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Mechanical Compression of the Iliopsoas Muscle by a Large Vertebral Osteophyte, Presenting with Abdominal and Lumbar Pain Myron M. LaBan, MD, MMSc, Matthew Jones, MD, and Adam Lenger, MD From the Department of Physical Medicine and Rehabilitation (MML, MJ), and Department of Diagnostic Radiology, Section of Musculoskeletal Radiology (AL), Oakland University William Beaumont School of Medicine, Royal Oak, Michigan. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. 0894-9115/15/9408-e75 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHM.0000000000000286
FIGURE 1 Large osteophyte at L2 to L3 intruding into the IM muscle (asterisk/arrow).
A
n 82-yr-old woman presented with complaints of right lumbar and abdominal pain. The results of neuromusculoskeletal and abdominal examinations were normal, other than marked weakness in the right iliopsoas muscle (IM). The straight-leg raising maneuver was unrestricted. A magnetic resonance image of the lumbosacral spine and an abdominal computerized axial tomographic scan were obtained. These studies demonstrated both evidence of significant degenerative disk disease and, uniquely, a large, lateral osteophyte protruding from the L2 to L3 vertebral interspace into the adjacent IM, provoking an inflammatory myositis (Fig. 1). Initially, the history and clinical examination had suggested lumbar spinal stenosis, especially with the presence of marked weakness in the IM in an elderly patient.1 Although the identification of significant degeneration of the lumbar spine at her age was not a surprise, the traumatic iliopsoas myositis secondary to a large osteophyte obviously was. A subsequent search of the medical literature failed to find a similar case report. Retroperitoneally, the compound IM is composed of three distinct muscles: the greater psoas, the smaller psoas, and the adjacent iliac muscle. The origin of the iliac muscle is from the iliac fossa, and that of the psoas muscles is from the transverse process of the spine, T12 to L5. As a conjoined tendon, they insert distally on the femur’s lesser trochanter.2 Crossing both the sacroiliac and hip joints, the IM is a classic Btwo-joint[ muscle able to functionally reverse its origin with its insertion. With the hip fixed, it flexes the lumbar spine, and conversely, with the lumbar spine
stabilized, it flexes the thigh at the hip. The IM is innervated by the spinal roots, L2 to L4. Multiple pathologic processes can afflict the IM retroperitoneally, including, among others, infection, hemorrhage, and neoplastic invasion, and have demonstrated, in this case, a Bstructural[ lesion. Both infections and neoplastic invasion of this muscle are usually caused by extension from contiguous areas, whereas hemorrhage within the IM can be either spontaneous or related to systemic pathology, that is, hemophilia and/or anticoagulation therapy.3 Both the lumbar pain complaint and the IM weakness rapidly resolved in response to physical therapy, that is, thermotherapy followed by intermittent split-table pelvic traction. However, the abdominal discomfort persisted to a lesser degree. Mechanical compression of the IM by a large osteophyte provoking a painful myopathic response can now be added to the potential multiple causes of simultaneous abdominal and lumbar back pain. REFERENCES 1. LaBan MM: Iliopsoas weakness: A clinical sign of lumbar spinal stenosis. Am J Phys Med Rehabil 2004;83:224Y5 2. Bogduk N, Pearcy M, Hadfield G: Anatomy and biomechanics of psoas major. Clin Biomech (Bristol, Avon) 1992;7:109Y15 3. Torres GM, Cernigliaro JG, Abbitt PL, et al: Iliopsoas compartment: Normal anatomy and pathologic processes. Radiographics 1995;15:1285Y97
All correspondence and requests for reprints should be addressed to: Myron M. LaBan, MD, MMSc, 3601 W 13 Mile Rd, Royal Oak, MI 48073.
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Mechanical Compression of the Iliopsoas Muscle by a Large Vertebral Osteophyte, Presenting with Abdominal and Lumbar Pain Myron M. LaBan, MD, MMSc, Matthew Jones, MD, and Adam Lenger, MD From the Department of Physical Medicine and Rehabilitation (MML, MJ), and Department of Diagnostic Radiology, Section of Musculoskeletal Radiology (AL), Oakland University William Beaumont School of Medicine, Royal Oak, Michigan. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. 0894-9115/15/9408-e75 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHM.0000000000000286
FIGURE 1 Large osteophyte at L2 to L3 intruding into the IM muscle (asterisk/arrow).
A
n 82-yr-old woman presented with complaints of right lumbar and abdominal pain. The results of neuromusculoskeletal and abdominal examinations were normal, other than marked weakness in the right iliopsoas muscle (IM). The straight-leg raising maneuver was unrestricted. A magnetic resonance image of the lumbosacral spine and an abdominal computerized axial tomographic scan were obtained. These studies demonstrated both evidence of significant degenerative disk disease and, uniquely, a large, lateral osteophyte protruding from the L2 to L3 vertebral interspace into the adjacent IM, provoking an inflammatory myositis (Fig. 1). Initially, the history and clinical examination had suggested lumbar spinal stenosis, especially with the presence of marked weakness in the IM in an elderly patient.1 Although the identification of significant degeneration of the lumbar spine at her age was not a surprise, the traumatic iliopsoas myositis secondary to a large osteophyte obviously was. A subsequent search of the medical literature failed to find a similar case report. Retroperitoneally, the compound IM is composed of three distinct muscles: the greater psoas, the smaller psoas, and the adjacent iliac muscle. The origin of the iliac muscle is from the iliac fossa, and that of the psoas muscles is from the transverse process of the spine, T12 to L5. As a conjoined tendon, they insert distally on the femur’s lesser trochanter.2 Crossing both the sacroiliac and hip joints, the IM is a classic Btwo-joint[ muscle able to functionally reverse its origin with its insertion. With the hip fixed, it flexes the lumbar spine, and conversely, with the lumbar spine
stabilized, it flexes the thigh at the hip. The IM is innervated by the spinal roots, L2 to L4. Multiple pathologic processes can afflict the IM retroperitoneally, including, among others, infection, hemorrhage, and neoplastic invasion, and have demonstrated, in this case, a Bstructural[ lesion. Both infections and neoplastic invasion of this muscle are usually caused by extension from contiguous areas, whereas hemorrhage within the IM can be either spontaneous or related to systemic pathology, that is, hemophilia and/or anticoagulation therapy.3 Both the lumbar pain complaint and the IM weakness rapidly resolved in response to physical therapy, that is, thermotherapy followed by intermittent split-table pelvic traction. However, the abdominal discomfort persisted to a lesser degree. Mechanical compression of the IM by a large osteophyte provoking a painful myopathic response can now be added to the potential multiple causes of simultaneous abdominal and lumbar back pain. REFERENCES 1. LaBan MM: Iliopsoas weakness: A clinical sign of lumbar spinal stenosis. Am J Phys Med Rehabil 2004;83:224Y5 2. Bogduk N, Pearcy M, Hadfield G: Anatomy and biomechanics of psoas major. Clin Biomech (Bristol, Avon) 1992;7:109Y15 3. Torres GM, Cernigliaro JG, Abbitt PL, et al: Iliopsoas compartment: Normal anatomy and pathologic processes. Radiographics 1995;15:1285Y97
All correspondence and requests for reprints should be addressed to: Myron M. LaBan, MD, MMSc, 3601 W 13 Mile Rd, Royal Oak, MI 48073.
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