Adduction of the thigh

As mentioned with the pelvic discussion of these medial thigh muscles, adduction of the thigh includes moving the femur toward the mid-line from a neutral position or toward neutral from an abducted position. Adduction of the thigh is primarily achieved by the pectineus, adductors brevis, longus, magnus and minimus, gracilis, quadratus femoris (Platzer 2004), obturator externus (Kapandji 1987, Platzer 2004) and some fibers of gluteus maximus (Kapandji 1987, Platzer 2004). Kapandji (1987) also notes that the obturator internus and the hamstrings play a role in adduction (Platzer agrees with some hamstring action) while Travell & Simons (1992) note them to be antagonists to adduction. The adductor group can also play a role in lateral or medial rotation of the thigh (depending upon the starting position of the femur) while adductor magnus can contribute to extension of the thigh.

There exists considerable debate as to whether the adductors laterally or medially rotate the thigh. It is apparent that initial positioning of the thigh will most probably influence the role that the adductors play in rotation, as it does with many of the hip muscles. The movement these muscles produce will also be influenced by whether the femur is weight bearing or not, as well as whether the person is gait or stationary.

Gray’s anatomy (2005) notes:

Extensive or forcible adduction of the femur is not often required. Although the adductors can act in this way, they more commonly act as synergists in the complex pattern of gait activity, and to some degree controllers of posture … Magnus and longus are probably medial rotators of the thigh. The adductors are inactive during adduction of the abducted thigh in the erect posture (when gravity assists), but active in other postures, such as the supine position, or during adduction of the flexed thigh when standing.

Levangie & Norkin (2005) offer a supported theory that ‘the adductors function not as prime movers, but by reflex response to gait activities’. They also note:

Although the role of the adductor muscles may be less clear than that of other hip muscle groups, the relative importance of the adductors should not be underestimated. The adductors as a group contribute 22.5% of the total muscle mass of the lower extremity compared to only 18.4% for the flexors and 14.9% for the abductors.

The relationship of the muscles can be seen in cross-section (Fig. 12.20).

Figure 12.20 Transverse section through the right thigh at the level of the apex of the femoral triangle: proximal (superior) aspect

(reproduced with permission from Gray’s anatomy, 1995).

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Gracilis (Fig. 12.21)

Attachments: From near the symphysis on the inferior ramus of the pubis to the medial proximal tibia (pes anserinus superficialis)

Innervation: Obturator nerve (L2–3)

Muscle type: Phasic (type 2), with tendency to weaken and lengthen if chronically stressed

Function: Adducts the thigh, flexes the knee when knee is straight, medially rotates the leg at the knee

Synergists: For thigh adduction: primarily adductor group and pectineus

For flexion of the knee: hamstring group

For medial rotation of the leg at the knee: semimembranosus, semitendinosus, popliteus and (sometimes) sartorius

Antagonists: To thigh adduction: the glutei and tensor fasciae latae

To flexion of the knee: quadriceps femoris

To medial rotation of the leg at the knee: biceps femoris

Figure 12.21 The trigger points of gracilis lie within its common target zone of referral

(adapted with permission from Travell & Simons 1992).

Pectineus (Fig. 12.22)

Attachments: From the pecten of the pubis to the femur (pectineal line) between the lesser trochanter and the linea aspera

Innervation: Femoral and obturator nerves (L2–4)

Muscle type: Phasic (type 2), with a tendency to weaken and lengthen if chronically stressed

Function: Flexes and adducts the thigh

Synergists: For thigh adduction-flexion action: iliopsoas, adductor group, rectus femoris, and gracilis

For thigh adduction: primarily adductor group and gracilis

Antagonists: To flexion: gluteus maximus and hamstrings To adduction: gluteus medius and minimus, tensor fasciae latae and (sometimes) upper fibers of gluteus maximus

Figure 12.22 The trigger point referral pattern of pectineus

(adapted with permission from Travell & Simons 1992).

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Adductor longus (Fig. 12.23)

Attachments: From the front of the pubis between the crest and symphysis to the middle third of the medial lip of linea aspera

Innervation: Obturator nerve (L2–4)

Muscle type: Postural (type 1), with tendency to shorten when chronically stressed

Function: Adducts and flexes thigh and has (controversial) axial rotation benefits, depending upon femur position (see below)

Synergists: For thigh adduction: remaining adductor group, gracilis and pectineus

For thigh adduction-flexion action: iliopsoas, rectus femoris, remaining adductor group, pectineus and gracilis

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For axial rotation of the thigh: depends upon initial position of the hip (see below)

Antagonists: To adduction: gluteus medius and minimus, tensor fasciae latae, upper fibers of gluteus maximus

To flexion: gluteus maximus, hamstrings, portions of adductor magnus

Figure 12.23 The trigger point referral pattern of adductor longus and brevis courses from the groin to just above the foot

(adapted with permission from Travell & Simons 1992).

Adductor brevis

Attachments: From the inferior ramus of the pubis to the upper third of the medial lip of the linea aspera

Innervation: Obturator nerve (L2–4)

Muscle type: Postural (type 1), with tendency to shorten when chronically stressed

Function: Adducts and flexes thigh and has (controversial) axial rotation benefits, depending upon femur position (see below)

Synergists: For thigh adduction: remaining adductor group, gracilis and pectineus

For thigh adduction-flexion action: iliopsoas, rectus femoris, remaining adductor group, pectineus and gracilis

For axial rotation of the thigh: depends upon initial position of the hip (see below)

Antagonists: To flexion: gluteus maximus, hamstrings, portions of adductor magnus

To adduction: gluteus medius and minimus, tensor fasciae latae, upper fibers of gluteus maximus

Adductor magnus (Figs 12.24, 12.25)

Attachments: From the inferior ramus of the ischium and pubis (anterior fibers) and the ischial tuberosity (posterior fibers) to the linea aspera (starting just below the lesser trochanter and continuing to the adductor hiatus) and to the adductor tubercle on the medial condyle of the femur

Innervation: Obturator nerve (L2–4), tibial portion of sciatic nerve (L4–S1)

Muscle type: Postural (type 1), with tendency to shorten when chronically stressed

Function: Adducts the thigh, flexes or extends the thigh depending upon which fibers contract, and medially rotates the femur; lateral axial rotation benefits may exist (Kapandji 1987, Platzer 2004, Rothstein et al 1991) – see below

Synergists: For thigh adduction: remaining adductor group, gracilis and pectineus

For thigh flexion: iliopsoas, rectus femoris, remaining adductor group, pectineus and gracilis

For thigh extension: gluteus maximus, hamstrings

For axial rotation of the thigh: see discussion below

Antagonists: To adduction: gluteus medius and minimus, tensor fasciae latae, upper fibers of gluteus maximus

To flexion: gluteus maximus, hamstrings, portions of adductor magnus

To extension: iliopsoas, rectus femoris, remaining adductor group, pectineus and gracilis

Figure 12.24 The trigger point referral pattern of adductor magnus covers the medial thigh and also (not illustrated) into the pelvis, including the pubic bone, vagina, rectum and bladder

(adapted with permission from Travell & Simons 1992).

