Lumbar Biomechanics

Dural Column is a very dense and thick CT that invests itself onto the bone. It
travels from the body of the sacrum to the skull in one solid piece
o Can be seen with a laminectomy where you remove the transverse processes
from all vertebral segments
Lumbar Spine
o Three main functions
To protect the spinal cord
Allow movement
Support the upper body
o Complex system consisting of:
Spinal Cord
Nerves
Bones
Ligaments
Muscles & Tendons
o Relatively large, square and act as building blocks that stack up on top of
one another. Designed to be able to bear weight from the upper body

It is very easy for the lumbar spine to flex and extend, but not rotate
Lumbar rotation rotates among itself and also along the facet
joints. Because of this, the lumbar spine is not very good at
rotating > small range of motion
Most of the body rotation comes from the Thoracic spine
The only way to move the vertebral body is along the vertebral
disk and thus, put on a large amount of sheering force that
makes it relatively viable.

Facet connects one vertebrate to the next

Inferior facet will connect to Lumbar below whereas the superior facet
connects to the Lumbar spinous process above. It is relatively in line
with the body that it is connected to whereas in the Thoracics, they
may be a little lower.
o Spinal Ligaments

Longitudinal ligament One very long cable that connects all

vertebrate together.
o Anterior Longitudinal ligament anterior to vertebral body
and allows the spine to move as an individual unit. Very
broad and runs the entire width of the vertebral body to
provide tremendous stability in the anterior side for flexion
and extension.

Starred ligaments have nociceptors in them and have the ability

to generate pain

Back edge of the vertebral canal

Ligamenta flava connects between the vertebrate strongest
ligament
Transverse ligament cables that help to protect sidebending

Posterior longitudinal ligament Front of the vertebral canal but

runs posterior to the vertebral body. Much smaller compared to
the anterior longitudinal ligament. Connects to intervertebral
disks and provides a neural framework that makes their way out
in the body and extremities.
If a herniated disk in the lumbar spine occurs either on the lateral
side and the back, this can lead to paralysis and then pain since
it travels down and catches the nerve route from the side.
o Herniated disks are best diagnosed using an MRI vs. an XRay

White abnormal disk

Black normal disk
Blue Spinal cord/Roots
Red spinal canal

o Deltoid spine of scapula inserts on top of the humerus

and contributes to creating fine control of the shoulder with
the relatively large muscles.
This is how we generate control over large amounts
of the area and spare using the fine muscles as much
as we can in order to prevent them from being
overworked and supporting our body weight.
o Largest muscle is the most superficial and connects from
sacrum to the middle of the back.
o Trapezius overlaps with the Latissmus Dorsi (lateral of body
to the middle of the back)
Where these two muscles overlap, we have stability
and tons of control over movements

o Intermediate layers
Encases the erector spinous muscles intermediate
stability to the lumbar spine
Encased by the Longissimus, spinalis, and
iliocostalis
Iliocostalis
o Origin at the sacrum; iliac crest;
thoracolumbar fascia
o Inserts at 6-12th ribs; thoracolumbar
fascia (deep); upper lumbar vertebrae
(transverse processes)
o Spinal nerves C8-L1 (posterior rami;
lateral branches)
o Action: Bilateral: extends the spine;
Unilateral: Bends spine laterally to same
side
Longissimus
o Origin at Sacrum; iliac crest; lumbar
vertebrae (spinous processes); lower
thoracic vertebrae (transverse processes)
o Insertion at 2nd-12th ribs; lumbar
vertebrae (costal processes); thoracic
vertebrae (transverse processes)
o Spinal nerves C1-L5 (posterior rami,
lateral branches)
o Action: Bilateral: extends the spine;
Unilateral: bends the spine lateral to the
same side
Spinalis Thoracis
o Origin at T10-L3 (spinous processes,
lateral surfaces)
o Insertion at T2-T8 (spinous processes,
lateral surfaces)
o Spinal nerve (posterior rami)
o Action: Bilateral: extends cervical and
thoracic spine; Unilateral: bends cervical
and thoracic spine to the same side
Multifidus
o Origin & insertion at C2 Sacrum
(between transverse and spinous
processes skipping 2-4 vertebrae)
o Spinal innervation (posterior rami)
o Bilateral action: extends the spine
o Unilateral action: flexes the spine to the
same side and rotates to the opposite
side
Interspinales Lumborum
o Origin & insertion L1-L5 (between
spinous processes of adjacent vertebrae)

o Spinal innervation posterior rami

o Bilateral action: Stabilizes and extends
the cervical and lumbar spines
o Unilateral action: bends the cervical and
lumbar spines laterally to the same side
Intertransversarii Mediales Lumborum
o Origin & Insertion L1-L5 (between
mammillary processes of adjacent
vertebrae)
o Bilateral action: stabilizes and extends
cervical and lumbar spines
o Unilateral action: bends the cervical and
lumbar spines laterally to the same side
Intertransversarii Laterales Lumborum
o Origin & Insertion L1-L5 (between
transverse processes of adjacent
vertebrae)
o Bilateral action: stabilizes and extends
the cervical and lumbar spines
o Unilateral action: bends the cervical and
lumbar spines laterally to the same side
Thoracolumbar fascia is connected to the sacrum
from the cervical spine
Keep in mind that fascia is ONE large piece that
connects as ONE functional unit.
Intersegmental Motion
o How the spine moves under physiological conditions
considering that the spine is physiologically intact
o Dictated by Freyettes Laws Type I
When the spine is in neutral position, it is really
governed by the tiny muscles and in particular, the
multifidi and rotatores (rotation, stabilization). They
start on the transverse process and make their way
upwards and insert into the lateral process a few
segments above. One the spinous process

Soft Tissue Techniques - Direct

o Act to: Reduce spasm, increase circulation, decrease
hypertonicity, induce general relaxation, & identify areas of
restriction
o Contraindications
Absolute: lack of somatic dysfunction and lack of
consent
Relative: acute injury (fasciitis, fracture, tears,
burns), infection, neoplasm, blood disorders
o Longitudinal (superior inferior), Perpendicular (lateral
medial), Rotate (clockwise counterclockwise)
Myofascial Release Direct or Indirect
o More principle than technique
Piezoelectric viscosity related to amount of stress
placed on the ground substance. If you stress and
pull and keep under tension as long as you can, this
will change the tension and configuration so that it
now stretches and is able to move around.
o Based on fascial property of creep
o Contraindications the same as soft tissue

Innominate Diagnosis and Muscle Energy

Innominate
o Definition: means no name
o Composed of 3 bones:
Ilium most superior part; Feel at the flank
Ischium inferior and posterior; Hip
Pubis Inferior and anterior; Groin

When children are born, the three bones were unfused until about 6
years old.

Anterior Pelvis

o
o Components to diagnose
Iliac crest
Anterior Superior Iliac Spine (ASIS)
Anterior Inferior Iliac Spine (AIIS) harder to palpate
Pubic Symphisis
Ischial Ramus
Suprapubic Angle
Due to childbearing reasons, women have a wider pelvis and
suprapubic angle
o Other body elements
Sacrum very important sacroiliac joint
Acetabulum
Posterior Pelvis

o
o Components to diagnose
Posterior Superior Iliac Spine (PSIS)
Posterior Inferior Iliac Spine (PIIS)
Ischial Tuberosity
Iliac Crest
Ilium
Pubis
Gender differences
o Pelvis is heavier and has more pronounced muscle attachment sites in men
o Pubic arch is narrower and the suprapubic angle is more acute in men
o Ischial tuberosities are closer and pelvis outlet is comparatively smaller in men
o All ilia is less flared in men and thus, greater pelvis is deeper
o Pelvic inlet is heart shaped in men and transversely oval in women
o Obturator foramen is round in men and oval in women
o Pelvis is broader in women
Joints
o Sacroiliac (SI) joint
Small amounts of motion
Atypical synovial joint with fibrocartilage rather than hilar cartilage
Stabilized by anterior and posterior ligaments
o Pubic Symphysis
Cartilaginous joint
Stabilized by superior and inferior ligaments
Allows the joint to relax during childbirth
Ligaments

Anterior Longitudinal
Goes all the way up the course of the spine and connects to the
anterior tubercle of the cervical spine, terminating where it spreads
across the pelvic bone.
In order to switch that ligament you need to extend. Limits
hyperextension of the spine
Posterior Longitudinal ligament
Does the opposite and prevents hyperflexion of the spine
Sacrotuberous ligament
Sacrum and tuberosity of the ischium
Stabilization and posterior rotation/functions in conduction with the
ligament to stabilize posterior rotation of the pelvis
Anterior SI ligament
Attaches to the surface of the Ileum and the lateral part of the
sacrum. Common cause of pain in people. Attaches to the
transverse process of the 5th Lumbar and the inner iliac crest.

o
Interosseus SI ligaments
Deep to the posterior ligaments and connects tuberosities of the
sacrum and the Ileum. Funtions to keep the sacrum and the ileum
close together.
Posterior SI ligaments
Stronger than the anterior counterpart. Strengthens the bonds
between the sacrum and the ileum
Can also see the sacrospinous and sacrotuberous ligaments from the
posterior side.
o Muscles
Major Hip Flexors

Iliacus

o Ilia to the lesser trochanter of the femur

Psoas
o From the Lumber 5 vertebrae to the lesser trochanter of the
femur
o A huge muscle that attaches to every lumbar vertebrate,
crosses the hip joint anteriorly and attaches to the femur
o A spasm can lead to hip pain, groin pain, pain near the lesser
trochanter, etc
Iliacus and Psoas both located on each side that attaches from the
spine and then eventually comes together and ends at the inner
greater trochanter
Minor Hip Flexors

Rectus Femoris
o AIIS to patella
o Attaches to the AIIS, cross the anterior hip joint of the body,
and then attaches to the knee joint. On the anterior surface of
the thigh and hip, it will flex, and pull the leg up. This is
flexion of the lower legs.
Sartorius
o ASIS to medial tibia
o Minor flexor as it crosses the hip joint and also a hip flexor of
the lower leg
Extensor

Semimembranosus and Tendinosus

o Both attach at the ischial tuberosity and medial proximal tibia
o Work together and the attachments are pretty similar.
o Located on the posterior surface of the body and crosses the
hip joint.
o They will extend backwards and pull the leg upwards
o If the muscle comes together, it pulls the buttox closer to the
hip joint.
Biceps Femoris
o Attaches to the sacrotuberous ligament/Ischial tuberosity
Gluteus Maximus

o
o Originates at the Posterior sacral base and PSIS of
innominates
Crosses the hip joint and attaches to the posterior
surface of the femur. So when the two ends come
together, it pulls that part of the leg back towards the
hip joint and thus, extends
IT band extension of all the fibrous tissue that runs all
the way down. Common in marathon runners & runners
and is the major cause of pain on the side and knee
pain.
o Inserts at the lateral femur
Adductors

Adductors attach closest along the pubic symphisis and control

movements toward the body
Major Adductors
o Adductor Magnus
Inferior pubic ramus to the medial epicondyle
o Adductor Brevis
Inferior pubic ramus to the medial aspect of the femur
o Adductor Longus
Superior pubic ramus to the medial aspect of the femur
Minor Adductors
o Gracilis
Pubic ramus to the medial border of the tuberosity on
the tibia
o Pectineus
Pubic ramus, anterior to the posterior aspect of the
proximal femur
Abductors away from the body

Gluteus Medius
o Attaches to the ilium and greater trochanter of femur
o Common place of dysfunction that often goes ignored. It
spreads across the iliac crest and the greater trochanter on
the lateral side. If the muscle comes together, it pulls the leg
up and out laterally
Gluteus Minimus
o Attaches to the ilium and the greater trochanter of femur
Tensor Fascia Lata
o ASIS to the ITB tract
External Rotators

Piriformis
o Special since it is the only one that attaches to the anterior
sacrum
o Function depends on position
o Sciatic Nerve
Below
Through
Comes right under the muscle. If a muscle is in spasm,
it clamps down on those nerves and shoots down
causing sciatic pain = wallet syndrome
o The only rotator that connects directly to the sacrum and the
only muscle on the anterior surface of the sacrum
If the hip is flexed, it can function as an abductor
If it isnt extended, it is more like an external rotator
Most common
Obturator internus
o Ischial tuberosity > Lesser trochanter
Obturator externus
o
Gemellus superior
Gemellus inferior
o Ischial tuberosity > Lesser trochanter
Quadratus Femoris
o Pubis > lesser trochanter
o Weightbearing

Flexors
Pull the pelvis anteriorly (Rectus Femoris, Psoas, Iliacus)
Extensors
Pulls pelvis posteriorly (Hamstrings, Gluteus Maximus)
Adductors
Stabilize and pull medially (adducter, Magnus, Brevis, Longus)
Abductors
Stabilize and pull laterally (Gluteus Medius, Minimus)
All will work in conjunction to help stabilize the pelvis.
Somatic Dysfunctions
o Innominate
Rotate
Posterior Innominate & Anterior Innominate
Shear
Superior & Inferior
Flare
Inflare & Outflare
o Pubis
Shear
Innominate Diagnosis
o Standing Flexion Test
Tells us whether you have an innominate or a hamstring dysfunction
o ASIS compression test
Patient is supine and you place pressure on the ASIS. Purposeful palpation
to compare one side to the other.
The end feel is as if you are hitting a wall and cannot compress anymore.
The Side that moving more is normal and the other is the dysfunctional
side.
o Compare positions of the ASIS (patient supine) and PSIS (patient prone)
o Compare leg lengths and rotation of leg
Short vs. Long, Internal vs. External rotations
o Example
ASIS compression test positive on Left side. Thus, left is
abnormal and Right is normal. ASIS is more anterior/forward.
PSIS more posterior/inferior.
Left finger forward leg goes forward and becomes longer. ASIS
is more anterior compared to the normal right side. PSIS becomes
more forward and this is what an anterior innominate diagnosis
looks like.
Back towards you posterior innominate. Leg gets shorter
Right side is abnormal and PSIS and ASIS is both higher on the
left side. Inferior shear of the right innominate
Left side which is abnormal, its PSIS and ASIS are both higher
than the right side making it a superior shear on the left
innominate.
To determine outflares and inflares you can measure in
comparison to one another by using the umbilicus. Fingers on
ASIS and then pointer finger on the belly button. (ex. R side is

