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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Pelvic Rotation in Taiji and Qigong

 This month we will be focusing on rotation, specifically how this movement involves the innominate bones and the sacrum. I frequently find that, when demonstrating rotation, students often think of the pelvic structure as a block that rotates as a unit. However, the pelvis is quite dynamic and there can be much movement between the two innominate bones which allows sacral rotation to occur. This is seen also with walking or running. The back leg in gait pulls the innominate bone on that side into an anterior tilt, while the forward leg pulls the other innominate bone into a posterior tilt. The entire pelvis is 'twisted' or moves into torsion. 

When the practitioner is in a horse stance or in a neutral stance hip width apart and performs pelvic rotation, this same dynamic occurs, or at least the potential is there for it to occur. This movement will create a rotation all of the way from the feet and potentially upward throughout the body to the head, a movement that takes the joints through their full range of motion in the transverse plane.

We will be exploring this rotation in the Eight Pieces of Brocade, Taiji, Taiji Ball, and even the Core classes this month. Check out the schedule below.

May 2021 Taiji and Qigong Schedule

Monday	Tue	Wednesday	Thur	Friday	Saturday	Sun
Eight Pieces of Brocade 9:30-10:15am est		Eight Pieces of Brocade 9:30-10:15am est		Core (No Floor) Strengthening for Qigong 9:00-9:30am est	Taiji Ball 10:00-10:30 am est
Core (Floor) Strengthening for Qigong 10:30-11:15 am est		Five Animal Sports  10:30-11:15am est		Eight Pieces of Brocade 9:30-10:15am est	Five Animal Sports Practice 10:30-11:30 am est
Taiji (Tai Chi) 6:00-6:45pm est		Taiji (Tai Chi) 6:00-6:45pm est

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Taiji (Tai Chi) and Qigong for Health

Taiji (Tai Chi) and Qigong for Health and Wellness During Social Distancing

Below is the schedule for online video conferencing based (Zoom) Taiji (tai chi) and qigong classes to assist with health and wellness for my patients, colleagues, and friends during these times when we are isolated at home. My goal is to threefold: 1) to increase circulation and support optimal health; 2) to decrease stress; and 3) give something fun to learn or deepen your understanding if you are already doing some form of Taiji or qigong. It’s also a nice way for us to enjoy a social activity together while taking care of ourselves.

Classes will currently be free, though if you'd like to support this effort, you can find a donate button at the bottom of this page. These classes will be 'follow along,' so I will not be able to give much in the way of advice regarding personal health issues. Consult with your doctor if you have any concerns about starting a new exercise routine. If you have a particular health need that requires more individual attention, I can set a private consult and lesson tailored to your specific needs. This will be for a fee, but I am open to a sliding fee based on need as I am well aware of the financial difficulty facing most people. Also, insurance might cover this as there are changes underway for Telemedicine.

Send your name and email (indicate if you want to be contacted for future classes and you can opt out at any time), and I will send the code and password so that you can join the classes. I look forward to seeing you soon.

Schedule for the Week of March 15 - March 22

Saturday March 21

• Seated Work 1:00 -1:45pm est
• Eight Pieces of Brocade 2:00 - 2:45pm est

Schedule for the Week of March 23 - March 29

Monday March 23

• Eight Pieces of Brocade 9:30 - 10:15am est
• Opening the Breathing 10:30 - 11:15 am est
• Five Animal Sports 3:00 - 3:45pm est

Wednesday March 25

• Eight Pieces of Brocade 9:30 - 10:15am est
• Seated Work 2:00 - 2:45pm est
• Five Animal Sports 3:00-3:45pm est

Friday March 27

• Eight Pieces of Brocade 10:30-11:15am est
• Five Animal Sports 3:00-3:45pm est

Saturday March 28

• Five Animal Sports 10:30 - 11:15am est

Monday March 30

• Eight Pieces of Brocade 9:30 - 10:15am est
• Opening the Breathing 10:30 - 11:15 am est
• Five Animal Sports 5:00 - 6:00pm est

More classes in April will be added so keep an eye on the schedule. See below for class descriptions:

Eight Pieces of Brocade. This sequence includes 8 moves, each working on a specific organ system. This form is easy to do (but there can be a lot of nuance), does not require difficult stepping or shifting of weight and can even be done seated. This form is very accessible but has much to offer for all. It can be very meditative and calming, as there is some repetition and less difficulty in terms of learning the moves.

Five Animal Sports. This sequence includes 5 moves that are part of each "Animal" (25 moves total). Chinese physiology has many correspondences, and each Animal represents and organ that is being worked on. This form is a bit more difficult but can still be modified for individual health challenges. It does involve stepping and shifting, but it can be modified to be seated if necessary. This form is very dynamic and a lot of fun!

Seated Work. In seated work, we do either of the forms above in a seated position, with emphasis on expansion of the spine and movement of the chest and shoulder girdle. If these areas are moved in an expansive way, then the organs will be mobilized and there will be better circulation in the thoracic (chest) and abdominal cavities. This class will obviously be indicated for those who need to modify the forms in a seated position but can add extra insight for anyone at any level.

