Original Research

Palpation of the iliolumbar ligament

Ewan Kennedy, BPhty

MSc Student

Brendan Cullen, BPhty

MSc Student

J. Haxby Abbott, MScPT, DipPhty, MNZCP

PhD Candidate

Stephanie Woodley BPhty, MSc

PhD Candidate

Susan Mercer PhD, FNZCP

Senior Lecturer

Musculoskeletal Research Group

Department of Anatomy & Structural Biology
University of Otago.

ABSTRACT
Clinical texts have described methods for palpation of the iliolumbar ligament but
have not clearly illustrated the position of the ligament in relation to the surrounding
tissues. Examination of the clinical anatomy of the lumbar spine revealed that
the iliolumbar ligament is embedded in layers of muscle and fascia and its iliac
attachment lies on the deep inner surface of the ilium below the level of the iliac
crest. These findings highlight the need for consideration of the anatomy when
evaluating the biological rationale underlying a clinical procedure. Kennedy E,
Cullen B, Abbott JH, Woodley S, Mercer SR (2004). Palpation of the iliolumbar
ligament. New Zealand Journal of Physiotherapy 32(2) 76-79
Keywords: iliolumbar ligament, palpation, clinical anatomy

INTRODUCTION ligament. Using this information readers can form

Evidence-based practice relies not just on evidence
of efficacy. It is also important that assessment
and treatment techniques are based in defensible
biological rationale. Basic sciences such as anatomy
and biomechanics should therefore be understood
in such a way that a therapist can evaluate whether
the biological rationale offered for a particular
technique is justifiable (Bogduk and Mercer 1995;
Mercer and Rivett 2004). In this commentary, we
illustrate the need to consider the clinical anatomy
of an examination procedure that is intended to
directly palpate the iliolumbar ligament.
During examination of the lumbar spine palpation
is typically performed to assess structures that are
potential sources of pain. It has been suggested
that the iliolumbar ligament is one such potential
source of pain, with the ‘iliolumbar ligament
syndrome’ characterised by local tenderness over
the attachment site of the ligament on the iliac
crest (Broadhurst 1989; Brukner and Khan 2001;
Cashman 1986; Collee et al., 1991; Hirschberg
et al., 1979; Rucco et al., 1996). Palpation of this
ligament is based on the premise that the iliolumbar
ligament is readily accessible.
As a search of the clinical literature revealed
that the anatomical basis of this technique was
not discussed, the aim of this paper is to present
the relevant clinical anatomy of the iliolumbar
their own conclusions regarding the soundness of
the biological rationale underlying this technique.
Palpation
To gain access to the ligament the patient is
placed in prone lying with the hip joint in slight
extension. Pressure is then applied over the ligament
as it extends from the transverse process of the fifth
lumbar vertebrae to the iliac crest (Brukner and
Khan 2001). Clinical texts typically provide general
descriptions or photographs of the palpation
technique (Brukner and Khan 2001; Broadhurst
1989) or drawings of the isolated ligament in a
bony pelvis (Hirschberg et al., 1979). A reader may
therefore develop the impression that the ligament
is readily accessible to direct palpation. Although
some authors do mention the presence of lumbar
muscles and fascia, specifically the quadratus
lumborum, multifidus and iliocostalis lumborum
(Collee et al., 1991; Chaitow and Delany 2000), the
relevance of these structures to palpation of the
ligament was not discussed.
Iliolumbar Ligament Morphology
The iliolumbar ligament is described in the
anatomical literature as having from one to five
bands of connective tissue (Bogduk 1997). As it is
the short, thick band passing from the tip of the L5

