Back Pain Relief: Back pain radiating to the side, but I can't pinpoint the source

This is the case of one of my clients, whom I'll call "Joe." When Joe contacted me, I could tell his pain almost spoke through his voice. I could even say his tone included notes of despair and frustration. Joe is a percussionist and had several musical commitments, but unfortunately, he had injured himself several days earlier, and he understood that if he didn't do something about it, he wouldn't be able to fulfill them. As he explained during his call, he felt pain originating in his lower back and radiating to his side where the last ribs are felt. Joe claimed it was an injury to one of the obliques (we have two, the internal and external) on his right side. The reality was a little different, and discovering the cause of his pain, made all the difference for Joe.

The back can be a difficult area to treat as it contains a large number of muscles—small, very small, large, and very large. To complicate matters a bit, many of these muscles share common areas where they interconnect through the fascia that surrounds and encases them. This means (in short) that many of them are interrelated, and what affects some may end up affecting others. But all is not lost. With a few simple tests, we can get a clearer idea of which muscle or muscles could be involved in Joe's pain.

Let's first investigate the obliques, since they were Joe's cause for concern. The obliques are involved in twisting the torso and lateral bending. Any movement of this nature, depending on the specific area of the injury, could trigger the natural pain response to limit the pain. When I asked Joe to perform several of the aforementioned movements, he experienced some pain, but it was mild and not always present. Furthermore, analyzing his posture and gait, I didn't notice any compensatory factors that could be related to the area of concern, so the suspicion of the obliques was eliminated.

Another suspicion was that he might have an injury to the latissimus dorsi, the largest muscle in the back and one involved in many arm movements. I asked Joe to flex the arm on the side where he felt the discomfort and bend his elbow. I also asked him to use his other hand to support his elbow and force his arm toward extension. Again, the pain was mild and not constant. So the latissimus dorsi was eliminated from the list of suspects.

The possibility of another suspect loomed, one that, I admit, brought a small smile to my lips. One of those smiles that silently says, "You thought you were going to get away from me, but I caught you." I asked Joe to take a deep breath and exhale forcefully. With a shaky voice, as he exhaled, Joe said, "It hurts." Aha! This small muscle with a name much longer than its body had become the prime suspect for Joe's pain. The serratus posterior inferior is a muscle that is secondarily involved in body rotation by pushing the ribs back and down during rotation. It provides stability when standing and sitting, but it is also heavily involved in the exhalation part of breathing.

By Anatomography - en:Anatomography (setting page of this image), CC BY-SA 2.1 jp, https://commons.wikimedia.org/w/index.php?curid=22700198

I focused on treating this muscle and its synergists with some massage techniques focused on reducing inflammation, mobilizing the surrounding fascia, and reducing muscle tone.

After the second session, I contacted Joe to follow up on the status of his injury. The tone of his voice was completely different, and I could now detect notes of joy and excitement. Joe had recovered from his injury and was able to fulfill his musical commitments as scheduled.

Moral of the story... those tiny muscles can make a big difference. Let's not lose sight of them!

Japhet Rivera, MS, LMT