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The Multifidus Muscle: Anatomy, Assessment and Treatment

By Doug Alexander, BSc, RMT. In this article Doug Alexander explains how to recognise multifidi shortness and high tone associated with facet joint hypomobility, as well as multifidi inhibition that tends to be associated with disc pathology.
The lumbar multifidi are small but important muscles. They lie on each side of the spinous processes of the lumbar vertebrae and fill the deep space in the laminar groove. While the erector spinae and other long muscles move the spine as a whole, the multifidi provide segmental stability by orienting adjacent vertebrae to each other. In this article you will learn to recognise multifidi shortness and high tone associated with facet joint hypomobility, as well as multifidi inhibition that tends to be associated with disc pathology. multifidi muscles. When there is a more local inability to flex, it is more likely caused by a purely multifidus shortness and/or high tone.

Figure 3: Watching lengthening of the lumbar spine during forward flexion tells the therapist whether the multifidi are short and likely to be jamming the facet joints, or long/weak and contributing to segmental instability. Figure 1: Coss-section of the lumbar spine showing the relationship between the mutlifidi and the erector spinae and quadratus lumborum muscles. Note that the multifidi are not just deep muscles. They are medial muscles!
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Multifidi dysfunction is often interwoven with facet joint dysfunction. Hypertonic, short multifidi are often found in the location of a facet joint hypomobility. The multifidi may adapt to the hypomobility by becoming short, or they may encourage facet joint hypomobility by keeping the facet joint compressed and altering its ability to function properly. Multifidi can also be related to spinal disc dysfunction. The tone of multifidi in close proximity to spinal disc pathologies tends to be inhibited. The resultant weakness in the multifidi often sets the stage for recurrent disc issues.

Visual assessment

Figure 2: Go online for free reader support for this article. You can watch streaming video clips of all the key skills described in this article as well as take an online test and print out a certificate that documents all your learning objectives.

Clients who flex excessively in their lumbar spine have weak and/or eccentrically overloaded multifidi muscles. This sets the stage for chronic post-exercise muscle soreness in the multifidi as well as the other spinal extensor muscles as well as recurrent spinal disc pathologies.

People with an excessive lumbar lordosis often have short erector spinae, quadratus lumborum and multifidi muscles. By asking your client to flex forward at the hips you can determine whether the lumbar spinal segments are stuck in a lordotic (extended) posture or if they can flex with respect to each other. Clients who maintain a lumbar lordosis as they flex forward have short and inextensible (non-lengthening) erector spinae, quadratus lumborum, and/or

Figure 4: Feeling for fullness and development of the multifidi is a learned skill that is similar, but different than looking for tension and tight bands in a muscle.

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Safety/precaution issue!
While it is safe to treat clients with disc pathology with massage, it is important to avoid stressing the spine in such a way that causes the disc problem to become worse. People with neurological symptoms and/or pain in the buttock and down the leg are not safe to treat in lumbar spine flexed postures. If your client has these symptoms they are not safe to treat unless you have training appropriate to their care. If you client tends to have these types of problems (as noted above) but doesnt have them at the moment, you can probably treat associated multifidus dysfunction as outlined in this article. Just avoid strongly flexing their spine with your movements and/or positioning on the table.

Figure 5: Knowing the fiber direction of the multifidi allows us to palpate at right angles and get the clearest awareness possible of taut bands.

Myofascial palpation
Palpating each side of the clients spine as he or she lies in a relaxed prone position assesses muscular development and tone. This can also be done in sitting or standing (Hides 2000), although massage therapists dont usually assess this way. There should be a degree of muscular fullness on each side of the spinous processes. In a normally muscled and toned individual you will feel the spinous process along with a symmetrical fullness on either side that prevents you from sinking down toward the vertebral lamina. Sometimes you feel that a particular segment or segments have excessive multifidus tone, fullness and/or a textured ropy quality. These multifidi often have an excessive stabilising effect and may be approximating adjacent facet joints and altering their line of action making them prone to hypomobility and/or locking.

