Abdominal Muscles and Back Pain

Abdominal trigger points can refer to the low back

Many people are aware that the abdominal muscles have something to do with back pain and this awareness is centered around 'core' support and the role of these abdominal muscles in back support. While this is certainly the case, my patients are less aware that the abdominal muscles can be directly tied to the back pain they experience. The rectus abdominis specifically can harbor trigger points, or sensitive contractile knots, that can cause pain not necessarily in the abdomen, but can instead refer pain to the back.

Regardless if you have a developed rectus abdominis or not, this is the muscle that people refer to when the discuss a 'six pack' ab. Technically, there are four grouping of muscles on either side, and each of these compartment are bordered by a tendinous intersection. The upper compartment is lies over the lower ribcage and this compartment is less visible when people do have 'six pack abs', so you are really seeing the lower three compartments on either side.

The rectus abdominis attaches from the pubic bone to the lower ribcage and sternum. The muscle is involved with flexion of the trunk, forced exhale and compression of the abdominal organs.

While it is actively involved in forced expiration or exhale, when the muscle becomes rigid and restricted, it can reduce the ability to take a good, deep inhale and this is most frequently the case when this muscle becomes a component of low back pain.

There is a characteristic referral pattern when this muscle is contributing to back pain which can be seen on the image to the right. The low back portion of the refer specifically usually is associated with trigger points in the umbilical region, in my opinion, and they can frequently even occur in the tendinous intersection in this region. This image to the right shows and X at the pubic bone attachment which can also occur, but I still find this occurs more frequently at the umbilical region. The mid back pain referral is more often at the region just below the lower ribcage and close to the xiphoid process which is the lowest part of the sternum or breastbone.

Many people with low back pain will look at the referral that travels across the low back/upper pelvic region and say, 'That describes my back pain!" It could be the case, then that the rectus abdominis is a contributor. It is the case, thought, that there are other frequently causes of this horizontal distribution of low back pain. Specifically, the joints of the lower spine, referred to as facet joints, can become irritated and cause a similar pain distribution. Below is and image that illustrates this referral pattern and you can see that there is some overlap.

It can be a combination of causes, all contributing to the pain that brings people in to see me. Palpation can be used to see if this muscle is referring pain, but there are also other clues. Urinary problems, digestive disturbances, and dysmenorrhea (painful periods) can all be associated with trigger points in the rectus abdominis. Clinically, it is worth investigating if this important muscle is contributing to the back pain and other problems, and then adding protocols to treat it into the mix. Acupuncture, dry needling, manual therapy and specific corrective exercises are all helpful and tools I use for this trigger points in this muscle and for back pain in general.

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Upper Trapezius Pain and Dysfunction

Upper trapezius trigger point pain pattern

Restriction and pain associated with the upper trapezius muscle is a common finding in my clinical practice and something I address often with patients. Stress, excessive sitting at a computer, and poor core support are but a few of the things that can lead to this muscle forming painful trigger points (hypersensitive nodules that refer pain). The image on the left from Travell and Simon's excellent book, Myofascial Pain and Dysfunction: A Trigger Point Manual, illustrates the common pain referral from this muscle. Many people suffering from chronic neck pain and stiffness and/or muscle tension headaches will likely find this a familiar pain pattern.

Trigger point based acupuncture (trigger point dry needling), trigger point injection, and deep tissue myofascial release techniques are all excellent resources I use to treat this common complain. However, self stretching can be an excellent resource as well and here is a video showing a self stretch I frequently give my patients.

Upper Trapezius Stretch

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Mobility of the Lower Ribcage

Lower ribcage mobility has relationships to the diaphragm, spine and internal organs.

The lower ribcage has a lot of movement potential, especially when compared to the rest of the ribcage. Part of the movement potential of this region is determined by the anatomy. The lowest two ribs, called the floating ribs, articulate with the lowest two thoracic vertebrae. This is the only place they articulate with bone. Ribs 8-10, called false ribs, articulate with the thoracic vertebrae and then indirectly connect to the sternum through a large bit of cartilage. The remaining ribs, referred to as true ribs, attach directly to the thoracic spine and the sternum. The direct connection to the sternum limits the movement of these ribs (1-7), but since ribs 8-12 do not have this direct attachment, they allow more rotation, compression, and expansion.

There are attachments of the respiratory diaphragm and the internal organs to the lower ribcage. Specifically, the liver, intestines, spleen, and stomach have strong attachments to the lower ribcage. Good movement in this region helps massage the internal organs and take the diaphragm through a good range of motion. This keeps these structures healthy and supple.

Much of the movement of this region is driven by the Liver and Gallbladder sinew channels, especially the rotational movements of the ribcage in relationship to the pelvis. The obliques are the driving force of this rotation. The internal obliques are most associated with the Gallbladder sinew channel. The Liver sinew channel involves the medial line of the body, but includes the external oblique which fascially connects with the contralateral adductor longus. Trunk and pelvic rotations are very tied to these channel sinews and imbalances are treated through these channel sinews.

Another movement of this region involves the ability of the left and right sides to flare (move away from each other) and to hold stability preventing excessive rib flare. This is largely controlled by the transverse abdominis and has more to do with the Kidney sinew channel. When the Kidney sinew channel does not properly support this region, the ribs excessively flare and the ribcage tilts posterior.

Ribcage mobilization exercise

Check out the following videos for a simple qigong exercise to improve the mobility of this region, while massage the internal organs, mobilizing the diaphragm, and strengthening the core. This qigong pattern is derived from an internal martial art called liuhebafa and the movement is called 'Stop Cart and Ask Directions'. It is the first movement of this series.

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