Although there are multiple different muscles which can contribute to back pain and postural imbalances, there are three which are seen time and time again as major contributors. These are the ILIACUS muscle, the PSOAS muscle ( pronounced ?so-as? ) and the QUADRATUS LUMBORUM or QL. The iliacus and psoas muscles are part of what is known as the HIP FLEXOR group. In this post, we?ll discuss the iliacus, and then we shall discuss the psoas and quadratus lumborum in the next post. We shall see that uncorrected contraction of these muscles can set up physical changes in our bodies all the way from our feet to our necks. These muscles are very important to understand from a postural analysis point of view. In other words, they can cause one shoulder to appear lower than the other, one hip to appear higher than the other, etc.
The iliacus muscle is powerful and attaches at two places. The first attachment point is to a little piece of bone on the inner thigh, known as the LESSER TROCHANTER. The other attachment is all around the inside of the hip bone or ILIUM. We have two hip bones, called ILEA in the plural.
The following is a very good video for seeing some of the effects mentioned here:
When the iliacus becomes overused, for example from sitting at a desk all day, and from leaning over to work on a laptop computer, the muscle contracts in length. All the usual problems ( pain from excess lactic acid buildup etc ) can occur, but the mechanical effects of this muscle regarding postural analysis are what concern us here.
When this muscle is overused, it contracts from both ends, as all muscles do. We shall now look at the some of the effects that occur.
As the iliacus contracts from both ends, the leg bone ( the femur ) that the lesser trochanter is part of, is pulled upwards into the socket where the spherically shaped head of the femur fits. The socket is known as the ACETABELUM. The acetabelum is lined with cartilage like material. When this cartilage wears down, we often end up with a ?bone on bone? situation. After pain killers etc are given, the next stop is often a surgical hip replacement. In Africa, amongst villagers, hip replacements are practically unheard of ( with the exception of bone disease ). I have spoken to several doctors who performed surgeries at various villages. They told me they were astonished at the lack of hip problems amongst the elderly.
If the femur is pulled upwards by the contraction of the iliacus ( and more importantly by the psoas as we will discuss later ), the constant pressure can wear away the cartilage. Sadly, there are only a handful of therapists who understand this. I have yet to meet a doctor who is aware of this.
In order to understand the next mechanical effect that occurs, we need to understand a little more about the mechanics of the pelvis:
We mentioned that we have two ilium bones. Each one connects to the SACRUM at the base of the spine. The word ?sacrum? means ?sacred stone? in ancient script. The ?keystone? in a house or bridge is a very important stone which ?keeps everything together?. The Greeks understood that the ?sacrum? was the keystone for the spine. The tailbone or COCYX attaches to the bottom of the sacrum.
Each illium attaches to the sacrum by means of the SACRO-ILIAC joint. This is a very important joint, but is easily the least understood in the entire human body. It was this joint that was dislocated on myself, in an extremely rare accident. The joint is vitally important in cushioning shock when we are walking. If you have ever stepped off a sidewalk/pavement and not known that there is a small drop, the ?shock? you feel comes from the sacro-iliac or SI joint. The joint only moves 1 to 5 mm in normal operation, but that small movement is very important. SI joint problems can mimic lower back pain from herniated disks almost exactly ( as was the case with myself ), and have led to countless unnecessary back surgeries.
A bone, called the pubic bone leads outwards from each hip bone or ilium. These two bones meet together via a small flexible ?joint? known as the PUBIC SYMPHYSIS or PS. This little joint is vitally important. It means that the two hip bones are not physically ?hard-locked? together. There is a degree of flexibility. I cannot overemphasize how important this is. Few therapists understand this fact properly. When I realized that the doctors were unable to even diganose my condition properly, I spent hundreds of hours analyzing this joint using three dimensional pelvic models which I purchased from medical supply houses.
One more area needs to be looked at, then we will see the effects that a shortened iliacus can have on our pelvis ( and in turn our head and neck ).
In order to determine whether something has moved from it?s normal position, we need a reference point or ?landmark?. On the front of the pelvis, we have a small piece of bone that ?sticks out?. Just about everyone on the planet has one of these little ?bumps? on their pelvis. We have one on the left ilium and one on the right ilium.
The ?bump? is known as the ANTERIOR SUPERIOR ILIAC SPINE or ASIS. There is also another ?bump? at the back of the pelvis called the POSTERIOR SUPERIOR ILIAC SPINE or PSIS. That?s a bit of a mouthful. Let?s break the names down in a logical manner to try and make sense of them.
We refer to the front of the body as the ANTERIOR part. We refer to the rear of the body ( or bone etc ) as the POSTERIOR part. So, the ASIS is on the front of the pelvis and the PSIS is at the back. SUPERIOR refers to ?more towards the head? and INFERIOR refers to ?more towards the feet?.
There are actually two bumps on the front of the pelvis. One is called the ASIS and the other (below it ) is called the AIIS or ANTERIOR INFERIOR ILIAC SPINE. We will be mainly concerned with the ASIS. The term ILIAC simply means that the ?bump? is part of the ilium or hip bone, and the term SPINE merely refers to the ?bump or spine? of bone.
So, we have a ?bump of bone? ( SPINE ) that sits on the hip bone ( ILIUM ) at the front of the pelvis ( ANTERIOR ). It is the ?top bump? of the two ?bumps? on the front ( SUPERIOR ). Thus, ANTERIOR SUPERIOR ILIAC SPINE. Like a mile marker on a road, it is a very important reference point for postural analysis.