If you find ropy, full or high-toned fascicles of a multifidus, palpate the fibers fully. One often finds myofascial trigger points in fibres like these that create a local ache and may also create sharp buckling or jamming feelings in the spine underneath them. This is likely because of their physical proximity to the underlying facet joints as well as their effect to draw adjacent facet joints together. Palpation may reproduce a familiar quality in the client, with them saying, Ah, that is my back pain! Sometimes you find multifidus atrophy. As you compare the fullness in the multifidi along both sides of the spine, you may feel a relative softness at one or more spots. Attempt to localise it precisely. This is an area where the multifidi have been inhibited and likely do not contribute to intersegmental stability. This is a region that is vulnerable to excessive flexion and or flexion/rotation loading. When you find a segment that is underdeveloped in this way, apply a little more testing pressure to it and compare it to adjacent sections of the spine. It will often feel vulnerable and weak to your palpating fingers. Clients often report that it feels weak to them and may create part of the feelings of vulnerability they feel when their back is bothering them! You can check on the function of the multifidi in these inhibited regions by asking clients to actively contract the muscles. This often confirms their inability to get the

segment to contribute to spinal stiffness. This active test is done in the prone position, by asking the clients to Gently swell the muscle under the fingers (or thumbs). Hold the contraction while breathing normally. (Richardson). There should be no spinal or pelvic movement while clients do this. It is often easiest to ask them to do this in a region where they have multifidi fullness. Then when they can do this against the feedback of your fingers or thumbs, gradually move into the region where they seem to be inhibited. You generally find that their ability to recruit the multifidi deteriorates as they get closer and closer to the region where the muscle has less cross-sectional area.

Spinal Joint Play Assessment

Figure 6: Pressing the facet joints anteriorly on a segment-by-segment basis identifies which facet joints are hypomobile.

Figure 7: Pressing the spinous processes anteriorly on a segment-by-segment basis identifies which vertebral segment is most hypomobile.

The motion of the spinal segments with respect to each other can be assessed through joint play assessment (Magee). With the client in prone, palpate the lumbar

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spinous processes and give each one an anteriorly directed pressure. Each spinous process should feel similarly firm and give slightly in an anterior direction as you press on it. If a spinal segment is restricted in mobility, the spinous process of that vertebra will feel harder because the vertebra doesnt move anteriorly when it is pressed upon. Clients will often feel an ache or sharp pain when the segment that is restricted is pressed upon. You can further explore findings of sensitivity and lack of motion by applying anteriorly directed pressures over the facet joints on either side of the spine. Over time, a clinician can develop sensitivity to the quality of motion of the underlying facet joints. Clients will often confirm which facet joint is most vulnerable as you palpate up and down the spine.

Inhibited, low toned multifidi and unstable lumbar spinal segments require treatment that is directed toward facilitating contraction and strengthening/stiffening of the multifidi. In either situation, the erector spinae and quadratus lumborum usually have too much tone, and need to be treated with classic massage movements. In clients who have inhibited multifidi, this drop in tone of the longer muscles makes training the multifidi easier to perform and more effective. In clients with short multifidi, treating the erectors and quadratus lumborum helps to alleviate the general high tone and myofascial shortness in the area.

Short and/or Hypertonic Multidi

Interventions

Short and/or hypertonic multifidi can be treated with the spine on a bit of flexion (i.e. prone with one or even two pillows under the abdomen). The erector spinae, serratus posterior inferior, quadratus lumborum and oblique abdominal muscles usually require some attention. This can be done with a variety of conventional massage movements that cant be covered in this short article. The multifidi need to be scanned for hypertonicity by exploring all along the two sides of the spinous processes. Treatment can be through static contact, kneading or sustained bowing of the muscle. When the tone drops in a particular multifidus the muscle can be stripped to lengthen it. These stripping movements often lead your fingers to the attachments of the multifidi across a hypomobile facet joint. Facet joint hypomobilities can be treated with a variety of joint mobilisations that we also will not be exploring in this article.

Inhibited Multidi
An inhibited multifidus or a region of inhibited multifidi need to be facilitated into contracting and gradually strengthened. Ask the client to swell the muscle up against the resistance of your thumb and/or finger. Most people cannot do this right away: thats why the muscle is inhibited! Contraction of the multifidi is facilitated by contraction of the transverses abdominus muscle. This can be taught by asking your clients to draw their bellybuttons towards their spines when they exhale. If they recruit their pelvic floor as if they are trying to stop a stream of urine, the multifidi are facilitated even more. I often have clients practice just the transverses abdominus and pelvic floor recruitment on their own for a week or two, before asking them during a treatment to swell the multifidus at the same time as the other two muscles. When the client does this properly, there is a feeling of increased fullness or turgor in the multifidus region close to the spine

Figure 9: The multifidus attachments to the spinous processes can be stripped in a sequential flowing fashion as you allow your thumbs and/or fingers to travel down the spine. Figure 8: The erector spinae are globally acting muscles that often have high tone and need to be treated fully. This unloads the spine as a whole and lessens the amount of noise in the system, making if easier for clients to release tension in other muscles as well as to sense contraction of the multifidi if they need to become aware of it!

