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Keeping It Simple

By David Kent, LMT, NCTMB

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Little Muscles Can Create Big Pain

Sometimes it is the smallest of muscles that can create the most servere types of pain. Some clients come in to the clinic and report that hip and leg pain is so severe it caused them to visit an emergency room, a walk-in clinic or their primary care physician. Various tests were performed and x-rays taken.

Medications and therapy were prescribed. The symptoms persisted, specialists were seen, more tests and imaging were ordered. Ultimately they are still in pain and seeking relief. While the above symptoms could have numerous origins, let's take a look at the gluteus minimus muscle, its myofascial trigger point patterns, a few manual therapy techniques and self-care tips.

The symptoms produced from myofascial trigger points in the gluteus minimus muscle can be terrifying to clients. Some report the symptoms are new and presented quickly, while others state the symptoms increased over time. Frequently, clients report experiencing "low back" or "hip pain" as they point deep in the gluteal region, down the lateral and posterior thigh and leg. They may also mention the pain is more intense when walking and standing up straight after sitting or sleeping.

The gluteus minimus is the deepest of the three gluteal muscles, the smallest in length and lightest in weight. It attaches proximally to the external surface of the ilium and distally to the anterior surface of the greater trochanter of the femur (Photo 1A). The muscle fibers of gluteus minimus and gluteus medius run in the same direction and produce the same action, however, the trigger point patterns of these muscles are very different.

When the lower extremity is free to move and all fibers of the gluteus minimus contract, they produce abduction of the thigh. When the anterior fibers of gluteus minimus contract, and the lower extremity is free to move, they produce medial rotation of the thigh. When the lower extremity is in a fixed position, as during the weight bearing phase of gait or when balancing on one leg, the gluteus minimus, along with the gluteus medius, and tensor fascia lata, keep the pelvis level when the opposite limb is raised off the ground. These same muscles can tilt the pelvis when the lower extremity is in a fixed position.

gluteus minimus - Copyright – Stock Photo / Register Mark When checking range of motion, trigger points in the gluteus minimus and gluteus medius muscles will restrict adduction of the thigh. Trigger points in the gluteus maximus restrict hip flexion.

To make your practice stand out from the competition, use the camera and video recorder built into a smartphone or tablet to assess and educate clients, while documenting your objective findings. We all know the saying a picture is worth a thousand words. It takes seconds to capture a few postural analysis photos. A lateral view allows the client to see their forward head, rounded shoulder or rotated pelvic posture. An anterior view makes it easy to spot when the shoulders or pelvis are not level. Point out when the head or torso is held more to one side from midline. Record video to document restricted range-of-motion and gait.

Muscular, skeletal, postural analysis and trigger point charts are excellent for client education. Be sure to explain how to read the charts, for example in photos 1B and 1C, "X" indicates the common location of trigger points. Solid red areas indicate essential pain zones or the regions of referred pain that is present in nearly every person with active trigger points. The dotted red regions indicate spillover pain zones or the regions of referred pain on some, but not all, patients with active trigger points.

gluteus minimus - Copyright – Stock Photo / Register Mark Also, note in photo 1B the trigger points (TrPs) in the anterior fibers of gluteus minimus refer into the lower buttock and down the lateral aspect of the thigh into the fibular region of the leg. Rarely do the referrals cross the ankle, but on occasion will refer into the dorsum of the foot. While in photo 1C, the trigger points in the posterior fibers, tend to refer pain more medial into the lower buttock, posterior thigh and proximal calf.

Prior to treatment, as appropriate, use moist heat, stretching and any other techniques you like. As discussed in this article, the client is positioned prone during treatment, however, you can use side lying or other positions as necessary.

