Biomechanical Approach to the Evaluation and Treatment of the Low Back Charles R. Thompson, MS, ATC Princeton University EATA January 7, 2007 Boston, MA PurposesPurposes andand GoalsGoals • Develop a sound biomechanical approach to your evaluation. • Change how we look at backs, hips, and groins. • Eliminate the term “low back pain” as a diagnosis. PurposesPurposes andand GoalsGoals Reduce the use of the terms “groin strain”, “hip flexor strain”, and “lumbar strain/ sprain”. Learn to treat what you see. SimplifySimplify EverythingEverything There are actually only three bones: Two innominates. One sacrum. SimplifySimplify EverythingEverything There are only three joints: Right and left sacroiliac joint. Pubic symphasis. SimplifySimplify EverythingEverything There are 45 muscles that attach on the pelvis. However, we will mostly deal with them in groups. OsOs InnominateInnominate Ilium Pubis Ishium OsOs InnominateInnominate PSIS OsOs InnominateInnominate Ishium Acetabulum Ischial Tuberosity Obturator Foramen OsOs InnominateInnominate Pubis Pubic Symphysis SacrumSacrum Sacral Base The sacrum is the result of the fusion of 5 vertebral elements. Inferior Lateral Angle ImportantImportant BonyBony LandmarksLandmarks Iliac Crest ASIS AIIS Pubic Tubercles ImportantImportant BonyBony LandmarksLandmarks PSIS MusculatureMusculature ofof NoteNote How do “muscular” issues become resolved without the use of Muscle Energy? Which muscle groups are most involved? MusculatureMusculature ofof NoteNote As mentioned, there are 45 muscles that attach somewhere on the pelvis. 16 attach on the ilium 13 attach on the ischium 16 attach on the pubes MusculatureMusculature ofof NoteNote Transverse Abdominus MusculatureMusculature ofof NoteNote Quadratus Lumborum MusculatureMusculature ofof NoteNote Psoas Iliacus Rectus Femoris Sartorius MusculatureMusculature ofof NoteNote Six Outward Rotators Piriformis, obturator internus and externus, quadratus femoris, and the inferior and superior gemelli. MusculatureMusculature ofof NoteNote MusclesMuscles ofof thethe ButtocksButtocks GluteusGluteus maximusmaximus GluteusGluteus mediusmedius GluteusGluteus MinimusMinimus MusculatureMusculature ofof NoteNote HamstringsHamstrings-- Biceps Femoris Semitendinosus Semimembranosus MusculatureMusculature ofof NoteNote MusculatureMusculature ofof NoteNote SacroiliacSacroiliac JointJoint Diarthrodial joint OR amphiarthrodial with diarthrodial characteristics. Auricular shaped, with the “long leg” meeting the “short leg” anteriorly. NormalNormal MechanicsMechanics Pubic Motions Caliper Rotation Superior/ Inferior Shear NormalNormal MechanicsMechanics Iliosacral = ilium moving on the sacrum with the sacrum being the fixed point- Standing flexion and extension. Three types of motion: Caliper (flaring) Anterior and Posterior Rotation Superior and Inferior Shearing NormalNormal MechanicsMechanics Iliosacral Caliper motion The ilium moves posteriorly and laterally = outflare OR The ilium moves anteriorly and medially = inflare. NormalNormal MechanicsMechanics Iliosacral Anterior Rotation, referred to as an Anterior Innominate Rotation OR Posterior Rotation, referred to as a Posterior Innominate Rotation NormalNormal MechanicsMechanics Iliosacral Superior / Inferior Shearing Referred to as an upslip or a downslip NormalNormal MechanicsMechanics Sacroiliac = sacrum moving on the ilium The ilia are the fixed points. Seated flexion and extension. - Uni- and bilateral sacral extension and flexion. - Sacral torsions (rotation on an oblique axis). NormalNormal MechanicsMechanics Sacroiliac When the trunk extends, the sacrum flexes. When the trunk flexes, the sacrum extends. When the sacrum rotates, L5 rotates in the opposite direction. NormalNormal MechanicsMechanics Sacroiliac There are three major axes of motion: Horizontal = sacral flexion and extension Vertical = sacral vertical shear Oblique = sacral torsion PathomechanicsPathomechanics Once we understand, or at least agree, that there is motion occurring at these joints, no matter how minimal, then we can understand or agree, that with pathology, these joints can become stuck, or dysfunctional. PathomechanicsPathomechanics That being said, we can follow the McKenzie model of dysfunction. Pathology can occur when there is: abnormal stress on normal tissue or normal stress on abnormal tissue. PathomechanicsPathomechanics Abnormal stress on normal tissue essentially involves some type and level of trauma. Normal stress on abnormal tissue essentially involves normal stresses on dysfunctional tissue. BiomechanicsBiomechanics ofof WalkingWalking At heel strike, there is posterior ilial rotation and a forward sacral torsion on the weight bearing side. There is essentially no