Titled “Electroacupuncture treatment of acute low back pain: unlikely to be a placebo response” and written by Dr. Kwan Leung Chia, from the School of Medicine at Flinders University in SA, you could be forgiven for passing over the abstract if you weren’t interested in or currently using electroacupuncture, however this case report leads to broader discussion.
You can read the full case report here
As others treating this age group and gender will agree, this type of history and presentation is not uncommon when the pain is in the buttock or lateral thigh. Often the onset is an unremarkable single legged, sudden overload situation; like a miss step, trip or hop. Pain is initially mild and builds over 24 hours, becoming intense and often incapacitating. Rest eases, but weight bearing quickly aggravates. In this situation pain is localised on palpation to the buttock, most commonly along what I refer to as the ‘posterior gluteal line’ (an artificial line drawn between the PSIS and greater trochanter). Anatomically this coincides the most posterior arc of the gluteus medius and minimus attachment on the ilium – I wonder if this represents an enthesis irritation?
In Dr. Chia’s case study, the conclusion is drawn that the muscle at fault is psoas major, based upon active hip flexion being the most painful movement, and leaning forward causing pain. The hip flexion is logical but trunk flexion doesn’t clearly follow. Trunk flexion in standing is a low load movement, that would only require eccentric control via trunk extensors, rather that an active truck flexion or even a co contraction. Perhaps it was performed in supine like a sit-up, but this was not stated. The other point of examination that would have been useful to assist diagnosis was palpation.
While the posterior tissues were noted as thoroughly palpated, no anterior tissues were mentioned. Clinically I have been on the lookout for acute psoas dysfunction for a long time and believe I have only seen one. Sub clinical involvement of psoas however, I believe is reasonably common in lumbopelvic presentations. On palpating the psoas muscle there is often a hypersensitive place (lowered pain pressure threshold - PPT) just lateral to the umbilicus (L3 approximately) on the ipsilateral side. In addition, palpation of the iliopsoas muscle as it crosses the superior and inferior pubic ramus, is also hypersensitive relative to the contralateral side. Clinically the interesting thing here I have found, is that if you treat the distal point i.e. over the inferior pubic ramus (I use dry needling), the proximal point invariably settles spontaneously. So other than conceptually, I haven’t needed to explore deep needling of psoas from a postrolateral approach, because treating the distal trigger point has been successful.
Useful Clinical Psoas Resources
Here are a couple of case studies focusing on psoas, that I have previously detailed showing the variety of presentation and management strategies.
Also if you haven’t needled the before mentioned lower trigger point of psoas, beware of spontaneous reactions. This YouTube video captures a +ve jump response when needling the lower trigger point.
Like Dr. Chia, I heartily agree that review of anatomy is imperative to continue the learning process for manual based therapists and for this reason we have specifically developed a relationship with the UWA Anatomy & Physiology Department to enable regular access for AAP Education members via our workshops. Upcoming Anatomy Workshop details can be found here.
If this has perked your interest in upgrading your Lower Quadrant dry needling skills, click here to turn thought into action! Likewise for those planning on attending the Master Needling Course in 2015, this is your last opportunity to complete your Advanced Courses and qualify for the 2015 Master Needling Course in Esperance.
Joining the Discussion
I really appreciated the emails that people send through about these newsletters. Often these contain useful information that others would benefit from reading. So what I am doing is posting the newsletter on Creating Clinical Success, my blog post. In this way people will be able to comment and others will also be able to read replies. If you have a comment, perspective or question, please consider adding to the discussion.
All the best,
Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
Clinical Director AAP Education
ph/fx: 08 90715055
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