Muscles of Lower Torso Pain

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■ Quadratus Lumborum Muscle (Figs. 19.89,19.90,19.91) Origin

Lower rim of the 12th rib Insertion

• Costal processes of L1-L4

• Iliolumbar ligament Posterior third of the iliac crest

Action

• Lateral flexion of the torso

• Fixation of the 12th rib during respiration

Innervation

Ventral branches of the spinal nerves T12-L3

Location Lumborum Muscle

TP, cranial superficial

TP. caudal .superficial

Trigger Point Location

For easier palpation, lie the patient on their contralateral side with a rolled-up towel in the waist, resulting in a sidebend of the spinal column away from the muscle that is to be palpated. The arm that lies on top is placed in maximal abduction and the upper leg is stretched while the leg below is slightly flexed. The desired sidebend is thereby reinforced.

Palpate the following areas of the muscle for trigger points:

• In the angle above the iliac crest and lateral to the erector spinae

Along the iliac crest

• In the angle between the 12th rib and the erector spinae

The superficial trigger points are found in the lateral areas of the muscle, either below the 12 th rib or above the iliac crest.

The deep trigger points are found either above the iliac crest between the costal processes of the fourth and fifth lumbar vertebrae or at the height of the costal processes of the third lumbar vertebra in the medial regions of the muscle.

Referred Pain

• Cranial superficial trigger point: along the iliac crest, sometimes into the groin and the lower lateral abdominal region

• Caudal superficial trigger point: around the trochanter, partly pulling into the lateral thigh

• Cranial deep trigger point: into the area of the ISJ

• Caudal deep trigger point: caudal buttocks

lliacus Muscle Origin

Iliac fossa

Insertion

Lesser trochanter of the femur Action

• Flexion in the hip joint

• Outward and internal rotation in the hip joint

Innervation

Muscles Chains
Fig. 19.91

Associated Internal Organs

• Urinary bladder

• Uterus, adnexa, prostate

Psoas Major Muscle Origin

• Transverse processes of L1-L5

• T12-L5 and the discs below T12

Insertion

Lesser trochanter of the femur Action

• Flexion in the hip joint

• Outward and internal rotation in the hip joint

• Abduction in the hip joint Extension and lateral flexion of the LSC

Innervation

Ventral branches of the spinal nerves L1-L2

Trigger Point Inginal

Spinal column Psoas major lliacus Inguinal ligament

Symphysis

Fig. 19.92

Spinal column Psoas major lliacus Inguinal ligament

Symphysis

Fig. 19.92

Psoas Minor Muscle

Origin

T12-L1 including disk

Insertion

Iliac fascia

Action

Bending the torso (slight)

Innervation

Ventral branch of the spinal nerve LI

Trigger Point Location

TP1 Lateral border of the femoral triangle

TP2 In the iliac fossa at the height of the anterior superior iliac spine (ASIS)

TP3 Lateral of the rectus abdominis and below the navel. First palpate carefully to posterior and then to medial, to compress the psoas major against the spinal column f VV

f VV

Anteromedial Colume

Referred Pain

• Primarily in the LSC ipsilateral along the spinal column up to the ISJ and to the upper to middle buttocks area

• Groin and anteromedial thigh

Associated Internal Organs

• Urinary bladder

• Uterus, adnexa, prostate

Muscles of the Pelvic Floor (Figs. 19.95,19.96)

Obturator Internus Muscle Origin

• Inside of the obturator membrane

• Mediocaudal bone rim of the obturator foramen

Insertion

Trochanteric fossa

Action

• Stabilization of the hip joint

• Outward rotation in the hip joint

Innervation

Obturator nerve (L5-S2)

External Anal Sphincter Muscle Origin

Ring-shaped closing muscle Insertion

Perianal in subcutaneous, superficial, and deep connective tissue

Action

Closing the anal canal (fecal continence)

Innervation

Pudendal nerve (S2-S4)

Levator Ani Muscle Origin

• Backside of the pubic bone

• Tendinous arc of the levator ani

• Ischiadic spine

Ischiadic Spine

Fig. 19.95

Insertion

• Anococcygeal ligament

- Loop-shaped towards the rectum

Action

• Reinforcement of the pelvic floor

• Maintaining continence

Innervation

Ventral branches of spinal nerves S3-S4

Coccygeus Muscle

Origin

• Sacrospinous ligament

• Ischiadic spine

Insertion

Anococcygeal ligament

Gluteus Maximus Muscle (Figs. 19.97,19.98) Origin

• Outside of the wing of the ilium behind the posterior gluteal line

• Posterior third of the iliac crest

• Thoracolumbar fascia

• Sacrotuberous ligament

Insertion

• Gluteal tuberosity of the femur

• lliotibial tract (runs to the lateral condyle of the tibia)

Action

• Extension in the hip joint

• Outward rotation in the hip joint

Innervation

Inferior gluteal nerve (L5-S2) Trigger Point Location

You achieve good palpation of the trigger points by making the patient lie on the side with the side to be examined facing upward and slightly flexing the legs:

Action

Reinforcement of the pelvic floor Innervation

Ventral branches of spinal nerves S4-S5 Trigger Point Location

Trigger points are found by rectal, vaginal, or pelvic floor palpation

Referred Pain

• Caudal sacrum

• Dorsal thigh (obturator internus)