Figure 12.25 Thigh adductors are shown fully on the left side of this illustration. On the right side, the superficial layer is removed to reveal the underlying obturator externus, adductor brevis and the adductor magnus, which is the deepest and largest of the adductor group. Notice that the adductor magnus attaches distally to the adductor tubercle and forms the adductor hiatus, the opening through which passes the neurovascular components that serve most of the leg.

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone)

A thorough discussion of the adductors, including indications for assessment and treatment, is found in Chapter 11 on pp. 350–351 due to the extensive role they play in pelvic positioning. Adductor magnus is also treated with the hamstrings on pp. 441–442.

Travell & Simons (1992) note the following regarding the role of the adductors in walking.

• The adductor longus becomes active around the time of toe off, and the adductor magnus around the time of heelstrike during walking, jogging, running, and sprinting.

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• The adductor magnus becomes active during ascent of stairs but is inactive during descent.

• It [adductor magnus] is also active when ‘stemming’ during skiing and while gripping the sides of the horse with the knees when riding. …

• During the early swing phase (pick up), the adductor magnus brings the limb toward the midline.

• During late swing phase, the adductors and gracilis help increase and maintain hip flexion for the forward reach of the limb.

• During the earliest part of the stance phase the gracilis may be functioning to assist the other pes anserinus muscles and the vastus medialis in controlling the valgus angulation of the knee as body weight is shifted onto that foot.

• During early stance, the ischiocondylar part of the adductor magnus is in a position to assist the hamstrings and gluteus maximus in restraining the tendency toward hip flexion that is produced by body weight.

• Later in stance, as weight is shifting toward and across the midline to the other foot, the adductor longus and adductor magnus restrain abduction, controlling the weight shift and adding stability.

Before beginning hands-on applications the following points should be considered. These are discussed more fully with the supine treatment of the adductors in Chapter 11, on pp. 353–354.

• The practitioner should discuss with the patient why this region needs to be treated.

• Only a mild pressure should be used until tissue tenderness has been assessed as these muscles are often exceptionally tender.

• If the adipose tissue ‘bunches up’ and prevents the smooth passage of the hands, short (2–3 inch) repetitious gliding strokes may be applied instead of long gliding strokes.

• The pubic attachments cannot be easily reached in the sidelying position, but are fully described in the supine version of this treatment in Chapter 11.

NMT for adductor muscle group: sidelying position

• The patient is in the sidelying position with the uppermost hip fully flexed and supported on a cushion or lying directly on the table if stretch of the piriformis and obturator internus is not uncomfortable. The lower leg is straight and the medial thigh of the lowermost leg is undraped to reveal the adductor muscles.

• The practitioner stands behind the patient at the level of the knee or sits on the table posterior to the lower leg if the table is sufficiently wide.

• The practitioner can visualize the outline of the sartorius, which forms the anterior boundary of the adductor muscle group. The hamstrings form the posterior boundary and the proximal attachments at the pubic region form the cephalad boundary, though the uppermost portion of the adductors is not readily accessible in this sidelying position. Caution should be exercised at the top of this region just distal to the inguinal ligament where the femoral artery, nerve and vein course into the thigh and where the femoral pulse can usually be palpated.

• Gliding strokes are applied to the medial thigh muscles from the region of the medial knee toward the pubic attachments, although the attachments will not be reached (Fig. 12.26).

• The strokes are repeated 4–5 times to the same tissue and then the thumbs are moved onto the next segment. The first gliding stroke will lie beside the sartorius, with the next line of the stroke lying beside the first and posterior to it. The gracilis muscle courses from the medial knee to the pubic bone and, when clothed, lies directly beneath the medial seam (inseam) of the pants. This muscle demarcates the boundary between the anterior and posterior thigh from a medial aspect. Since a large portion of adductor magnus lies posterior to the gracilis, the gliding strokes should be continued posteriorly until the hamstrings are encountered. Encroachment upon the hamstrings will indicate the point at which the adductor palpation ceases, although the gliding can be continued onto the hamstrings as well.

• Adductor magnus continues its course deep to the hamstrings. A double thumb stroke can be applied to separate the two muscle groups by applying one thumb onto the adductor magnus and the other thumb onto the hamstrings with a slight ‘separating’ pressure as the thumbs are slid along the length of the muscles (Fig. 12.26).

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• The entire routine of application of gliding strokes may be performed 2–3 times to the adductor region in one session, if tolerable. The tenderness found in these muscles should decrease with each application. If, however, tenderness increases, lymphatic drainage techniques can be applied to the region and positional release techniques employed until local tissue health improves.

• The pubic attachments of the adductor muscles can best be treated with direct contact in a supine position, which is discussed in Chapter 11, pp. 353–354. as are MET and PRT treatment variations for these muscles. In a prone position, connective tissue between the medial hamstrings and adductor magnus can be encouraged to soften, as discussed later in this chapter on pp. 440–443.

Figure 12.26 The adductor muscle bellies on the inner thigh of the lowermost leg are easily accessible in a sidelying position. After general gliding strokes are applied, specific work can be applied. Here, a double thumb stroke applies the pressure of one thumb onto the adductor magnus and the other thumb onto the hamstrings with a slight ‘separating’ pressure as the thumbs are slid along the length of the muscles. The groin attachments of the adductor muscles, however, are best treated in a supine position (see p. 354).

Abduction of the thigh

Abduction of the thigh at the hip is carried out primarily by gluteus medius and gluteus minimus, with assistance from tensor fasciae latae and the highest fibers of gluteus maximus (both of which attach to the iliotibial (IT) band), piriformis (in some positions) and (perhaps) obturator internus. The most anterior fibers of the glutei, along with TFL, produce the combination of abduction-flexion-medial rotation, while the most posterior fibers of the glutei produce abduction-extension-lateral rotation. Pure abduction requires all these portions to be co-contracted as a balanced group (Kapandji 1987).

In the following section, tensor fasciae latae, gluteus medius and gluteus minimus muscles are treated, while the gluteus maximus and hip rotators are discussed in the next section following those. The importance of healthy function of these abductor muscles is emphasized in Chapter 3 with gait discussions, as well as Chapter 11 in regards to stabilization of the pelvis.

