OPP lecture 2

Question 1

quadratus lumborum

Answer 1

origin at iliac crest
insertion at 12th rib, iliac crest, and transverse process L1-L4
functions with respirations and stabilizes the diaphragm
Innervation - T12, L1-L3
Bilateral - extension
unilateral - extension and ipsilateral sidebending

Question 2

quadratus lumborum spasm

Answer 2

low back pain
referred to the hip and groin
exhalation 12th rib dysfunction
diaphragm restriction
differentiate from renal disease

Question 3

psoas syndrome

Answer 3

a spasm and/or an irritation of the psoas muscle. usually develops as a bilateral psoas spasm. eventually concentrates more on one side. Key somatic dysfunction is a non-neutral dysfunction of L1 or L2. may be seen in the acute or chronic stage.

Question 4

Psoas

Answer 4

Psoas origin: L1-L4 (L5)
extends over the superior pubic ramus and under the inguinal ligament. Inserts on the lesser trochanter on the medial side of the femur. Innervated by L2-L3. Flexes trunk on thigh, flexes lumbar spine, and laterally flexes lumbar unilaterally. Shortens and externally rotates the leg.

Question 5

must rule out these possible causes for psoas syndrome…

Answer 5

femoral bursitis and arthritis of the hip
iliac or femoral phlebitis
retroperitoneal lympadenopathy
diverticulitis of the colon
cancer of descending or sigmoid colon
renal or urethral dysfunction (calculi)
prostatitis, salpingitis, appendicitis

Question 6

functional etiology of psoas syndrome

Answer 6

sitting in a soft chair or slumped in a hard chair. bending over at the wait for a long period of time (weeding or working at a desk). Then the pt returns to neutral suddenly

Question 7

physiology of psoas syndrome

Answer 7

the person is in this flexed position
the intrafusal muscle fibers of its spindle tighten to better monitor the relaxed fibers of the psoas muscle.
Rapid return to neutral produces confusion at the spindle and spinal cord. Psoas muscle goes into spasm. Inappropriate signal report that they are being overstretched before the muscle’s extrafusal fibers have reached their usual resting lenth = spasm of the psoas.

Question 8

Somatic finding of for example left psoas spasm

Answer 8

at first, both are involved causing flattening of the lumbar spine (forward bending).
then one usually becomes more prominent.
L1 or L2 will rotate left then sidebend left.
then the rest of the spine sidebends left.
The other vertebrae act according to Type I.
Remember that L1 or L2 is the key lesion of any psoas syndrome.

Question 9

sacral torsion differ if they occur during neutral or non-neutral mechanics.

Answer 9

example: left oblique axis engaged
Neutral - No F or E, right pole moves forward relative to L5. = forward torsion (L on L)
Non-neutral - F or E, sacrum rotates right, right pole moves backward = backward torsion (R on L)

Question 10

if the psoas spasm continues (left psoas)

Answer 10

If the spastic psoas carries through to the sacrum, the left sidebending induces a non-neutral sacral response (lumbar flexed)
left oblique axis is engaged
sacrum rotates right
shallow right sacral sulcus (deep left)
prominent ILA on the right
e.g. L1 or L2 is now NN RLSL
The sacrum may then act with non-neutral mechanics and may rotate right on a left oblique axis of the sacrum

Question 11

3 left psoas spasm

Answer 11

• pelvic side shift occurs to the opposite side
• opposite piriformis spasm occurs
• may get sciatic nerve irritation opposite (on same side of piriformis spasm)
• gluteal muscular and posterior thigh pain that does not go past the knee (opposite side)
  e. g. hip shift occurs to the opposite side of the greatest psoas spasm (so, to the right)

Question 12

Symptoms of psoas syndrome (left psoas)

Answer 12

-first there’s pain when the patient sits especially sitting straight
-vague pain in lumbar or lumbosacral area
-soon the key lesion pain leaves and moves down and over to the right sacroiliac joint
-now the patient is bent forward and to left but doesn’t have much pain
-left leg short and externally rotated
-right piriformis is involved so pain includes the gluteal area on right
-then sciatic irritation occurs
-pain develops down the posterior thigh
-notice that although the pain may be similar to a disc problem, the posture of a psoas patient would lead to worsening of the symptoms.
In picture, lumbar is RLSL and left leg (psoas) is externally rotating. the right piriformis affected with sciatic nerve.

Question 13

treatment of psoas syndrome

Answer 13

Depends on acuteness and syndrome stage.
Remember to rule out and treat any organic causes
Use counterstrain on the iliopsoas point:
patient supine with knees flexed

Question 14

treatment of psoas more specific

Answer 14

ICE (heat would irritate/worsen problem)
As acuteness recedes, HVLA of key lesion
MUST cool down an acute muscle - do not stretch

Question 15

chronic psoas shortening

Answer 15

-if left untreated my get fibrosis of muscle
-Thomas test - pt supine, flexes hip, if other knee raises from the table then it is positive
Treatment is to stretch it.
Above position and operator pushes the affected knee toward the table, the patient tries to pull opposite knee toward chest, hold position for 3-5 seconds, pt relaxes, repeat

Question 16

weak psoas

Answer 16

allows excessive backward bending of the lumbar spine because of strong back muscle.
increase lordosis and protruding abdomen.
Treatment - pt supine and Dr….has a hand-palm up under midlumbar area.
pt asked to push against Dr.s fingers (told not to use abdominals) for count of 6.
pt should do this 3-4 times twice a day. Will see a decrease in lordosis in one month.

Question 17

piriformis syndrome

Answer 17

peripheral neuritis of the sciatic nerve caused by an abnormal condition of the piriformis muscle

Question 18

origin and insertion of piriformis

Answer 18

origin - anterolateral border of the sacrum at the sacroiliac joint capsule
Anterior portion of the sacrotuberous ligament
insertion: superomedial aspect of the greater trochanter of the femur

Question 19

sciatic nerve tract

Answer 19

passes through the greater sciatic foramen
under the piriformis
posterior thigh

Question 20

causes of irritation of the sciatic nerve

Answer 20

• piriformis muscle spasm
• piriformis contracture
• local trauma to the buttocks
• repeated mechanical stressors (running)
• sacral base unleveling
• pelvic instability
• excessive local pressure, especially in thin or cachectic patients (hip pocket neuritis)
• local perineural inflammation secondary to the endogenous release of vasoactive substances from an inflamed piriformis muscle.

Question 21

sciatic nerve variations

Answer 21

common peroneal and tibial components remain separate in 10% - one of them passes directly through the piriformis muscle
-piriformis arises from 2 tendinous origins with the sciatic nerve passing between them in 10%

Question 22

symptoms of piriformis syndrome

Answer 22

easily confused with herniated disk disease or facet joint pathology
Hip and buttock pain radiating down the posterior thigh.
Sometimes to the calf or foot
Low back pain not common.
usually no neurological deficits.

Question 23

physical exam of the piriformis

Answer 23

muscle strength, sensation, DTR normal
extreme tenderness along the piriformis
may produce radicular pain when palpated
gluteal tender points may be present

Question 24

assessment of the pyriformis prone

Answer 24

patient prone 
knees flexed
hold the ankles
internally rotate both hips until you feel resistance
compare

Question 25

piriformis assessment supine

Answer 25

pt supine
leg grasped above the ankle
internally rotate both hip joints unitl you feel resistance
compare

Question 26

treatment of piriformis

Answer 26

OMT
muscle energy techniques
myofascial techniques to lumbar and lumbosacral area
counterstrain
myofascial release of the sacrum
trigger poin therapy