Each week, I treat several clients who complain of "low back pain." For many patients, however, the primary cause of their pain is not the lower back but the gluteus medius muscle. No matter what kind of massage practice you have, a great deal of your success will depend on how quickly you are able to determine the origin of a patient's complaint and your ability to produce measurable results. This article will review some ways to identify when the gluteus medius muscle is responsible for causing pain.

Anatomy

The gluteus medius muscle lies superficial to the gluteus minimus muscle and deep to the gluteus maximus muscle. Proximally, it attaches along the external surface of the ilium between the anterior and posterior gluteal lines. Distally, it attaches to the lateral surface of the greater trochanter of the femur. (See Figure 1) The gluteus medius muscle "abducts the hip joint; the anterior fibers medially rotate and may assist in flexion of the hip joint; [and] the posterior fibers laterally rotate and may assist in extension."1 It also helps to keep the pelvis level when the opposite leg is raised during activities such as walking, running, or standing on one leg.

Intake and History

The first step to designing and implementing an effective treatment plan is to understand the client's medical history and current circumstances. Utilizing health history intake forms will help you gather the appropriate information; they will also reveal important factors that could be relevant to a patient's condition.

Using pain scales to document a client's pain patterns are beneficial, as well. Ask the client to color the diagram form illustrating where on the body he/she experiences pain. Then ask the client to add modifiers that adequately describe the pain, followed by a number from 1-10 to rate its intensity. (See Figure 2) This diagram provides a helpful visual tool that you can reference during the session. You will also see how pain patterns often match common trigger point patterns, which are discussed in more detail below. (Read "Charting Your Progress: Visuals for Success," Massage Today February 2008.)

Ask the client if any of his/her daily activities are affected by the pain. If the answer is "yes," ask the client which muscles hurt, what movements aggravate the pain, and what he/she believes caused the pain. Ask if the client has recently started or modified an exercise program. Answers like walking, running, tennis, aerobics and other types of activities may indicate gluteus medius involvement. Has the client had any falls or sustained any hip injuries? What is the client's occupation? Does the client place a wallet or tools in a back pocket? All of these questions will help you narrow down the origin of pain. (Read "Questions With Direction," Massage Today September 2008.)

Gait and PosturalAnalysis

Observe the client as he/she walks. A painful or "weak gluteus medius muscle forces the client to lurch toward the involved side to place the center of gravity over the hip; such movement is called an abduction, or gluteus medius lurch."² Show your client the relationship between posture and pain, and describe how you can help. Just like chiropractors who advertise free "spinal exams" to attract new patients, you could provide free postural analysis to attract new clients. Market the postural analysis as a value that you include during the initial visit; then include a second postural analysis taken upon completing a series of treatments. This is a great way to sell packages, and it also demonstrates postural progress. (Read "Getting Comfortable With Postural Analysis," Massage Today July 2008.) When conducting a postural analysis, look for signs of gluteus medius muscle involvement. Shortness of the gluteus medius muscle "may be seen as a lateral pelvic tilt, low on the side of tightness, along with some abduction of the extremity."¹

Trigger Points

"Myofascial trigger points (TrPs) in the gluteus medius are a commonly overlooked source of low back pain."³ There are three trigger points frequently identified in the gluteus medius muscle. TrP1 (Figure 1) is located lateral and superior to the posterior superior iliac spine (PSIS) just below the iliac crest. TrP1 refers pain and tenderness over the sacrum, above the iliac crest into the lumbar region, and throughout the gluteal region on the same side of the body as the trigger point. TrP2 (Figure 1) is positioned midway between the anterior superior iliac spine (ASIS) and the PSIS just below the iliac crest. "Pain referred from TrP2 is projected more laterally and to the midgluteal region; [and] may extend into the upper thigh posteriorly and laterally."4 TrP3 (Figure 1) is rarely present and can be located just posterior to the ASIS and just below the iliac crest. Referred pain is primarily produced over the sacrum bilaterally.

Educate your clients about trigger points. Use wall charts or flip charts to demonstrate their location on the body. Using charts and other aids will not only help the client, but it will also build your credibility with the client. This is also an excellent time to explain how the muscle affects posture.

Pain is a symptom. As massage therapists, our job is to address the cause of the pain and work to prevent its return. Educate your clients. Discuss proper ergonomics, stretching and strengthening. Identifying the gluteus medius as a source of back pain is easy once you have the knowledge.

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