Iliocostal friction syndrome

Last updated
Iliocostal friction syndrome
Other namesCostoiliac impingement syndrome
Meyers b13 s0296 b1.png
Kyphosis (left) and scoliosis (right) depicting iliocostal contact (a)
Symptoms Pain in the lower rib, flank, groin, thigh, or buttocks.
CausesContact between the ribs and the iliac crest
Risk factors Osteoporosis, hyperkyphosis, and scoliosis
Diagnostic method Physical examination, x-ray, CT scan
Treatment Orthosis, nerve blocks, prolotherapy, surgery

Iliocostal friction syndrome, also known as costoiliac impingement syndrome, is a condition in which the costal margin comes in contact with the iliac crest. The condition presents as low back pain which may radiate to other surrounding areas as a result of irritated nerve, tendon, and muscle structures. It may occur unilaterally due to conditions such as scoliosis, or bilaterally due to conditions such as osteoporosis and hyperkyphosis.

Contents

Diagnosis is predominately clinical, with assessment into the underlying pathology causing iliocostal contact, to which radiological imaging may be used. The differential diagnosis can be extensive due to the presentation of the condition, however includes neuropathic pain, hip pathologies, pinched nerves, myofascial pain, and visceral causes. Treatment of the condition is typically by addressing the underlying cause, commonly with the use of orthosis and injection therapies, however surgical resection may be necessary if other forms of treatment fails to provide relief.

Presentation

Iliocostal friction syndrome can be a disabling painful condition that can affect the quality of life for individuals. [1] The predominant symptom is low back pain, which may radiate to the lower rib cage, flank, groin, buttock, and thigh. [2] Individuals may also experience intermittent aches along with a 'grating sensation' in the hip. [3] The pain may be aggravated by moving, twisting, bending, or by changing positions. [4] The condition may be bilateral as seen in individuals with hyperkyphosis or osteoporosis, but is more commonly unilateral as seen in individuals with scoliosis. [5]

Cause

Iliocostal friction syndrome is a result of the lower ribs coming in contact with the iliac crest due to a reduced costoiliac distance. [6] There are several conditions in which may cause iliocostal friction syndrome to occur both unilaterally or bilaterally.

X-ray of individual with scoliosis Medical X-Ray imaging GEX04 nevit.jpg
X-ray of individual with scoliosis

Unilateral causes

Scoliosis has been known to cause unilateral iliocostal friction syndrome. [5] It is a condition in which the lateral curvature of the spine is measured to be more than 10 degrees. Scoliosis is typically categorized into congenital, neuromuscular, idiopathic, degenerative, and pathologic forms. [7] The decreased distance between the ribcage and the iliac crest can come in contact depending on the severity of the scoliosis curve. [8] There has also been reported instances where individuals experience iliocostal friction syndrome due to an abnormally long twelfth rib. This can be presented both bilaterally or unilaterally, depending on the individual. [3] [8]

Bilateral causes

Iliocostal friction syndrome most commonly occurs bilaterally as a result of spinal osteoporosis. [2] Osteoporosis is a condition in which the bone density and quality deteriorates, resulting in an increased risk for fractures. More than 2 million fractures occur anually in the United States due to osteoporosis. [9] The most common fractures that occur due to osteoporosis is in the hip or vertebrae, [10] resulting in a loss of space between the ribs and the iliac crest. It is estimated that osteoporosis can cause 25% of females over 50 years of age within the United States to have at least one vertebral fracture in their lifetime. [11] Factors that make an individual more at risk for experiencing a fracture includes age, sex, weight, height, family history, rheumatoid arthritis, previous fracture, secondary osteoporosis, alcohol or smoking use, glucocorticoid use, and the femoral neck bone mineral density of the individual. [10]

Effects of osteoporosis on the spine 722 Feature Osteoprosis of Spine.jpg
Effects of osteoporosis on the spine

Another cause for bilateral iliocostal contact is based on the kyphosis curve of the spine. The thoracic spine is slightly curved due to the shape of the vertebral bodies and intervertebral discs, with a normal Cobb angle measurement between 20 and 40 degrees. Hyperkyphosis is a condition in which the curve of the kyphosis angle measures over 50 degrees. The kyphosis angle can be influenced by age, muscle tone, [12] vertebral fractures, and intervertebral degenerative disc disease. [13] Hyperkyphosis can result from posture, a congenital deformity, heritable conditions such as Scheuermann's disease, [14] tumours, trauma, neuro-muscular disease, postlaminectomy syndrome, dwarfism, and infections such as tuberculosis which can result in Pott's disease. [15] The curvature of hyperkyphosis may result in a decrease of space between the ribs and the iliac crest, causing iliocostal friction syndrome. [11]