Positioning

Boney landmarks are used for precise hand positioning to isolate and treat the deep gluteus minimus muscle. You will be able to treat through the superficial gluteus maximus, medius and tensor fascia latae. The piriformis muscle is positioned adjacent to the gluteus minimus muscle.

gluteus minimus - Copyright – Stock Photo / Register Mark The client is positioned prone. The therapist is standing at the level of the thigh facing the hip. Palpate the iliac crest, anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS). Next palpate the greater trochanter by placing the flat fingers of one hand in the region of the greater trochanter, apply and maintain pressure. With the other hand, flex the knee 90 degrees, then move the leg medial and lateral to internally and externally rotate the thigh. (Photo 2)

Pincher Compression

This step will isolate the superficial gluteus maximus muscle. First, shorten the muscle by externally rotating the femur. Use pincer compression to lift the gluteus maximus muscle while moving the thumbs and finger tips in opposite directions. Reposition your hands at different locations and angles to isolate the entire muscle. (Photo 3)

gluteus minimus - Copyright – Stock Photo / Register Mark Posterior llium

Now we will treat the muscle bellies and attachments on the posterior surface of the ilium. Remain standing at the level of the thigh and keep the thigh externally rotated. Start at the lateral aspect of the ASIS and treat an area on the posterior ilium, to the lateral border of the sacrum and continue to the sacrotuberous ligament. Using thumbs or fingers, check for sensitivity by applying static pressure. Next, while applying more pressure in one direction, move the skin in a with-fiber direction. Repeat treating the area in a cross-fiber direction. (Photo 4)

Reposition your hands and treat as above the area mid point between the iliac crest and greater trochanter. Reference your trigger point charts throughout the treatment session.

gluteus minimus - Copyright – Stock Photo / Register Mark Olcecranon Process

The olcecranon process (elbow) can be used as an optional treatment instrument. To maintain control of the movement, place one hand palm down on the treatment region. Place your oleconon process in the space between the thumb and fingers. Pressure is controlled by the treating olecranon process. (Photo 5)

Greater Trochanter

Stand at the level of the clients shoulder, facing their feet. Use with-fiber then cross-fiber movements, treat the attachments around the superior border of the greater trochanter and trochanteric notch. (Photo 6)

gluteus minimus - Copyright – Stock Photo / Register Mark Continue treating the around the greater trochanter effecting the tendon attachments of piriformis, obturator internus, gemelli superior, gemeli inferior and quadratus femorus.

Clients will ask for advice pertaining to self-care. Identify any perpetuating factors that negatively influence the client's condition and recommend cost effective self-care tips. For example, when standing, do they place their weight on the same leg all the time? When sitting, do they always cross the same leg over the other? Explain the effects on muscles, the pelvis and spine. Do they keep a wallet, tools or a large set of keys in their back pocket? If the answer is yes, recommend removal immediately. Do they sit immobilized for long periods working on the computer, reading, watching a movie, etc.? Suggest a timer be set to ring every fifteen minutes as a reminder to stand up and stretch. Do they drive for long distances? Plan additional time for more frequent stops to stand up, move and stretch. Do they sleep in a fetal position? Then a pillow placed between the knees and in front of the chest will be helpful. Simple actions can quickly improve symptoms.

Clients become raving fans when you teach them simple cost effective self-care tips. They feel empowered having the knowledge to care for themselves between sessions. Review their daily activities and discuss proper ergonomics. Show them stretches and other self-treatment tips. I recommend clients use professional self-care equipment verses something like a basic tennis ball. Professional materials can heated, stay warm and are available in various sizes. Show clients how to lengthen and strengthen their muscles with exercise balls and resistance bands to create structural balance.

Topical analgesics are also beneficial for relieving pain. Apply some during therapy and educate your clients on its use. Give samples for clients to try between treatments. Selling products like topical analgesics, hot/cold packs and other self-care aids can generate a tremendous amount of additional income.

Pain is scary to clients and they fear it will never go away. The pain starts affecting every area of the client's life: physically, emotionally, spiritually, financially, relationships at home and work, etc. They scheduled a treatment with you looking for answers and relief. Take the time to assess and educate clients before, during and at the end of the therapy session. Clients want to know what caused the pain, how you can help and if there is anything they can do to prevent it in the future. While the client's symptoms could have numerous origins, remember the gluteus minimus is a little muscle that creates big pain.

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