Lumbar Strain

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Original Editors - Pieter Jacobs

Top Contributors - Bo Hellinckx, Hannah Willocx, Sarah Harnie, Lynn Leemans, Kim Jackson, Elodie Baele, Lilian Ashraf, Nel Breyne, Wanda van Niekerk, Olajumoke Ogunleye, WikiSysop, Lucinda hampton, 127.0.0.1, Admin, Rachael Lowe and Naomi O'Reilly - 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

The lumbar spine consists of 5 moveable vertebrae numbered L1-L5. The complex anatomy of the lumbar spine is a remarkable combination of these strong vertebrae, multiple bony elements linked by joint capsules, and flexible ligaments/tendons, large muscles, and highly sensitive nerves. It also has a complicated innervation and vascular supply.
The lumbar spine is designed to be incredibly strong, protecting the highly sensitive spinal cord and spinal nerve roots. At the same time, it is highly flexible, providing for mobility in many different planes including flexion, extension, side bending, and rotation.[18] [level of evidence: 5] [19] [level of evidence: 2C]

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

Strains are defined as tears (partial or complete) of the muscle-tendon unit. Muscle strains and tears most frequently result from a violent muscular contraction during an excessively forceful muscular stretch. Any posterior spinal muscle and its associated tendon can be involved, although the most susceptible muscles are those that span several joints.You can define acute and chronic lumbar strain. Acute pain is most intense 24 to 48 hours after injury. Chronic strains are characterized by continued pain attributable to muscle injury. [13] [level of evidence: 2C]

Low back pain is the second most common symptom that causes patients to seek medical attention in the outpatient setting. Approximately 70% of adults have an episode of LBP as a result of work or play.

Frequency

Exact numbers regarding the international frequency of low back injuries are not known. Studies done in The United States have shown that 7-13% of all sports injuries in intercollegiate athletes are low back injuries. The most common back injuries are muscle strains (60%) and
disc injuries (7%). Athletes are more likely to sustain injuries in practice (80%) than during competition (6%).[10] American football (17%) and gymnastics (11%) are reported to have the highest rates of low back injury.[10] [ level of evidence: 2C]
A recent French study reported over 50% of French individuals aged 30-64 years had experienced at least 1 day of LBP over the previous 12 months. 17% had suffered LBP for more than 30 days in the same 12-month period.[11] [level of evidence 3]. The authors noted that the prevalence of LBP varied between men and women. There was an increased incidence with increasing age for LBP that lasted more than 30 days . These data were similar to those of other countries.
In an African study, the mean LBP point prevalence among adults was 32%, with an average 1-year prevalence of 50% and an average life-time prevalence of 62% [12] [level of evidence: 1A]

characteristics/Clinical Presentation

Common symptoms include pain (1)(level of evidence 5). This pain is a diffuse pain in the lumbar muscles, with some radiation to the buttocks.(4) (level of evidence 2A)The pain could be exacerbated during standing and twisting motions. With active contractions and passive stretching of the involved muscle the pain will increase. (2) (level of evidence 5)
Other symptoms are point tenderness, musle spasm, possible swelling in and around the involved musculature, a possible lateral deviation in the spine with severe spasm, and a decreased range of motion. (3)(level of evidence:2A)

Differential Diagnosis

• Degenerative disk or facet process ^{(Leven of Evidence: 3B)}
• Herniated disk 
• Osteoporotic compression fracture  ^{(Level of Evidence: 2C)}
  
• 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 [8](level of evidence:5) [14](level of evidence:5)
 Inspect the spine for abnormal curvatures (f.e. scoliosis)
 Erythema
 Observe the gait (posture and movement)  let the patient walk across the room, turn around and let him come back.
 Observe the seated position of the patient abnormal posture caused by pain and muscle spasm
• Palpation  Point tenderness
 Bony tissue
 Soft tissue
• 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.[8](level of evidence: 5)
• Special tests
 Neurovascular assessment (L4-S1)
- Test heel and toe walking
- Positive test: marked asymmetry

 Sensation tests
 Movement tests

 SLR± ankle dorsiflexion
- Positive test: radiated pain into calf

 Crossed SLR
- Pain in the affected limb, when testing the unaffected limb

 SLR + Lasègue(link)

 Bowstring sign
- SLR until pain, then flex the knee.
- Positive test: reduces pain when nerve is irritated

 FABER test
- Flexion ABduction External Rotation of the hip
- Pain when SI-pathology

 One leg extension test
- standing on 1 leg with the back in extension
- pain can indicate spondylolysis

 Hamstring flexibility

 Leg length evaluation[8]
- Measure from ASIS to medial malleolus (cm)

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.[9]

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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