76 NZ Journal of Physiotherapy – July 2004. Vol. 32, 2

 transverse process to the ilium that is implicated in
the iliolumbar ligament syndrome, it is this part of
the ligament that requires further consideration.
A survey of the anatomical literature revealed wide
variation among descriptions of this iliac attachment
of the iliolumbar ligament. General descriptions
included attachment to the ilium (Agur and Dalley
2004; Moore and Dalley 1999), the inner surface of
the ilium (Hollinshead 1969), the iliac crest (Boileau,
Grant and Basmajian 1965; Hall-Craggs 1995; Snell
1995), or the iliac crest and tuberosity (Basadonna
et al., 1996). Some authors provide more precise
descriptions, such as the medial lip of the iliac crest
(Wood Jones 1953), the posterior part of the inner
lip of the iliac crest (Romanes 1972; Woodburne and
Burkel 1988), the upper and anterior part of the
iliac tuberosity (Hanson and Sonesson 1994), the
anterior portion of the iliac tuberosity and anterior
margin and apex of the iliac crest (Rucco et al.,
1996) or to the iliac crest anterior to the sacroiliac
joint (Williams et al., 1995).
These descriptions, however, provide little practical
information for the therapist considering accuracy of
palpation. A description that would allow the therapist
to envisage the exact site of attachment is the distinct
triangular area located between the iliac fossa, the iliac
crest and the iliac tuberosity (Figure 1).
Figure 1 A postero-medial view of the ilium. The bony
attachment of the iliolumbar ligament (ILL) is anterior
to quadratus lumborum (QL) and erector spinae
(ES), in the triangular area located between the iliac
fossa (IF), the iliac crest and the attachment site of
the interosseous sacroiliac ligament (ISIL) on the iliac
tuberosity. Articular surface (A) of the sacroiliac joint,
ischial spine (IS), posterior superior iliac spine (PSIS).
NZ Journal of Physiotherapy – July 2004. Vol. 32, 2
Clinical Anatomy
To evaluate the biological rationale of iliolumbar
ligament palpation the ligament must be considered
in situ, not as an isolated structure as it is commonly
portrayed in clinical texts. Due to its insertion
on the inner surface of the ilium (Figure 1) the
ligament is not readily accessible. It is tucked down
on the deep, anterior aspect below the level of the
iliac crest, medial to the more superficial external,
intermediate and inner lips of the iliac crest (Figure
2). Furthermore the iliolumbar ligament is closely
associated with the lower attachments of the anterior
and middle layers of the thoracolumbar fascia and the
quadratus lumborum muscle (Bogduk 1997; Frazer
1940; Fujiwara et al., 2000; Pool-Goudzwaard et al.,
2001; Shellshear and Macintosh 1949; Williams et
al., 1995). In fact different bands of the ligament
appear to be derived from the quadratus lumborum
and iliocostalis lumborum muscles (Bogduk 1997).
This means that the more superficial portions of the
ligament are partially buried within the inferior fibres
of the erector spinae and quadratus lumborum,
while the bulk of the ligament lies medial, anterior
and below the insertion of quadratus lumborum
(Frazer 1940) (Figure 3).
Figure 2 Anterolateral view of the right iliolumbar
ligament (black arrows) passing from the right L5
transverse process towards the right iliac crest. The
iliac attachment of the ligament is anterior and below
the iliac crest. L4 vertebral body (L4), iliac crest (IC),
posterior superior iliac spine (PSIS).
Access from a posterior approach requires
palpation through the skin, a substantial amount
of subcutaneous tissue, the thoracolumbar fascia,
erector spinae aponeurosis, and finally through the
iliocostalis lumborum and quadratus lumborum
muscles (Frazer 1940; Shellshear and Macintosh
1949) (Figure 4). Palpation from a more lateral
approach over the iliac crest may avoid the bulk
of the erector spinae, however the latissimus
dorsi, external oblique, internal oblique, and
transversus abdominus muscles underlie the
77
 skin and subcutaneous tissue in this region. It is
worth noting that access to the iliolumbar ligament
from either direction can only occur through the
quadratus lumborum muscle.
Figure 3 Anterior view of the right lumbosacral region.
Above and attaching inferiorly to the iliolumbar
ligament (black arrows), the quadratus lumborum
(QL) is enveloped in the anterior and middle layers of
the thoracolumbar fascia. The iliolumbar ligament is
therefore embedded in soft tissue below the level of
the iliac crest. The cut edge of the inferior fibres of the
quadratus lumborum muscle is in the top left of the
figure. L4 vertebral body (L4), L5 vertebral body (L5).
CONCLUSIONS
An examination of the relevant anatomy of the
lumbar spine reveals the depth and type of tissues
that lie between a palpating finger and the iliac
attachment of the iliolumbar ligament. In addition
to skin and variable amounts of subcutaneous
tissue a posterior approach encounters a thick
layer of overlying muscle and tough fascia that
would confound attempts to specifically palpate
the ligament. While a more lateral approach
encounters less soft tissue, the iliac crest and
attachment of quadratus lumborum hinder direct
access to the ligament on the deep inner surface
of the ilium. Physiotherapists need to be aware
of these overlying structures when attempting
to palpate the iliolumbar ligament. This review
highlights the importance of considering the clinical
anatomy of a structure in situ when evaluating the
biological rationale of a technique.
78
Figure 4 Transverse section through the L5 spinous
process, L5 transverse process and the L5-S1
zygapophyseal joints. On the left, the ilium (I) is seen
flanked by the gluteus medius (posterior) and iliacus
(anterior) muscles. The left iliolumbar ligament (red
arrow) is passing from the L5 transverse process to its
attachment on the ilium. Posterior to the iliolumbar
ligament are the erector spinae muscles (ES)
covered by the erector spinae aponeurosis (ESA), the
posterior layer of the thoracolumbar fascia (TLF), the
subcutaneous tissue and skin.
Key Points
• Palpation of the iliolumbar ligament is
confounded by the overlying soft and bony
tissues.
• The clinical anatomy of a procedure must be
considered if a defensible biological rationale
is to be established
ACKNOWLEDGEMENTS
The authors gratefully acknowledge Mr Brynley
Crosado, Mrs Shannon O’Nill and Mr Russell Barnett
in preparation of the anatomical material.
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ADDRESS FOR Correspondence:
Dr Susan Mercer,, Musculoskeletal Research Group,
Department of Anatomy & Structural Biology, University of Otago,
Dunedin, New Zealand.
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