motion in the pelvis on the non-weight bearing side as the ilium remains anteriorly rotated. BiomechanicsBiomechanics ofof WalkingWalking At the mid-point of the cycle, the ilium on the weight bearing side begins to move anteriorly, with the sacral torsion on that side at maximum. There has still not been any change on the non- weight bearing side. As the opposite limb strikes the ground, the original weight bearing side changes from posterior to anterior ilial rotation and sacral torsion is eliminated. BiomechanicsBiomechanics ofof WalkingWalking As the opposite limb strikes the ground, the original weight bearing side changes from posterior to anterior ilial rotation and sacral torsion is eliminated. The new weight bearing side now assumes the ilial and sacral changes previously mentioned. MuscleMuscle EnergyEnergy “Facilitates the correction of biomechanical dysfunctions by normalizing neuromuscularskeletal balance”. Any manipulative technique that involves the voluntary use of the patient’s muscles. MuscleMuscle EnergyEnergy Hands on technique that stresses the importance of a good biomechanical evaluation. Must have a working knowledge of the anatomy and biomechanics of the pelvis and low back. Must understand that there is motion occurring at the small joints of the pelvis and spine. MuscleMuscle EnergyEnergy Must become adept at discerning subtle changes in the biomechanics of movement and tissue texture. Can be more difficult on some athletes than others. MuscleMuscle EnergyEnergy MuscleMuscle EnergyEnergy Look for “barriers” to motion. Recognize that dysfunctions and corrections are found and treated in more than one plane. Pain may remain for 24- 72 hours after the correction is completed. MuscleMuscle EnergyEnergy This is not a technique that can be learned from a book; it takes practice to be able to note the subtle changes of palpation and motion. Must establish a rule for the number of treatments before referral. AdjunctAdjunct TherapyTherapy Techniques utilized to eliminate muscle/ soft tissue barriers- Myofascial Release; Strain- Counterstrain; Therapeutic Massage; Modalities- ice and/ or stim, hot packs, etc. AdjunctAdjunct TherapyTherapy Techniques utilized for diagnosis and treatment- McKenzie program; Mulligan Techniques (“NAGS”, “SNAGS”, and “MWMS”). DifferentialDifferential DiagnosisDiagnosis Spondylosis: Degeneration of the intervertebral disc associated with reactive changes to the vertebral bodies above and below the derangement. DifferentialDifferential DiagnosisDiagnosis Spondylolysis: Uni- or bilateral stress fracture at the pars interarticularis (isthmus) without vertebral slippage. Spondylolisthesis: Bilateral stress fracture at the pars resulting in anterior slippage of the superior vertebra on the inferior. DifferentialDifferential DiagnosisDiagnosis Netter, Ciba Clinical Symposia, Vol. 32, No. 6, 1980 DifferentialDifferential DiagnosisDiagnosis Spondylitis: Degenerative hypertrophy (osteoarthritis); may be associated with any of the aforementioned conditions. Netter, Ciba Clinical Symposia, Vol. 32, No. 6, 1980 DifferentialDifferential DiagnosisDiagnosis Posterior Lateral Disc Derangement Usually unilateral. Neurological S & S’s Decrease strength, reflex, etc. Eliminate as diagnosis prior to treating w/ ME. Special testing/ imaging to confirm. DifferentialDifferential DiagnosisDiagnosis Central Disc Derangement Present with mid- line back pain. Usually no neurological S & S’s. May or may not present with signs of dysfunction. Special testing/ imaging to confirm. Usually do well. Rowing. DifferentialDifferential DiagnosisDiagnosis Osteitis Pubes Pain in groin or hip flexor area. May have symptoms uni- or bilaterally. Usually have associated dysfunctions, which may be different day- to- day. Referral and special testing/ imaging. Good luck!!! DifferentialDifferential DiagnosisDiagnosis Harris and Murray, British Medical Journal, 1974, 4, 211- 216 DifferentialDifferential DiagnosisDiagnosis ASIS Avulsion Fracture Pavlov, Clinics in Sports Medicine, Vol. 6, No. 4, October, 1987 DifferentialDifferential DiagnosisDiagnosis Tumor Pubic Stress Fracture Facet Joint Inflammation Hip Joint (Acetabulum) Pathology All of the Hernia’s (Gilmore’s Groin, Sportsman’s Hernia, Athletic Pubalgia) DifferentialDifferential DiagnosisDiagnosis Transitional vertebrae (variation) Sacralization of L5 Fusion of L5 with sacrum DifferentialDifferential DiagnosisDiagnosis Transitional Vertebrae (variation) Lumbarization of S1 Resulting in a sixth lumbar vertebrae, and only four sacral vertebrae. BarrierBarrier ConceptConcept Point beyond which a joint will not move Types: Physiological- limit of active range Anatomical- limit of passive range Going beyond anatomical