Clinical pearls
Treating the low back
Nick Soloway, LMT, DC, LAc
Chronic low back pain is common. In my practice the most common finding is that the person presenting with chronic low back pain has the following: a short leg, a short hemipelvis, or both. Occasionally a person may present with an asymmetrical tension pattern in the quadratus lumborum muscles that is not due to either a short leg or short pelvis. In this case, the person may have a tilted sacral base or a wedged vertebra. If this is a case, the asymmetry of the quadratus lumborum tension will not change in standing or in sitting position. Putting the appropriate size lifts in standing and sitting may resolve asymmetrical tension in the quadratus lumborum.
The next important thing to check is the ease of dorsiflexion of the ankle. Ideally, the ankle should dorsiflex 110°. Often times, the ankle can barely make it to 90° which causes postural problems. The tibia is unable to be 90° to the ground without tension which makes the upper body have to compensate for the backward force of the calf muscles. Occasionally, one foot will significantly have less dorsiflexion than the other. This will cause a change in gait and cause the opposite quadratus lumborum to have increased tension. If the foot cannot dorsiflex easily, during the swing phase where the leg and foot are coming forward to heel strike the person will lean away in order to clear the toes. This leaning away increases tension in the opposite quadratus lumborum. Increasing dorsiflexion in the offending foot will often reduce the opposite quadratus lumborum tension significantly.
The first thing I do with all of my patients is to treat the acupuncture point Large Intestine 4. I treat this point with acupuncture and literally within seconds the quadratus lumborum muscles release 20 to 30% of their tension. If acupuncture cannot be used, manual pressure on this point or electrical stimulation will have similar effects.
Next, I do a sacral lift. I sit at the right side of the supine patient and place my right fingers just slightly above the sacral-coccygeal junction and my left fingers between the posterior superior iliac spines. With both hands I push and lift the sacrum towards the ceiling. Within 10 seconds or so the sacral iliac joint will begin to free and the patient will feel a melting sensation and relaxation. I may hold this for up to a minute to start the process of overall body relaxation.
In the past, I would then go down and start treating the feet, calf muscles, and the extensor digitorum brevis but I have found that treating flexion restrictions in the neck is a very powerful technique to relax all the posterior muscles.
Many years ago, I came across an article that compared stretching the hamstring muscles to stretching the neck muscles in increasing hip flexion range of motion. Stretching the neck muscles increased hip range of motion much more than stretching the hamstring. These days, I will do a slight flexion nodding of the head and neck to determine where the biggest flexion restriction is. I will then do light cross friction massage on the midline until I perceive a release. The patient will perceive a generalized relaxation of the entire body. Depending on the level treated, they will experience other releases. Frequently they will feel their jaw and face relax, eyes relax and in about 30% of people treating their area of C-5 will cause a relaxation of the epigastric region.
Let me briefly explain how this technique works. Imagine you’re standing and going to bend forward and touch your toes. When you decide to stand straight again several things occur: your eyes look up and your head and neck extend backwards then all the muscles on the posterior part of the body pull you up. If the neck extensors are tight it’s almost as if your brain thinks that you’re going to stand up and as a result the tone of all the posterior muscles increases. By releasing the tension in the neck extensors that signal to the brain is stopped and all the muscles in the posterior portion of the body relax. This includes all the muscles on the bottom the feet, all calf muscles, hamstrings, glutes and the back muscles. One of the fun things you can do with this technique is first do a straight leg raise to see how much hip flexion there is. Then do the cross friction technique on the neck usually for 3 to 5 minutes at the most and then recheck the hip flexion. Usually people will gain anywhere from 20 to 90° more flexion. Often times the patient will be amazed as they have been trying to stretch the hamstrings for years without much change. I will then instruct them in the proper way of stretching hamstrings which includes sitting on a stable surface putting a heel up which allows access to percuss the hamstrings and then very importantly flexing the head and neck as they bend forward and once they reach the end of their range of motion percuss with their fists the hamstring.
Though the only range of motion that was checked was the hip range of motion all other ranges of motion that are connected to any muscle in the posterior the body will have increased too.
After treating the neck I will then start treating the feet and especially the extensor digitorum brevis. The extensor digitorum brevis connects to the proximal interphalangeal joint and dorsiflexes the metacarpophalangeal joint. If the extensor digitorum brevis is tight the toes cannot plantar flex and as a result there is a decrease in balance due to a decrease in toe pressure on the ground. It is close to 100% of people that have decreased plantar flexion in the left forefoot. This can be corrected by a chiropractic adjustment by pulling the metatarsals inferiorly to free up the metatarsal cuneiform joints. It also can be corrected by doing a myofascial release pulling the metatarsals inferiorly while pushing the cuneiforms superiorly. Getting the toes and forefoot to plantar flex more will be improved balance and they’ll be less compensatory tension in the entire body.