Mechanism

Under normal conditions, there is no iliocostal contact due to enough distance between the lower ribs and the iliac crest. Individuals with iliocostal friction syndrome may have their 10th, 11th, or 12th rib come in contact with the iliac crest. [4] Structures of the body can be irritated as a result of iliocostal contact includes the nerves, [8] tendons, and muscles surrounding the area. [16]

There are several nervous branches surrounding the iliac crest that may be impinged or irritated upon contact. The superior cluneal nerves travel through the thoracolumbar fascia and drape over the iliac crest. [5] The posterior branches of the iliohypogastric nerve can emerge on the surface above the iliac crest, with the nerve draping lower than usual in some individuals. [8] Similarly, the ilioinguinal nerve runs below the iliohypogastric nerve, following just above the iliac crest. [17] These nerves may be impinged or irritated as a result of the lower ribs coming in contact with the iliac crest. [5]

Muscles of the abdomen 1112 Muscles of the Abdomen.jpg
Muscles of the abdomen

The top of the iliac crest includes the attachments of the latissimus dorsi, the transversus abdominis, as well as the internal and external obliques. The quadratus lumborum also connects from the back tip of the iliac crest up to the 12th rib. [18] These tendon and muscle structures surrounding the iliac crest are at risk for irritation due to iliocostal contact. Tendon irritation can result in referred pain, therefore affected individuals may experience pain throughout the hip, low back, the groin, chest, and thigh. This contributes towards the difficulty in diagnosis of iliocostal friction syndrome. [4]

Diagnosis

The diagnosis of iliocostal friction syndrome can be made clinically without any imaging. [4] Typically, individuals with the syndrome will have an underlying condition such as scoliosis or osteoporosis in which may cause the iliocostal contact. [8] The examiner will assess for the possibility of contact by noting the medical history and reported symptomology by the individual. The clinician will examine the individual for iliocostal contact within a standing position and in movement. [4] Tenderness of the iliac crest and the lower ribs will be assessed with physical palpation. [16] Usually, flexion of the trunk laterally can trigger pain on the affected side(s), which is useful in diagnosis to pinpoint the exact location of iliocostal contact. [8]

Though radiological imaging is not needed for iliocostal friction syndrome diagnosis, it is often uses to assess for underlying conditions and rule out differential diagnosis. Imaging such as the use of an x-ray can reveal irregularities of the surfaces of the lower ribs and iliac crest or abnormally long 12th ribs, which may give suspicion to the diagnosis of iliocostal friction syndrome. [3] [6] Computed tomography (CT) scans can reveal kyphotic deformities, including a reduced distance between the lower ribs and the iliac crest, giving rise to the possibility of iliocostal contact. [19]

Muscles of the back, with iliac crest depicted in red Iliac crest.PNG
Muscles of the back, with iliac crest depicted in red

Differential diagnosis

Since iliocostal friction syndrome can present in pain in many areas surrounding the back, flank, and abdomen, the differential diagnosis for the condition can be extensive. Some of the diagnosis include but not limited to neuropathic pain of the intercostal nerves, conditions of the hip, pinched nerves within the spine, myofascial pain, and visceral causes. [6] Differential diagnosis may also include an investigation into the pathology which caused the iliocostal contact if it is not previously known, such as undiagnosed scoliosis, back strain, osteoporosis, or a compression fracture. [4]

Iliocostal friction syndrome should also be differentiated from other conditions affecting the lower ribs such as slipping rib syndrome, which is a condition that involves the increased mobility of the 8th to 10th ribs at their interchondral joints. Additionally, hypermobile 11th and 12th ribs may cause twelfth rib syndrome due to the floating ribs impinging on the intercostal nerves (intercostal neuralgia). Neither of these conditions involve the iliac crest. [3]

Treatment

A brace used to treat hyperkyphosis Kyphosis brace 2.jpg
A brace used to treat hyperkyphosis

