Evaluation and Management of Scapular Dysfunction

International Academy of Orthopedic Medicine

Volume 3, Issue 1

Anatomy and Landmarks for the Superior A Proposed Diagnostic and Middle Classification of Cluneal Nerves: Patients with Application to Evaluation and Temporomandibular Posterior Iliac Management Disorders: Crest Harvest of Scapular Implications for Physical and Entrapment Dysfunction Therapists Syndromes IAOM-US Connection Directory is published by John Hoops PT, COMT The International Managing Editor Academy of Orthopedic Medicine-US (IAOM-US) Valerie Phelps PT, ScD, OCS, FAAOMPT PO Box 65179 Chief Editor / Education Director Tucson, AZ 85728 (p) 866.426.6101 Tanya Smith PT, ScD, COMT (f) 866.698.4832 Senior Editor (e) [email protected] (w) www.iaom-us.com John Woolf MS, PT, ATC, COMT Business Director Contact (p) 866.426.6101 Sharon Fitzgerald (f) 866.698.4832 Executive Assistant (e) [email protected] (w) www.iaom-us.com Andrea Cameron All trademarks are the property Administrative Assistant/ of their respective owners. Marketing Liaison The IAOM-US CONNECTION VOLUME 3

Connection Admin Comment: Greetings to all of our colleagues from the IAOM-US team! 2014 was a year of learning and growing for the IAOM, and we’ve accomplished some exciting things. Starting in January 2015, all of our 12 orthopedic manu- Evaluation and Management al therapy courses will be Hybrid courses, with 8 hours of Scapular Dysfunction of online content in addition to two days of traditional hands-on course. This also means that we 2 will be offering 12 stand-alone 8-hour online modules that correspond to these courses. Colleagues have told us that they really appreciate the flexibility the new hybrid format brings. A Proposed Diagnostic We are continuing to create a strong partnership with Classification of Patients our colleagues in Chile in an effort to provide IAOM with Temporomandibular content to Latin America. Look for more exciting devel- Disorders: Implications opments in this arena in 2015. 7 for Physical Therapists If you haven’t had a chance to check it out, our 2015 courses are now listed on our website www.iaom-us. com. And, we’re planning to run some discount promo- tions that will EXCLUSIVELY be posted on Facebook, so Anatomy and Landmarks be sure to Like our Facebook page so you don’t miss for the Superior and Middle out. Cluneal Nerves: Application to Posterior Iliac Crest Harvest And lastly, we’re very excited to announce a new 13 feature of the IAOM-US Connection – the addition of a and Entrapment Syndromes “Letters to the Editor” section. One of the goals of the IAOM-US editorial staff is to facilitate conversations about the clinical commentaries. We would like to invite readers to write in and start a dialogue about the content of the connection. All letters should be scholarly in nature, and should address a relevant topic that you’ve seen in past publications. Conversely, if there’s a topic you’d like to see us address, we’d love to hear that, too. Anything that’s on your mind in the orthopedic manual therapy world - let us know! Letters will be approved by the editorial staff and we will also invite the author for a follow up response. Tell us what you think! email: info@ iaom-us.com.

The entire IAOM-US team appreciates your continued support and wishes you a healthy and prosperous 2015!!

Cheers! Sharon & Andrea

International Academy of Orthopedic Medicine Evaluation and Management of Scapular Dysfunction

McClure P, Greenberg E, Kareha S. Sports Med Arthosc Rev. 2012;20:39-47. Abstracted by Matt Stump, PT, ScD, COMT, CSCS, Camarillo, California - Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, OCS, FAAOMPT, Fellowship Director, IAOM-US Fellowship program.

INTRODUCTION Scapular motions are frequently described by three pri- In this article, the authors set out mary rotations: Upward/downward rotation (Figure 1), anterior/posterior tipping, and internal/external rotation to review normal scapular motion, (Figure 2). Upward/downward rotation occurs around describe key elements of an an axis that is perpendicular to the plane of the scapula examination for scapular and is the greatest and easiest to observe. Anterior/posterior tilting occurs around an axis that is through the spine dysfunction and address of the scapula where anterior tilting appears as winging of associated intervention strategies. the inferior scapular angle and posterior tilting involves

