MID BACK, LOW BACK, AND BUTTOCK PAIN

The solution for back pain may be simpler than been led to believe. Many people are haunted by the fear that pinched nerves, ruptured disks, or arthritis are causing back pain, when there is a good chance that the pain may be coming solely, or at least in part, from myofascial trigger points in muscles.
Even when back pain is due to genuine problems in the vertebral column, myofascial trigger points always contribute a major part of the pain. In fact, there’s reason to believe that trigger points are the root cause of many spinal problems because of Muscle tension they maintain. Muscle tension displaces vertebrae and causes compression of nerves and disks. When investigating back pain, trigger points should be at the top of the list.
The reason there are so many differing opinions about the cause of back pain is that it’s mostly referred pain. Trigger points in the buttocks muscles are frequent causes of low back pain. The reverse is also true: trigger points in the low back often refer pain down the buttocks and hips.

Deep Spinal Muscles

The many  kinds of muscles associated with the spine make a confusing array, but it helps to think of them as belonging to two groups: the outer layers and the inner layers. The outer layers are the superficial spinal muscles, which are long muscles running parallel to the spine. The inner layers are the deep spinal muscles, which are very short muscles oriented diagonally to the spine to gain leverage on individual vertebrae. The names of the various deep spinal muscles are the semispinalis, multifidi, rotators, and  lever costae. The last group, the lever costae, attaches the vertebrae to the ribs. The other all attach the vertebrae to one another at successively deeper levels. Their angular arrangements gives them good leverage for twisting and side bending the spine. When the deep spinal muscles all work together, they help extend the spine, like when you straighten back up after bending over.

Symptoms

Pain from the trigger points in the deep spinal muscles may feel like it’s in the spine itself. Trigger points in the thin multifidi muscles that cover the sacrum at the base of the spine cause sharp pain in the low back. This is one of the few examples of trigger points that cause pain right at the site rather than referring it away. This is because the tension in these small diagonal muscles tend to pull one or more vertebrae out of line to one side. When vertebrae are not perfectly seated together, they send out pain signals of their own, adding to the pain from the muscles. Trouble with deep spinal muscles and their associated vertebrae can be extremely disabling, all motion –front, back or sideways. Your back typically feels as stiff as a board. Turning your body is next to impossible.

Trigger points in the deep spinal muscles of your lower back can send pain forward to the abdomen and downwards into the buttocks. The tailbone can be quite tender because of the referred pain. Your sacroiliac can be put “ out of line by trigger points at the base of the  spine. This is because tension in the deep spinal muscles twist the sacrum, the board bone that joins the spine to the pelvis, causing a slight disarticulation. It’s likely that when chiropractic or osteopathic adjustments to the spine succeed, it’s because the trigger points it’s because trigger points in the deep spinal muscles are incidentally deactivated. When an adjustment fails to the affect the trigger points, the vertebrae are pulled right back out of place again. When trigger points are deactivated directly with deep trigger point, massage clients often feel vertebrae popping back into place on their own.

Extreme tension in the deep spinal muscles can result in damage to the intervertebral disks. Nerves can also be squeezed by the compression vertebrae, causing pain, numbness, and other symptoms in the parts of the body served by the nerve. Chronic, long term tension in the deep spinal muscles can cause scoliosis curves. A proper understanding by physicians of the myofascial source of back pain could make many back operations unnecessary.

Osteoarthritis is given the credit for much back pain, especially when it shows up on the X-ray. The problem with medical diagnosis of arthritis is that it shuts off all further inquiry and leaves you with painkillers as your only solution and they are a poor solution to pain when trigger points are the cause. Back pain is banished by trigger points therapy a very high percentage of the time, even in the presence of “provable” arthritis. It’s a fact that osteoarthritis doesn’t always cause pain. Active trigger points always do (1999,925; Crow and Brodgon 1959, 97).

Superficial Spinal Muscles

There are three long, superficial muscles on each of the spine; the longissimus, the illiocostalis and the spinalis. They make up the long vertical mounds of muscles that run down between the shoulder blades and the spine. They’re thicker in the low back and get progressively thinner as they move up past the shoulder blades. The word  “superficial” tells you that they are closer to the surface, covering the deep spinal muscles.

