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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 77 the SIJ. When the patient runs, every time her right leg contacts the ground and goes through the gait cycle, the left latissimus dorsi is overcontracting. This causes the left scapula to depress, and the muscles that resist the downward depressive pull will be the upper trapezius and the levator scapulae. Subsequently, these muscles start to fatigue. For the patient in question, this fatigue occurs at approximately 4 miles, at which point she feels pain in her left superior scapula. TREATMENT You might think the easy way to treat a weakness in the gluteus maximus is to encourage your client to do strength-based exercises. However, in practice, this is not always the correct solution, as sometimes the tighter antagonistic muscle is responsible for the apparent weakness. The muscle in this case is the iliopsoas (hip flexor), and the shortening of this can result in a weakness inhibition of the gluteus maximus. My answer to this puzzle was to stretch the patient's right iliopsoas muscle to see if it promoted the firing activation of the gluteus maximus, while at the same time introducing strength exercises for the gluteus maximus. PROGNOSIS I advised the patient to abstain from running and to get her partner to assist in lengthening the iliopsoas, rectus femoris, and adductors twice a day (see the iliopsoas technique described on page 79). Strength exercises were also advised twice daily until the follow- up treatment. I reassessed her 10 days later and found normal firing of the gluteus maximus on the hip extension firing pattern test, and a reduction in the tightness of the associated iliopsoas, rectus femoris, and adductors. Because of these positive results, I advised her to run as far as felt comfortable. How to Perform a Muscle Energy Technique This type of technique is excellent for relaxing and releasing tone in tight, shortened soft tissues. 1. The client's limb is taken to the point where resistance is felt—the point of bind. It can be more comfortable for the client if you ease off to a point slightly short of the point of bind in the affected area that you are going to address, especially if these tissues are in the chronic stage. 2. The client is asked to isometrically contract the muscle to be treated (post-isometric relaxation—PIR) or the antagonist (reciprocal inhibition—RI), using approximately 10–20 percent of the muscle's strength capability against a resistance that is applied by the therapist. 3. The client should be using the agonist if the method of approach is PIR; this will release the tight, shortened structures directly. 4. If the RI method of MET is used, the client is asked to contract the antagonist isometrically; this will induce a relaxation effect in the opposite muscle group (agonist) that would still be classified as the tight and shortened structures. 5. The client is asked to slowly introduce an isometric contraction, lasting 10–12 seconds, avoiding any jerking of the area. This contraction is the time necessary to load the Golgi tendon organs, which allows them to become active and to influence the intrafusal fibers from the muscle spindles. This has the effect of overriding the influence from the muscle spindles, which inhibits muscle tone. The therapist then has the opportunity to take the affected area to a new position with minimal effort. 6. The contraction by the client should cause no discomfort or strain. 7. The client is told to relax fully by taking a deep breath in, and as they breathe out, the therapist passively takes the specific joint that lengthens the hypertonic muscle to a new position, which therefore normalizes joint range. 8. After an isometric contraction, which induces a PIR, there is a relaxation period of 15–30 seconds; this period can be the perfect time to stretch the tissues to their new resting length. 9. Repeat this process until no further progress is made (normally 3–4 times) and hold the final resting position for approximately 25–30 seconds, which is considered to be enough time for the neurological system to lock onto this new resting position.