2 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US Connection the inferior angle of the scapula moving anteriorly while GH joint is primarily responsible for the motion. the superior border moves posteriorly. Scapular internal/ Scapular motion is achieved via muscular force couples. external rotation occurs around a vertical axis. Move- Upward rotation is controlled primarily by a force couple ment of the medial border of the scapula away from the between the upper and lower trapezius and the serratus thoracic wall is termed scapular internal rotation. The anterior (Figure 3) whereas the lower fibers of the ser- scapula demonstrates a consistent pattern of upward ratus anterior and lower trapezius are thought to produce rotation, posterior tilting, and external rotation through scapular posterior tilting; the middle trapezius is thought arm elevation. However, the greatest amount of scapu- to produce scapular external rotation. lar motion occurs after 90° of arm elevation when the contribution of glenohumeral (GH) motion and scapular motion are almost equal. Below 90° of arm elevation the

Figure 3. Upward rotation is controlled primarily by a force couple between the upper and lower trapezius and the serratus anterior. Figure 1: Upward/downward rotation (From: Wikimedia Com- mons, public domain). The goal of shoulder girdle examination is not only to identify abnormal scapular motion or positioning, termed “scapular dyskinesis”, but also to determine whether the abnormal motion correlates with the patient’s complaints of symptoms. Clinical evaluation of scapular dysfunction should include three basic elements: (1) visual observation; (2) the effects of manual correc- tion of dysfunction on symptoms; and (3) evaluation of surrounding anatomic structures potentially responsible for dyskinesis.

The Lateral Scapular Slide Test has been used to assess the side-to-side differences from the inferior angle of the scapula to the spinous processes. The distance from the inferior angle to the spinous process most directly horizontal from it is measured. The test is performed in three different positions and a side-to-side difference of > 1.5 cm is considered pathological; however, the validity Figure 2. Internal/external rotation. of this test has been questioned for three main reasons: (From: Wikimedia Commons, public domain). (1) both symptomatic and asymptomatic individuals can IAOM-US | CONNECTION 3 demonstrate asymmetry; (2) the possibility of bilateral performed by manually positioning and stabilizing the pathologic dyskinesis; and (3) the dynamic and three- entire medial border of the scapula on the thorax, in a dimensional nature of scapular movement is not assessed retracted position. The test is considered positive when with a static test. there is a decrease in pain or increased shoulder elevation strength when the scapula is stabilized during isometric The Scapular Dyskinesis Test (Figure 4), a visually based arm elevation in the scapular plane at 90°. test, involves a subject performing weighted shoulder flexion and abduction movements while visual observation of the scapula is performed. The test consists of characterizing scapular dyskinesis as present or absent. The presence of winging or dysrhythmia was considered positive for dyskinesis.

Figure 6. Scapular reposition test. Isometric elevation strength is tested with manual pressure on the scapula encouraging posterior tilting and external rotation by forearm pressure on the medial border. A positive test occurs when strength is substantially increased or pain is decreased.

Figure 4: Scapular dyskinesis test. The test is performed by the patient flexing against a 3-pound weight and observing for scapular Once the examiner determines that the scapular dyski- winging or dysrhythmia. (A) Obvious dyskinesis (winging) on the nesis is present and contributing to dysfunction, exami- left. (B) Increased dyskinesis on the left. nation of the surrounding tissue should be performed to identify factors that might be responsible for causing the altered scapular motion. Factors to consider include Because scapular dyskinesis has been reported in symp- deficits in strength or motor control of the scapular tomatic and asymptomatic individuals, one must de- stabilizing muscles (serratus anterior, middle trapezius, termine whether the dyskinesis is contributing to an and lower trapezius), postural abnormalities (forward individual’s problem. There are two main tests that do head posture, protracted scapula, and increased thoracic so: The Scapular Assistance Test (SAT) (Figure 5), and kyphosis), and impaired flexibility (pectoralis minor and the Scapular Reposition Test (SRT) (Figure 6). The posterior shoulder tightness). Treatment for scapular dys- SAT is performed by manually assisting scapular upward kinesis includes strengthening both the scapulothoracic rotation and posterior tilting during shoulder elevation and glenohumeral joint musculature with an emphasis and assessing the effect on pain. The test is considered on facilitation of lower and middle trapezius and serratus positive when the pain with elevation is decreased or anterior while avoiding or minimizing abolished during the assisted maneuver. The SRT is the upper trapezius activity (Figure 7) F.

A. B. C. D. E.

Figure 5. Scapular assistance test. The tester assists scapular upward rotation and posterior tilting during active elevation. A positive test occurs when symptoms are immediately decreased during active elevation.

4 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US Connection as well as self-neuromuscular re-education via the “wall slide” exercise (Figure 8). The “wall slide” exercise is performed through shoulder elevation in the plane of Figure 9. Stretching for posterior shoulder tightnesswith elevation. the scapula. The patient places their forearms on a wall in neutral with the elbows flexed and arm in the plane of the scapula. The patient is then instructed to move their forearms up the wall and lower with control. Addition- ally, treating soft tissue tightness (posterior shoulder and/or pectoralis minor) as well as thoracic kyphosis is important to normalize scapular mobility (Figures 9 and 10).