At their upper ends, the longissimus muscles attach to the rib and the ribs and the transverse processes (small lateral projections) of the vertebrae. The upper ends of the illiocostalis muscles attach only to the ribs and the lower ends of both muscles attach the sacrum, the large board bone at the base of the spine. The spinalis muscles running right along the spine, attach only to the vertebrae. They’re present only in the upper half of back.

The superficial spinal muscles help with exhalation, bowel movements, couching, and sneezing. They also function to checkrein the body when you bend forward or to the side. They participate in keeping the body upright and balanced. Like the deep spinal muscles, these long muscles of the spine can be quite relaxed when you’re standing still if the body is well centered. 

Symptoms

In addition to pain, Trigger points  cause tightness of the superficial spinal muscles over their entire length They can bulge out in a hard contraction, giving the impression that one whole side of the back is in trouble, when a single trigger point somewhere is actually the prime instigator. Although this is commonly called a “back spasm,” it’s not a true spasm that will respond to treatment with heat and stretching. A contraction that’s being maintained by trigger points won’t give up until you locate the trigger points and deactivate them.

Trigger points in the superficial spinal muscles cause a more diffuse kind of pain than trigger points in the deep spinal muscles. The deep spinal muscles cause pain right around the trigger point. Trigger points in the longissimus and spinalis are found within a couple inches of the spine and send their pain generally down the low back and buttocks. The iliocostalis trigger points are found three or four inches from the spine and send their both upwards and downwards and a little more to the side. Trigger points in the region of the lowest ribs send pain down to the buttocks, no matter what muscles they’re in. A trigger point in the longissimus right on the lowest rib is a frequent cause of deep pain along the top of the illac chest (hip bone). This is experience as low back pain and one of its major causes. This trigger point can occur on either side.

Pain from the illiocostalis muscles may also be projected to the front of the body or to the internal organs, and can be mistaken for pain of angina, pleurisy, or appendicitis, or other visceral disease. Pain from trigger points in any of the superficial spinal muscles can be misinterpreted as a symptom of kidney stones, tumors, rib inflammations, ligaments tears, or disk problems. When you do have one of these more serious conditions, remember that myofascial pain from the back muscles is likely to be contributing to your discomfort. Often, trigger points are the only real problem that exists.

Buttock Pain

Gluteus Maximus

Gluteus Maximus is as simply something to sit on. The truth is that without your gluteal muscles you’d literally fall on your face. You wouldn’t be able to walk, run, jump, or even stand up. Of the nine buttock muscles the gluteus maximus is the largest. Trigger points in the gluteus maximus cause pain in the lower back and in the buttocks themselves.

The function of the gluteus maximus is hip extension, which is the action employed in climbing stairs. Jumping, running and fast walking requires the power of these muscles; The gluteus maximus muscles contract strongly when you lean over when your knee are bend or when you squat or do a deep knee bend . They also help you get up from sitting; position.

Symptoms

Gluteus maximus trigger points don’t send their pain very far, depending on the trigger point location, pain is felt in the low back, outer hip, tailbone, or gluteus fold, or the sacroiliac joint at the base of the spine. You may find yourself constantly changing position while sitting due to a general aching and burning in the buttocks. The hips may feel stiff, may have difficulty getting up out of the chair, or can no longer bend over and touch the toes, part of the problem is undoubtedly a shortening of the gluteus maximus muscles caused by trigger points. Pain caused by gluteus maximus trigger points is often blamed on bursitis of the hip, a compressed disk, arthritis, sciatica, or a sprung sacroiliac joint. Pain in the tailbone can be mistaken for damage or disease when it’s only referred pain from  a nearby trigger point.

Causes

Trigger points can also come from a sudden hard contraction experience in a fall. Sitting on hard surfaces or just sitting to much activates trigger points in gluteus maximus muscles. Office chairs are particularly bad for them, often having only one layer of highly compressible foam over a rock hard plywood or molded plastic seat. Office workers who must sit all day are guaranteed an eventual chronic backache emanating from gluteus trigger points.