Tensor fasciae latae (see Fig. 10.62) (Fig. 12.27) (Fig. 12.28)

Attachments: Anterior aspect of the outer lip of iliac crest, lateral surface of ASIS and deep surface of the fascia lata to merge into the iliotibial band (tract), which attaches to the lateral tibial condyle

Innervation: Superior gluteal nerve (L4, L5, S1)

Muscle type: Postural (type 1), with tendency to shortening

Function: Flexes, abducts and medially rotates the thigh at the hip, stabilizes the pelvis during stance, stabilizes the knee by tensing the iliotibial tract

Synergists: For flexion: rectus femoris, iliopsoas, pectineus, anterior gluteus medius and minimus, sartorius and perhaps some adductors

For abduction: gluteus medius, minimus and part of maximus, sartorius, piriformis and iliopsoas

For medial rotation: semitendinosus, semimembranosus, iliopsoas, pectineus, the most anterior fibers of gluteus minimus and medius and (perhaps) adductor longus and magnus

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Antagonists: To hip flexion: gluteus maximus, the hamstring group and adductor magnus

To abduction: adductors brevis, longus and magnus, pectineus and gracilis

To medial rotation: long head of biceps femoris, the deep six hip rotators, gluteus maximus, sartorius, posterior fibers of gluteus medius and minimus, and psoas major

Figure 12.27 Tensor fascia latae and gluteus maximus merge together to form the dense, thick iliotibial band, which overlies the vastus lateralis. Vastus lateralis is visible anterior and posterior to the band.

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Figure 12.28 Trigger point pain pattern of tensor fasciae latae

(adapted with permission from Travell & Simons 1992).

Indications for treatment

• Pain or tenderness on palpation of the hip joint and greater trochanter, in the absence of inflammation (‘pseudotrochanteric bursitis’ or greater trochanteric pain syndrome) with the patient in the side-lying position. (Segal et al 2007)

• Greater trochanteric bursitis, i.e pain in the presence of inflammation (Note: greater caution is required in all manual applications where inflammation is a feature)

• Pain or sensations down the lateral surface of the thigh

• Discomfort when lying with pressure on the lateral hip region or in positions that stretch the tissues of the lateral hip

Special notes

Tensor fasciae latae (TFL) is generally considered to be a flexor, abductor and medial rotator of the thigh at the hip. It also stabilizes both the knee and the pelvis, particularly during gait, where it most probably controls movement rather than producing it (Travell & Simons 1992). TFL’s influence on positioning of the pelvis is substantial (see p. 356) and its influence on the knee is also discussed there. A sidelying treatment position is offered here along with a treatment of the iliotibial band.

NMT for tensor fasciae latae in sidelying position

• The patient lies on his side with the cervical region supported. The hip to be treated is uppermost, fully flexed and resting on a cushion and the lowermost leg is straight. The practitioner stands in front of the patient at the level of the hip. The degree of hip flexion can be varied to alter the amount of tension placed on the tissues. Caution should be exercised if the tissues are being treated while also being elongated as they are more vulnerable in this situation.

• TFL fills the space between the anterior iliac spine and the greater trochanter and is readily available in this sidelying position. The practitioner’s cephalad hand can palpate the TFL fibers while her caudad hand is slid under the knee (onto its medial aspect) to resist medial rotation. TFL’s fiber movement can easily be felt with resisted medial rotation of the femur.

• Once location of the TFL is confirmed, short gliding strokes, combination friction or static compression (using the thumbs, flat pressure bar or elbow) can be applied at 1 inch intervals to the thickened portion of the TFL belly until the entire muscle has been treated. The most anterior portion of gluteus medius and minimus lies deep to the TFL and can be addressed with deeper pressure, if appropriate. The techniques, as described, can also be applied to the tissues that lie posterior to the TFL, which will include the remainder of gluteus minimus and medius and (further posteriorly) a portion of gluteus maximus where it overlaps the two smaller glutei. Portions of the glutei muscles are more easily accessed in the prone position, which is described on p. 380 with the abductors.

• Trigger points in the TFL and anterior fibers of the two small glutei can produce a ‘pseudo-sciatica’ pattern. While true sciatica radiates down the posterior thigh, this trigger point pattern radiates down the lateral surface of the thigh and leg (see Fig. 11.61).

• Lubricated gliding strokes can be applied to the IT band with the thumbs, flat palm or proximal forearm of the practitioner’s caudad hand while the cephalad hand stabilizes the pelvis (Fig. 12.29). The practitioner should avoid straining her own body by supplying pressure and movement using her body weight and body positioning rather than muscular effort from her shoulder and arms.

• Deeper pressure through the band, if appropriate, will address the central portion of vastus lateralis. Portions of vastus lateralis will also be addressed when gliding anterior and posterior to the IT band. Numerous trigger points within vastus lateralis lie directly under the IT band and should be treated as noted on pp. 356–360. Additionally, the patient can use a tennis ball to apply compression to the IT band and vastus lateralis to treat these lateral thigh tissues (Fig. 12.30).

Figure 12.29 Stability of the pelvis is provided by the practitioner’s cephalad hand while the palm of the opposite hand is used to apply gliding strokes to the lateral surface of the thigh to treat the IT band. A supine version is shown in Chapter 11.

Figure 12.30 A tennis ball can be used to compress the lateral surface of the thigh

(adapted with permission from Travell & Simons 1992).

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Soft tissue manipulation treatment of iliotibial band (Figs 12.31, 12.32)

Mennell (1964) has described efficient soft tissue stretching techniques for releasing TFL. These involve a series of snapping actions applied by thumbs to the anterior fibers, with the patient sidelying, followed by a series of heel-of-hand thrusts across the long axis of the posterior TFL fibers. These ‘snapping’ and ‘thrusting’ methods have the potential for being uncomfortable, if not very carefully applied, requiring expert tutoring. We suggest that the thumb positions in Figure 12.33 can be used, creating a C-shaped bend in which sustained pressure should be applied for 30–90 seconds, as if ‘bending the twig’, to produce a myofascial release effect. Alternatively an S-shaped bend (Fig. 12.33) can be created involving the same timing as for the ‘C’ bend. These manual ‘stretching’ techniques of the IT band are usually more comfortable than the snapping version and are moderately effective, although unlikely to be as effective as Mennell’s protocol.

Figure 12.31 Iliotibial band treatment, using a ‘twig snapping’ approach to address extreme shortness and fibrosity of these tissues, particularly the anterior fibers. This is applied sequentially up and down the band using a degree of force that is easily tolerated

(reproduced with permission from Chaitow 1996).

Figure 12.32 The posterior fibers of the iliotibial band are treated using the heel of one hand to alternately thrust against the band while it is stabilized by the other hand. An alternating sequence of this sort, applied up and down the band, produces marked release of hypertonic and shortened fibers

(reproduced with permission from Chaitow 1996).

Figure 12.33 A, B: ‘S’ and ‘C’ bends applied for slow myofascial release. Note: These stretches can be applied to any tense or fibrotic soft tissue areas, not only TFL

(adapted from Chaitow 2001).