The most common method for treating iliocostal friction syndrome is usually with acupuncture, [16] physical therapy, muscle relaxants, and activity modification. [19] Treatment may involve addressing the underlying pathology of the condition as hyperkyphosis, osteoporosis and scoliosis may be treated with postural training and muscle strengthening methods. Orthosis, a specialty that involves individuals being fitted with a brace or harness may help correct the curvature of the spine. [6] [20] Rib-compression belts have also been used as a conservative form of treatment for iliocostal friction syndrome. A 3-inch wide lower rib-compression belt is fitted above the iliac crests and tightly adjusted to provide pressure on the lower ribs. Since the lower ribs are attached to the sternum by flexible hyaline cartilage, they can be pushed inward with ease, and as a result, the compression shifts the ribs away from the iliac crests, preventing iliocostal contact. [2] [4]

Local injections or nerve blocks containing steroids or lidocaine may also be used if other conservative methods of treatment have failed to provide adequate relief. [8] The injections are inserted into the junctions near the iliac crest as well as the lower rib margins, [2] and often have to be repeated as they only give relief for a short duration of time. [3] Prolotherapy has also been used to treat iliocostal friction syndrome, as the tendinous and muscle structures surrounding the iliac crest may be damaged as a result of iliocostal friction. Hypertonic dextrose is a common medication used in prolotherapy, sometimes diluted with lidocaine, which is injected along the iliac crest. Treatment is usually weekly or bi-weekly, and up to 6 sessions may be necessary to relieve tenderness in the area. [4] The most invasive method for treating iliocostal friction syndrome is the surgical resection of the floating ribs, [2] which excises the outer two-thirds of the rib while the individual is under anesthesia. [3] Special attention is made to preserve the intercostal nerve not to cause intercostal neuralgia. [8]

Related Research Articles

<span class="mw-page-title-main">Tietze syndrome</span> Inflammation, tenderness, and pain of the chest wall with swelling present

Tietze syndrome is a benign inflammation of one or more of the costal cartilages. It was first described in 1921 by German surgeon Alexander Tietze and was subsequently named after him. The condition is characterized by tenderness and painful swelling of the anterior (front) chest wall at the costochondral, sternocostal, or sternoclavicular junctions. Tietze syndrome affects the true ribs and has a predilection for the 2nd and 3rd ribs, commonly affecting only a single joint.

<span class="mw-page-title-main">Kyphosis</span> Medical condition

Kyphosis is an abnormally excessive convex curvature of the spine as it occurs in the thoracic and sacral regions. Abnormal inward concave lordotic curving of the cervical and lumbar regions of the spine is called lordosis. It can result from degenerative disc disease; developmental abnormalities, most commonly Scheuermann's disease; Copenhagen disease, osteoporosis with compression fractures of the vertebra; multiple myeloma; or trauma. A normal thoracic spine extends from the 1st thoracic to the 12th thoracic vertebra and should have a slight kyphotic angle, ranging from 20° to 45°. When the "roundness" of the upper spine increases past 45° it is called kyphosis or "hyperkyphosis". Scheuermann's kyphosis is the most classic form of hyperkyphosis and is the result of wedged vertebrae that develop during adolescence. The cause is not currently known and the condition appears to be multifactorial and is seen more frequently in males than females.

<span class="mw-page-title-main">Thoracic outlet syndrome</span> Medical condition

Thoracic outlet syndrome (TOS) is a condition in which there is compression of the nerves, arteries, or veins in the superior thoracic aperture, the passageway from the lower neck to the armpit, also known as the thoracic outlet. There are three main types: neurogenic, venous, and arterial. The neurogenic type is the most common and presents with pain, weakness, paraesthesia, and occasionally loss of muscle at the base of the thumb. The venous type results in swelling, pain, and possibly a bluish coloration of the arm. The arterial type results in pain, coldness, and pallor of the arm.

<span class="mw-page-title-main">Lordosis</span> Medical condition

Lordosis is historically defined as an abnormal inward curvature of the lumbar spine. However, the terms lordosis and lordotic are also used to refer to the normal inward curvature of the lumbar and cervical regions of the human spine. Similarly, kyphosis historically refers to abnormal convex curvature of the spine. The normal outward (convex) curvature in the thoracic and sacral regions is also termed kyphosis or kyphotic. The term comes from the Greek lordōsis, from lordos.