Other hidden factors make trouble. Trigger points can cause tension in the gluteus maximus muscles to disturb the sacroiliac joint and add to the low back pain. Stiffness in trigger points afflicted spinal, abdominal, or thigh muscles can put extra strain on gluteus muscles. Unfortunately, the recommended practice of lifting with bent  knees to avoid straining the back can overload gluteus maximus  when done repetitively.

Gluteus Medius

Gluteus Medius is on top of the list of the many muscles that cause low back pain. A great deal of low back pain could be ended quickly with proper attention to gluteus medius muscles

Symptoms

Pain from trigger points in gluteus medius muscles is felt in the low back just above and below the belt line and often extends into the buttocks and hips. Back pain from this source can be excruciating and disabling, seriously undermining endurance. Pain in the hips can make it hard to find a comfortable sleeping position. Pain in both hips and low back pain can make walking impossible.

Afflicted gluteus medius muscles pull the rim of the pelvis down, stiffness and flattening the lower back and adding to the disability. Chronic shortening of gluteus medius muscles caused by latent trigger points make standing and walking with the pelvis thrust forward. The common assumption is that pain in the low back is caused by some problems in the lumbar spine, such as arthritis, a herniated disk, disarticulated vertebrae, a compressed nerve, or a sacroiliac joint dysfunction. X ray evidence of these spinal abnormalities is often used to justify surgery for low back pain, although such abnormalities are often found in people who suffer low back pain. Pain from myofascial trigger points that remain after surgery can be greatly mystifying and frustrating to both doctor and patient. It’s disturbing to think that trigger points may have been the only thing needing correction the first place.

Causes

Although the gluteus medius  is no more than half the size of the gluteus maximus , it’s  still a very thick strong muscle, whom primary function is allowing to walk upright. When walking, the gluteus medius muscles takes turns supporting the entire weight of the upper body. Because of the leverage at the hips, gluteus medius muscles have to alternately generate a force equal to more than twice the body weight.

Any additional demands or imbalance is compounded in this way. For instance, consider that each pound of excess body weight adds two pounds to the workload of the gluteus medius muscles. Heavy people may often lumber or waddle, throwing their weight from side to  side as they walk. This is the body’s natural effort to protect itself by moving the weight fully over the leg with each step instead of requiring the gluteus medius muscles to lever it.

Gluteus Minimus

Gluteus Minimus muscle attaches to the lower half of the wing of the hip bone and to the top of the greater trochanter. Its functions just like the gluteus medius in supporting the pelvis during walking. The gluteus miniums is the smallest of the gluteus muscles, buried under the maximus and the medius, which is six times as large. Considering its size, might think the minimus would be little consequence, but it can create great discomfort over a surprisingly widespread area, leaving doctors full of consternation and puzzlement.

Symptoms

Trigger points in the gluteus minimus muscles cause pain down the back or the side of the thigh and the lower leg as far as the ankle. Tracking down the problem can be made difficult by pain from the associated trigger points in the quadrates lumborum, gluteus medius, piriformis, tensor fasciae latae, vastus lateralis, peroneus longus, and hamstring muscles. Pain from the gluteus minimus trigger points can be excruciating and constant. Numbness can occur anywhere in the referral areas. In addition to leg pain, there is often diffuse tenderness in the buttocks. Walking is painful. Getting up from a chair is painful. You may limb to favour the afflicted side or have difficulty crossing the legs. Rolling over on the bad side can awaken up at night.

Pain and other symptoms in the buttocks and backs of the legs and collectively called sciatica, independent of the cause. Sciatica is a description, not a diagnosis, although it’s usually assumed to result from compression of the sciatic nerve or a nerve in the spine, bursitis of the hip, or sacroiliac joint dysfunction. Surgery for sciatic symptoms is appallingly common, though it regularly fails to erase the pain when a physician has neglected to consider myofascial  trigger points in the diagnosis.(1992, 173-175 Sheon, Moskowitz, and Goldberg 1987, 165, 168-169)

Causes

Sitting on a fat wallet is well known cause of trigger points in the gluteus miniums, resulting in “back pocket sciatica.” Pressure from a wallet inhibits blood flow. Trigger points predicably arise in muscles where circulation is restricted.

