Constrictions and trigger points in the lumbar erector myofascia are a common cause of pain in the gluteal and sacroiliac areas. An essential step in relieving these myofascial pain syndromes is to effectively stretch the constricted myofascia.
The stretching position most often recommended in the myofascial literature requires that the patient sit with his legs out in front of him while he flexes forward at the hips.1,2,3 While the patient stretches, the doctor may spray vapocoolant over the muscles to distract the patient from pain. This position works best with the more superficial erector muscles close to the spine, when they are so hypertonic that virtually any lumbar flexion hurts.
In many cases, however, the standard position doesn't adequately stretch the muscle that houses the trigger point. For example, I occasionally suffer from myofascial pain generated from my left longissimus thoracis muscle adjacent to L4. The longissimus muscle is hypertonic, yet not enough to limit my lumbar flexion. The usual stretching position is of no help, so I experimented with various other positions until I found one that worked well. This position, illustrated in the figure, works so well that it often relieves pain without the aid of other techniques. I've also found that the lumbar erector muscles (the longissimus thoracis and iliocostalis lumborum) aren't the only ones this position stretches. It also stretches the muscles under the lateral to the erectors (quadratus lumborum and internal oblique) and the overlying dorsolumbar fascia. Since I first used the position to relieve my own pain, I've taught it to scores of patients with excellent results.
Using the position effectively requires a few minutes of practice, even with patients adept at motor skills. To help them get the hang of it, I explain the purpose of the stretch: to lengthen the small but tightly knotted part of the involved muscle. "Stretching pulls the knot loose, and when you release the stretch -- gradually, of course -- fresh blood flows through the painful area of muscle. This washes away the pain-causing chemicals trapped in the knot." This is a caricature of the facts, but the mental picture enhances the patient's cooperation.4
To teach your patient the position, you must comprehend it kinetically by experiencing it. There are five steps (see the figure):
- Start out by standing at an oblique angle from a door knob or door facing. The foot on the non-painful side is closest to the door, and the foot on the painful side is further back.
- Reach forward and grasp the knob with the hand on the painful side.
- Lean away from the door.
- Lift your back foot off the floor to intensify the pull on the lumbar myofascia.
- Keep modifying your position until you feel the stretch in the painful part of the muscle.
I help the patient practice the position by first demonstrating it to him and then by coaching him to perform it correctly himself. After I demonstrate the position, I ask the patient to perform the five steps. Some patients fail to position their feet obliquely from the door. Instead, they face it too directly. This is easy to correct; what's hardest is tutoring them on the proper way to lean back and adjust their positioning to stretch the muscle.
It's common for a patient to stand up too straight when trying the position. I encourage him to bend and form an arch from his door-knob-clasping hand to the crest of his ilium on the painful side. I explain: "You're standing too tall. Lean back so that your line of pull is from the door knob, through your arm, shoulder and back to the top of your pelvis on the painful side. And keep shifting your position -- slightly but progessively -- until you feel the painful part of your low back stretching."
The pain induced by the stretch shouldn't exceed a moderate level. It's critical that your patient understand this. If the pain is too intense, the muscle may recoil into a protective spasm and worsen the pain.
If stretching the involved muscle becomes too painful in this position, I spray the skin over it with vapocoolant. This provides enough distraction from the pain to enable the patient to effectively stretch the fibers in the contractured part of the muscle. I keep a hot-pack ready to warm the skin after several series of sweeps of the vapocoolant. I have the patient stretch the muscle for a couple of minutes and then I apply the moist heat. In most cases, the pain is markedly diminished or completely absent after the stretch.
This stretching movement takes longer to set up than the more often recommended forward flexion while sitting. But as a rule, it relieves the patient's pain faster and saves time you'd spend applying other therapies. Most important, the movement stretches and elongates muscles in the low back far more thoroughly than does the sitting position. Its benefits are immediately obvious, once you set the patient up properly. And once the patient gets used to the position, it's much easier for him to do it more often throughout the day than is the sitting position. Use this position with a couple of patients and you're likely to find yourself using it a lot.
References
- Travell, J.G.; and Simons, D.G. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore. Williams and Wilkins 1983; p.648.
- Smolders, J. Myofascial Pain Syndromes (Trigger Points). Huntington Beach. Motion Palpation Institute 1987; p.31.
- Lowe, J.C. Spasm. Houston. McDowell Publishing Co. 1983; pp.103-111.
- Lowe, J.C. The Purpose and Practice of Myofascial Therapy (audio cassette album and treatment room manual). Houston. McDowell Publishing Co. 1989; p.16.
