Issue link: https://www.massageandbodyworkdigital.com/i/296580
102 m a s s a g e & b o d y w o r k m a y / j u n e 2 0 1 4 discomfort and he feels a sharp aching sensation down the lower extremity. By combining deep, specific pressure with this muscle-resistance test, any existing pathology within the muscle will become much more apparent. The physical examination revealed significant tightness in muscles throughout the lumbar, gluteal, and lower extremity regions. These muscles form a long and continuous myofascial chain, and it is very common to see tightness patterns that exist throughout. None of the other evaluation procedures we performed strongly pointed to a potential cause for Darren's pain. However, that doesn't mean there isn't another simultaneous, underlying pathology. In fact, it would be very helpful to have additional evaluation and high-tech diagnostic procedures performed by another health professional, just to rule out any potential neural structure involvement in the lumbar region. However, we have established that there does not appear to be any contraindication to performing massage treatment, and with the extensive muscle tightness Darren is demonstrating, massage would be helpful for addressing his problem. TREATMENT CONSIDERATIONS Having established that a primary component of Darren's pain complaint is muscle dysfunction and trigger-point activity throughout his low- back and gluteal region, a treatment strategy can be created for him. The primary focus will be on techniques to encourage muscle lengthening and deactivation of the involved trigger points. CLINICAL APPS reproduces some of the common pain sensations in his low back. However, nothing in the initial palpatory examination reproduces his lower extremity pain. Assessment shows he has range of motion restriction in forward flexion and lateral flexion of the lumbar region to each side. This restriction is present in both active and passive movements. However, none of our simple range of motion movements produce the primary pain complaint Darren has been experiencing. He does mention that his back feels tight and there is mild discomfort with some of these motions as he stretches his back, but it's not the same pain he's been experiencing. In a supine position, he has limited hip flexion and says he can feel the hamstrings pulling taut as his fully straightened leg is raised in a hamstring stretch position. This same stretching position is used with a special orthopedic test called the straight leg raise and will often reproduce neurological sensations in individuals who have disc protrusions pressing on a nerve root. However, Darren has no radiating neurological-type lower extremity symptoms aggravated by this stretching position. To investigate the possibility of sacroiliac joint dysfunction, several special orthopedic tests are used that stress the sacroiliac joint to see if any symptoms are reproduced. It is challenging to identify if the sacroiliac joint is involved with a single physical examination test. Greater accuracy comes if several tests are performed together and then the results are cumulatively considered. Darren describes no discomfort with any of these procedures except for the side-lying compression test, where he is lying on his side and his lateral hip region is pressed with the palms. However, there is also pressure on his hip abductor muscles as this test is performed, so I want to make sure this is a sacroiliac joint response and not a muscle response. To investigate further, I try using significant pressure with just a thumb pressed into the gluteus medius and minimus muscles. By using a small contact surface of pressure, I can apply more compressive load to the muscles and very little to the sacroiliac joint region for better assessment of those tissues. Darren reports that this reproduces the pain he's been feeling down his lower extremity. At this point, I am suspicious about involvement of the gluteus medius and minimus muscles in Darren's lower extremity pain. While maintaining pressure on these muscles with a thumb, I ask him to abduct his thigh. Immediately, he responds that this really causes Treating the intrinsic spinal muscles in the lamina groove. Image courtesy of Whitney Lowe. 4