Wednesday, December 13, 2017

Iliac Crest Syndrome

Iliac Crest Syndrome - A Common Cause of Low Back Pain

Fig. 1: Pain site at the posterior iliac crest region

Pain experienced at the iliac crest is a frequent low back condition affecting patients seeking help from Sports Medicine Acupuncturists®. The iliac crest is the top (or ‘crest’) of the ilium, which is the most superior or upper portion of the pelvic structure. If you were to place your hands on your hips, they would be resting on the iliac crest. Pain at the iliac crest, referred to as ‘iliac crest syndrome,’ is experienced at the posterior (back) portion of the iliac crest and can be persistent (Fig. 1).

Fig. 2: Palpation of yaoyan at 
the superficial and deep vectors
This pain is at an acupuncture point called yaoyan which is a commonly used 'extra point'. Extra points are points which are not on main acupuncture channels, but have been found to be clinically important nonetheless. This particular extra point is found at the attachment site of two important back muscles. Depending on the depth, these muscles are either the iliocostalis lumborum or the quadratus lumborum (Fig. 2).

The iliocostalis lumborum is the more superficial of the two of these muscles. It is one of three muscles which are part of a group called the erector spinae (Fig 3 left image). This is the group of muscles that span the back from the hip through the neck and run parallel to the spine. The iliocostalis lumborum is the ‘lumbar’ or low back portion of this group; it runs from the top of the iliac crest (the ‘ilio’ part of the name) to the ribs (the ‘costo’ part of the name). This muscle then continues upward (but it is then called the iliocostalis thoracic and iliocostalis cervicis) and is the most lateral of the three muscles of the erector spinae. The iliocostalis functions with the other muscles of this group to perform extension of the torso, which is the motion involved in bending backward. However, since this muscle is a bit more lateral than the others in the group, it is also involved in side bending motion. In this case, only one side is primarily involvedthe right muscle in right side bending and the left in left side bending.

The quadratus lumborum is a deeper muscle underneath the iliocostalis (Fig. 3 right image). It runs from the iliac crest and has attachments on the lumbar (low back) vertebrae, and ends at the 12th (lowest) rib in the back. This muscle laterally flexes the trunk. It does this by shortening the space between the top of the hip and the 12th rib. This would either pull the rib towards the hip (sidebending on that side) or pull the hip towards the rib (elevating or hiking the hip up on that side).

Both of these muscles have attachments on the iliac crest and both can become pain-producing sites. In both cases, these muscles would be in a shortened position when the hip is hiked on the side of pain. This is frequently what is seen with iliac crest pain.
Fig. 3: Image on the left shows the iliocostalis which is the lateral muscles of the erector spinae group. The image on the right has this group removed to highlight the deeper quadratus lumborum muscle. Both are common sites of pain at the iliac crest. Both images are from Netter's Atlas of Human Anatomy.
When the hip is elevated on one side, as is often the case with iliac crest syndrome, it is not simply the muscles discussed which are involved. Other muscles whose job it is to stabilize the hip and prevent it from elevating are also part of the overall picture. The gluteus medius and minimus are the primary muscles which do this, and these muscles have a propensity to become inhibited and fail in their stabilization roll.

When treating iliac crest syndrome, it is important to address all of the muscles involved in the imbalance. This includes both the shortened and overactive muscles such as the iliocostalis and quadratus lumborum, along with the inhibited and overlengthened muscles such as the gluteals. Acupuncture and manual therapy are powerful treatment options to correct these imbalances, and corrective exercises performed by the patient can solidify treatment at continue to return function.

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