What do I use to determine if my pelvis has shifted off-balance ?
A simple spirit level. I get someone to lay it horizontally across my pelvis while I lay on the floor. One end is put on top of one ASIS point. The level is then laid at 90 degrees to the center line of the body. Whichever ASIS has rotated anteriorly ( towards the feet ) will show up by movement of one of the bubbles ( I won?t get into the details here ). I was contacted recently by someone who had been living with back pain since childhood. They had gone to the best spinal doctors in the US. All sorts of CAT scans etc. Had two back surgeries. In less than sixty seconds via Skype we were able to determine that their right ilium was severely rotated. Two weeks of the correct treatment and they were pain free. Now they will have to try and sort out the multitude of problems which have since arisen from those unnecessary surgeries.
Let?s now imagine that the right iliacus muscle has become tight ( from overuse of the gas pedal for example ). It will contract at both ends. As mentioned, this will cause the femur ( or upper leg bone ) to be pulled upwards and to press even more into the hip socket. The right ilium will also move. It will rotate downwards. We call this an anterior rotation. Because of the little pubic symphysis joint ( provided the joint is functional and not ?stiff? ), the left ilium will not be moved very much.
We know that the ilium connects to the sacrum, but the sacrum also connects to the spine via an interverterbral disk called L5-S1. There are five lumbar vertebrae in the lower back. From a direction going from head downward, they are labelled L1, L2, L3, L4 and L5. When we are young, the sacrum is not solid, but is made up of a number of segments, which later fuse together. The first segment of the sacrum is called S1. The L5-S1 disk sits between the L5 verterbra and the S1 segment. This disk is the junction between the sacrum and the spine. Along with the disk L4-L5, it is one of two most ?herniated disks? among patients. Many doctors will tell you that they herniate more because they are at the bottom of the spine and have the most pressure. That is not correct. While those disks do indeed experience the largest amount of pressure, they ARE DESIGNED TO DO SO, PROVIDED THAT THE LUMBAR ( LOWER BACK ) SPINAL CURVATURE REMAINS CORRECT. This is the most important statement that will be made in any of these posts. Without a therapist having a good solid grasp of this concept, it will be a ?hit and miss afair? as to whether their patients ever get rid of their back pain.
As the iliacus shortens and rotates the ilium, the lumbar column is forced to go into a greater curve than normal, due to the mechanical connection between the spine and the sacrum/ilium group. I will repeat the previous video here, as it is very important:
If nothing else happened, this would start to topple you over, due to the fact that the pelvis is now being tipped downwards. This causes the head to also start to tip downwards. The brain recognizes what is level and what is not around our surroundings via the inner ear and the eyes. The brain is programmed to do whatever is necessary to restore the eyes to a proper horizontal level. If the head cannot be pulled further back, the brain sends a signal to the lower back muscles to tighten up in order to bring the head back up to a proper level. As a result of this, the back muscles can cause pain if the muscles tighten to such a degree that the pain threshold ( discussed in a previous theory post is reached ). But that is only part of it. Because the curve in the lower back has now increased beyond what it is supposed to be, pressure increases on the disks leading to degeneration, possible herniation and also reduction in size of the foramen holes through which the spinal nerves pass.
But that?s not the end of it, even more problems can be caused.
When one side of the pelvis ( an ilium ) rotates forward as a result of a tight muscle or muscles, it causes the acetabelum ( the socket in which the upper leg bone fits ) to rotate backwards and upwards. Since the femur ( upper leg bone ) is attached to the acetabelum, it also is rotated upwards and backwards, resulting in the APPEARANCE that one leg is shorter than the other. This also causes twisting in the pelvis. There?s a lot more to it than that, but this should give you an antroduction to some problems that can result from excessive sitting/hunching. Truck drivers are the number one patient group in the US for back pain/surgeries. Followed by policemen/firemen/nurses/IT and office workers. As we get further into back and neck pain issues, you will see why those occupations can affect your health if preventive/corrective measures are not taken. X-Rays are an excellent diagnostic tool in identifying these issues. Sadly very few doctors are properly trained in how to analyze postural problems via X-ray pictures. I?ll put up a separate post on X-rays later. A final problem is that the vast majority of X-rays are taken in the wrong position of the patient, and also at the wrong angle.
Imagine that you are standing on the right side of someone. You dig your thumb into the top of their hip. Their right hip is then rotated forward ( an anterior rotation ). Due to the complex shape of the hip bone, you would see your thumb rise in a VERTICAL direction. This can stand out quite clearly on an X-ray.
When I was ill, I ended up at the clinic of a very famous postural ?expert?. This person lectures on cruises etc, charging very large amounts of money. He had x-rays taken of my pelvis, and told me that I needed ?shoe lifts? ( small pieces of material to ?equalize? leg length ). I could clearly see that one hip was much higher than the other. Something inside me said not to do this. I eventually ended up seeing Al Meilus and Aaron Mattes in Florida who showed me that my pelvic height differences were actually being caused my right iliacus being severely contracted, hence resulting in rotation, and subsequent hip height increase. After corrective exercises, my last set of X-rays showed both sides of my pelvis ( perfectly aligned ). Had I used those lifts ( as so many do ), it would have kept a bad situation bad, and eventually would have made it worse. My scoliosis disappeared after that ( more on scoliosis in the next post ).
Pelvic rotation sets up a chain of unwanted postural distortions that we will discuss in the next post, when we discuss the psoas.
Previous theory posts: