Download The Multifidus Muscle: Anatomy, Assessment and Treatment

F ea t ur e
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.
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.
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.
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!
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.
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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.
Visual assessment
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.
Journal of the Australian Asso ciation of M assage Therapists
F ea t ur e
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 doesn’t 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.
Myofascial palpation
Palpating each side of the client’s 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
don’t 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.
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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.
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
Journal of the Australian Asso ciation of M assage Therapists
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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 doesn’t 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 Multifidi
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 can’t
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 Multifidi
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 multifidi’s 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.
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: that’s 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
Winter 2008
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F ea t ur e
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.
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
client’s 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.
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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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.
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
client’s spine!
Doug Alexander has been absorbed in his
own and other people’s 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
[email protected]
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
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Hides J, Scott Q, Jull G, Richardson C: A Clinical Palpation
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Kjaer P, Bendix T, Lorenson JS, Korsholm L, Leboef-Yde
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Journal of the Australian Asso ciation of M assage Therapists