Myofascial low back pain
Mitsutoshi Hayashi
Mitsutoshi Hayashi
Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association
Myofascial low back pain
Disease Overview
Lower back pain is a general term of pain at low back. It is one of the most common injuries in sports and there are several types. Myofascial low back pain is a type of lower back pain caused by damage to the fascia and muscles of the lower back due to sports activities.
Cause and mechanism of onset
The lumbar spine consists of five layers of bones of the vertebrae that make up the spine. There are tissues named lumbar disc that substitute for cushions between the bones and absorb the shock between them. The abdominal muscles (abdominal rectus muscle, internal and external oblique muscle, and transversus abdominal) and the dorsal muscles (erector spinae, latissimus dorsi, and psoas major) also support the spine by surrounding it.
Myofascial low back pain is said to occur when excessive strain is placed on the back muscle due to improper position (bending and stretching, rotation and impact) during sports. Acute fascial or muscle damage is the so-called muscle strain. Lumbar spine sprains (including ligament and joint capsule injuries) have similar implications. The symptoms include low back pain, tenderness, and pain during exercise that occurs along the lumbar spine. In chronic cases, fatigue caused mainly by overuse leads to increased tensions of the back muscles, and develops a pain along the muscles.
The pain developed by general sports movements such as pitching, jumping, swinging, hyperextension of the trunk (dorsal muscles), flexion (abdominal muscles), rotation (oblique abdominal muscles), and twisting of the lower back from the mid-lumbar position. It usually occurs with strenuous movements that are stressful to the lower back. Maintaining an anteversion position in golf and impact on landing in volleyball may also cause lower back pain.
Diagnosis
There are no neurologic symptoms, such as numbness or muscle weakness in lower extremity or sensory disturbances, or bone changes on X-ray. Differentiation is difficult, but it is common in lower back pain without the aforementioned findings. Many of the so-called acute lower back pains seem to occur as a result of damaged fascia.
Differential diagnosis
Lumbar spine disc herniation
The nucleus pulposus protrudes from the intervertebral disc between the lumbar vertebrae, compresses the nerves and causes pain in the lower back, buttocks, and posterior aspect of the lower extremity (sciatica) and numbness at the toe. It seems to be caused by excessive strain on the lumbar region, and MRI is more useful than X-ray in the diagnosis.
Lumbar spine sequestration
It is prevalent in athletes who are heavily loaded on their lower back during their developmental period. The pain appears due to abnormal mobility in separated part, as vertebrae arch on the posterior aspect of lumbar spine has separated (stress fracture). Low back pain is easily aggravated when the trunk is retroflexed. X-ray and CT may differentiate it.
Treatment and rehabilitation
Physical mobility may be difficult in acute low back pain. In such cases, it is recommended to keep a patient at rest and treat with icing secondly. However, unnecessary prolonged rest may decrease muscle strength and flexibility, therefore stretching needs to be performed as soon as the pain is relieved. Thus, a full understanding of lower back pain and routine management such as stretching are necessary. There are also a variety of treatments, including the use of oral anti-inflammatory analgesics, external preparation such as packing sheet, and hyper thermic hot packs (especially in the chronic phase), physical therapies (electrotherapy, low-frequency or interference waves), ultrasound, low-power lasers (Photo 1), acupuncture, massage and chiropractic. The choice of treatment may vary depending on the symptoms and condition. Belts for lower back pain are also helpful for athletes as they are designed to stabilize the lumbar spine and pelvis against excessive dynamic strain (Photo 2).
Photo 1: Laser treatment is also conducted in the management of lower back pain in all of the National volleyball team in Japan.
Photo 2: Using a belt for lower back pain during playing reduces the burden on the lower back and ensures stability.
Important tips
[Hip joint flexibility]
It is important to acquire flexibility of the adjacent hip joint in order to improve lower back pain. Flexibility checks are performed such as the SLR test, standing forward flexion, and heel-to-hip distance in the prone position. Decreased muscle flexibility around the hip joint increases strain on the lower back. Make sure to acquire the range of motion of hip joint by stretching such as flexion (extension of the posterior aspect of the hamstrings of the thigh), extension (quadriceps muscle), abduction (abducent muscles), and adduction (iliotibial ligament) of hip joint. Training and rotary stretching of the trunk muscles may be helpful, especially in chronic lower back pain.
Yasuhiro Nakajima
Yasuhiro Nakajima
Head coach of Shonan Bellmares Sports Club Triathlon Team, Head coach of Triathlon Team of Nippon Sport Science University, and Chairman of the Japan Triathlon Union Multi-sports Committee
Trainer’s Edition
Prevention
It is important to train the trunk to increase flexibility around the hip joints, shoulders and scapula, and to improve the stability of the lumbar and abdominal muscles.