Opening the Breathing. This class supports the other classes by focusing on proper use of the chest and shoulder girdle muscles, so that the chest can remain open during practice and breathing can be regulated.

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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 involved–the 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 12^th (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 12^th 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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Injures Caused by Foot Overpronation

Foot Overpronation Can Cause Many Different Injures.

Pronation of the foot involves dorsiflexion of the ankle, abduction of the foot, and eversion of the foot. In layman's terms this is described below, but the important aspect is that these movements drop the medial arch of the foot.

• Dorsiflexion involves a bend of the ankle in the direction of the dorsum or top of the foot. It brings the top of the foot towards the knee.
• Abduction is a turning out of the foot away from the midline.
• Eversion is a turning out of the foot which brings the medial arch down.

Fig. 1: Comparing a neutral foot (middle) to foot overpronation (left) and supination (right). Notice how the pronated foot turns away from the midline (this is abduction) and the medial arch falls towards the floor (this is eversion). Image Ducky2315 (Own work) [CC BY-SA 3.0 9http://creativecommons.org/licenses/by-sa/3.0)]

A certain amount of pronation is normal in weight bearing as this acts as a shock absorption. Connective tissue structures in the foot elongate and produce a certain amount of tension which, upon recoil, helps propel the movement, thus acting as an energy saving mechanism during walking and running. However, overpronation is a frequent occurrence which is an excessive pronation. This can lead to a range of injuries of the foot, ankle and lower leg, but also can cause or contribute to injuries of the knee, hip and really anywhere in the body.

Frequent injuries are listed below with a brief description of how overpronation contributes.

• Plantar fasciitis/fasciosis: As the foot goes excessively into pronation, the plantar fascia is overstretched. The reoccurring motion eventually irritates the plantar fascia and can lead to chronic pain in the bottom of the foot, usually where this tissue attaches to the calcaneus.

Fig. 2: Both tibialis anterior and tibialis posterior attach to 

the medial arch. In foot overpronation, the arch drops and these 

muscles are pulled long. This can irritate the tendons of these 

muscles and can also contribute to shin splints.

• Tibialis posterior tendinopathy: This condition can be misdiagnosed as plantar fasciitis, but pain is usually more at the medial ankle. The tibialis posterior supports the medial arch and can become irritated with excessive pronation as it too is repetitively overlengthened when walking or running.
• Shin splints: Shin splints can be classified as anterior or medial shin splints. The involve either the tibialis anterior or the tibialis posterior, respectively. Both of these muscles support the medial arch and can have a shearing effect where they attach to the tibia with overpronation.

Fig. 3: Note the effects on the knee and hip.

• Knee pain: There are many knee conditions that can become aggravated with overpronation. As the foot pronates, the lower leg turns inward. This becomes excessive with overpronation, and the knee tends to collapse in. This can contribute to medial knee pain from conditions such as pes anserine tendinopathy or lateral knee pain from conditions such as iliotibial band friction syndrome.
• Hip pain: Like knee pain, there are many hip conditions that can be aggravated from foot overpronation. One example is greater trochanteric bursitis which is often caused by an excessive raising of the hip during weight bearing. This frequently occurs with foot overpronation and with the knee moving in.
• Back pain, shoulder pain, neck pain: Foot overpronation can be involved with many other muscle imbalances as described above with knee pain and hip pain. These imbalances can affect regions as far away as the neck.

Sports Medicine Acupuncture® is a great system for treating both the injury and the underlying causes of the injury such as foot overpronation. It employs acupuncture, manual therapy, and corrective exercises in addition to other possible treatment options. Both local acupuncture and manual therapy techniques can be used to reduce pain and improve the health of the injured soft tissue. And acupuncture to specific points within the muscles can correct the underlying muscle imbalances that occur with foot overpronation which lead to the injury and, if uncorrected, will cause a recurrence. Corrective exercises help the treatment hold and further corrects the underlying muscle imbalance.

Fig. 4

A simple exercise which can strengthen the intrinsic muscles of the foot and help to correct foot overpronation is the short foot exercise. This exercise strengthens the adductor hallucis (hallucis refers to the big toe) muscle (Fig. 4), in particular. The following steps are followed to perform this exercise:

1. Sit upright with both feet flat on the floor. Alternately, the exercise can be performed standing on the foot to be exercised. This is more advanced.
2. Raise the arch of your foot by bringing your big toe towards your heel. The trick is to do this without curling your toes. Your emphasis is on lifting the arch away from the floor.
3. Hold for 5-10 seconds. You can perform this exercise multiple times. 

While this exercise is helpful, foot overpronation often involves other structures not only in the foot. These include muscle imbalance in the lower leg, knee and thigh, hip and low back. Comprehensive work with these structures is often necessary for lasting effects. Evaluation and treatment of these contributing muscle imbalances along with treatment of associated injuries are what your certified Sports Medicine Acupuncturists® work with.

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