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Understanding Anatomy:
LIGAMENTS, TENDONS & MUSCLES

Ligaments and tendons are fibrous bands of connective tissue that attach to bone. Ligaments are flexible bands that serve to connect two or more bones together and help stabilize joints. Ligaments of the spine provide stability while allowing flexion, extension, and rotation.

Ligaments
Spine ligamentsThere are five main ligamentous structures seen throughout the spinal column:

  • Anterior Longitudinal Ligament (ALL)
  • Posterior Longitudinal Ligament (PLL)
  • Ligamentum Flavum
  • Interspinous ligaments
  • Supraspinous ligament[1]

The system of ligaments in the vertebral column, combined with the tendons and muscles, provides a natural brace to help protect the spine from injury.  Ligaments aid in joint stability during rest and movement and help prevent injury from hyperextension and hyperflexion (excessive movements).

Ligament Name and FunctionDescription
Anterior Longitudinal Ligament (ALL) - a primary spine stabilizerAbout one-inch wide, the ALL runs the entire length of the spine from the base of the skull to the sacrum.  It connects the front (anterior) of the vertebral body to the front of the annulus fibrosis.  
Posterior Longitudinal Ligament (PLL) - a primary spine stabilizerAbout one-inch wide, the PLL runs the entire length of the spine from the base of the skull to sacrum.  It connects the back (posterior) of the vertebral body to the back of the annulus fibrosis.
Supraspinous Ligament - limits flexionThis ligament attaches the tip of each spinous process to the other.
Interspinous Ligament - limits flexionThis thin ligament attaches to another ligament called the ligamentum flavum that runs deep into the spinal column.
Ligamentum Flavum - the strongest ligamentThis yellow ligament is the strongest.  It runs from the base of the skull to the pelvis, in front of and between the lamina, and protects the spinal cord and nerves.  The ligamentum flavum also runs in front of the facet joint capsules.
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Over the course of time, these ligaments can become strained, stretched and damaged. These changes to the ligaments can result in laxity, tears, and even scar tissue. An increase in laxity can result in excessive movement leading to damage to the intervertebral discs – ultimately resulting in pain. Another source of pain is a condition called spinal stenosis. This is where the space of surrounding spinal cord and exiting nerve roots is reduced. A contributing factor to spinal stenosis can be hypertrophied (enlarged) or thickened ligamentum flavum.

Tendons & Muscles

Psoas MuscleTendons attach muscle to bone.  Tendons vary in size and are somewhat elastic. Tendons are similar to ligaments, except these tension-withstanding fibrous tissues attach muscle to bone.  Tendons consist of densely packed collagen fibers.

Muscles, either individually or in groups, are supported by fascia.  Fascia is strong sheath-like connective tissue.  The tendon that attaches muscle to bone is part of the fascia.  

The muscular system of the spine is complex, with several different muscles playing important roles.  The primary function of the muscles is to support and stabilize the spine. Specific muscles are associated with specific movements of parts of the anatomy.  For example, the sternocleidomastoid muscle (neck area) assists with movement of the head, while the psoas major muscle (low back area) is associated with flexion of the thigh.  

The muscles in the vertebral column serve to flex, rotate, or extend the spine.  If there are pathology with the aforementioned components of the spine, such as discs, bone, ligaments, and their subsequent alignment, it often falls on the muscles to work hard to compensate.[2] This can result in muscle strain, spasm, and tightness in response. These muscles themselves can irritate small nerves contributing to pain themselves. With so much movement possible in the spine, the muscles are overlooked as a source of pain.[3]

Muscles connect to the vertebrae and bones via ligaments. The deep muscles of the back fit into or affix parts of themselves to the grooves in the spinous process (the protrusion of the bone than can be felt through the skin).

Important muscles of the lumbar spine include:

  • Multifidus: a long muscle traveling nearly the entire length of the back. It stabilizes and rotates the lumbar spine
  • Longissimus: located in the middle of the lumbar spine
  • Spinalis: a superficial muscle that begins as a thick tendon in the sacrum and travels up into the neck
  • Quadratus Lumborum: contributes mainly to lateral bending of the lumbar spine. This muscle spans from the pelvis and lower lumbar area to the ribs and upper lumbar vertebrae
  • Psoas: extends from the inner thigh bone to the lumbar vertebrae. It flexes the trunk at the hip and has little effect on flexing the spine itself.

The main lumbar spine flexors are:

  • Front muscles of the Abdominal Wall
  • Rectus Abdominis
  • Abdominal Internal and External Oblique muscles

SpinalisThe primary extensor of the spine is the Erector Spinae. This is the most important extensor muscle group of the back and is responsible for returning the vertebral column to its “erect” position following motion. Its tendinous origin is extensive, arising from the top of the pelvis (iliac crest), most of the lumbar vertebrae, and several of the lower thoracic vertebrae.[4]  The subdivisions of the erector spinae blend in the lower back, and in so doing, offer great strength to the lumbar area. The appearance is that of one common back muscle.

Any of these muscles can be generators of pain from muscle strain, muscle sprain, muscle spasm, or an even more complex form of muscle-related back pain is called Myofascial Pain Syndrome. Back strain or sprain often refers to some stretching or microscopic tearing of muscle fibers and/or ligaments of the back. The muscles usually involved are those producing movemnts of the lumbar region but can occur at any level of the spine.[5]  These pain mechanisms can benefit from many therapies such as physical therapy and antinflammatories, and sometimes short course of muscle relaxants. Often times however, injections such as trigger point and medial branch blocks can greatly reduce pain.

Get Answers to Your Questions at the Ainsworth Institute

The key to finding the proper treatment for any type of pain is getting a proper diagnosis.  Not all types of pain respond to the same treatments and the window for improvement can be limited. The experts at Ainsworth Institute offer the most advanced pain management treatments available today, including advanced clinical trials that aren’t yet available to the general public. Call us today for an appointment so we can get you started on your road to recovery.

References

[1] Grenier N, Greselle JF, Vital JM, et al.: Normal and disrupted lumbar longitudinal ligaments. Radiology. 1989;171:197-205 

[2] Malanga, G, Nadler S : Musculoskeletal Physical Examination, An Evidence Based Approach, Elsevier Mosby, Philadelphia, 2006

[3] Hollinshead WH: Functional Anatomy of the Limbs and Back, 2nd edition, Elsevier, Philadelphia, 1960

[4] Cuccurullo S, et al: Physical Medicine and Rehabilitation Board Review, 2nd Edition, Demos Medical Publishing, 2002

[5] Moore K, Agur A: Essential Clinical Anatomy, 2nd edition, Lippincott & Williams Wilkins, Philadelphia, 2002

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