Associated Internal Organs

• Urinary bladder

• Uterus, adnexa, prostate

TP1 Approximately at the upper edge of the gluteal fold not far from the insertion of the muscle to the sacrum

TP2 Slightly cranial from the ischiadic tuber TP3 On the mediocaudal border of the muscle—at the caudal end of the gluteal fold-well palpable with pinching palpation

Fig. 19.97

Referred Pain

TP1 From the ISJ along the gluteal fold into the caudal muscle area and the beginning of posterior thigh

TP2 Across the entire muscle with emphasis on the caudal sacrum, the lateral area below the iliac crest, and the caudal buttocks: The pain is partly felt deep down, as if the small gluteus muscles were hurting. No referred pain into the coccyx

TP3 Coccyx and mediocaudal muscle area

Associated Internal Organs

None

Fig. 19.98

19.101)

Gluteus Medius Muscle (Figs. 19.99,19.100, Origin

Outside of the ilium (between the anterior and posterior gluteal line)

Insertion

Greater trochanter (dorsolateral)

Action

• Abduction in the hip joint

• Inward rotation in the hip joint (ventral and lateral part)

Outward rotation in the hip joint (dorsal and medial part)

Horizontal stabilization of the pelvis in the swing leg phase of the gait

Gluteus maximus

Gluteus maximus

Gluteus Maximus Pain

Thoracolumbar fascia Pelvic ridge Gluteus maximus Tensor fasciae latae lliotibial tract

Gluteus medius

, Gluteus medius

Thoracolumbar fascia Pelvic ridge Gluteus maximus Tensor fasciae latae lliotibial tract

Gluteus medius

, Gluteus medius

Trigger Points

Innervation

Superior gluteal nerve (L4-S1) Trigger Point Location

Palpate the trigger points in contralateral side position with flexed legs:

TP1 In the posterior muscle belly not far below the iliac crest and in the vicinity of the ISJ TP2 Immediately below the iliac crest approximately in the center of its course TP3 It is also found immediately below the iliac crest, but slightly further ventrally in the vicinity of the ASIS

Referred Pain

TP1 The pain radiates from the posterior area of the iliac crest through the ISJ and sacrum into the entire buttocks

TP2 The pain projection runs across the lateral and central gluteal area into the posterior and lateral proximal thigh

TP3 Along the iliac crest and lower lumbar area, the pain radiates especially into the sacrum

Associated Internal Organs

None

Gluteus Minimus Muscle (Figs. 19.102,19.103) Origin

Outside of the ilium (between the anterior and posterior gluteal lines)

Insertion

Greater trochanter (ventral) Action

• Abduction in the hip joint

• Inward rotation in the hip joint (ventral and lateral section)

• Horizontal stabilization of the hip in the swing leg phase of the gait

Innervation

Superior gluteal nerve (L4-S1)

Trigger Point Location

• Anterior trigger points: They are found at the height of the ASIS, but slightly further below the iliac crest than in the gluteus medius

• Posterior trigger points: You find these in the entire muscle along the upper edge of its origin

Gluteus Ventral

Referred Pain

• Anterior trigger points: Pain is projected into the lower and lateral buttocks, the lateral thigh, knee, and shank

• Posterior trigger points: Throughout the entire buttocks, especially caudal-medial, and continuing on into the posterior thigh, back of the knee, and proximal third of the shank

Associated Internal Organs

None

■ Piriformis Muscle (Figs. i9.i04,19.105) Origin

Pelvic side of the sacrum in the area of the anterior sacral foramina 2-4

Insertion

Greater trochanter

Action

• Outward rotation in the hip joint

• Inward rotation in the hip joint at 90° flexed hip

• Abduction in the hip joint at 90° flexed hip

Innervation

Ventral branches of the spinal nerves S1-S2

Sacrum

Gluteus maximus

Piriformis

Gemelli muscles ligaments

Obturator internus

Adductor magnus

And Foramina Location

Gastrocnemius

Iliac crest

Biceps femoris (short head)

Biceps femoris (longhead)

tendinosus

Gracilis

membranosus

Fig. 19.104

Sacrum

tendinosus

Gastrocnemius

Gluteus maximus

Piriformis

Gemelli muscles ligaments

Obturator internus

Adductor magnus

Gracilis

membranosus

Iliac crest

Tensor fasciae latae

TPs of the gluteus minimus

— Gluteus minimus TPs of the piriformis

Quadratus femoris Vastus lateralis

Gluteus maximus

Vastus intermedius

— Adductor magnus

Biceps femoris (short head)

Biceps femoris (longhead)

Location Piriformis Muscle
Fig. 19.105

Fig. 19.104

Trigger Point Location

Referred Pain

For an auxiliary line for localizing trigger points, connect the proximal end of the greater trochanter to that point of the sacrum that corresponds to the ilium. The upper edge of the piriformis lies approximately on this line:

TP1 When you divide the described auxiliary line into thirds, this trigger point lies slightly lateral to the transition from the middle to the lateral third

TP2 At the medial end of the auxiliary line

Entire gluteal area

Dorsal two-thirds of the thigh

Associated Internal Organs

■ Urinary bladder

• Sigmoid colon

- Uterus, ovaries, adnexa, prostate

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Responses

  • Rudibert
    What internal organs refer pain to lateral shank?
    7 years ago
  • joe
    What is internal organ or muscle is above the iliac crest?
    7 years ago

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