In practice, even if the muscles in the lower back are painful but the location that influences the burden on the lower back is broad, and the balance between full-body stretching and muscle strength should be adjusted.
Persistent postures that place strain on the lower back in daily life may cause fatigue prior to playing sports and increase the strain. Make sure to do stretching and exercising to improve posture.
Loss of flexibility in the buttocks just below the lower back also greatly affects lower back pain, and a decrease in the flexibility of the iliopsoas that performs hip joint flexion on the opposite side, raises anteversion of the pelvis as increases the strain on the lower back. Caution should be exercised not only for the muscles on the dorsal surface but also for the muscles on the anterior surface as they may be greatly affected.
Improvement of flexibility
Poor flexibility in the chest muscles may adversely affect scapula movement and the flexibility of the scapula on the reverse side. Therefore, make sure to start stretching the pectoralis major muscle firstly, followed by stretching the muscular group beside the scapula.
Improvement of trunk muscle strength
A variety of muscular group of abdominal and back muscles are presented. During sports activities, it is necessary to demonstrate strength in various directions and postures. A combination of exercises is recommended rather than focusing on one exercise.
Increased intra-abdominal pressure by stretching the trunk muscles reduces the spinal load by 30 to 50% (see the figure below) and increases the ability to support the spinal column with abdominal pressure. If you have the lower back pain and are unable to perform exercise to strengthen trunk, it is recommended to start with small movements and move gradually and dynamically.
If the person feels lower back instability even though the pain has not developed, reducing the strain on the lower back by using the supports during daily life and sports activities may also be preventive measures.
Figure: Ability of abdominal pressure spinal indicator
Displacement of organs of viscera and misalignment of lumbar spine may be prevented by increasing abdominal pressure with tightly contracted abdominal muscles, thoracic muscles and muscular group of the back that consist of abdominal pressure. That improves the ability of lumbar spine support and reduces compression force in the direction of the long axis (S2) compared to S1: quoted from "Sports Traumatology 2", Ishiyaku Publishers, Inc.
Photo 1: Stretching of hamstrings
Photo 2: Stretching of quadriceps muscle and iliopsoas
Photo 3 Stretching of the buttocks
Photo 4 Stretching of the lower back
On-site evaluation and first aid
If the patient is in great pain or unable to move, he/she should not forcibly stretch or massage. Instead, make sure to keep a patient at rest and do icing on the location of pain.
Because lower back pain may include the problems of bones and cartilage, such as a lumbar disc herniation, it is recommended to seek medical attention by a sport medicine doctor.
If the patient with lower back pain caused by weakness of muscle flexibility or poor muscle balance is allowed to move, check of flexibility should be done in the region involved.
Assumption of cause
Humans have acquired amazing civilizations by standing on two legs and enjoying using hands freely. However, they have to always face with the lower back pain in exchange for that. Finding the underlying stress and reducing it even slightly is important. Unlike a fracture or sprain, lower back pain does not have a single cause. As most cases are caused by inextricably intertwined, it is important to think of and assume various cases instead of simply identifying.
Majority of the common types of "lower back pain" are divided into five types: extension (Photo 5), flexion (Photo 6), rotation (Photo 7), rest and instability. It is difficult to identify the causes in the rest type and instability, but extension, flexion and rotation types are more likely to identify the cause.
In the extension type, backward movement increases pain and discomfort. The causes include decreased flexibility of the muscular group involved in hip joint flexion, such as the iliopsoas, quadriceps muscle, and tensor fasciae latae, or failure of the hip joint extensors (hamstrings). In the flexion type, pain and discomfort occur when the body is tilted forward like forward flexion in the standing position, and tightness of the lumbar back and buttock muscles and hamstrings are believed to be the causes. Rotation type is originated from increased pain caused by rotation of the trunk, which may result from inability of the abdominal muscles to function properly, the lack of muscle strength, and decreased flexibility of the lumbar quadrate muscle (the lumbar muscles on the rotated side). These classifications are not necessarily applied to the cause or related to the symptoms of lower back pain. However, they are helpful for identifying the characteristics of each muscle’s flexibility and the balance of muscle strength in the stage of dealing with them.
Reconditioning
Make sure to consult with a physician to check the symptoms and to move on to rehabilitation painlessly.
Stretching needs to be performed gradually from in small range to large range, and load of exercise gradually shifts from light to heavy.
It is recommended to use the supports to reduce the strain on the lower back to return to athletic activities in the process of preparation for restarting sports and in daily life.
Basic postures without load to the lower back and exercises with a foam roller or a balance ball in order to create movement needs to be performed while checking the existence of the lower back pain and instability.