Figure 7. Common scapular strengthening exercises of varying Figure 10. Stretching for pecto- difficulty. Low level: (A) external rotation with scapula stable. (B) ralis minor. End-range position ceiling punch for serratus anterior. Moderate level: (C) “prone is typically held for 30 seconds. T” for middle trapezius. (D) “prone Y” for lower trapezius. High Level: (E) half-knee diagonal lift. (F) single leg and body blade the additional tests, the SAT and SRT, to more pre- cisely identify if scapular dyskinesis is contributing to an individual’s pathology. These added “special tests” might further the clinician’s ability to determine and ac- curately diagnosis their clients. Additionally they may assist in treatment planning to more efficiently rehabili- tate an individual’s shoulder complaints.

The authors suggested posterior shoulder tightness as a cause of scapular protraction that might contribute to scapular dyskinesis; however, their assessment does not differentiate between muscle tightness and capsu- lar tightness. The IAOM suggests that the posterior Figure 8. Wall slide exercise superior capsule of the glenohumeral joint is assessed and stretched with internal rotation in the adducted IAOM-US Comment: arm (Figure 9) whereas the posterior inferior capsule is This review article on evaluation and management of tested and stretched through internal rotation (IR) in a scapular dysfunction provides a very well rounded and pre-position of 60° of abduction and 30° of horizon- complete approach to scapular assessment. The IAOM tal adduction (Figure 10); tight rotator cuff muscles considers the aberrant movement of the scapula (de- can be identified with IR in 90° of abduction1. The creased upward rotation, decreased posterior tilting, IAOM considers the differentiation of these tissues and decreased scapular external rotation) as contribu- important in an effort to identify the exact pain tory to shoulder pathology. The authors bring to light generator and develop an effective treatment plan. IAOM-US | CONNECTION 5 Overall this article underscores the importance of Once identified as pathologic, the clinician can outline an effective assessment for scapular dyskinesis and a treatment plan to restore scapulothoracic strength, the need to correlate the dyskinesis with the patient’s motor control and mobility as well as posture to return symptoms to identify the neuromuscular control of patients to successful overhead activity. the scapula’s contribution to the patient’s complaints.

References:

1. Sizer PS, Jr., Phelps V, Gilbert K. Diagnosis and management of the painful shoulder. Part 2: examination, interpretation, and management. Pain Pract 2003 June;3(2):152-85.

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A Proposed Diagnostic Classification of Patients With Temporomandibular Disorders: Implications for Physical Therapists

Harrison AL, Thorp JN, Ritzline PD. J Orthop Sports Phys Ther. 2014;44(3):182-97.

Abstracted by: Tanya Smith PT, ScD, COMT, IAOM-US Fellowship Candidate

The purpose of this article is to characterize epidemiol- nervous system and the trigeminal nucleus causing wide- ogy and pathophysiology of temporomandibular joint spread and/or central pain disorders. The complexity of dysfunction (TMD), describe a systematic screening for TMD as well as referred pain from a multitude of sur- inter-professional referrals, and propose a clinical exami- rounding structures can present challenges in differential nation and classification system of patients with TMD diagnosis and classification of dysfunction. who are commonly seen in outpatient physical therapy settings. Research and Diagnostic criteria (RDC/TMD) devel- oped by Dworkin and LeResche1 classify TMD based on TMD describes pathologies of the temporomandibular an integration of impairments and systems. The RDC/ joint (TMJ) and associated structures, some of which TMD provides a valid classification of TMD based on include: myofacial pain syndromes affecting muscles of impairments commonly seen by the outpatient physical mastication, articular disc displacement, TMJ capsulitis, therapist. The RDC/TMD separates TMD diagnosis inflammation and/or degeneration of the articular carti- into two axes. Axis I encompasses the physical examina- lage, synovium and ligaments. The TMJ has a complex tion of the structure and function, while axis II focuses interplay of systems, which can affect the sympathetic on psychological factors that contribute to the primary

IAOM-US | CONNECTION 7 physical complaints. Axis I is separated into three groups (classifications): (1) Masticatory muscle disorders, (2) Disc displacements, and (3) Joint dysfunction.

Further division is as follows: (1) Masticatory muscle disorders a. with normal opening b. with limited opening (2) Disc displacement a. with reduction b. without reduction & limited opening Figure 1. (A) Masseter. (B) Masseter palpation c. without reduction & no limitation opening (3) Joint dysfunction a. arthralgia b. osteoarthritis c. osteoarthrosis

This article focuses on the axis I classifications in devel- oping examination procedures and diagnostic classification of TMD for physical therapists.

