Athletes Treating Athletes

This is part ten in the Self Muscle Massage Series. In the introduction post to this series we introduced and demonstrated the three muscle release techniques that will be used in this post. If you would like to review them, click here. If you would like to see any other parts of the series, click here.

In this installment of the series, we’re going to be talking about the Low Back (Lumbar Spine). This area plays a major role in stabilizing the spine and holding the body upright. It is frequently injured in athletes due to it’s involvement with the hip as part of the Lumbo-pelvic complex (meaning…if the hip is tight/weak, extra strain can be placed on the low back and vice versa). The primary example of this is an anterior pelvic tilt (when the front of the pelvis tips down towards the ground due to muscle imbalances). When this occurs, the muscles in the front of the hip are kept in a shortened position and can become stuck that way. As a result, the hamstring and glute muscles in the back of the thigh are kept in a lengthened position and become weak under the increased strain. The result is that the pelvis becomes stuck in this forward tilt and the low back becomes stuck in that tight/shortened position. The abs become weak and the low back is left to carry the the workload for maintaining posture and stability. Once that happens, it doesn’t take much to injure the low back muscles.

Anatomy

Bony Landmarks

#1 L1-5 (aka the five lumbar vertebrae). You may have heard of the spine being described by letters and numbers. Traditionally, the spinal column is broken down into four regions (the neck/cervical - C, thoracic/midback - T, lumbar/low back - L, and sacrum/tailbone- S) and then given a number based on it’s level. The number refers to each specific vertebrae (they are stacked up one on top of the other). The easiest way to visualize the the level is to count the little bumps down the middle of your back. These are the spinous processes ( the little circles in the middle of the picture above). There are five vertebrae in the lumbar spine, numbered one thru five. In the picture above, you’ll also notice little “knobs” coming off either side of the vertebrae. These are the transverse processes.

#2 Upper Border- T12/Last Rib. The easiest way to find L1 is to start by finding the last rib. The thoracic/midback spine are the easiest to identify because each level in this region has a rib coming off it’s side. Start with your hands on your rib cage and work your way down till you find the last one (note: not all of the lower ribs reach around to the front; the lower two in particular do not. For this reason, keep your thumbs on your back and your hands on your side to make sure you feel them). When you find the last one, follow it to the spine and find the little bump (spinous process). This is T12 (or vertebrae #12 of the thoracic spine). If you drop just below it to the next bump you will have found L1. The key here is that when working on the muscles of the low back you need to work all the way up to the rib cage! Consider this the upper border for the area when trying to loosen up the muscles.

#3 Lower Border - Illiac Crest/Hip Bone. The easiest way to find L5 is to start by placing your hands on your hips on the top of your hip bones (iliac crests). If you follow this level to the spine, you will be at the L4 level. From here drop down to the next bump (spinous process) and you will have the last lumbar vertebrae, L5. The key here is that when working on the muscles of the low back you need to work all the way down to just below the level of the hip. This area may seem rather bony depending on your body type, but there are plenty of little muscles that love to be problematic nestled in there.

Muscles

The large muscles that make the lumbar spine move are actually organized into three seperate layers. The first layer is the deepest (closest to the bone) and the third layer is the most superficial. While these three layers are in the back, there is also an additional layer that inserts into the front of the lumbar spine.

Layer One:

There are two muscles in the deepest of the three layers: the Quadratus Lumborum (QL) and the Multifidus.

1) Quadratus Lumborum- this muscle starts on the posterior hip bone and then moves up and in to insert on the spinous processes of the lumbar spine and the lower rib. This muscle helps hike the hip up towards the ribs, as well as, extend the spine  (bend backwards) and sidebend towards that side. This muscle is most easily found closer to it’s attachment to the hip. As you move closer to the spine itself, the muscle travels underneath layer #2 (which you can see on the left). To find this muscle, start with your hand on your hip while standing. You want your thumb to be towards your back. From here, hike that hip up so that your foot comes off the floor (keep the leg straight! you don’t want to bend your knee and use your hip muscles). As you hike your hip, you will feel the muscle move under your thumb. From here you can trace it up and in towards the spine. Note: you will only be able to palpate (feel) the outer portion of this muscle. As you move closer to the spine, it will be hidden underneath the muscles in the second layer.

2) Multifidus- this muscle starts lower on the spine of the sacrum itself. From there, it moves up along the lumbar spine, inserting onto the spinous processes. The muscle fibers move up and in for this muscle, running from the transverse process of one vertebral level to the spinous process of the level above. This allows the muscle to extend the spine (bend backwards), sidebend, and rotate towards the opposite side. To find this muscle, you’ll first want to find your PSIS (bony landmark on the back of the hip).