A soft tissue injury is the damage of muscles, ligaments and tendons throughout the body. Common soft tissue injuries usually occur from a sprain, strain, a one-off blow resulting in a contusion or overuse of a particular part of the body. Soft tissue injuries can result in pain, swelling, bruising and loss of function.

<span class="mw-page-title-main">Shin splints</span> Medical condition

A shin splint, also known as medial tibial stress syndrome, is pain along the inside edge of the shinbone (tibia) due to inflammation of tissue in the area. Generally this is between the middle of the lower leg and the ankle. The pain may be dull or sharp, and is generally brought on by high-impact exercise that overloads the tibia. It generally resolves during periods of rest. Complications may include stress fractures.

<span class="mw-page-title-main">Costochondritis</span> Human disease

Costochondritis, also known as chest wall pain syndrome or costosternal syndrome, is a benign inflammation of the upper costochondral and sternocostal joints. 90% of patients are affected in multiple ribs on a single side, typically at the 2nd to 5th ribs. Chest pain, the primary symptom of costochondritis, is considered a symptom of a medical emergency, making costochondritis a common presentation in the emergency department. One study found costochondritis was responsible for 30% of patients with chest pain in an emergency department setting.

<span class="mw-page-title-main">Foot drop</span> Gait abnormality

Foot drop is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the deep fibular nerve, including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself. Foot drop is characterized by inability or impaired ability to raise the toes or raise the foot from the ankle (dorsiflexion). Foot drop may be temporary or permanent, depending on the extent of muscle weakness or paralysis and it can occur in one or both feet. In walking, the raised leg is slightly bent at the knee to prevent the foot from dragging along the ground.

<span class="mw-page-title-main">Kyphoscoliosis</span> Medical condition

Kyphoscoliosis describes an abnormal curvature of the spine in both the coronal and sagittal planes. It is a combination of kyphosis and scoliosis. This musculoskeletal disorder often leads to other issues in patients, such as under-ventilation of lungs, pulmonary hypertension, difficulty in performing day-to-day activities, psychological issues emanating from anxiety about acceptance among peers, especially in young patients. It can also be seen in syringomyelia, Friedreich's ataxia, spina bifida, kyphoscoliotic Ehlers–Danlos syndrome (kEDS), and Duchenne muscular dystrophy due to asymmetric weakening of the paraspinal muscles.

<span class="mw-page-title-main">Scheuermann's disease</span> Medical condition

Scheuermann's disease is a self-limiting skeletal disorder of childhood. Scheuermann's disease describes a condition where the vertebrae grow unevenly with respect to the sagittal plane; that is, the posterior angle is often greater than the anterior. This uneven growth results in the signature "wedging" shape of the vertebrae, causing kyphosis. It is named after Danish surgeon Holger Scheuermann.

<span class="mw-page-title-main">Superior cluneal nerves</span>

The superior cluneal nerves are pure sensory nerves that innervate the skin of the upper part of the buttocks. They are the terminal ends of the L1-L3 spinal nerve dorsal rami lateral branches. They are one of three different types of cluneal nerves. They travel inferiorly through multiple layers of muscles, then traverse osteofibrous tunnels between the thoracolumbar fascia and iliac crest.

Geniculate ganglionitis or geniculate neuralgia (GN), also called nervus intermedius neuralgia, Ramsay Hunt syndrome, or Hunt's neuralgia, is a rare disorder characterized by severe paroxysmal neuralgic pain deep in the ear, that may spread to the ear canal, outer ear, mastoid or eye regions. GN may also occur in combination with trigeminal or glossopharyngeal neuralgia.

In medicine, Carnett's sign is a finding on clinical examination in which (acute) abdominal pain remains unchanged or increases when the muscles of the abdominal wall are tensed. For this part of the abdominal examination, the patient can be asked to lift the head and shoulders from the examination table to tense the abdominal muscles. An alternative is to ask the patient to raise both legs with straight knees.

<span class="mw-page-title-main">Spinal disease</span> Diseases involving the vertebral column

Spinal disease refers to a condition impairing the backbone. These include various diseases of the back or spine ("dorso-"), such as kyphosis. Dorsalgia refers to back pain. Some other spinal diseases include spinal muscular atrophy, ankylosing spondylitis, lumbar spinal stenosis, spina bifida, spinal tumors, osteoporosis and cauda equina syndrome.