Group 1: Masticatory muscle disorders can include masseter, temporalis, medial and lateral pterygoids and Figure 2. (A) Temporalis. (B) Temporalis palpation can be classified as overuse/tensile strain, muscle guard- ing or mediated myalgia. Muscle dysfunction can occur as a result of an inflammatory process, sinusitis, dental pathology, direct trauma, delayed onset muscle soreness, tendinopathy or associated strain from parafunctions (clenching, grinding, etc…).

Group 2 & 3 disorders are grouped together as the disc and joint disorders are rarely isolated from each other. Joint dysfunction incorporates the disc, joint surfaces, ligaments, synovium and/or any combination.

Differential diagnosis of TMD should include evaluation Figure 3. (A) Lateral Pterygoid. (B) Lateral Pterygoid palpation of the musculoskeletal system and psychological factors, while screening for primary headache (HA), secondary HA associated with cardiovascular disease and rheumatic disorders, disorders of the cervical spine, ears, sinuses, eyes, medications, dental structures, and cranial and pe- ripheral neuralgias and central nervous system disorders.

Musculoskeletal examination should include palpation of the TMJ, masseter and temporalis bilaterally. The lateral and medial pterygoids cannot be effectively palpated; therefore, additional testing should be performed by an isometric contraction or stretch to these muscles specifi- Figure 4. (A) Medial Pterygoid. (B) Medial Pterygoid palpation cally. (Figures 1 to 4)

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Mobility testing should include opening/depression, protrusion, retrusion and lateral deviation to both sides. Opening should be measured with a ruler between the bottom and top incisors, with normal opening from 40-50mm. Retrusion and protrusion are not measured; however, the bottom teeth should clear the top with protrusion. Lateral deviation should be 8-11mm in normal joint mobility. (Figure 5)

Figure 5. AROM

Figure 5. PROM

Special tests of the TMJ are not included in the RDC/TMD but can add insight into musculoskeletal diagnosis. Spe- cial tests that have been described by clinical experts include: bilateral manual loading of TMJ and biting on a separator (tongue depressor) to reproduce joint pain on the contra-lateral side.

In the TMD physical examination, a systems’ screening should include evaluation of primary and secondary HA. Primary HA is described as migraine, cluster, tension and other neurological or vascular origin HA. Secondary HA and facial pain can include cervicogenic HA, those referred from myocardial infarction, rheumatoid arthritis, systemic lupus erythematosus and fibromyalgia. Dental history should account for aching teeth, pain with eating and dental procedures that could have traumatized the TMJ. The health of gums and occlusion should be observed. The physical therapist should observe for obvious malalignment, overbite, underbite, open bite and signs of redness and edema in the gums. Ear screening should include a visual exam of the tragus, mastoid, and auricle for redness, edema or scaliness, and internal visualization of the tympanic membrane for redness or edema. Eye screening includes questions about visual loss and facial pain with eye movements. Cranial nerve (CN) screening should include special attention to CN V (via jaw jerk and sensory testing V1, V2, V3) & VII (via corneal reflex) (Figure 6), along with psychological screening with a graded chronic pain scale or questionnaire for anxiety and depression.

IAOM-US | CONNECTION 9 Figure 6. Cranial nerve reflex testing. IAOM COMMENTS: disorders to identify the pain generator(s) and thus Temporomandibular joint disorder presents as a reach an accurate differential diagnosis. The authors significant clinical problem that affects approximately of this commentary include AROM, PROM, end-feel 2-4 12% of the population. TMD refers to a complex testing, palpation of the mastication muscles and spe- set of conditions manifested by pain and dysfunction cial testing of TMJ. In order to make this clinical ex- in the region of the face, jaw and head that can limit amination more complete, sensory, reflex and resisted normal speech, facial expression, eating, swallowing tests should also be performed. Resisted testing would and affect the quality of life both physically and psy- include isometric resistance of depression, elevation, chologically. Signs and symptoms of TMD include protrusion and lateral deviation.6 decreased mandibular range of motion, muscle and joint pain, joint crepitus, functional limitation of jaw Reflex testing should include CN V jaw jerk reflex opening and headache. Proper management of pa- and sensory/light touch testing of CN V ophthalmic, tients with TMD begins with an extensive history and maxillary and mandibular branches. Special testing can thorough clinical examination to achieve an accurate include distraction and compression of the articular diagnosis. Diagnostic classification is difficult because structures. Compression can be performed in a dorso- of the multi-system contributions of the sympathetic cranial, ventrocranial or cranial direction and as sug- nervous system, trigeminal nucleus, surrounding pain gested by the clinical commentary, the bite test. The generators as well as the local system dysfunctions of bite test is described by biting on tongue depressors on 5 the TMJ. This abstracted clinical commentary is a one side at rear molars. Increased pain on contralateral comprehensive approach to clinical evaluation of local TMJ can implicate the joint capsule; pain on ipsilateral TMD dysfunction as well as a thorough systems screen side may increase joint compressive forces possibly of related dysfunction. The IAOM-US advocates a indicating joint pathology. (Figure 7) systematic clinical examination of musculoskeletal