To find the PSIS (posterior superior illiac spine), you’re going to start with your hands on your hip bones (iliac crest) so that your thumb is pointing towards your back and your fingers are pointing forwards towards your stomach. As you reach behind with your thumbs, you’re looking for two small bumps on either side of your spine. Visually, you can see them. They are the two “dimples” at the small of your back. Once you find the PSIS, move to the middle of the spine. This in between area is where the multifidus muscle lies. It looks like a skinny triangle that is thickest at the bottom and gets smaller as it moves up the lumbar spine. Note: this muscle is deep to the overlying muscles in layer two. To differentiate it, lay flat on your stomach. Extend your neck and upper back. As you do this, try to rotate away from the side you are working on. This rotation will trigger just the multifidus and the top layer will remain relaxed.

Layer Two:

In this layer, there are also two muscles: the Erector Spinae (ES) and the Serratus Posterior (SP).

1) Erector Spinae (ES). The ES is actually three seperate muscles that work together as a thick “rope” that runs parallel to the spine. These muscles are easy to find due to their thickness and are primarily responsible for extending the spine (bending backwards). It is important to note that these muscle fibers run vertically from the sacrum all the way to the base of the skull. When working on these muscles, use the PSIS and spinous processes as your borders and stay in between them for best results. The ES muscles run vertically between those two landmarks. When trying to differentiate the ES from the multifidus, lay flat on your stomach and lift your neck and upper back up from the floor. This motion will activate the ES from skull to sacrum. If you add in rotation, you will trigger the multifidus.

2) Serratus Posterior (SP). This muscle is a small breathing muscle that overlaps the ES muscles (so technically it is between the second and third layer of muscles). The reason for it’s inclusion is that it can be a site for trigger points along the lower rib cage. The muscle itself runs from the transverse processes of L1 + L2 up and out to the lower four ribs. It’s muscle fibers run in the same direction as the larger and more superficial muscle of the latissimus dorsi.

Layer Three:

There is one muscle in this layer, the Latissimus Dorsi, and it covers the previous two layers completely. It starts on the sacrum and posterior illiac crest (hip bone) and runs up to the humerus (upper arm bone). It’s primary function is to move the shoulder backwards and in towards the body, however, due to it’s attachments in the low back, it also assists with positioning of the pelvis. Note: the reason for it’s involvement here in the low back is that if the muscle is overused or becomes stuck in a tightened position, it can put extra strain on it’s attachments along the lumbar spine. This muscle is easy to find. While sitting, move your arm straight back behind you with your elbow straight. You will feel the muscle moving over the back and towards the outside of the rib cage as the muscle moves up and out to the back of the shoulder. The thickest part of the Lats are along the rib cage and are where you want to look for trigger points or muscle spasms.

Layer Four (Front Layer):

Layer four is made up of the large hip flexor (Psoas) muscle. This muscle runs from the front of the hip and femur (large thigh bone) up to insert on the front of the lumbar spine. Soft tissue restrictions in this muscle will likely impact the low back so it is important to remember this muscle group when working to relieve tension in the low back. For more details on the how to find and work on the front of the hip, click here.

Soft Tissue Release

What you’ll need: stick/foam roller and tennis ball

The techniques: click here for an introduction to the techniques and a video demonstration

1) Lengthening/elongation with the foam roller or stick.
2) Cross friction with your hand or tennis ball.
3) Sustained pressure or trigger point release with the tennis ball.

Key Areas to Work On

#1 When working on the muscles of the low back, try to visualize the muscles moving in three different directions:

a) Running vertically (or parallel) along either side of the spine (yellow line 1 in the picture).

b) Running up and in towards the spine from the hip bone (illiac crest) and PSIS (yellow line 2 in the picture).

c) Running up and away from the spine towards the back of the shoulder (yellow line 3 in the picture).

#2 Always start with the foam roller to warm up the muscle and lengthen the muscle fibers before moving on to the deeper cross friction and trigger point techniques.

#3 Cross friction works best on the ES and multifidus muscles. Remember- let the tennis ball sink into the muscle and work PERPENDICULAR to the way the muscle fibers run. There should be minimal movement of the tennis ball (approx 1 inch) when performing this technique.

#4 Here are some popular trigger points in the low back (trigger points = yellow x’s. note: for the ES muscle, there may be multiple points. start at the lower border and work your way up- follow the yellow up arrow):

#5 Don’t forget to include work on the hip flexors!!! They insert onto the front of the lumbar spine and can all kinds of problems, especially with long distance biking and running. Click here for specifics on how to target this area.

Video

Here is a video demonstration of these techniques on the low back.

References

1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

2) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

3) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

4) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.