Issue link: https://www.massageandbodyworkdigital.com/i/530196
F r e e S O A P n o t e s w i t h M a s s a g e B o o k f o r A B M P m e m b e r s : a b m p . u s / M a s s a g e b o o k 99 likely some muscle-tendon pathology of the hip abductors. Lisa was already experiencing lateral hip pain prior to the accident, so it is unlikely that all of her symptoms result from that accident. There may have been pre-existing, low- level chronic overuse of these tendons, and the accident caused additional damage, further aggravating her pain. Another factor to consider is the immediate swelling after her fall. It is likely there was acute inflammation of the trochanteric bursa from the impact. Lisa could still be irritating that bursa with repetitive hip motions as she continues training. The gluteus maximus and tensor fasciae latae insert into the iliotibial band (ITB), which courses over the trochanteric bursa. Increased tightness in these two muscles can pull the band taut and increase pressure on the trochanteric bursa during repetitive movements. In sum, Lisa is experiencing a couple of key issues. The piriformis muscle appears significantly tight and may be compressing the sciatic nerve. And there appears to be dysfunction affecting the distal tendons of the gluteus medius and minimus, causing pain in the trochanteric bursa. The next step is to determine an effective massage treatment approach. TREATMENT STRATEGIES Treatment should begin with the most superficial muscles. The gluteus maximus is the largest and most superficial muscle in this region, and plays an important role because of its attachments into the ITB. While there was no significant hypertonicity in the gluteus maximus, this muscle has numerous fascial connections throughout the area, and treating it will improve overall biomechanics of the entire hip, pelvis, and low-back region. Treating the gluteal muscle group requires good communication with your client. Asking permission to treat this area is important, and proper and conscientious draping techniques are necessary. Some older draping techniques, like tucking the drape into undergarments, may no longer be appropriate. The gluteus maximus is tender on most people, but especially so on runners. You can prevent reactive muscle splinting (tightening) by beginning treatment with a broad contact surface. Broad open-fist compressions, sweeping cross-fiber movements, and good compressive effleurage are all very effective for reducing initial tension in the gluteus maximus. Once tightness is reduced, treatment on the underlying piriformis can begin. CLINICAL APPS The piriformis is a deep muscle, and its treatment can be uncomfortable, so communicate well with your client as you work. Trying to press too deep and hard too early can cause reactive muscle splinting. Deeper pressure will be required, but it can be done slowly and gently. It is also important to reduce pressure or stop if neurological symptoms are aggravated. One of the most effective ways to address the piriformis without trying to press too deep is with an active engagement lengthening technique. To begin, have the client lie in a prone position, flex the knee, and place the hip in full lateral rotation. Instruct the client to hold as you attempt to gently pull the lower leg toward you (Image 5, page 100). Instruct the client to slowly let go of the contraction as you continue moving the leg toward you (in medial rotation). As you perform this movement, apply a slow specific stripping technique directly on the piriformis, moving forward along the piriformis 3–4 inches with each movement. This technique can be repeated several times until the entire piriformis is addressed. Follow this technique with stretching to encourage full tissue lengthening and advise the client to do home stretches for these tissues. To address the hip abductor muscles, begin with broad contact techniques for the lateral pelvis. Broad contact techniques can be applied to the gluteus medius and minimus from the edge of the iliac crest to their attachment on the greater trochanter. Once initial muscle relaxation techniques have been engaged, more specific work can be applied to the muscle bellies, as well as the potentially affected tendons. Role of the gluteus medius and minimus in pelvic balance. Left-side abductors contract during weight bearing. 4