<span class="mw-page-title-main">Cracked tooth syndrome</span> Medical condition

Cracked tooth syndrome (CTS) is where a tooth has incompletely cracked but no part of the tooth has yet broken off. Sometimes it is described as a greenstick fracture. The symptoms are very variable, making it a notoriously difficult condition to diagnose.

<span class="mw-page-title-main">Nerve compression syndrome</span> Human disease

Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by chronic, direct pressure on a peripheral nerve. It is known colloquially as a trapped nerve, though this may also refer to nerve root compression. Its symptoms include pain, tingling, numbness and muscle weakness. The symptoms affect just one particular part of the body, depending on which nerve is affected. The diagnosis is largely clinical and can be confirmed with diagnostic nerve blocks. Occasionally imaging and electrophysiology studies aid in the diagnosis. Timely diagnosis is important as untreated chronic nerve compression may cause permanent damage. A surgical nerve decompression can relieve pressure on the nerve but cannot always reverse the physiological changes that occurred before treatment. Nerve injury by a single episode of physical trauma is in one sense an acute compression neuropathy but is not usually included under this heading, as chronic compression takes a unique pathophysiological course.

<span class="mw-page-title-main">Spinal stenosis</span> Disease of the bony spine that results in narrowing of the spinal canal

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.

<span class="mw-page-title-main">Intercostal nerve block</span> Procedure for pain relief

Intercostal nerve block is a nerve block which temporarily or permanently interrupts the flow of signals along an intercostal nerve, usually performed to relieve pain.

<span class="mw-page-title-main">Slipping rib syndrome</span> Pain in the false ribs due to the partial dislocation of the costal cartilage

Slipping rib syndrome (SRS) is a condition in which the interchondral ligaments are weakened or disrupted and have increased laxity, causing the costal cartilage tips to subluxate. This results in pain or discomfort due to pinched or irritated intercostal nerves, straining of the intercostal muscles, and inflammation. The condition affects the 8th, 9th, and 10th ribs, referred to as the false ribs, with the 10th rib most commonly affected.

<span class="mw-page-title-main">Twelfth rib syndrome</span> Medical condition caused by mobile floating ribs

Twelfth rib syndrome, also known as rib tip syndrome, is a painful condition that occurs as a result of highly mobile floating ribs. It commonly presents as pain that may be felt in the lower back or lower abdominal region as a result of the 11th or 12th mobile rib irritating the surrounding tissues and nervous systems. Diagnosis is often made by a physical examination after other conditions are ruled out. The condition is often labelled as slipping rib syndrome due to the unclear definitions of the conditions, with twelfth rib syndrome sometimes being referred to as a subtype of slipping rib syndrome.

