Positive Health Online

by Jane Johnson PhD MSc BSc(Hons) BA(Hons) CSP HCPC

 This is an excerpt from Soft Tissue Therapy for the Lower Limb by Jane Johnson

In this excerpt from Jane Johnson’s book Soft Tissue Therapy for the Lower Limb, you will learn how to help clients with trigger points in the gluteal muscles, hamstrings, and quadriceps using massage, trigger point release, and soft tissue release (STR).

https://www.human-kinetics.co.uk/9781718215597/soft-tissue-therapy-for-the-lower-limb/

Trigger Points in Gluteal Muscles

Trigger points are found throughout all three gluteal muscles – in the gluteus maximus close to the lateral border of the sacrum, in the gluteus medius running inferior to the iliac crest and in the gluteus minimus. Trigger points in the gluteal muscles are aggravated by prolonged immobility, either when sitting or standing, and they are associated with trigger points in the quadratus lumborum muscle.

Figure 1: Trigger points in the gluteal muscles

The gluteus maximus trigger point causes pain along the sacroiliac joint and into the base of the buttock on that side, and it is easy to identify when your client is in a side-lying position. The gluteus maximus is also associated with trigger points in the hamstrings and lumbar erector spinae; pain is perpetuated by prolonged sitting and activities that require hip and spine extension, such as repeated lifting of a heavy object.

The trigger points in the gluteus medius cause pain in the sacrum, sacroiliac joint and ipsilateral (same-side) buttock. Palpate for these triggers when your client is in either the side-lying or the prone position, sliding your fingers inferiorly off the iliac crest. Trigger points in the gluteus medius, perhaps more than in the other two gluteal muscles, are perpetuated by gait abnormalities, as might be caused by leg-length discrepancy or Morton foot (in which the second toe is longer than the big toe). They are also aggravated by prolonged sitting and prolonged hip flexion.

Trigger points are found throughout the upper portion of the gluteus minimus and cause pain in the buttock and lateral thigh and leg on that side. To palpate these trigger points, position your client supine, locate the tensor fasciae latae, and work your fingers posteriorly into the gluteus minimus. Because it is a deep muscle, you are unlikely to be able to identify specific triggers easily, but you may be able to reproduce mild tenderness when applying pressure here.

Onik and colleagues (2020) conducted an interesting study of myofascial trigger points in the gluteal region that they had identified using both palpation and thermal imaging. Their study involved 30 participants who were asked to rank pretreatment and posttreatment trigger point pain that was reproducible on palpation, using a numerical rating scale. Treatment consisted of simple progressive compression of a trigger point for 1 minute. All participants reported a significant reduction in posttreatment pain and had an initial increase in skin surface temperature, followed by a decrease. The researchers postulated that after compression of the trigger point, there was local occlusion of blood to the area, followed by vasodilation once the pressure was released. They were reluctant to speculate as to the reasons for this; however, their study provides a useful contribution to the understanding of trigger points.

Soft Tissue Release

Soft tissue release can be used successfully to release trigger points in the gluteal muscles too. It can be done with your client in the side-lying position or prone. Two methods are described here.

With experimentation, it is possible to locate the fibres of the gluteus minimus with your client in the side-lying position. Trigger points in this muscle can be more difficult to access when using STR in the prone position. You may find that you need to lower your treatment couch to make working with the side-lying client easier, because their body will be higher than when they rest prone or supine. When you begin, it is challenging to keep a client balanced in the side-lying position whilst you focus your lock in the correct spot on the muscles.

With practice, you will be able to identify triggers in the gluteus maximus and use STR in this position to deactivate them. With your client in the side-lying position and the hip in neutral, use your forearm (close to the elbow) to lock the gluteal muscles, directing your pressure towards the sacrum. Whilst maintaining your lock, ask your client to flex the hip, perhaps by asking them to take the knee to the chest. Repeat this action for a few minutes, varying the position of your lock and working on the area that feels most beneficial for the client.

Another way to apply STR to the gluteal muscles is with your client in the prone position. Grasp the ankle of the leg closest to you and flex the knee. Gently lock the tissues using your elbow, fist or thumb. Maintaining your lock, rotate the femur by passively moving the ankle towards you or away from you, experimenting to determine where your client feels the stretch most.

Hamstring Strains

Tears to hamstring muscles are common and frequently involve the proximal musculotendinous junction of the biceps femoris. Strains are classified as mild, moderate or severe. In mild strains, few muscle fibres are torn. Moderate strains cause damage to more fibres and a distinct loss of function. When the strain is severe, complete rupture of the muscle occurs. In addition to being very painful, moderate to severe strains are extremely disabling.

In severe cases, there is bruising and loss of strength in knee flexion or hip extension. A systematic review by Green and colleagues (2020) provides useful information about risk factors for hamstring strain injury. However, there is inconclusive evidence regarding the most effective interventions for a hamstring strain. A systematic review by Prior, Guerin and Grimmer (2009) provides a clear discussion of this topic.

Acute Stage

Deep tissue massage and all forms of stretching are avoided during the early stages of tissue repair after a hamstring strain, when protection of the damaged tissues is the goal of treatment.

Sub-Acute Stage

With a strain to any muscle, it is important to remember that pain subsides long before the healing process is complete. It is therefore wise to treat the client conservatively during the sub-acute phase of a hamstring strain, when there may be decreased pain and swelling. During this phase of recovery, the treatment aims are to minimise loss of hamstring strength and loss of range of motion in the hip and knee joints.