Other techniques for addressing the assessment and treatment of TFL and the IT band are described in Chapter 11, including muscle energy techniques and positional release. The attachments at the knee are considered in Chapter 13.

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Gluteus medius (see Fig. 11.56)

Attachments: From the outer surface of the ilium (anterior three-quarters of the iliac crest between the posterior and anterior gluteal lines and from the gluteal aponeurosis to attach to the posterosuperior angle and lateral surface of the greater trochanter (inserted ‘like a cap’ – Platzer 2004)

Innervation: Superior gluteal nerve (L4, L5, S1)

Muscle type: Phasic (type 2), with tendency to weakening and lengthening (Janda 1983, Lewit 1999)

Function: All fibers strongly abduct the femur at the hip, anterior fibers flex and medially rotate the femur, posterior fibers extend (Kendall et al 1993, Platzer 2004) and (weakly) laterally rotate the femur. When the leg is fixed, this muscle stabilizes the pelvis during lateral trunk flexion and during gait

Synergists: For abduction of hip: gluteus minimus and part of maximus, sartorius, tensor fasciae latae, piriformis and iliopsoas

For flexion: rectus femoris, iliopsoas, pectineus, anterior gluteus minimus, tensor fasciae latae, sartorius and perhaps some adductors

For medial rotation: semitendinosus, semimembranosus, pectineus, the most anterior fibers of gluteus minimus, tensor fasciae latae and (perhaps) adductor longus and magnus

For extension: hamstrings (except short biceps femoris), adductor magnus, gluteus maximus and posterior fibers of gluteus minimus

For lateral rotation: long head of biceps femoris, the deep six hip rotators (especially piriformis), sartorius, gluteus maximus, posterior fibers of gluteus minimus and (maybe weakly) iliopsoas

For lateral pelvic stability: contralateral lateral trunk muscles and contralateral adductors

Antagonists: To abduction: adductors brevis, longus and magnus, pectineus and gracilis

To hip flexion: gluteus maximus, the hamstring group and adductor magnus

To medial rotation: long head of biceps femoris, the deep six hip rotators, gluteus maximus, sartorius, posterior fibers of gluteus minimus and iliopsoas

To extension: mainly iliopsoas and rectus femoris and also pectineus, adductors brevis and longus, sartorius, gracilis, tensor fasciae latae

To lateral rotation: mainly adductors and also semitendinosus, semimembranosus, pectineus, the most anterior fibers of gluteus minimus and tensor fascia latae

To lateral pelvic stability: ipsilateral lateral trunk muscles and adductors and contralateral abductors

Indications for treatment

• Lower back pain (lumbago)

• Pain at the iliac crest, sacrum, lateral hip, posterior and lateral buttocks or upper posterior thigh

Gluteus minimus (see Fig. 11.56)

Attachments: From the outer surface of the ilium between the anterior and inferior gluteal lines to the anterolateral ridge of the greater trochanter

Innervation: Superior gluteal nerve (L4, L5, S1)

Muscle type: Phasic (type 2), with tendency to weakening and lengthening when stressed (Janda 1983, Lewit 1999)

Function: Same as gluteus medius above

Synergists: Same as gluteus medius above

Antagonists: Same as gluteus medius above

Indications for treatment

• Hip pain, which can result in limping

• Painful difficulty rising from a chair

• Pseudo-sciatica

• Excruciating and constant pain in the patterns of its target zones

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Special notes

These two muscles play an important role in maintaining an upright trunk when the contralateral foot is raised from the ground (especially during walking and running). During the stance phase of gait, body weight should naturally cause a downward sagging of the pelvis on the unsupported side; however, this is countered by these two gluteal muscles with ‘such powerful traction on the hip bone that the pelvis is actually raised a little on the unsupported side’ (Gray’s anatomy 2005, p. 1450). Gray’s anatomy further points out:

The supportive effect of the glutei (medius and minimus) on the pelvis when the contralateral foot is raised, depends on the following conditions:

(1) the two muscles, and their innervation, must be functioning normally

(2) the components of the hip joint, which forms the fulcrum, must be in their usual relation

(3) the neck of the femur must be intact, with its normal angulation to the shaft.

If the glutei are paralyzed or if congenital dislocation of the hip exists, or the neck of the femur is fractured (non-united) or in coxa vara position, ‘the supporting mechanism is upset and the pelvis sinks on the unsupported side when the patient tries to stand on the affected limb’. This results in a positive Trendelenburg’s sign, further evidenced by a characteristic lurching gait. If these muscles are intact and functional, even paralysis of the other hip muscles ‘produces remarkably little deficit in walking, or even running’ (Gray’s anatomy 2005). This explains why gluteus medius and minimus are considered to be the abductors of the thigh.

Grimaldi et al (2009) present evidence that, in subjects with advanced unilateral hip joint pathology, the gluteus medius and minimus as well as piriformis were smaller around the affected hip.

This atrophy was not measurable in subjects with mild pathology, however differing processes are likely in place associated with differing functional weight-bearing patterns. In subjects with mild pathology [gluteus medius] muscle size was significantly larger on the affected side than control group subjects suggesting the [gluteus medius] muscle may hypertrophy at this stage of pathology.

Assessment and rehabilitation strategies should carefully consider stage of pathology and specific changes occurring within the abductor synergy. This more specific approach may improve long-term outcomes of conservative intervention in the management of OA of the hip, and may provide a direction for future prevention programmes.

The trochanteric bursae of gluteus medius and minimus lie in the region of the greater trochanter. If palpation of the trochanteric region reveals highly tender tissues, inflammation of these bursae should be suspected, especially if the bellies of the muscles are taut. The muscle bellies may be treated in this instance but caution should be exercised to avoid further irritation of the inflamed tissues or placing additional stress on the bursae.

More details regarding these two glutei muscles are discussed in Chapter 11 (treatment protocols for a side-lying position are offered on pp. 363–366) and trigger point illustrations are shown in Figures 11.57, 11.60 and 11.61. The following prone position NMT protocol can be usefully applied to the posterior portions of the two smaller glutei and used for the entire gluteus maximus, especially in preparation for addressing the lateral hip rotators, as will be discussed in the next segment.

NMT for gluteus medius and minimus

• The patient is placed in a prone position following the sidelying treatment of the tensor fasciae latae and the anterior portions of these two gluteal muscles. The practitioner stands at the level of the pelvis and faces the hip.

• The middle and posterior portions of the gluteal muscles are easily accessed in this prone position. Although most of the anterior portions can be palpated as well, they are best treated in the sidelying position, which was previously discussed.

• The practitioner locates the greater trochanter. If the greater trochanter is not distinct, the practitioner’s cephalad hand can be used to palpate for it while the caudad hand takes the thigh (knee flexed to 90°) through medial and lateral rotations, which creates a palpable movement of the greater trochanter (see note above regarding trochanteric bursitis).

