range of motion. CORRECTIVE AC- tendency toward hip flexion and helps regain TIONS include restriction of uninterrupted sitting body position over the forward foot. This muscle to 15 or 20 minutes, use of a soft doughnut helps maintain an erect posture and assists lat- cushion with the hole centered under the ischial eral rotation at the hip. SYMPTOMS from TrPs tuberosity of the painful side, and placement of a in this muscle commonly include restlessness pillow between the knees when sleeping. Self- and pain on prolonged sitting, increased pain stretch exercises that are augmented with post- when walking uphill in a bent-forward posture, isometric relaxation and with coordinated exha- and pain induced by swimming the crawl stroke. lation are important. Lying on a tennis ball pro- The TrPs of the gluteus maximus are distin- vides effective ischemic compression. Overload- guished from TrPs in the gluteus medius by lo- ing the gluteus maximus by long uphill hiking cation and are distinguished from TrPs in the and by swimming the crawl stroke should be deep gluteus minimus by the latter's more dis- avoided. 132
Search
Read the Text Version
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- 73
- 74
- 75
- 76
- 77
- 78
- 79
- 80
- 81
- 82
- 83
- 84
- 85
- 86
- 87
- 88
- 89
- 90
- 91
- 92
- 93
- 94
- 95
- 96
- 97
- 98
- 99
- 100
- 101
- 102
- 103
- 104
- 105
- 106
- 107
- 108
- 109
- 110
- 111
- 112
- 113
- 114
- 115
- 116
- 117
- 118
- 119
- 120
- 121
- 122
- 123
- 124
- 125
- 126
- 127
- 128
- 129
- 130
- 131
- 132
- 133
- 134
- 135
- 136
- 137
- 138
- 139
- 140
- 141
- 142
- 143
- 144
- 145
- 146
- 147
- 148
- 149
- 150
- 151
- 152
- 153
- 154
- 155
- 156
- 157
- 158
- 159
- 160
- 161
- 162
- 163
- 164
- 165
- 166
- 167
- 168
- 169
- 170
- 171
- 172
- 173
- 174
- 175
- 176
- 177
- 178
- 179
- 180
- 181
- 182
- 183
- 184
- 185
- 186
- 187
- 188
- 189
- 190
- 191
- 192
- 193
- 194
- 195
- 196
- 197
- 198
- 199
- 200
- 201
- 202
- 203
- 204
- 205
- 206
- 207
- 208
- 209
- 210
- 211
- 212
- 213
- 214
- 215
- 216
- 217
- 218
- 219
- 220
- 221
- 222
- 223
- 224
- 225
- 226
- 227
- 228
- 229
- 230
- 231
- 232
- 233
- 234
- 235
- 236
- 237
- 238
- 239
- 240
- 241
- 242
- 243
- 244
- 245
- 246
- 247
- 248
- 249
- 250
- 251
- 252
- 253
- 254
- 255
- 256
- 257
- 258
- 259
- 260
- 261
- 262
- 263
- 264
- 265
- 266
- 267
- 268
- 269
- 270
- 271
- 272
- 273
- 274
- 275
- 276
- 277
- 278
- 279
- 280
- 281
- 282
- 283
- 284
- 285
- 286
- 287
- 288
- 289
- 290
- 291
- 292
- 293
- 294
- 295
- 296
- 297
- 298
- 299
- 300
- 301
- 302
- 303
- 304
- 305
- 306
- 307
- 308
- 309
- 310
- 311
- 312
- 313
- 314
- 315
- 316
- 317
- 318
- 319
- 320
- 321
- 322
- 323
- 324
- 325
- 326
- 327
- 328
- 329
- 330
- 331
- 332
- 333
- 334
- 335
- 336
- 337
- 338
- 339
- 340
- 341
- 342
- 343
- 344
- 345
- 346
- 347
- 348
- 349
- 350
- 351
- 352
- 353
- 354
- 355
- 356
- 357
- 358
- 359
- 360
- 361
- 362
- 363
- 364
- 365
- 366
- 367
- 368
- 369
- 370
- 371
- 372
- 373
- 374
- 375
- 376
- 377
- 378
- 379
- 380
- 381
- 382
- 383
- 384
- 385
- 386
- 387
- 388
- 389
- 390
- 391
- 392
- 393
- 394
- 395
- 396
- 397
- 398
- 399
- 400
- 401
- 402
- 403
- 404
- 405
- 406
- 407
- 408
- 409
- 410
- 411
- 412
- 413
- 414
- 415
- 416
- 417
- 418
- 419
- 420
- 421
- 422
- 423
- 424
- 425
- 426
- 427
- 428
- 429
- 430
- 431
- 432
- 433
- 434
- 435
- 436
- 437
- 438
- 439
- 440
- 441
- 442
- 443
- 444
- 445
- 446
- 447
- 448
- 449
- 450
- 451
- 452
- 453
- 454
- 455
- 456
- 457
- 458
- 459
- 460
- 461
- 462
- 463
- 464
- 465
- 466
- 467
- 468
- 469
- 470
- 471
- 472
- 473
- 474
- 475
- 476
- 477
- 478
- 479
- 480
- 481
- 482
- 483
- 484
- 485
- 486
- 487
- 488
- 489
- 490
- 491
- 492
- 493
- 494
- 495
- 496
- 497
- 498
- 499
- 500
- 501
- 502
- 503
- 504
- 505
- 506
- 507
- 508
- 509
- 510
- 511
- 512
- 513
- 514
- 515
- 516
- 517
- 518
- 519
- 520
- 521
- 522
- 523
- 524
- 525
- 526
- 527
- 528
- 529
- 530
- 531
- 532
- 533
- 534
- 535
- 536
- 537
- 538
- 539
- 540
- 541
- 542
- 543
- 544
- 545
- 546
- 547
- 548
- 549
- 550
- 551
- 552
- 553
- 554
- 555
- 556
- 557
- 558
- 559
- 560
- 561
- 562
- 563
- 564
- 565
- 566
- 567
- 568
- 569
- 570
- 571
- 572
- 573
- 574
- 575
- 576
- 1 - 50
- 51 - 100
- 101 - 150
- 151 - 200
- 201 - 250
- 251 - 300
- 301 - 350
- 351 - 400
- 401 - 450
- 451 - 500
- 501 - 550
- 551 - 576
Pages:
