Lumbar Strain

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Original Editors - Pieter Jacobs

Lead Editors - Bo Hellinckx - Lynn Leemans - Nel Breyne - Sarah Harnie

Search Strategy

Key Words: Lumbar strain, Musculair strain, Low back strain, soft tissue damage, low back pain

Databases: PubMed, Web Of Knowledge, Pedro, Bibliotheek VUB

Definition/Description

Lumbar strain is a commonly wielded diagnosis (Depalma 2011, Houglum 2001) for mechanical low back pain but is without anatomical or histologic evidence.(Depalma 2011) Much of the knowledge of lumbar strain is extrapolated from peripheral muscle strains. (Depalma 2011)

In strains, the muscle is subjected to an excessive tensile force leading to the overstraining of the myofibres and, consequently, to their rupture near the myotendinous junction. (Jarvinen 2007, Depalma 2011)

The current classification of muscle injuries identifies mild, moderate and severe injuries based on the clinical impairment they bring about. (Jarvinen 2007)

Clinically Relevant Anatomy

Lumbar strain can origine in the following muscles (Houglum 2001, Putz 1997, Meeusen1 2001): M. erector spinae (M. iliocostales, M longissimus, M. spinalis) M semispinales, Mm multifidi, Mm rotatores M. quadratus lumborum M. serratus posterior

Epidemiology /Etiology

Contributional factors to the development of a lumbar strain are poor posture, muscular inbalance, poor conditioning, weak abdominal muscles, inflexibility of the hamstrings, hip flexors or back extensors (Shultz 2005, Meeusen 1 2001), activation timing and muscle length before stretch. (Butterfield 2005)

Characteristics/Clinical Presentation

Common symptoms include: ^{(Level of evidence: 5)}

• Pain (exacerbated during standing and twisting motions) ^{(Level of evidence: 2B)}
  
• Point tenderness
• Muscle spasm
• Possible swelling in and around the involved musculature
• Possible lateral deviation in the spine with severe spasm
• Decreased ROM
• Increased pain with active contraction and passive stretching of the involved muscle

Differential Diagnosis

- Degenerative disk or facet process
- Herniated disk 
- Osteoporotic compression fracture
- Spinal stenosis or osteoarthritis 
- Spondylolisthesis 
- Ankylosing spondylitis 

Diagnostic Procedures

Laboratory tests
     No abnormalities.  ^{(Level of evidence: 3B)}

Radiographs
     Imaging is not indicates unless there are: 

• any red flag signs
• any radicular or abnormal neurological clinical features
• or if the symptoms have persisted for more than a month.
  In these cases, it is important to exclude other differential diagnosis, by using X-rays or MRI. ^{(Level of evidence: 5)}

Examination

The physical examination contents:

• Inspection
• Palpation --> Point tenderness
• ROM --> flexion of the back

Signs of limited range of motion or a decreased lumbar lordosis are important but most of the low back pain patients show this symptoms.^{(level of evidence 3B)}

More tests are necessary:

• Neurovascular assessment (L4-S1) --> Test heel and toe walking, the test is positive when there is marked asymmetry shown.
• Sensation tests
• Movement tests
• SLR + Ankle dorsiflexion
• SLR + Lasègue
• Bowstring sign --> SLR until pain, then flex the knee. The pain must reduce if the nerve is irritated.
• Faber test --> Flexion abduction external rotation of the hip --> Pain if SI-pathology
• One leg extension test --> standing on 1 leg with the back in extension --> pain if spondylolysis
• Hamstring flexibility
• Leg length evaluation ^{(level of evidence 4)}

The neurological tests are mostly negative and a lumbar strain is not accompanied by paresthesias or weakness in the legs or feet. Patients with lumbar spine are tender to palpation in the lower back. Other physical findings are loss of normal lumbar lordosis and spasm of the paraspinal muscles. The SLR’s may cause pain in the lower back just like other tests that cause spinal motion. Often there’s an antalgic posture. ^{(level of evidence 5)}

Medical Therapy

Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended (Jarvinen 2007) grade of evidence=A

Corticosteroids are not recommended. (Jarvinen 2007) grade of evidence=C

Therapeutic ultrasound does not have proven therapeutic effect on the regeneration of injured skeletal muscle. (Jarvinen 2007) grade of evidence=C

Physical Therapy Management

The immediate treatment of an injured skeletal muscle should follow the RICE principle. (Bleakly 2004, Jarvinen 2007, Meeusen1,Kannus 2000) grade of evidence=A There are still more high quality studies needed on developing modes, durations and frequencies of these aplications. (Jarvinen 2007, Bleakly 2004) grade of evidence=A The resulting pain and muscle spasm from acute strains must first be resolved with modalities, mild stretching exercises along with limited activity. (Houglum 2001, Jarvinen 2007) grade of evidence=B

As spasm and pain are reduced, soft tissue mobilisations is indicated if restriction is noted with palpation. (Houglum 2001, Jarvinen 2007, Meeusen2 2001, Kannus 2000) Treatment of the trigger points is applied to the area that reproduces pain. (Houglum 2001, Meeusen2 2001, Vazquez-Delgado 2010) This contains deep frictions, followed by ice-and-stretch treatment. The ice strokes are swept in a cephalad-to-caudad motion. (Houglum 2001, Meeusen2 2001) grade of evidence=B. According to Vazquez-Delgado et al, 2010 is the spray-and-stretch technique the most effective. (Vazquez-Delgado 2010) grade of evidence= A.

Joint mobilization may be useful if the restriction is the result of joint hypermobilisation. (Houglum 2001, Meeusen2 2001) grade of evidence= C.

As with all spinal injuries, posture and body mechanics should be assessed and corrected as needed. (Houglum 2001)

A progression of strengthening exercises should begin once the pain and spasm are under control. (Houglum 2001 , Meeusen1 2001). grade of evidence= B. The muscles requiring the most emphasis are the abdominals, especially the obliques, the trunk extensors and the gluteals. (Houglum 2001,Meeusen2 2001) grade of evidence= F. Placing all of the emphasis in the rehabilitation specifically on the injured muscle is not beneficial. (Jarvinen 2007) grade of evidence= B

The therapist can give guidelines for prevention in low back pain.(Meeusen1 2001, Burton 2005) grade of evidence=A

Key Research

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Resources

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Recent Related Research (from Pubmed)

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References

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