References

  1. ↑ Sinaki M, Pfeifer M (2017). Non-pharmacological management of osteoporosis: exercise, nutrition, fall and fracture prevention. Cham, Switzerland: Springer International Publishing. pp. 211–212. ISBN   978-3-319-54016-0. OCLC   990294268.
  2. 1 2 3 4 5 Brubaker ML, Sinaki M (June 2016). "Successful management of iliocostal impingement syndrome: A case series". Prosthetics & Orthotics International. 40 (3): 384–387. doi: 10.1177/0309364615605394 . ISSN   0309-3646. PMID   26527757.
  3. 1 2 3 4 5 6 Wynne AT, Nelson MA, Nordin BE (1985). "Costo-iliac impingement syndrome". The Journal of Bone and Joint Surgery. British Volume. 67 (1): 124–125. doi:10.1302/0301-620X.67B1.3155743. ISSN   0301-620X. PMID   3155743.
  4. 1 2 3 4 5 6 7 8 Hirschberg GG, Williams KA, Byrd JG (1992). "Diagnosis and Treatment of Iliocostal Friction Syndromes". Journal of Orthopaedic Medicine. 14 (2): 35–39. doi:10.1080/1355297X.1992.11719682. ISSN   1355-297X.
  5. 1 2 3 4 McAnally HB, Rescot AM (May 2020). "Superior Cluneal Neuralgia from Iliocostal Impingement Treated with Phenol Neurolysis: A Case Report". Pain Management Case Reports. 4 (3): 77–84. doi:10.36076/pmcr.2020/4/77. ISSN   2575-9841.
  6. 1 2 3 4 Patel SI, Jayaram P, Portugal S, et al. (July 2014). "Iliocostal Friction Syndrome Causing Flank Pain in a Patient with a History of Stroke with Scoliosis and Compensated Trendelenburg Gait". American Journal of Physical Medicine & Rehabilitation. 93 (7): 632–633. doi:10.1097/PHM.0b013e318282e939. ISSN   0894-9115. PMID   23370590.
  7. ↑ Blevins K, Battenberg A, Beck A (August 2018). "Management of Scoliosis". Advances in Pediatrics. 65 (1): 249–266. doi:10.1016/j.yapd.2018.04.013. PMID   30053928. S2CID   51727835.
  8. 1 2 3 4 5 6 7 8 Huber P, Arroyo J (March 1995). "Syndrome algique ilio-costal". Douleur et Analgésie (in French). 8 (1): 25–27. doi:10.1007/BF03005024. ISSN   1951-6398. S2CID   71158860.
  9. ↑ Anthamatten A, Parish A (May 2019). "Clinical Update on Osteoporosis". Journal of Midwifery & Women's Health. 64 (3): 265–275. doi:10.1111/jmwh.12954. ISSN   1526-9523. PMID   30869832. S2CID   76663413.
  10. 1 2 Ensrud KD, Crandall CJ (August 2017). "Osteoporosis". Annals of Internal Medicine. 167 (3): ITC17–ITC32. doi:10.7326/AITC201708010. ISSN   0003-4819. PMID   28761958.
  11. 1 2 Rosen CJ, Glowacki J, Bilezikian JP (1999). The aging skeleton. San Diego: Academic Press. p. 447. ISBN   978-0-12-098655-2. OCLC   162570766.
  12. ↑ Roghani T, Zavieh MK, Manshadi FD, et al. (August 2017). "Age-related hyperkyphosis: update of its potential causes and clinical impacts—narrative review". Aging Clinical and Experimental Research. 29 (4): 567–577. doi:10.1007/s40520-016-0617-3. ISSN   1720-8319. PMC   5316378 . PMID   27538834.
  13. ↑ Koelé MC, Lems WF, Willems HC (January 2020). "The Clinical Relevance of Hyperkyphosis: A Narrative Review". Frontiers in Endocrinology. 11: 5. doi: 10.3389/fendo.2020.00005 . ISSN   1664-2392. PMC   6993454 . PMID   32038498.
  14. ↑ Bettany-Saltikov J, Schreiber S (2017). Innovations in Spinal Deformities and Postural Disorders. [Erscheinungsort nicht ermittelbar]. p. 76. ISBN   978-953-51-3541-8. OCLC   1193044993.{{cite book}}: CS1 maint: location missing publisher (link)
  15. ↑ Yaman O, Dalbayrak S (2013). "Kyphosis and review of the literature". Turkish Neurosurgery. 24 (4): 455–465. doi: 10.5137/1019-5149.JTN.8940-13.0 . ISSN   1019-5149. PMID   25050667.
  16. 1 2 3 Marcus A (2004). Foundations for integrative musculoskeletal medicine : an east-west approach. Berkeley, Calif.: North Atlantic Books. p. 655. ISBN   1-55643-540-1. OCLC   56657689.
  17. ↑ Elsakka KM, Das JM, Allam AE (2021), "Ilioinguinal Neuralgia", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   30855844 , retrieved 2021-07-26
  18. ↑ Myers TW (2020). Anatomy Trains E-Book: Myofascial Meridians for Manual Therapists and Movement Professionals. United Kingdom: Elsevier Health Sciences. pp. 79, 85. ISBN   9780702078149.
  19. 1 2 Banik RK, McDaniel E, DeWeerth JC, Sembrano JN (February 2021). "Iliocostal Friction Syndrome Due to Hair-Pin Shaped Thoracic Kyphosis". Pain Medicine. 22 (5): 1223–1224. doi: 10.1093/pm/pnab027 . ISSN   1526-2375. PMID   34019652.
  20. ↑ Braddom, RL (2010). Physical medicine and rehabilitation (4th ed.). Philadelphia, PA: Elsevier Health Sciences. p. 926. ISBN   978-1-4377-0884-4. OCLC   502393170.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.