Figure 7. Bite test

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Figure 7. Distraction & compression test

Additionally, a cervical spine examination should in- sory loss at V2, V3 with no abnormal reflex or motor clude AROM of flexion, extension, right rotation, left function. Trigger points are a main feature of trigemi- rotation, right sidebending, left sidebending as well as nal neuralgia with sharp shooting pain lasting briefly; mobility testing of C0-2 and C2/3. 95% present with unilateral symptoms and tic doulou- Literature reports 47%-67% of TMD’s are related to reux (attacks of intense, stabbing pain in trigeminal myofascial pain disorders of the masticatory muscles. nerve territory) can be present.7-9 Sinusitis is an inflam- Disc disorders are second most common but typically mation of the mucosal lining of the paranasal sinuses there is a combination of both disc, joint and muscle with features including painful palpation to sinus, local system dysfunction.2-5 Physical therapists have a pri- swelling and pain that increases with head down and mary role in the treatment of patients with TMD as reduces with head up position.9 Temporal arteritis is the primary disorders are of musculoskeletal origin. typically seen in patients greater than 50 years old with a new onset of HA or localized head pain, temporal Extensive screening is necessary when a pain generator artery tenderness to palpation, ESR>50 mm/h (Eryth- of musculoskeletal origin cannot be found or does not rocyte Sedimentation Rate) and acute visual dysfunc- make sense. Possible pain generators can include den- tion (diplopia or acute visual loss). Temporal arteritis tal caries/abscess, Trigeminal Neuralgia (TN), sinusitis, is a medical emergency and can result in permanent temporal arteritis, otitis media, systemic arthropathies visual loss without timely ophthalmic referral.9 Otitis and primary HA. The screening of dental caries/ab- media is typical in the pediatric population and features scess can include painful percussion to teeth via tongue include acute onset of ear pain, middle ear effusion depressor, pain when eating sweet, acidic, hot or cold and inflammation.9 Systemic arthropathies can include foods and/or red, swollen gums and bad breath. In Lyme disease, gout and pseudogout. Features include the case of any of these signs patient should be re- elevated ESR, ANA (Antinucular antibody; helps to ferred to a dental professional.7 Trigeminal neuralgia diagnose autoimmune disorders), constitutional signs is a diagnosis of exclusion of other clinical features. of malaise, fever, myalgias, arthralgias, neurological There are rarely any physical/clinical features that are symptoms and characteristic rash with Lyme 7-14 days prominent in trigeminal neuralgia. There can be sen- after tick removal.9

Summary of Clinical Testing in Examination of TMD AROM/PROM Palpation Resisted Tests Other Open/depression Medial pterygoids Open Trigeminal Jaw Jerk reflex Close/elevation Lateral pterygoids Close Corneal reflex Lateral deviation Masseter Lateral deviation Joint compression Medial deviation Temporalis Medial deviation Joint traction Protrusion protrusion Bite test Retrusion

IAOM-US | CONNECTION 11 References:

1. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord. 1992;6(4):301-55.

2. Kundu H, Basavaraj P, Kote S, Singla A, Singh S. Assessment of TMJ Disorders Using Ultrasonography as a Diagnostic Tool: A Review. J Clin Diagn Res. 2013;7(12):3116-20.

3. Poveda-Roda R, Bagan JV, Jimenez-Soriano Y, Fons-Font A. Retrospective study of a series of 850 patients with temporomandibular dysfunction (TMD). Clinical and radiological findings. Med Oral Patol Oral Cir Bucal. 2009;12:e628-34.

4. Liu F, Steinkeler A. Epidemiology, Diagnosis, and Treatment of Temporomandibular Disorders. Dental Clinics of North America. 2013;57(3):465-479.

5. Peck CC, Goulet JP, Lobbezoo F, Schiffman EL, Alster-Gren P, Anderson GC, DeLeeuw R, Jensen R, Michelotti A, Ohrbach R, Petersson A, List T. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. Journal of Oral Rehabilitation. 2014;41:2-23.

