Massage & Bodywork

MAY | JUNE 2021

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88 m a s s a g e & b o d y wo r k m ay/ j u n e 2 0 2 1 Deep Gluteal Syndrome and Tendinopathy Getting to the Bottom of Buttock Pain †† BY ERIK DALTON, PHD The buttock has been assigned more syndromes than any other bodily region. This is due to the biomechanical complexity of the sciatic nerve and the tremendous torsional forces traversing the pelvis and lumbar spine during daily activities. Piriformis syndrome, gemelli- obturator internus syndrome, ischial tunnel syndrome, and greater trochanteric pain syndrome are but a few of the names used to describe symptoms associated with tendinopathies and sciatic-nerve entrapment sites in the buttocks. Special orthopedic tests may help rule out possible offenders, and a comprehensive intake aids in detecting biopsychosocial factors that may be contributing to the client's pain. However, the problem I often encounter when assessing buttock pain is symptom overlap, which can make pinpointing the exact location difficult and unreliable. In this column, I'll use the umbrella term deep gluteal syndrome (DGS) to describe generalized sciatic-related buttock pain. I'll also outline a few techniques I find helpful in freeing up musculofascial tissues that may be possible perpetrators. SCIATIC NERVE MOBILITY AND FLEXIBILITY Covered on top by the gluteus maximus muscle, the sciatic nerve travels between the ischial tuberosity and the greater trochanter of the femur on its way to innervate the legs and feet (Image 1). Researchers found the sciatic nerve has 28 millimeters of excursion during hip flexion, and, under normal patterns of joint movement, it's flexible enough to stretch and slide to give way during moderate strain or compression. 1 However, trauma, injuries, or repetitive technique | MYOSKELETAL ALIGNMENT TECHNIQUES Sciatic nerve pathway. Sciatic nerve kinked between the piriformis and gemelli-obturator internus muscles. ‡ ˆ motion activities can cause tethering, inflammation, and—if the brain perceives threat—pain. Below is a routine I find helpful in relieving symptoms for two of the most common buttock conditions. EASING THE HIP'S EXTERNAL ROTATORS I typically begin by addressing three of the "deep six" external hip rotators as they insert at the greater trochanter. Note in Image 2 how the sciatic nerve can become kinked between the piriformis and gemelli- obturator internus muscles. To help soften fibrotic bands that may be compressing the sciatic nerve, my right forearm contacts and fascially hooks the piriformis, gemelli, and obturator internus tendons at the posterior border of the greater trochanter while my left hand braces the client's thorax. A counterforce occurs as my right forearm gently drags the tendons inferiorly while my left hand resists (Image 3). The client is asked to begin slow anterior and posterior pelvic tilting as I resist this motion. Note: None of these techniques are performed on those with hip replacements or diagnosed hip and lumbar spine pathology. MISTAKEN IDENTITY Greater trochanteric pain syndrome is a disorder of the gluteus medius and minimus tendons—gluteal tendinopathy— but is often mistaken for DGS. In some clients, there is accompanying irritation in nearby structures, including the greater trochanteric bursa and iliotibial (IT) band (Image 4). Since the bursa and IT band are affected by the same mechanisms of overuse or injury, treatment aims Ischial Piriformis Sciatic nerve Gemelli- obturator internus Greater trochanter tuberosity

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