abnormal and shorter thus, that is an inflare stuck in making it

shorter and closer together!)
Standing normal anterior innominate
Sitting normal posterior innominate
Pubic Diagnosis
o Palpation of Pubic rami
Want to determine whether one is more superior or inferior to the other
Muscle Energy
o Anterior Innominate
Patient prone affected leg is lowered off the table with the foot
contacting the doctors thigh. The patients leg is pushed forward rotating
the innominate posteriorly. The patient pushes backward with the leg
against the doctors leg while the doctor resists
Patient supine doctor lifts the leg up, rotatin the innominate backward
and the flexes the knee, externally rotating and abducting the leg while
applying pressure on the shin with the torso while exerting a cephalward
and lateral force with the lower hand on the ischial tuberosity.
Hamstring muscles are used.
o Posterior Innominate
Prone doctor stands on the side opposite of the dysfunction. Dysfunction
side leg is lifted to barrier of anterior rotation while cephalward hand
applies the anterior pressure over PSIS
Supine affected side leg is lowered off the table while the doctor pushes
down from just above the knee while stabilizing the opposite side of ASIS.
Prone doctor lifts the affected side leg from the contralateral side of the
table while the patient pushes back down towards the table
Quadricep muscles are used.
o Inflare
Patient supine crosses the leg of the dysfunction side so that the ankle
rests on the opposite knee, physician on side of dysfunction places caudal
hand on patients knee of leg on dysfunctional side and places cephalad
hand on the patients opposite (non-dysfunctional) ASIS
Patient exerts a force of internal rotation of hip joint on the dysfunction
side, physician isometrically opposes the patients force.
Adductor muscles are used
o Outflare
Patient supine with the leg of dysfunction side bent. Physician sits on the
dysfunction side with torso against the knee and leg internally rotating
the patients hip, cephalad hand under patient monitoring and applying
traction force on dysfunction side PSIS laterally
Patient attempts to externally rotate leg at hip joint, physician
isometrically opposes patients force
Abductors & external rotator muscles are used
o Inferior
Patient prone with dysfunction side leg bent at hip and knee off table,
grasping table leg with the same side hand. Physician on the side of
dysfunction rests patients foot on physicians upper thigh and closest to
the table same first applies cephalad force on the patients ischial
tuberosity.

Patient asked to extend bent leg while pushing against a table leg,
physician isometrically opposes patients force.
Hamstring and Quadricep muscles used.

Pubic Somatic Dysfunction

Pelvic girdle and pelvic ring

o
Composed of two innominate bones and a sacrum in between
them. The pubic symphysis comes right in front to the form the
pelvis (innominate & sacrum)
The pelvic girdle is the pubic rim formed by the innominate
coming together with the sacrum
The female pubic is oval shaped and has a wide angle
The presence of the pubic arch can be seen in females (90
degrees) and the suprapubic angle in males (70 degrees)
Pregnancy plays a very large role in this and thus the
reason why the aperture is much larger in females in order
to allow the baby to pass through.
Pelvic Diaphragm
o Often overlooked as a source of pain
o Major crossroads for blood, lymph, and nerves
This is the reason that problems with the diaphragm can cause
kinking of all the items that pass through it
o Houses GI and GU organs
The prostate is held directly within and around the pelvic
diaphragm and thus would often lead to problems with the pelvic
floor
o Closely connected to the abdominal diaphragm
The pelvic diaphragm and abdominal diaphragm work in
conjunction with another. The pelvic floor is another end of the
process since it functions as a hydraulic system.

Schematic side view

o Diaphragm comes down, blends into the abdominal
pubic fascia and inserts onto the pelvic floor. Muscles
that come along will transverse the anterior portion
of the spinal column and then comes back up and
around.
o It functions as one continuous container so that when
you breathe, it squeezes the contents of the
abdomen in order to cause increased pressure
pumping action that the abdominal muscles have.
Both the bottom and top of the container work
together.

o Lymphatics

Lymph is a secondary circulatory system that brings

lymphatics from the periphery back into cardiac circulation
Since the lymphatic system runs through the pelvic
diaphragm and is only one cell thick, sheer strain can lead
to restriction of fluid that comes back up into circulation
can lead to ligamentous edema.
On the R side: R arm, head, and neck > R lymphatic duct >
Jugular vein

On the L side: lymphatic channels > Inguinal lymph nodes

> Cisternal chyle > thoracic duct > Subclavian vein
o These drain all of the lower extremities
Superficial beyond the pelvic diaphragm
Deep within the pelvic diaphragm
Both superficial and deep must make their way back into
circulation for drainage.
o Pelvic Muscles

Three muscles make up the Levator Ani

o Puborectalis
o PUbococcygeus
o Iliococcygeus
o These muscles pass between the sacrum and the
pubic symphysis. These muscles connect the
innominate to the sacrum
Urogenital Hiatus where the urethra passes through
Openings apertures through which the rectum and the
anus passes through
Obturator Foramen (Internus) where the pelvic diaphragm
firmly attaches. It is relatively small and has really strong
fascial attachments to the pelvic.