6. Winkel D, Aufdemkampe G, Matthijs O, Meijer OG, Phelps V. Diagnosis and Treatment of the Spine. Gaithersburg, Maryland; Aspen Publishers Inc:1996.

7. Ogi N, Nagao T, Toyama M, Ariji E. Chronic dental infections mimicking temporomandibular disorders. Australian Dental Journal. 2002;47:(1):63-65.

8. Dorsch JN. Neurologic Syndromes of the Head and Neck. Prim Care Clin Office Pract. 2014;41:133-149.

9. Stern H, Greenberg MS. Clinical Assessment of Patients with Orofacial Pain and Temporomandibular Disorders. Dent Clin N Am. 2013;57:393-404.

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Anatomy and Landmarks for the Superior and Middle Cluneal Nerves: Application to Posterior Iliac Crest Harvest and Entrapment Syndromes Tubbs RS, Levin MR, Loukas M, Potts EA, Cohen-Gadol AA. J Neurosurg Spine. 2010 Sep;13(3):356-9. Abstracted by Pedro Castex, PT, COMT from Santiago, Chile. IAOM-US Fellowship Candidate

INTRODUCTION TO THE STUDY Lumbago is a common musculoskeletal yet possible cause of low back pain. The disorder affecting a significant portion of superior cluneal nerves are formed by the the population. This term describes the L1 to L3 dorsal rami. These nerves pro- presence of pain in the lumbar area, most vide the sensory innervation of the upper likely due to the involvement of a struc- gluteal and posterior iliac crest areas. The ture in the lumbosacral spine (interverte- middle cluneal nerves arise from S1 to S3 bral disc, facet joints, neural tissue, etc.). dorsal rami, travelling near to the poste- However, a specific group of patients rior superior iliac spine (PSIS). Consid- presents with equivocal symptoms that ering the anatomical distribution of these do not fit with expected clinical presenta- nerves, patients with cluneal nerve pa- tions and/or lack of significant imaging thology may present with persistent low findings. Among these, cluneal nerve back pain, possibly radiating to the upper pathology is considered an infrequent gluteal area. (Figure 1)

IAOM-US | CONNECTION 13 Middle cluneal nerves pierced the posterior layer of the thoracolumbar fascia and the lower inferior portion of the latissimus dorsi muscle, demonstrating no evident osteofibrous tunnels in their path to the iliac crest. At their origin, the middle cluneal nerves had mean distances of 2 cm superior to the PSIS, 0 cm from the PSIS, and 1.5 cm inferior to the PSIS. These nerves first passed through the paraspinal muscles of the sacral area and overlying fascia to run into the gluteus maximus muscle, supplying the skin of the postero-medial fifth of this muscle.

Based on the information in this study, the authors rec- ommend (in case of posterior iliac crest harvest) a linear incision approximately 2.5 cm anterior to the PSIS and perpendicular to the long axis of the posterior iliac crest, which will most likely avoid injury of the superior and medial cluneal nerves. They also defined a secure zone for incision around the PSIS. (Figure 2)

Figure 1. Superior and inferior cluneal nerves and their relation- ship with pelvic bone landmarks. (Adapted from Wikimedia Commons, public domain.)

In this study, the anatomy and landmarks for the superior and medial cluneal nerves were described, and considerations for entrapment and possible nerve injury as a consequence of surgical procedure were revised. Dissec- tion of 10 embalmed cadavers was performed following the path of the superior and medial cluneal nerves, from origin to termination.

RESULTS The results of this study demonstrated that although some specimens lacked one superior cluneal nerve, all cadavers had at least two cluneal nerves. In cases when one cluneal nerve was absent, the other two cluneal nerves Figure 2. In green, the second lumbar dorsal spinal ramus: lateral covered this territory. From their origin, these nerves branch, part of the superior cluneal nerves (L1 to L3). (Not passed through the psoas major and paraspinal muscles, shown: inferior cluneal nerves). In blue, the relative safe zone to then passing just posterior to the quadratus lumborum avoid these nerves during surgical procedures. between this muscle and the anterior layer of the thoracolumbar fascia. The superior cluneal nerves passed an average of 5 cm, 6.5 cm and 7.3 cm from the midpoint of Another cause of cluneal nerve pathology is the entrap- the PSIS, laterally on the iliac crest. Then, the nerves ex- ment between the different fascial layers, especially when tended covering the area of the upper half of the gluteus passing next to the iliac crest. The authors in this study maximus and medius. After these nerves passed the iliac noted no osteofibrous tunnels in the path of the superior crest, they demonstrated the tendency to anastomose and medial cluneal nerves; therefore they concluded with one another. entrapment pathology of these nerves might be less likely to occur due to lack of evidence of entrapment sites. 14 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US Connection

