Includes MPS causing low back pain. S,i,J pain & hip joint pain . Including various tests to examine these pathology.

1. Myofascial Pain conditions
causing low back pain
Dr. Ravi Shankar Sharma
Moderator – Dr. Praveen Talawar

2. Myofascial pain
syndromeFrench physcian Baillou Muscular rheumatism
1950s Travell and Rinzler referred Myofascial pain
A common non-articular local musculoskeletal pain
syndrome caused by myofascial trigger points
located at muscle, fascia, or tendinous insertions.
Affecting ~ 95% of people

3. the presence of
Myofascial trigger points
(MTrPs)
Hyperirritable spot, usually within a taut band of skeletal
muscle

4. Active Vs
Latent Tp.

5. Pathophysiol
ogy

6. Trigger point formation hypothesis
(Sourced from: Starlanyl & Sharkey 2013.)

7. Aetiological factors
Travell and Simons
(1999)Direct
• Mechanical overload
• Sudden cooling of fatigued
muscles
• Repetitive usage resulting in
fatigue
• Trauma
Indirect stimuli
• Myopathy
• Other TrPs
• Visceral Disease
• Arthropathy
• Neuropathy
• Metabolic dysfunction
• Endocrine dysfunction
• Toxicity
• Infection
• Emotional Distress

8. Clinical
feature :

9. Symptoms of
MFPSU/L pain / Referred pain (caudally or cranially)
 Character  deep, aching, and burning pain.
Intensity – Depends on TrP activity/Irritability
Autonomic features ,Swelling, Tenderness,
Paresthesia +
Weakness, muscular imbalances & ↓ROM
 Fatigue, sleep disturbances & depression

10. Examination

11. • A trigger point & taut band
• Referral of pain to a zone of reference
• Reproduction of the patient’s usual pain
• Local tenderness
• Local twitch response
• Painfully restricted range of motion,
• Muscle strength limited by pain

12. PalpationFLATPALPATION
PINCERGRASP

13. Diagnostic
criteria of an
MTrP

14. Gerwin described the
following features:-
1) Tender spot found in a taut band of muscle
2) An LTR and/or referred pain to distant sites
3) Restricted range of motion;
4) Reproduction of the patient’s pain complaint
5) Regional muscle weakness
6) Autonomic symptoms

15. Limitation
s :1) Not an objective, reliable, and sensitive method of
diagnosis and measurement of treatment efficacy
2) Can’t make Quantitative comparisons of the tissue
properties before and after treatment;
3) Can’t Differentiate among active MTrPs, latent
MTrPs, and palpably normal tissue;

16. Dry Needling and the Local Twitch
Response

17. Visualization
and
Characteriz
ation of

18. Vibration sonoelastography
Reduced vibration amplitude on elastography, indicating a localized
area of stiffer tissue compared to surrounding soft tissue

19. MTrP. A hypoechoic region and a well-
defined focal decrease of color variance
Doppler ultras

20. The lumbar
back muscles

21. Paraspinal
Muscles

24. Psoas Muscle
Active while sitting, standing, and maintaining posture

26. Clinical examination involves tests that restrict
extension of the thigh at the hip.
• ↑pain with active SLR, which is ↓ with passive SLR.
• Extension of the leg at the hip in the lateral
decubitus position often increases the pain.
• Pressure over the trochanter  tenderness of the
iliacus and psoas muscles

27. QUADRATUS
LUMBORUM
lateral flexor and stabilizer of the lumbar spine.
•Extension of lumbar vertebral column.
•Fixes 12th rib during forced expiration.
•Elevates ilium bone

29. Clinical feature:--
-• weight-bearing posture↑ pain,
• Discomfort turning over in bed.
Relief unload the lumbar spine of the upper
body's weight ( support and stabilize their
upper body with hands )
coughing or sneezing can exacerbate the pain.

30. Piriformis
External rotation and abduction

31. • Local tenderness and buttock pain  sitting
cross legged.
• Flexion/ adduction/ internal rotation 
painful
• L4-S4 sciatic nerve  Pseudoradiculopathy
Clinical
feature

32. Gluteal Muscles
• Gluteus Maximus, gluteus medius, gluteus,
minimus
• The gluteals - allow you to walk and move your legs
in, out, and back.
• common source of low back pain – (G. medius)
• low back pain, also felt over the sacrum & buttock..

35. Sacroiliac
Joint (SIJ)
Pain
Sacro-Iliac joint arthropathy 15-30%

37. Effective load transfer & Acts as a shock-absorbing structure

38. Primary Ligaments: Secondary
Ligaments

39. Innervation
Anterior aspect :
• Ventral rami of L5 to S2 via sacral
plexus
Posterior aspect :
• lateral branches L4,L5 S1, S2, S3 and S4
predominantly by S1 dorsal ramus

40. Causes :
• Osteoarthritis.
• Inflammatory including SpA --(AS)
• Traumatic
• Pregnancy
• Walking patterns.
• Gout
• Malignancy

41. Risk Factors
leg length discrepancy,
abnormal gait pattern,
trauma,
heavy physical exertion,
pregnancy.
scoliosis,
lumbar and sacrum fusion surgery

42. Local tenderness present in the region of the SIJ
+ve Clinical SI joint stress tests (painful).
+ve diagnostic interventional procedure
(completely relieves the pain)

43. Clinical
feature:-

44. Symptoms :
Paramedian Low back pain –
U/l or b/l
Unilateral Buttock, hip or Thigh
pain
↑on sitting , relieves on
standing
LBP with radiculopathy (non
dermatomal)

45. Signs:
• Paramedian tenderness
• Provocative maneuvers
1. Compression test (approximation test):
2. Distraction test (gapping test):
3. Patrick’s sign (Flexion Abduction External Rotation test):
4. Gaenslen test (pelvic torsion test):
5. Thigh thrust test (posterior shear test):
6. Fortin’s finger test:
7. Gillet test:

46. FABER TEST

47. GAENSLEN
test

48. Distraction
test

49. Thigh thrust

50. Compression
test :

51. Gillet/March
test

52. X- ray of S.I. joint

53. Diagnostic
injection

54. USG guided

55. Hip joint pain
The prevalence of hip pain in the general population
is 10%, and increases with age.

56. Anatomy

57. Attachments &
Movements around hip
joint

58. Ligaments

59. Bursa:

60. D/d:-

61. D/d:

62. History
• Groin pain M.C.
• Thigh pain & buttock pain
• Pain, stiffness and difficulty doing activities
degenerative disease
• Referred to buttock and lower extremity
• Peritrochanteric area pain with mild swelling
• Complaints of clicking, catching, snapping, etc.

63. Locations of “Hip Pain

65. Examination:-
• Inspection
Gait
 Muscular atrophy
Pelvic symmetry
• Palpation
• Range of motion
• Special tests

66. Gait

68. Range of Motion

69. Special tests

70. FADIR Test
• Positive for FAI if it reproduces the patient’s hip
pain

71. Snapping Hip
Maneuver
Iliopsoas bursitis

72. Stinchfield Test
Straight leg raise against resistance
Helpful for diagnosis of: • FAI • SCFE

73. The resisted hip
extension test
Ischial bursitis.

74. Resisted hip abduction test
Gluteal bursitis,

75. Resisted hip abduction release test
Sudden release will increase the pain in the lateral thigh over the
greater trochanter which may indicate trochanteric bursitis.

76. X -ray

77. O.A. Hip joint

78. USG