• The practitioner can visualize the outline of the gluteus medius and minimus, which are both fan shaped. The minimus is smaller and lies deep to the medius so that the cephalad edge of the minimus is in approximately the mid-fiber region of the medius. The trochanter serves as the ‘base’ so that the practitioner’s hands return to the ‘base’ with each progressive step in examining strips of gluteal tissues, which radiate outwards (sometimes described, along with the lateral hip rotators, as being like spokes of half a wheel).

• The practitioner begins at the top of the greater trochanter and applies short gliding strokes from it to the iliac crest or applies combination friction or static compression, if tolerable, using the thumbs, flat pressure bar or elbow, at 1 inch (2.5 cm) intervals toward the iliac crest. The most anterior portions of gluteus medius and minimus lie deep to the TFL and are difficult to address sufficiently in this prone position. However, the posterior half of the muscles is readily accessible.

• When a segment is completed, the practitioner’s hands return to the greater trochanter and change direction slightly, to address the next section (Fig. 12.34). As the most posterior fibers of the two smaller gluteals are treated, the tissue becomes appreciably denser as the practitioner encounters the uppermost edge of gluteus maximus. This thickened tissue, where the three gluteals overlap, is sometimes mistaken for the piriformis muscle, which actually lies just caudad to the thickened glutei fibers. This protocol can be continued throughout the remaining portion of the hip tissues as discussed in the next segment with lateral hip rotators.

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• Lief’s (European) NMT for this region is discussed in Chapter 11.

Figure 12.34 When a segment is completed, the practitioner’s hands return to the ‘base’ (greater trochanter) and change direction slightly, to address the next section of gluteal tissues.

Rotation of the thigh

Lateral rotation of the thigh is produced by the gluteus maximus, posterior fibers of gluteus medius and minimus and (predominantly) by six short muscles known as the lateral hip rotators (piriformis, gemellus superior, obturator internus, gemellus inferior, obturator internus and quadratus femoris). The six lateral hip rotators are oriented nearly perpendicular to the femoral shaft, which positions them to very effectively perform their rotary function as well as provide tonic stabilization of the hip joint during most activities (Levangie & Norkin 2005).

Levangie & Norkin (2005) note:

There are no muscles with the primary function of producing medial rotation of the hip joint. The more consistent medial rotators are the anterior portion of the gluteus medius, gluteus minimum, and the [tensor fascia lata] muscles. Although controversial, the weight of evidence appears to support the adductor muscles as medial rotators of the joint.

All the medial hip rotators are discussed in other sections of this chapter. In this section, the six deeply placed hip rotators are discussed as well as gluteus maximus, not only for its role in lateral rotation but also because it overlies the deep muscles and should be treated prior to addressing them.

Gluteus maximus (see Fig. 11.56)

Attachments: From the posterolateral sacrum, thoracolumbar fascia, aponeurosis of erector spinae, posterior ilium and iliac crest, dorsal sacroiliac ligaments, sacrotuberous ligament and coccygeal vertebrae to merge into the iliotibial band of fascia lata (anterior fibers) and to insert into the gluteal tuberosity (posterior fibers)

Innervation: Inferior gluteal (L5, S1, S2)

Muscle type: Phasic (type 2), with a tendency to weakness and lengthening (Janda 1983, Lewit 1999)

Function: Extends the hip, laterally rotates the femur at the hip joint, IT band fibers abduct the femur at the hip while gluteal tuberosity fibers adduct it (Platzer 2004); posteriorly rotates the pelvis on the thigh when leg is fixed, thereby indirectly assisting in trunk extension (Travell & Simons 1992)

Synergists: For extension: hamstrings (except short biceps femoris), adductor magnus and posterior fibers of gluteus medius and minimus

For lateral rotation: long head of biceps femoris, the deep six hip rotators (especially piriformis), sartorius, posterior fibers of gluteus medius and minimus and (maybe weakly) iliopsoas

For abduction: gluteus medius and minimus, tensor fasciae latae, sartorius, piriformis and (maybe weakly) iliopsoas

For adduction: adductors brevis, longus and magnus, pectineus and gracilis

For posterior pelvic rotation: hamstrings, adductor magnus, abdominal muscles

Antagonists: To extension: mainly iliopsoas and rectus femoris and also pectineus, adductors brevis and longus, sartorius, gracilis, tensor fasciae latae

To lateral rotation: mainly adductors and also semi-tendinosus, semimembranosus, pectineus, the most anterior fibers of gluteus minimus and medius and tensor fasciae latae

To abduction: adductors brevis, longus and magnus, pectineus and gracilis

To adduction: gluteus medius and minimus, tensor fasciae latae, sartorius, piriformis and (maybe weakly) iliopsoas

To posterior pelvic rotation: rectus femoris, TFL, anterior fibers of gluteus medius and minimus, iliacus, sartorius

Indications for treatment of gluteus maximus

• Pain on prolonged sitting

• Pain when walking uphill, especially when bent forward

• When ‘no chair feels comfortable’ (Travell & Simons 1992)

• Sacroiliac fixation

• An antalgic gait

• Restricted flexion of the hip

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Special notes

Gluteus maximus is the largest and most superficial muscle of the region. It fully covers the underlying six hip rotators as well as a portion of the other glutei. It covers (usually) three bursae: the trochanteric bursa (which lies between the gluteal tuberosity and the greater trochanter), the gluteofemoral (which separates the vastus lateralis from gluteus maximus tendon) and the ischial bursa (which lies between the muscle and the ischial tuberosity) (Gray’s anatomy 2005). Discussion of these bursae and palpation of the ischial tuberosity is found in Chapter 11 on p. 365, while trigger point target zones of gluteus maximus are shown in Figure 11.57. A sidelying position for treating gluteus maximus as well as a full discussion of the muscle are found in Chapter 11 on pp. 363–364. A prone position for treating it is offered here in preparation for treatment of the deep six hip rotators.

NMT for gluteus maximus: prone position

• The patient is prone with his face resting in a face cushion and a bolster placed under his feet. A thin draping can be used and the work applied through the cloth or through shorts, gown or other thin clothing. However, thicker material, such as a towel, may interfere with accurate palpation.

• The practitioner stands at the level of the upper thigh or hip to treat the ipsilateral hip. The practitioner can also reach across to address the contralateral hip by using her elbow as the treatment tool. However, she should avoid straining her back, which can easily occur in that position.

• The fibers of the uppermost edge of the gluteus maximus are found by palpating along a line that runs approximately from the greater trochanter to just cephalad to the PSIS. These fibers overlap the gluteus medius and minimus fibers and the tissue is distinctly thicker here.