IAOM-US COMMENTS: Aly et al5 described the clinical presentation of two The iliac crest is the most common donor site for har- patients with a suspected superior medial cluneal vesting of autologous bone. It has been reported that nerve entrapment. In both cases, neurological exam, the most common complication after this procedure nerve tension signs or other clinical information was is pain at the donor site.1 In fact, in a 10-year follow- unremarkable. Presence of a trigger point of pain 6-7 up study of 100 patients who underwent spinal fusion cm lateral to the midline over the iliac crest raised the procedure using iliac crest graft, 37% complained of theory for a medial superior cluneal nerve entrapment. persistent donor site pain.2 Cluneal nerve injury due In this study, authors introduced the “hip-knee flexion to posterior iliac crest harvest is a reasonable cause of test” as an alternative for diagnosis of this condition. persistent pain after this procedure. In this test, hip and knee are fully flexed in an attempt to cause tension in the cluneal nerves without tensing A non-surgical reason for cluneal nerve pathology is other structures. The test is positive when symptoms the entrapment of one of these nerves along their are provoked in the distribution of the nerve (Figure course. In a previous report of Maigne3, it has been 4). The two cases in this study were successfully treated suggested that entrapment of the medial superior with local nerve blocks in the area of entrapment. cluneal nerve (derived from L1) may occur as the nerve runs through an osteofibrous tunnel between the The cluneal nerves are a possible cause of pain in the thoracolumbar fascia and the rim of the posterior iliac upper outer quadrant of the buttock area. However, crest. This area was invariably found 7 cm from the there is a high probability that the results of the IAOM midline over the iliac crest. In a later study of Maigne4, basic clinical examination may not provide the infor- the criteria for diagnosis of medial superior cluneal mation we need to establish a proper diagnosis. There nerve entrapment was established as the presence of is no consensus about the genesis of this condition a “trigger point” of pain 7 cm from the midline over except when pathology occurs as a consequence of the iliac crest (corresponding to the entrapment zone), surgery. Based on the presentation of other common pain in the distribution of the cluneal nerve (Figure nerve entrapment conditions, we could assume it can 3) and relief of symptoms by local nerve block in the develop as a result of excessive friction, traction, direct area of entrapment. Twenty-nine patients were selected trauma, compression or any other mechanical force, for intervention; all of them received nerve block either micro or macro-traumatic, that could create ir- injections (1 to 3 total per subject), which relieved ritation of the nerve, local edema, scarring and possibly symptoms in 8 out of 29 patients. Of the remaining 21 narrowing of the nerve space. In cases when cluneal subjects, 19 patients underwent surgery, demonstrating nerve pathology is suspected, a checklist of clinical an evident osteofibrous tunnel in 15 cases. Of these signs and symptoms could assist in the decision-making 15 cases, 13 reported satisfactory results from surgical process. procedure. Although the results of this study fail to confirm the presence of an osteofibrous tunnel over PROPOSED CRITERIA FOR DIAGNOSIS the posterior iliac crest, it is evident that the possibil- OF CLUNEAL NERVE PATHOLOGY ity of entrapment of the medial superior cluneal nerve 1. Onset probably associated with mechanical stress cannot be overlooked. (compression, traction, trauma, etc.) over the nerve, especially in the classic entrapment site. Also, suspect this condition in presence of persistent pain status post posterior iliac crest harvest. 2. Intolerance to sitting for long periods of time. 3. Pain in the distribution of the nerve (Figure 4). 4. Presence of a painful “trigger point” about 7 cen- timeters (2.75 inches) lateral to the midline over the posterior iliac crest. 5. Pain relieved with local nerve block injection in the entrapment site. Figure 3. Distribution of symptoms in the presence of superior 6. Possibly, pain provocation in the distribution of the medial cluneal nerve pathology: L1, L2, L3. (From: Wikimedia medial superior cluneal nerve with the hip-knee flexion Commons, public domain). test.

IAOM-US | CONNECTION 15 MANAGEMENT STRATEGIES Local nerve block injections, alcohol neurolysis and surgery have been proposed as options for treatment of cluneal nerve pathology. As advocated by IAOM- US, neural flossing or gliding could be an effective treatment option in the presence of nerve entrapment since flossing techniques may help improve nutrition and mobility of the nerves in the entrapment site. Aly5 postulates that tension in cluneal nerves increases with trunk and/or hip flexion. This makes clinical sense as the nerve is located “behind” the axis of rotation of these two segments.