The next important area to treat is the hip flexors. When they are tight they cause an anterior tilt of the pelvis which causes a compensatory extension of the low back to get the body weight over the pelvis and feet. Hip flexors tend to be quite tight because most people sit all day and these muscles shorten. It may take quite a long time of treatment to get a significant reduction in the hip flexor tension. Often, as the hip flexors release a decrease in tension in the buttock muscles and low back will be perceived by you the practitioner and the patient.
Another very important area to treat is the psoas muscle. Usually the right psoas is tighter due to physiological scoliosis. According to literature, the psoas can do three things: flex the lumbar spine, extend the lumbar spine and cause flexion of the upper lumbar and extension of the lower lumbar vertebrae. The most effective technique to treat the psoas is to go about 2 inches below the navel and then laterally palpate for tight bands of muscle in the psoas. Apply digital pressure towards the table taking up any slack in the muscle and then apply low-frequency vibration either on your hand or next to it for a fairly quick release of muscle tension. Treat both sides but usually the right side is the tightest.
While you are in the abdominal area is important to check for tension in the epigastric region for a hiatal hernia. Palpating just below the xiphoid process will reveal in many people quite a bit of tightness. If this tension is found when asked if they have heartburn will often answer the affirmative. Often engaging the top area of the tension and pulling down towards the sacrum will cause a pulling sensation to be felt in the patient’s throat. If the patient has perceived or occult heartburn this will cause irritation to the esophagus causing it to shorten and when you pull the stomach down this will tension tissues in the throat. The most effective technique in releasing this tension is to first treat the rib cage and diaphragm to normalize the diaphragm muscle. I sit to the right side of the supine patient placing my left fingers on the lower anterior lateral rib cage and my forearm on the right side. I then compress the right and left rib cages towards the middle and apply low-frequency vibration to my forearm in a very short time the rib cage will regain some more suppleness and re-palpating the previously tight area in the epigastric region will show it to be much less tight. This compression of the rib cage can be done several times lasting for about 20 seconds each time. I will then go below the xiphoid process palpating the top of the tension area and engage this tension by pushing anterior to posterior and then pulling the stomach towards the sacrum. Again low-frequency vibration is applied to either the treating hand or adjacent to it until a release of tension is felt. Once this release of the stomach tension occurs, the thoracic spine will be felt as it is extending. The chest will feel as if it’s opening. In tension in the low back will be released. Because of the tension in their upper G.I. system people will tend to hunch forward to prevent feelings of tension in the throat and as a result the thoracic erector spinae muscles will be tight holding the body in this forward hunched position and the lumbar muscles will be tight trying to pull the body to the best gravitational line. Once this upper G.I. tension is released whatever has compensated for it will also release.
This is the minimum that should be done on the anterior for all low back patients. Treating the anterior deltoid is useful and relaxing the shoulder complex and especially the latissimus dorsi which spans from the pelvis to the shoulder. When it releases the side will be perceived as lengthening. Treating the scalene muscles is useful in helping to bring the head over the shoulders.
So now it’s time to turn the patient over so they are prone. I place a pillow under their ankles and wedges under the anterior superior iliac spines to help bring the lumbar spine into a little bit more flexion. In this position I will usually start treating the popliteus muscle at the back of the knee and after that has released I will pinch the lateral and medial hamstring tendons near the insertions towards the midline of the knee and apply low-frequency vibration and wait for the main bulk of the muscle to relax. Treating the tendons is important to do first and then palpate the hamstrings to find any residual trigger points and treat them directly. The soleus is an important muscle to treat, one of the trigger point referral area is at the PSIS/sacral multifidus area. The sacral multifidi when tight, seem to increase the tone of all the back extensor muscles. Treating the soleus and then the sacral multifidi will greatly relax the back muscles
I will then move up and span the sacrum at the level of S2 and push posterior to anterior with my middle finger and thumb. In the vast majority of patients the right side is tighter again adding low-frequency vibration will cause the spots to release. I will then palpate the posterior border of each trochantor to find tender spots. I treat these with firm digital pressure and low-frequency vibration to release the muscle involved. Treating the tender spot of any tendon insertion will release the involved muscle much faster than treating the muscle belly itself.