Your treatment of the multifidi will depend on what you have found during the assessment. High toned and/or short multifidi require interventions to drop their tone, lengthening movements and often some joint mobilisation to help restore more normal movement of the related spinal segments.

Figure 10: The multifidis lock on the facet joint can be reduced by lengthening the muscle fibers from spinous process attachment to the attachment just past the margin of the facet joint.

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preparation for spinal loading such as extending legs or arms in an all fours position, or balancing on a gym ball or just in activities of daily living.

Conclusion
We have reviewed the anatomy of the multifidi and identified two very different (but often correlated) dysfunctions: hypertonic and/or short multifidi often with trigger points that go hand in hand with facet joint locking, and inhibited weakened multifidi that often go hand in hand with disc dysfunction. Hopefully this article will bring more clarity and more options the next time you are running your fingers or thumbs down a clients spine! Doug Alexander has been absorbed in his own and other peoples multifidus muscles for over two decades! The author of the Nerve Mobilisation DVD series, he is the editor of Massage Therapy Practice.com and teaches at Algonquin College in Ottawa, Canada. Doug can be reached at alexander2000@sympatico.ca Acknowledgment: This article is reproduced by kind permission of the author and Massage Therapy Practice.com The original article, palpation and treatment video clips, online quiz and certificate of learning are available free of charge to readers of the Journal of the Australian Association of Massage Therapists at http:// massagetherapypractice.com/ Text/1203645573508-8672/ References
Bogduk N: Clinical Anatomy of the Lumbar Spine, 3rd ed. London; Churchill Livingstone: 1997. Cavanaugh JM, Lu Y, Chen C, Kallakuri S: Pain Generation in Lumbar and Cervical Facet Joints. J Bone & Joint Surgery 2006;88-A(Supp 2):63-67. Hides J, Scott Q, Jull G, Richardson C: A Clinical Palpation Test to Check the Activation of the Deep Stabilizing Muscles of the Lumbar Spine. International Sport Med Journal 2000;1(4):1-4. Kjaer P, Bendix T, Lorenson JS, Korsholm L, Leboef-Yde C: Are MRI-defined fat infiltrations in the multifidus msuces associated with low back pain? BMC Medicine 2007, 5:2 doi:10.1186/1741-7015-5-2 Lewin T, Moffett B, Viidik A: The morphology of the lumbar synovial joints. Acta Morphologica Neerlando Scandanavia 1962;4:299-319. Macintosh JE, Valencia F, Bogduk N, Munro RR: The morphology of the human lumbar multifidis. Clinical Biomechanics 1986;1:196-204. Magee D: Orthopedic Physical Assessment. Matejka J, Zuchova M, Koudela K, Pavelka T: Changes of muscle fiber types in erector spinae and multifidus muscles in unstable lumbar spines. J Back Musculoskeletal Rehabilitation 2006;19:1-5. Macintosh JE, Bogduk N: The biomechanics of the

Homecare

Figure 11: When the client recruits their transversus abdominus appropriately the waistline visibly narrows.

Figure 12: Tapping on a muscle activates intramuscular receptors and facilitates the clients efforts to contract the muscle. Work from a region where they can recruit only weakly, and work your way into the region where the muscle is most inhibited.

Go to http://massagetherapypractice. com/Text/1203645573508-8672/ to download Client Handouts that teach Transversus Abdominus Recruitment, Multifidi Stretching, Core Stabilization and more. The homecare your clients need to perform depends on the situation in their multifidi. Short multifidi need stretching and long multifidi need recruiting and strengthening. It can take quite a bit of finesse to teach people these skills, but it is a necessary job. We intersect with our clients bodies for an hour or so a week. They are with their body 24/7 and need to learn how to take care of themselves, as well as support our care for them. Go online at http://massagetherapy practice.com/Text/1203645573508-8672/ to download client handouts that teach stretching and core stabilisation.

without any recruitment of the long spinal muscles (erector spinae) and no movement of the spine. People with inhibited multifidi need to gradually train the muscle by practicing this exercise every day. Clients often benefit from sticking their own thumb or finger into the muscle when practicing in order to ensure they are recruiting it properly. Eventually, the multifidus is recruited in

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