It is important to improve both the muscle strength and endurance of the trunk and flexibility centered on the hip joints. It is preferable not only to stretch the parts involved, but also systematically. Let me introduce mainly on stretching and exercising around the hip joint, lumbar region, and scapula. However, it is recommended to work out after easing excessive tension of the muscle, as there is a risk to increase the pain due to muscular strain when the pain is severe. Ideally, a patient should be warmed with a hot pack, do stretching from more distant parts of the lower back and the trunk to gradually proximity to the trunk in a relaxed way, and finally do some exercise. Make sure to consult with a physician or an athletic trainer about the appropriate treatment. The support of the lower back pain to reduce the strain is also available and it is recommended to use proactively.
Photo 5
Photo 6
Photo 7
In the extension type, backward movement increases pain and discomfort. The causes include decreased flexibility of the muscular group involved in hip joint flexion, such as the iliopsoas, quadriceps muscle, and tensor fasciae latae, or failure of the hip joint extensors (hamstrings). In the flexion type, pain and discomfort occur when the body is tilted forward like forward flexion in the standing position, and tightness of the lumbar back and buttock muscles and hamstrings are believed to be the causes. Rotation type is originated from increased pain caused by rotation of the trunk, which may result from inability of the abdominal muscles to function properly, the lack of muscle strength, and decreased flexibility of the lumbar quadrate muscle (the lumbar muscles on the rotated side). These classifications are not necessarily applied to the cause or related to the symptoms of lower back pain. However, they are helpful for identifying the characteristics of each muscle’s flexibility and the balance of muscle strength in the stage of dealing with them.
Reconditioning
Make sure to consult with a physician to check the symptoms and to move on to rehabilitation painlessly.
Stretching needs to be performed gradually from in small range to large range, and load of exercise gradually shifts from light to heavy.
It is recommended to use the supports to reduce the strain on the lower back to return to athletic activities in the process of preparation for restarting sports and in daily life.
Basic postures without load to the lower back and exercises with a foam roller or a balance ball in order to create movement needs to be performed while checking the existence of the lower back pain and instability.
It is important to improve both the muscle strength and endurance of the trunk and flexibility centered on the hip joints. It is preferable not only to stretch the parts involved, but also systematically. Let me introduce mainly on stretching and exercising around the hip joint, lumbar region, and scapula. However, it is recommended to work out after easing excessive tension of the muscle, as there is a risk to increase the pain due to muscular strain when the pain is severe. Ideally, a patient should be warmed with a hot pack, do stretching from more distant parts of the lower back and the trunk to gradually proximity to the trunk in a relaxed way, and finally do some exercise. Make sure to consult with a physician or an athletic trainer about the appropriate treatment. The support of the lower back pain to reduce the strain is also available and it is recommended to use proactively.
Hip joint flexors
Photo 8: Reduced flexibility of the iliopsoas, rectus femoris, and tensor fasciae latae of the hip joint flexors tends to limit the posterior tilt of the pelvis and increase anteversion, and leads to increase the lordosis of the lumbar spine and cause the extension type of the lower back pain. Majority of those people tend to do stretching on the anterior aspect of the thigh, but not much to the hip joint flexors.
Hip joint extensors
Reduced flexibility of hip joint extensors, such as the gluteus maximus and hamstrings, and lateral rotator muscles, such as the piriformis, may cause the lower back pain, as the pelvis does not lean forward when operating flexion of the trunk. By sport, reduced flexibility on the posterior aspect of the lower leg may cause lower back pain in volleyball as players take a posture in lower positions, and reduced flexibility around the scapula may cause lower back pain in swimming. In light of this, it is important to perform comprehensive full-body stretching on a daily basis as well as individual stretching by region. Trunk relaxation and stretching may be accomplished with foam
Photo 9: Please place the left foot on the right knee in a supine position so that the left foot crosses over and lifts the right knee. With the left foot facing the knee, slowly move down the right foot. Make sure to place the lower back, shoulder and head on the ground.
Abdominal muscles
Lift the head up as like you are looking at the navel (Photo 10). It is OK as long as the scapula leaves the floor. Hold the position for seconds to tens of seconds and repeats several times.
Latissimus dorsi
Photo 11: Get down on all fours and keep raising one arm and one leg on opposite side flat in alignment in case of becoming painful by the exercise to lean back the whole body in a prone position. Begin with exercises in this position and hold for seconds to tens of seconds. Once the pain is relieved, you may proceed to normal training. Make sure to increase peritoneal pressure simultaneously with abdominal muscle group when doing exercises on the muscular group of the back.
Hip joint extensors
Photo 12: With the entire sole of the foot is placed on the ground with both knees bent in a supine position, lift the lower body up while supporting with both hands. At that time, the abdominal muscles and back muscles need to concentrate on the mind to the hip joint extensors while maintaining a balance with putting strength into abdominal muscles and the spine.
Abdominal and back muscles
Photo 13: Assume a position like push-ups by keeping both hands on the ground and with both feet on the ball. Put strength into the abdominal muscle group and the back muscle group to make the body as straight as a line.