• Once the uppermost fibers have been located, the thumb, fingers, carefully controlled elbow or flat pressure bar can be applied in a probing, compressive manner to assess for taut bands and tender regions of gluteus maximus. Moving the palpating digits transversely across the fibers usually identifies them more distinctly than sliding with the direction of fibers. The palpating hand (elbow, etc.) can then be used to systematically examine the entire gluteal region caudad to this first strip until the gluteal fold is reached.

• It should be remembered that deeper pressure through the gluteus maximus in the first strip of fibers will also access more deeply placed posterior fibers of the other two gluteal muscles or hip rotator muscles, depending upon the location (Fig. 12.35).

• The lower portions of gluteus maximus can often be easily picked up between the thumb and fingers and pincer compression applied. It is important to address fibers that attach to the coccyx when the patient complains of ‘tailbone pain’ or when a diagnosis of coccydynia or of a misaligned, rigid or dislocated coccyx has been given. Protective gloves to prevent transmission of bacteria or viruses are suggested when working in the lower medial gluteal region near the anus, even if palpating through the sheet (see Fig. 11.59).

• The attachment of gluteus maximus on the gluteal tuberosity of the femur can be addressed with repetitious gliding strokes unless contraindicated by excessive tenderness, heat, swelling or other signs of inflammation of the gluteofemoral bursa. It is common for the patient who reports tenderness when the gliding strokes are first applied to report an easing of the tenderness when the strokes are reapplied a few minutes later, as the tissues respond.

Figure 12.35 Palpation transversely across the fibers will reveal their tautness. Pressure can be applied through the gluteus maximus to influence the deep six hip rotators. Awareness of the course of the sciatic nerve is important to avoid injury to the nerve.

Piriformis (Figs 12.35, 12.36A)

Attachments: From the ventral aspect of the sacrum between the first four sacral foramina, margin of the greater sciatic foramen, capsule of the SI joint and (sometimes) the pelvic surface of the sacrotuberous ligament to attach to the superior border of the greater trochanter

Innervation: Sacral plexus (L5, S1, S2)

Muscle type: Postural (type 1), with tendency to shortening

Function: Laterally rotates the extended thigh, abducts the flexed thigh and (perhaps) extends the femur, tilts the pelvis down laterally and tilts the pelvis posteriorly by pulling the sacrum downward toward the thigh (Kendall et al 1993)

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Synergists: For lateral rotation: long head of biceps femoris, five remaining deep hip rotators, sartorius, gluteus maximus, posterior fibers of gluteus medius and minimus and (maybe weakly) iliopsoas

For abduction of hip: gluteus medius, minimus and part of maximus, sartorius, tensor fasciae latae and iliopsoas

For extension: hamstrings (except short biceps femoris), adductor magnus, gluteus maximus and posterior fibers of gluteus medius and minimus

Antagonists: To lateral rotation: mainly adductors and also semitendinosus, semimembranosus, pectineus, the most anterior fibers of gluteus minimus and medius, and tensor fasciae latae

To abduction: adductors brevis, longus and magnus, pectineus and gracilis

To extension: mainly iliopsoas and rectus femoris, and also pectineus, adductors brevis and longus, sartorius, gracilis, tensor fasciae latae

Figure 12.36 Posterior hip muscles. A: Gluteals and deep hip rotators.B: Hamstrings and adductor magnus extend the thigh.

(Reproduced, with permission, from Gray’s anatomy for students, 2^nd edn, 2010, Churchill Livingstone)

Gemellus superior

Attachments: From the ischial spine (and usually merge with the tendon of obturator internus) to attach to the medial surface of the greater trochanter of the femur

Innervation: Sacral plexus (L5–S2)

Muscle type: Not established

Function: Rotates the extended thigh laterally and abducts the flexed thigh

For abduction of flexed thigh: gluteus medius, minimus and part of maximus, sartorius, tensor fasciae latae and (perhaps) iliopsoas

Antagonists: To lateral rotation: mainly adductors and also semitendinosus, semimembranosus, pectineus, the most anterior fibers of gluteus minimus and medius and tensor fasciae latae

To abduction: adductors brevis, longus and magnus, pectineus and gracilis

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Obturator internus

Attachments: Inner surface of obturator foramen and the obturator membrane to attach (usually fused with the gemelli) to the medial surface of the greater trochanter of the femur

Innervation: Sacral plexus (L5-S2)

Muscle type: Not established

Function: Rotates the extended thigh laterally and abducts the flexed thigh

For abduction of flexed thigh: gluteus medius, minimus and part of maximus, sartorius, tensor fasciae latae and (perhaps) iliopsoas

Antagonists: To lateral rotation: mainly adductors and also semitendinosus, semimembranosus, pectineus, the most anterior fibers of gluteus minimus and medius and tensor fasciae latae

To abduction: adductors brevis, longus and magnus, pectineus and gracilis

Gemellus inferior

Attachments: From the superior aspect of the ischial tuberosity (and usually merge with the tendon of obturator internus) to attach to the medial surface of the greater trochanter of the femur

Innervation: Sacral plexus (L4–S1)

Muscle type: Not established

Function: Rotates the extended thigh laterally and abducts the flexed thigh

For abduction of flexed thigh: gluteus medius, minimus and part of maximus, sartorius, tensor fasciae latae and (perhaps) iliopsoas

Antagonists: To lateral rotation: mainly adductors and also semitendinosus, semimembranosus, pectineus, the most anterior fibers of gluteus minimus and medius, and tensor fasciae latae

To abduction: adductors brevis, longus and magnus, pectineus and gracilis

Obturator externus

Attachments: Outer surface of the obturator membrane and the medial side of the obturator foramen to attach (usually fused with the gemelli) to the medial surface of the greater trochanter of the femur

Innervation: Obturator (L3–4)

Muscle type: Not established

Function: Rotates the thigh laterally

Synergists: For lateral rotation: long head of biceps femoris, five remaining deep hip rotators, sartorius, gluteus maximus, posterior fibers of gluteus medius and minimus and (particularly in infants) iliopsoas, weakly

Antagonists: To lateral rotation: mainly adductors (controversial) and also semitendinosus, semimembranosus, pectineus, the most anterior fibers of gluteus minimus and medius, and tensor fasciae latae

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Quadratus femoris

Attachments: From the superior aspect of the lateral border of the ischial tuberosity to the quadrate tubercle and intertrochanteric crest of the femur

Innervation: Sacral plexus (L4–S1)

Muscle type: Not established

Function: Rotates the thigh laterally

Synergists: For lateral rotation: long head of biceps femoris, five remaining deep hip rotators, sartorius, gluteus maximus, posterior fibers of gluteus medius and minimus and (particularly in infants) iliopsoas, weakly

Antagonists: To lateral rotation: mainly adductors (controversial) and also semitendinosus, semimembranosus, pectineus, the most anterior fibers of gluteus minimus and medius, and tensor fasciae latae

Indications for treatment (primarily regarding piriformis)

• Pain (and paresthesias) in the lower back, groin, perineum, buttock

• Pain in the hip, posterior thigh and leg, and the foot

• Pain in the rectum during defecation

• Pain during sexual intercourse (female)

• Impotence (male)

• Nerve entrapment of sciatic nerve (piriformis syndrome)

• SI joint dysfunction

• Pain in the lower back, SI joint, buttocks

Special notes

The piriformis muscle arises from the anterior surface of the sacrum and courses through the greater sciatic foramen before attaching to the uppermost surface of the greater trochanter. It is more fully discussed in Chapter 11, p. 368, while its trigger point target zone is shown in Figure 12.37.

Figure 12.37 The pain pattern of the piriformis is shown. This pattern has not been distinguished from the other deep lateral hip rotators

(adapted with permission from Travell & Simons 1992).

Piriformis paradox The performance of external rotation of the hip by piriformis occurs when the angle of hip flexion is 60° or less. Once the angle of hip flexion is greater than 60° piriformis function changes, so that it becomes an internal rotator of the hip (Gluck & Liebenson 1997). This postural muscle, like all others that have a predominance of type 1 fibers, will shorten if chronically stressed.

In the region of the hip rotators, the primary cause of most symptoms lies in the piriformis muscle, not only because of its tendency to form trigger points but also its ability to create neural entrapment. Most texts place primary emphasis in their discussion of the deep hip rotators on the piriformis, including its entrapment possibilities, anterior sacral attachment and its influence on the SI joint, which it crosses. All these matters (and others) have been discussed in Chapter 11. Box 12.8 discusses it as a ‘pump’.

Box 12.8 Piriformis as a pump

Richard (1978) reminds us that a working muscle will mobilize up to 10 times the quantity of blood mobilized by a resting muscle. He points out the link between pelvic circulation and lumbar, ischial and gluteal arteries and the chance this allows to engineer the involvement of 2400 square meters of capillaries by using repetitive pumping (contraction/relaxation), for example of piriformis, as a means of enhancing circulation of the pelvic organs.

The therapeutic use of this knowledge involves the patient being asked to repetitively contract both piriformis muscles against resistance. The patient is supine, knees bent, feet on the table; the practitioner resists the effort to abduct the flexed knees, using the pulsed muscle energy approach (Ruddy’s method – see Chapter 9, p. 201) in which two isometrically resisted pulsation/contractions per second are introduced for several series of 20–30 contractions.

The following points apply to the remaining deep hip rotators (gemellus superior and inferior, obturator internus and externus and the quadratus femoris).

• The trigger point target zones of the remaining five muscles have not been distinguished from those of the piriformis muscle (Travell & Simons 1992).

• Piriformis clearly plays a much greater role in neural entrapment syndromes in this region than the other hip rotators.

• Platzer (2004) notes that the two gemelli usually merge and blend with the obturator internus tendon before attaching to the femur, representing ‘marginal heads of obturator internus…all three muscles together may be termed the triceps coxae.’

• It is common for one or both gemelli to be absent (Platzer 2004), whereas piriformis is rarely absent (Travell & Simons 1992).

• Quadratus femoris may be absent or fused with adductor magnus.

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• Levangie & Norkin (2005) note that ‘exploration of function of these muscles has been restricted because of the relatively limited access to electromyography (EMG) surface or wire electrodes’.

• Bursae are usually present between the tendons of the hip rotators and the trochanter of the femur. A bursa also usually lies between the obturator internus and the ischium.

• The obturator externus is completely covered by the overlying quadratus femoris and adductors, and is visible only when these adjacent muscles have been removed.

• The course of the sciatic nerve overlies the lower five hip rotators and may be compressed by the examination methods described here. Caution should be exercised when the nerve exhibits signs of inflammation to avoid further irritation to the nerve.

NMT for deep six hip rotators

• The patient and practitioner are positioned as described above. The thin draping can be laid back to reveal exposed skin if gliding strokes need to be applied, which are generally used when compression of the tissue is not tolerable.

• The practitioner palpates the PSIS and the greater trochanter. A line is imagined from just caudal to the PSIS to the greater trochanter to represent the location of the piriformis muscle. To confirm correct hand placement, the fibers just cephalad can be palpated and should represent the appreciably ‘thicker’ overlapping of the three gluteal muscles. Piriformis lies just caudad to this overlapped region.

• The practitioner’s thumb, fingers or carefully controlled elbow or the flat pressure bar can be applied in a probing, compressive manner to assess for taut bands and tender regions. Awareness of the course of the sciatic nerve and its tendency toward extreme tenderness when inflamed should be ever present on the practitioner’s mind as she carefully examines these tissues.

• The tissue is palpated from the superior aspect of the greater trochanter to the lateral border of the sacrum, just caudal to the PSIS. Moving the palpating digits (or elbow) transversely across the fibers usually identifies them more distinctly than sliding with the direction of fibers (see Fig. 12.35). If very tender, only mild, sustained compression is used. Sustained compression can be used to treat ischemia, tender points and trigger points.

• If tissues are encountered that are too tender to tolerate compression or friction, then lubricated gliding strokes could be repetitiously applied directly on the skin, from the trochanter toward the sacrum. The frictional and compressive techniques should then be attempted again at a future session when tenderness has been reduced.

• The practitioner can visualize the outline of the six hip rotators. The trochanter serves as the ‘base’ so that the practitioner’s hands return to the ‘base’ with each progressive step in examining strips of hip rotators, which radiate outwards toward the sacrum and ischium.

• The practitioner begins at the top of the greater trochanter and applies short gliding strokes from the trochanter to the middle of the lateral border of the sacrum or applies combination friction or static compression (using the thumbs, flat pressure bar or elbow) at 1 inch (2.5 cm) intervals.

• When a segment is completed, the practitioner’s hands return to the greater trochanter and change direction slightly to address the next section. Each segment is treated in a similar manner until the gluteal fold is reached to address the remaining five hip rotators.

• The tissues around the greater trochanter can be examined with gentle friction. The practitioner faces the patient’s feet and places her thumbs (pointing tip to tip) onto the most cephalad aspect of the greater trochanter. Compression and friction can be used on piriformis, gluteal and hip rotator attachments in a semi-circular pattern (see Fig. 11.68).

• Note: The origins of the obturators are treated with the sacrotuberous ligament and the adductors. The origin of the piriformis may be reached internally on the anterior surface of the sacrum. Advanced techniques are used with piriformis internal attachment and should not be attempted unless specifically trained. See Chapter 11 for details.

Supine MET for piriformis and deep external rotators of the hip

• The patient lies supine with the practitioner standing ipsilaterally, holding both knee and ankle of the leg to be treated.

• The hip is fully flexed and externally rotated to its first barrier of resistance.

• The patient is asked to use no more than 20% of strength to attempt to take the leg into internal rotation and to extend it, against the unyielding resistance of the practitioner, for 7–10 seconds.