Falls , prolonged sitting, prolonged standing are examples of things that can foster trigger points in the gluteus minimus  muscles. Low back pain that comes on after standing or walking can usually be blamed on trigger points in these muscles. Limping to favour a bad knee or a sore foot places undue stress on this muscle. Carrying your weight on one leg makes the gluteus minimus on that side work double time.

Chronic sacroiliac joint displacement with its resulting pain is often due to trouble in the gluteus minimus and medius. If frequent sacroilica adjustments by the chiropractor seems to help but never have  a lasting effect.

Piriformis

Piriformis is the largest and most important of six shorthip rotator muscles that are located between the sacrum and the greatest trochanter in the middle of the buttocks. The piriformis muscle attaches just inside the rim of the sacrum and then travels across to attach the top of the greater trochanter. With the leverage gained by these attachments, the piriformis is able to strongly rotate the leg outward. When the leg is stationary the piriformis turns the body in the opposite direction. Over doing either of these rotary  movements tend to set up trigger points in piriformis muscle. Piriformis muscle cause an incredible amount of misery, as much from nerve and blood vessel entrapment as from the referral of myofasica pain. When the piriformis is to blame for your trouble, you’re lucky if you ever find out.

Symptoms

Pain and other symptoms in the buttocks are likely to be composite effect from more than one muscle. Nevertheless, in most instances, can expect the piriformis muscles make a great deal of trouble, especially for women. For some reason, problems caused by trigger points in piriformis muscles are six times as prevalent in women as in men. Luckily, once grasp the cause and effect of myofasica pain, these problems aren’t difficult to cope with (1992, 193 Pace and Nagle 1976,  435-439)

Referred pain from the piriformis is felt in the sacrum (base of the spine), the buttock, and the hips. Either trigger point may refer to the entire buttock area. Occasionally, pain spread to the upper hamstring. Trigger points occur in the other short hip rotator muscles just below the piriformis are to have similar referral patterns.

Tension in the piriforms can put a twist in the sacroiliac joint, adding to the pain. The resulting tilted sacrum can make appear to have a short leg. Shortening of the piriformis sponsored by trigger points make it difficult to cross the legs or rotate the leg inwards. Spreading the legs may also be extremely painful. May limp cause of the pain. When trigger points are bad enough, may not be able to walk. Will be unable to find a comfortable sitting position; tend to squirm and shift around constantly. Sitting aggravates afflicted piriformis muscles. Lying down brings little relief.

A shortened piriformis muscle also grows in diameter, causing compression of the sciatic nerve, which results in an entirely separate set of symptoms. Pain from sciatic nerve compression is harsher than the pain produced by trigger points and is felt in the back of the thigh, the calf, and the sole of the foot. There may also be other abnormal sensations, such as numbness, tinging, burning, or hypersensitivity, in any of these areas. A familiar example of the effects of pressure on sciatic nerve is the prickly tingling in the legs and feet after sitting to long on a toilet seat.

A piriformis muscle that is shortened and swollen by trigger points can entrap numerous other nerves and blood vessels coming out of the pelvis, making all kinds of trouble. One result can be a sense of swelling in the buttocks, leg, calf, and foot. Even worse, a tight piriformis muscle can impinge upon the pudendal nerve, causing impotence in males and pain in the groin, genitals, or rectal area of either gender. Piriformis muscles compressing gluteal nerve and blood vessels are to believed to be responsible for gluteal muscle atrophy, wherein one or both buttocks waste away.

Pain and all other symptoms caused by piriformis trigger points are commonly misinterpreted to be the results of inflammation of the sciatic nerve, Intervertebral disk protrusion, arthritic spur formation, or spinal nerve root compression. Wider recognition of the myofascial  causes of “piriformis syndrome” could eliminate many unnecessary spinal operations.

Causes

When not well conditioned for such activities, vulnerable muscles like the piriformis are the first to suffer. Work that requires twisting while lifting also can stress them unduly.

On the other hand, inactivity, especially too much sitting, can promote the development  of trigger points in the piriformis muscles.

 

References:

  • Travell J.G , and D C . Simon " 1992 Myofasical Pain and Dysfunction.
    Baltimor : Lippincott, Williams and Wilkins.
  • Clair Davies and Amber Davies 2004 The Trigger Point Therapy Workshop, 2nd ed.
    New Harbinger, United States of America.