In the vast majority of cases, the lumbar muscles which are hurting are generally compensating for some other imbalance. One of the most common imbalances is the thoracic spine not being able to extend properly. When the thoracic spine cannot extend it moves the center of gravity of the trunk anteriorly and as a result the lumbar spine has to extend to bring the body weight over the pelvis and feet. I have coined the phrase “treat the kyphosis and cure the lordosis”. Getting the thoracic spine to extend easily will reduce tension in the low back and in the neck. There are a number of ways to increase the extensibility of the thoracic spine. Percussion with a closed fist across the spinous processes is one way. Using a dowel and hammer as an option. Standing at the head of the table and placing the heel of the palm on the flexed spinous process and pushing at about a 45° angle to the spine will increase extensibility. Another very effective technique is to percuss the sacrum with a fist for about 5 to 10 minutes. This will loosen the sacral iliac joint allowing the sacral base to move posterior, reducing the lumbar lordosis and you’ll reduce the stiffness of the thoracic spine.
Generally the right quadratus lumborum is tighter than the left because of physiological scoliosis. Because of this the fascia on the right lateral side from the iliac crest to the rib cage has shortened I will generally palpate for a restriction and push into the barrier adding low-frequency vibration which causes the fascia to release. The quadratus lumborum after releasing the right side fascia will be significantly looser.
I’ve also palpate the lumbar spine feeling for any vertebra that are flexed. If a vertebra is flexed the vertebral below will tend to go into more extension in order to get the body weight over the pelvis and feet by doing myofascial release techniques to reduce the flexion of the vertebra the vertebra that have been compensating below will relax.
Often spinous processes of L5 and L4 are an extension. I will place a thumb below the spinous process and try to lift it into flexion. I will also palpate the lumbar fascia for ease of movement from inferior to superior direction, often there is a significant block in the movement of the fascia towards the head I will take up tissue tension add low-frequency vibration and wait for the fascia to release. Once these releases happen the quadratus lumborum will again be much looser.
Another technique to use is the modified Logan Basic Technique. Palpate the sacrotuberous ligaments. In the vast majority of patients the right side is tighter, again because of physiological scoliosis. Place your thumb about a third or half way of the length of the ligament and apply pressure towards the head. I place low-frequency vibration device spanning the lumbar spine at the level of about L3 to get the quadratus lumborum muscles to relax this takes about 30 seconds or less and again causes significant relaxation of the lumbar muscles.
Next I moved to the upper body. My table has an armrest which allows the humerus to be perpendicular to the floor. I palpate for the anterior deltoid muscle trigger point. Again I apply digital pressure and low-frequency vibration to the trigger point and wait for a release often times the body will feel as if it straightening due to the relaxation of latissimus dorsi which spans from the pelvis to the humeral head.
I’ll palpate the spinous process of C2. I will push it into extension and add low-frequency vibration to relax the suboccipital muscles that are attached to it. I will then palpate for the posterior processes C1 and press straight posterior to anterior again with low-frequency vibration to disengage the occipital condyles and relax suboccipital muscles that are attached to C1. And again because of the mechanism explained above involving neck tension often times treating C1 and C2 will evoke an entire body relaxation.
I will also treat each individual vertebra by placing my fingers to the side of the spinous process and pulling it as to try to rotate it with added low-frequency vibration. This will release much of the deep intrinsic muscle tension of the rotator muscles and multifidi muscles.
I generally will finish the treatment by spanning the cervical spine with my index finger and thumb placing them at the base of the skull and tractioning the skull superiorly again using low-frequency vibration to aid the release. If I perceive any remaining tension in the erector spinae muscles I will treat them and then return to the cervical traction. Often times the will be tight spot on the right lateral neck around the level of C3 to C4. To treat that I place my middle finger on the left, opposite the tender and tight spot on the right and place my thumb at the base the skull behind the mastoid process. I will traction the skull with my thumb and put pressure with my middle finger towards the tender spot on the right side. This causes a relaxation of the right lateral flexion of the cervical spine.
As you treat the thoracic and lumbar spine you should check the tension in the mid cervical area. As the curves soften the trunk will lengthen . This will cause the forehead to be pushed against the face cradle which in turn will cause the head and neck to extend and increase the tension in the cervical muscles. Just pull the face cradle away from the table about ¼-3/8 of an inch. Repalpate the neck and it will be looser.
By doing these procedures I expect a significant if not complete resolution of the symptoms in one treatment.