The deep transverse perineal muscle is a very thin extra

layer of support that attaches directly to the Levator Ani
and also has lateral attachments. This is muscle is
important to hold when you need to pee!

Levator Ani muscles fan out and swoop their way up and
insert into the Obturator Foramen and onto the sacrum.
Iliococcyxgeal ligamens attaches from the coccyx and
onto the tail bone
Piriformis

The pelvic floor is directly medial to the ischial tuberosity

Arrow indicates where we press up against the bone. In this
area, there is loosely packed adipose tissue that fills the
space around the rectum and the urogenital organs. It is
very compressible and if you push up far enough, you can
hit the ischial muscles that make up the pelvic diaphragm.
A patient may come to you and say that their genitalia
hurts, pain when they have bowel movements or even
when urinating. This is a deep seeded pain and doctors
have a tendency to shy away from this area. Realistically,
its an easy muscle to access and because there are so
many muscles that pass through the pelvic diaphragm and
its so prone to shearing, its a VERY EASY fix and
instantaneous relief will be shown!
o Pubic Symphysis
Held together by dense fibrocartilage
Under physiological conditions, pubic tubercles should be <1 cm
apart
Symphysis has the ability to move about 2 mm superior or
inferior, and has about 1-2 degrees of rotation
Designed to transmit forces in typical conditions
Characteristics change dramatically in 2nd or 3rd trimester of
pregnancy for females
Since the pelvis is not big enough to allow for a baby to
pass through under physiological conditions, the body will
release Relaxin during the 2nd and 3rd trimesters in order
to soften up the cartilage and allow for the cartilage in the
pubic symphysis to pull apart. This then allows the baby to
pass through. Once they pass through, the pubic will snap
back together.
Relaxin only delivers for so long, but once the baby is born,
it will go away and you only have about 6 weeks for the
pubic symphysis to come back together. If doesnt, this
leaves the mom with a gapped peripartum!
o Pubic Symphysis dysfunction

Gapped (pubic symphysis diastasis)

Common with child-birth
Where it widens and stays widens
Compressed
Superior shear
Mirrors a posterior innominate shear
Inferior shear
Mirrors an anterior innominate shear
Shears are where the symphysis is gapped slightly
Invariable fall into 1 of 2 categories
o If someone that has pelvic pain and points to the pubic symphysis,
check for unleveling since this region is not very tolerant to being
pulled and being stretched. This would lead to significant pain in the
area.
o However, if someone doesnt have pubic pain (possibly because this
was a chronic issue) and they get diagnosed with lower back
innominate dysfunction thats been treated multiple times and still
doesnt help, then you can confirm it as a pubic symphysis sheer. This
can occur anytime, but most of the time it occurs peripartum

Superior & Inferior longitudinal ligaments

Adductors

Muscles all have insertions onto this pubic ramus, so the

adductors are used to open/close the pubic symphysis
when treating a dysfunction.
Pectineus
Gracilis
Rectus Abdominus
Inserts on top of the pubic symphysis
Many times, you can have tenderpoints that are usually
problems from this muscle
i.e. sports hernia will display a pinpoint tenderness
Pelvic X-Rays

Gapped peripartum in female due to childbirth. Must be treated

aggressively since the relaxin will only last for about 6 weeks
after childbirth.

Sports player with superior pubic sheer of L pubic symphysis &

transverse process fracture at L5 that also disrupted the pubic
ligament
This patient required a plate and screws in order to hold it back
together since it was so severe. It could not be fixed with just
OMT.