Massage

In the sub-acute stage of a hamstring strain, light effleurage superior to the site of the tear could be helpful in aiding lymphatic drainage, but deep tissue massage should be avoided. Begin with exploratory massage, using your fingertips to identify areas of adhesion. Using your forearms is an easy way to deliver broad strokes, which, along with stretching, can help collagen fibres realign in a more optimal way than they otherwise might. Whilst supporting yourself in flexion at the waist, position your forearm just above the knee. Use your left forearm if treating the client’s right hamstrings. Lean onto the client and glide gently up to the ischium. End your stroke at the point on the thigh that is appropriate for your client. In sport massage, it is common to take the stroke all the way to the origin of the hamstrings at the ischium.

Another technique is to apply massage with your client supine. In this position, the hamstrings are shortened, and this can be helpful. This technique is ideal for clients who cannot lay prone because of injury; however, the technique is not appropriate for all clients, some of whom might not wish to place their leg in this position.

Tight Hamstrings

There are many reasons why tightness may develop in the posterior thigh. Tightness is commonly reported by runners and people regularly engaged in sports involving the lower limbs, such as tennis or rowing. Shortening of soft tissues of the posterior compartment of the thigh and knee is also likely to occur in people who remain seated for long periods of time, such as drivers, office workers or people with a sedentary lifestyle. Trigger point release, active and passive stretches and soft tissue release (STR) are all helpful in combatting tight hamstrings.

Massage

Massage feels soothing to receive and is likely to have a relaxing effect on muscles. However, it is unlikely that massage alone will be effective in alleviating tight hamstrings, and therefore, you may wish to use additional techniques such as stretching or STR.

Trigger Point Release

Trigger points are found in the middle to lower portions of all three hamstring muscles – the semimembranosus, semitendinosus and biceps femoris (see Figure 2). These triggers refer pain primarily to the back of the knee and proximal part of the posterior thigh and are perpetuated by activities such as sitting for prolonged periods with the knees flexed, as when driving or working at a desk or when immobilised in bed or a wheelchair after an injury or illness. Prolonged pressure to the back of the thigh is another perpetuating factor. You can palpate trigger points in this muscle group with your client in the prone, side-lying and even supine positions, in each case with the knee flexed.

 Figure 2: Trigger points in the hamstrings

Tight Quadriceps

The quadriceps may feel tight as a result of a sporting activity or after injury.

Massage

Once you have warmed the area using effleurage and petrissage, applying deep massage to the quadriceps is helpful to reduce feelings of tightness in this muscle group. For example, you could glide from just superior to the patella to the proximal end of the thigh using your forearm, or you could grip and squeeze the muscle.

Trigger Point Release

Deactivation of trigger points in the thigh can also help reduce feelings of tightness. Four common trigger points are found in the quadriceps. The trigger point at the proximal attachment of the rectus femoris is close to the anterior superior iliac spine (Figure 3) and refers pain into the knee. To identify the rectus femoris, palpate the area as you have your client perform isometric knee extension in a manner that does not engage the hip. The rectus femoris will contract, and you will be able to palpate it for this trigger.

Two trigger points in the vastus medialis (Figure 3) refer pain to the medial thigh and knee. To palpate for these trigger points, either stand facing the side of the couch with the client in the supine position and gently glide your fingers from the adductors through to the vastus medialis or begin at the knee and palpate from the knee to the hip.

Trigger points exist in the proximal, distal and middle portions of the vastus lateralis, one of which is shown in Figure 3.

There are trigger points in the vastus intermedialis (not shown in Figure 3), and they refer pain over the anterolateral portion of the thigh.

The trigger points in the quadriceps are aggravated by trigger points in the hamstrings, and they may not resolve unless the hamstrings are first addressed. Tight hamstrings can prevent full knee extension, meaning that the hamstrings are unnecessarily strained during weight bearing. Trigger points in the hamstring muscles are perpetuated by immobilisation of the thigh, as is common after injury.

Figure 3: Trigger points in the quadriceps

One way to apply pressure is using your elbow. Position your hand and elbow just above the knee, with the client’s knee supported with a bolster if necessary. Using oil, apply pressure with your elbow, and use your hand to guide your elbow slowly up towards the hip.

References

• Onik, G., T. Kasprzyk, K. Knapik, et al. “Myofascial Trigger Points Therapy Modifies Thermal Map of Gluteal Region.” BioMed Research International 2020(1): 4328253. 2020.
• Green, B., M.N. Bourne, N. van Dyk, et al. “Recalibrating the Risk of Hamstring Strain Injury (HSI): A 2020 Systematic Review and Meta-Analysis of Risk Factors for Index and Recurrent Hamstring Strain Injury in Sport.” British Journal of Sports Medicine 54(18): 1081-88. 2020.
• Prior, M., M. Guerin, and K. Grimmer. “An Evidence-Based Approach to Hamstring Strain Injury: A Systematic Review of the Literature.” Sports Health 1(2): 154-64. 2009.

Further Information

Soft Tissue Therapy for the Lower Limb is available to purchase from Human Kinetics.

https://www.human-kinetics.co.uk/9781718215597/soft-tissue-therapy-for-the-lower-limb/