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Small contact surface pressure on the gluteus maximus. 1 In the previous column, I discussed a complex cascade of biomechanical deviations known as miserable malalignment syndrome (MMS) that leads to numerous complaints of pain and altered movement or function. In this issue, we'll tackle a few treatment strategies that address the different soft-tissue disorders that can result from this syndrome. To recap, MMS involves a series of interrelated biomechanical dysfunctions throughout the lower extremity kinetic chain, including: a broad pelvis, a large quadriceps angle (Q angle), femoral anteversion along with a squinting patella, genu valgum (knock-knees), and excessive pronation with internal tibial rotation. Be sure to review the previous article for the condition details (September/October 2015, page 96). Clearly, some components, such as the broad pelvis or femoral anteversion, are issues of skeletal structure over which we have no control. Yet, structural problems frequently produce soft-tissue compensations or problems. Soft tissues are stressed by the attempt to correct biomechanical dysfunction and, for these concerns, massage can be very helpful. HIP & PELVIS REGION Let's start by taking a look at some of the detrimental effects of the broad pelvis and femoral anteversion. As discussed in Part 1, femoral anteversion causes the forward-facing condyles of the femur to angle inward, and the tibia may also rotate internally in order to properly connect with the femur. This postural alteration can increase tension on the iliotibial band (ITB) due to its attachment site on the tibia. A broader pelvis can also increase the distance that the iliotibial band (ITB) must span, and so it, too, can be a factor leading to ITB dysfunction. In a 2006 article, John Fairclough and his colleagues showed how increased tension on the ITB due to tibial rotation may be a prominent factor in the development of iliotibial band syndrome. 1 In fact, the increased tension on the band is likely more important in producing lateral knee pain than friction from repetitive flexion and extension of the knee (the previously believed cause of the pain syndrome). Helping to reduce tension on the ITB will not reverse the process of femoral anteversion because it is a structural deviation in the femur bone itself. However, it could decrease the likelihood that the altered femoral alignment produces lateral knee pain from ITB irritation. The most effective way to reduce tension on the ITB is to encourage elongation in the myofascial tissues that insert into the superior portion of the band and pull on it. The primary focus for this treatment is on the gluteus maximus and tensor fasciae latae (TFL). Because the gluteus maximus is such a thick muscle, reducing tightness in the entire muscle generally requires significant pressure to access the deepest fibers of the muscle. Static compression or very slow gliding techniques are effective for releasing tightness within the muscle. Start with broad surface compression, such as the back of the fist or heel of the hand, so the muscle can begin to initially respond to that level of pressure. After broad contact applications, deeper or more specific areas of tightness can be addressed with 98 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 1 5 technique CLINICAL APPS Miserable Malalignment Syndrome, Part 2 By Whitney Lowe

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