PROPOSED TECHNIQUE FOR CLUNEAL NERVES Figure 7. The hip and knee of the unaffected side are positioned in 90° of flexion (reduces stress in lumbar spine) and held with mo- NEURAL FLOSSING (Figures 5 to 8) bilization belt or manually with the tableside hand of the patient (as shown here). The shoulder of the affected side is positioned in slight extension to decrease tension in thoracolumbar fascia.

Figure 8. Therapist initiates neural mobilization technique by moving the hip of the affected side from neutral position in the sagittal plane (A), to flexion (B), Figure 5. Patient is positioned in sidelying, affected side up, and and back to neu- trunk sidebent towards the affected side (decreases nerve and tral. Excessive quadratus lumborum tension). pelvic movement is avoided by stabilizing with the cranial hand.

Movement should be performed within painfree range of motion. Stop the technique as soon as the patient reports symptoms. The goal is to gradually increase both excursion of leg movement and number of repetitions up to 30 to 60 repetitions, 1-2 times per session Figure 6. The hip of the affected side is positioned in neutral posi- with a 1 minute rest between 30-repetition intervals. tion in the frontal plane, and slight external rotation in the trans- This can be done twice per day: maximum 60 at one verse plane (decreases gluteal muscle tension); theknee is slightly given time with 1-minute rest after the first 30 repeti- flexed to reduce tension on sacral plexus. Avoid excessive tension tions. The patient should perform a maximum of no on anterior thigh muscles. more than 120 repetitions per day. Symptoms should not be provoked during technique execution.

16 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US Connection

PROPOSED SELF-FLOSSING TECHNIQUE FOR CLUNEAL NERVES

Figure 8. Self-mobilization technique for the cluneal nerves. Patient lies supine and places a towel roll around the distal thigh. Both hips and knee are flexed comfortably. The patient sidebends the trunk toward the affected side. The patient initiates hip flexion with assistance of the towel and returns to the initial position. A small soft pillow may be placed under the affected side if contact surface is uncomfort- able. The technique could be performed in sidelying using the same conditions (not shown).

CONCLUSION other adjacent nerves when understanding clinical The anatomical description derived from this study presentation and results of the clinical examination provides useful information about the location of pain and proposed tests. Entrapment pathology, perhaps due to cluneal nerve injury when suspecting pathology less frequent than surgical injury of the cluneal nerves, of these nerves. Although there seems to be consensus is still a plausible cause of persistent pain in the lum- about the entrapment site of the medial superior clu- bosacral spine, and could be considered when other neal nerve, it is also important to consider the possible treatment options have failed to relieve symptoms, and variations in the number of cluneal nerves, distribu- when history and clinical presentation make sense for tion of nerve territory, and possible anastomosis with this condition.

References

1.- Delawi D, Dhert WJ, Castelein RM, Verbout AJ, Oner FC: The incidence of donor site pain after bone graft harvesting from the posterior iliac crest may be overestimated: a study on spine fracture patients. Spine 32:1865–1868, 2007

2.- Frymoyer JW, Howe J, Kuhlmann D: The long-term effects of spinal fusion on the sacroiliac joints and ilium. Clin Orthop Relat Res 134:196–201, 1978

3.- Maigne JY, Lazareth JP, Guérin-Surville H, Maigne R. The lateral cutaneous branches of the dorsal rami of the thoracolumbar junction: A study on 37 dissections. Surg Radiol Anat 1989;11:289-93.

4.- Maigne JY, Doursounian L. Entrapment neuropathy of the medial superior cluneal nerve. Nineteen cases surgically treated, with a minimum of 2 years’ follow-up. Spine (Phila Pa 1976). 1997 May 15;22(10):1156-9. 9 5.- Aly TA, Tanaka Y, Aizawa T, Ozawa H, Kokubun S. Medial superior cluneal nerve entrapment neuropathy in teenagers: a report of two cases. Tohoku J Exp Med. 2002 Aug;197(4):229-31.

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Through a business arrangement the IAOM-US provides administrative and promotional support to Optimal Dry Needling Solutions (ODNS) as the content provider. Although the IAOM-US believes in the use of Dry Needling as a tool, and the quality provided by Dry Needling Workshops, ODNS and Dry Needling Workshops is solely responsible for the content provided in the courses. These Dry Needling courses are not considered IAOM-US courses, thus are not subject to IAOM-US Member Discounts. Dry Needing course completion does not apply toward IAOM-US Certifications, Fellowship Training or ScD requirements. PTAs are not eligible to attend these courses. If you are pregnant, you need special permission to attend, as you cannot participate fully as a model for your partner. Please check with your State to see if it is within your scope of practice.

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