Issue link: https://www.massageandbodyworkdigital.com/i/530196
ASSESSMENT When the patient came for a consultation at my clinic, the physical therapist working the case asked about the woman's pain. She reported that the potential tissues responsible for the pain in her superior scapula were the upper trapezius, levator scapulae, scalenes, thoracic rib, and cervical rib. Once a subjective history was conducted, an objective assessment began, including active range of motion, passive range of motion, resisted range of motion, and palpation tests to determine the condition of the affected tissues. When considering this patient's case, there were a variety of potential causes of her pain ranging from dysfunction of the glenohumeral or the acromioclavicular joint to an elevated first rib. TAKING A HOLISTIC APPROACH When I see a new patient for the first time, no matter what the presenting pain is, I normally assess the pelvis for position and movement, as I consider this area of the body in particular to be the foundation for everything that connects to it. I often find that when I correct a dysfunctional pelvis, the patient's presenting symptoms tend to settle down. However, when I assessed this particular patient, I found her pelvis was level and moving correctly. I then went on to test the firing patterns of the gluteus maximus, which I often do with patients and athletes who participate in regular athletic activities. However, I only test the firing pattern sequence once I feel that the pelvis is in its correct position; the logic here is that you often get a positive result of the muscle misfiring when the pelvis is slightly out of position. With the patient in question, I found a bilateral weakness/misfiring of the gluteus maximus, but the firing on the right side seemed a bit slower. As I had not found any dysfunction in the pelvis, I pursued this line of approach a little further. Before we continue, I would like to pose a few questions for you to think about: • How does a weakness of the gluteus maximus on the right side cause pain in the left trapezius? • Is there a link between the gluteus maximus and the trapezius, and if so, how is this possible? • What can be done to correct the issue? • What happened to cause it in the first place? To answer these questions, we need to put on our detective hats and look at the functional anatomy of the gluteus maximus, as well as the relationship of the gluteus maximus to other anatomical structures. Gluteus Maximus Function The gluteus maximus operates mainly as a powerful hip extensor and a lateral rotator, but it also plays a part in stabilizing the sacroiliac joint (SIJ) by helping it to "force close" while going through the gait cycle. Some of the gluteus maximus muscular fibers attach to the sacrotuberous ligament, which runs from the sacrum to the ischial tuberosity. This ligament has been termed the key ligament in helping to stabilize the SIJ. To gain a better understanding of this action, we first need to consider two concepts—form closure and force closure—that are both associated with stability of the SIJ. Form Closure and Force Closure The shape of the sacrum—along with its ridges and grooves and the fact that it is wedged between the ilia—helps to bring natural stability to the SIJ. This is known as form closure. If the articular surfaces of the sacrum and the ilia fit together with perfect form closure, mobility would be practically nonexistent. However, form closure of the SIJ is not perfect and movement is possible, which means stabilization during loading is required. This is achieved by increasing compression across the joint at the moment of loading; the surrounding ligaments, muscles, and fascia are responsible for this. The mechanism of compression of the SIJ by these additional forces is called force closure. When the body is working efficiently, the forces between the innominates and the sacrum are adequately controlled, and loads can be transferred between the trunk, pelvis, and legs. So, how do we link this to the patient's complaint? The posterior oblique sling directly links the right gluteus maximus to the left latissimus dorsi via the thoracolumbar fascia. The latissimus dorsi has its insertion on the inner part of the humerus, and one of the functions of this muscle is to keep the scapula against the thoracic rib cage and aid in depression of the scapula. PIECING IT ALL TOGETHER So what do we know? We know that the right side of the patient's gluteus maximus is slightly slower in terms of its firing pattern, and that this muscle plays a role in the force closure process of the SIJ. This tells us that if the gluteus maximus cannot perform this function of stabilizing the SIJ, then something else will assist in stabilizing the joint. The left latissimus dorsi is the synergist that helps stabilize the right gluteus maximus and, more importantly, 76 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 5