• The patient then releases this effort and relaxes completely, while the practitioner takes the hip into further external rotation and flexion.

• This is repeated once or twice more and held in its final position for 20–30 seconds to stretch the external rotators of the hip (Fig. 12.38).

Figure 12.38 MET treatment of piriformis with hip in full flexion and external rotation

(adapted from Chaitow 2001).

PRT of piriformis’ trochanter attachment

• If there is piriformis dysfunction and marked tenderness is noted on the posterosuperior surface of the greater trochanter, this tender point can be used to monitor the PRT procedure.

• The patient is prone and the practitioner stands ipsilaterally with her cephalad hand palpating the tender point, to which the patient ascribes a value of ‘10’ on the pain scale (Fig. 12.39).

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• The patient’s ipsilateral thigh is extended and abducted until some reduction of pain is noted in the tender point.

• The practitioner places her caudad knee on the table and supports the patient’s extended leg on her thigh, in this position.

• The patient’s thigh is then rotated to bring the hip into external rotation, slackening piriformis fibers. The pain reported should drop markedly and once it is below ‘3’ the position is held for at least 30 and ideally up to 90 seconds, before slowly returning the leg to neutral.

Figure 12.39 PRT for piriformis involving extension, abduction and external rotation of the leg.

Extension of the thigh

Extension of the hip is carried out by muscles that lie posterior to the frontal plane that passes through the center of the iliofemoral joint. The hip extensors include gluteus maximus, posterior fibers of the gluteus medius and (perhaps) minimus, adductor magnus, piriformis (sometimes) and the hamstring group (biceps femoris, semimembranosus and semitendinosus). All these muscles, except the hamstring group, have been discussed and treated in other sections of this chapter, as well as in other chapters of this text. Treatment of gluteus maximus, the most powerful hip extensor, is presented with the lateral rotators as well as on pp. 361–367 with the pelvis.

The following points apply to the gluteus maximus and are followed by a full discussion of the hamstrings.

• The gluteus maximus is the largest and most powerful hip extensor and comprises 12.8% of the total muscle mass of the lower extremity.

• Its greatest influence as a hip extensor occurs at 70° of hip flexion and it ‘appears to be active primarily against a resistance greater than the weight of the limb’ (Levangie & Norkin 2005).

• When gluteus maximus is paralyzed, standing from a seated position is not possible, although walking on level surface or standing is still possible.

• Gluteus maximus, along with the hamstrings, is responsible for checking forward tilt of the pelvis (such as occurs during forward bending). However, it is ‘considerably more active when the subject lifts a load from the floor while using the safer straight-back, flexed knee posture, than it is when employing a forward flexed, straight-knee lift’ (Travell & Simons 1992).

• It is more active during running and jumping than when walking.

• It also acts to stabilize the fully extended knee by applying tension to the IT band.

• Gluteus maximus assists extension of the trunk through its pelvic influences and ‘when the thigh is fixed, this muscle forcefully tilts the pelvis posteriorly (rocks the pubis anteriorly), as during sexual intercourse’ (Travell & Simons 1992).

• The interlinking of gluteus maximus and the contra-lateral latissimus dorsi through the lumbosacral fascia as an elastic component of gait is discussed in Chapter 3.

• Injection protocols have been described by Travell & Simons (1992) and by Travell (1955) for the gluteal region, which incorporated a 2% procaine content to reduce the potential for irritation of latent trigger points.

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• Correction of pelvic dysfunctions (innominate rotations or flares, small hemipelvis) and structural problems of the lower extremity (Morton’s foot structure, lower limb length discrepancies) may be necessary for long-lasting results following trigger point deactivation. However, in some cases, trigger points may also become activated in gluteus maximus as it attempts to compensate after structural corrections have been performed (Travell & Simons 1992).

Biceps femoris (see Fig. 12.36B)

Attachments: Long head: from the ischial tuberosity and sacrotuberous ligament to the lateral aspects of the head of the fibula and tibia

Short head: from the lateral lip of the linea aspera, supra-condylar line of the femur and the lateral inter-muscular septum to merge with the tendon of the long head and attach to the lateral aspects of the head of the fibula and tibia

Innervation: Sciatic nerve (L5-S2)

Muscle type: Postural (type 1), with tendency to shorten when chronically stressed

Function: Long head: extends, laterally rotates and adducts the thigh at the hip, posteriorly rotates the pelvis on the hip, flexes and laterally rotates the lower leg at the knee

Short head: flexes the knee and laterally rotates the leg at the knee

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Synergists: For extension: gluteus maximus, semimembranosus, semitendinosus, adductor magnus and posterior fibers of gluteus medius and minimus

For lateral rotation of the thigh: gluteus maximus, the deep six hip rotators (especially piriformis), sartorius, posterior fibers of gluteus medius and minimus and (maybe weakly) iliopsoas

For adduction: remaining true hamstrings (cross two joints), adductors brevis, longus and magnus, pectineus, portions of gluteus maximus, quadratus femoris, obturator externus and gracilis

For posterior pelvic rotation: remaining hamstrings, adductor magnus, abdominal muscles

For knee flexion: remaining hamstrings, sartorius, gracilis, popliteus and (weakly) gastrocnemius

Antagonists: To hip extension: mainly iliopsoas and rectus femoris and also pectineus, adductors brevis and longus, anterior fibers of adductor magnus, sartorius, gracilis, tensor fasciae latae

To lateral rotation of the hip: mainly adductors and also semitendinosus, semimembranosus, iliopsoas, pectineus, sartorius, the most anterior fibers of gluteus minimus and medius, and tensor fasciae latae

To adduction: gluteal group, tensor fasciae latae, sartorius, piriformis and (maybe weakly) iliopsoas

To posterior pelvic rotation: rectus femoris, TFL, anterior fibers of gluteus medius and minimus, iliacus, sartorius

To knee flexion: quadriceps group

Semitendinosus

Attachments: From a common tendon with biceps femoris on the ischial tuberosity to curve around the posteromedial tibial condyle and attach to the medial proximal anterior tibia

Innervation: Sciatic nerve (L5-S2)

Muscle type: Postural (type 1), with tendency to shorten when chronically stressed

Function: Extends, medially rotates and adducts the thigh at the hip, posteriorly rotates the pelvis on the hip, flexes and medially rotates the leg at the knee

Synergists: For hip extension: gluteus maximus, semimembranosus, biceps femoris, adductor magnus and posterior fibers of gluteus medius and minimus

For medial rotation of the thigh: semimembranosus, the most anterior fibers of gluteus medius and minimus, tensor fasciae latae and (perhaps) some adductors

For hip adduction: remaining true hamstrings, adductor group, quadratus femoris, obturator externus and portions of gluteus maximus

For posterior pelvic rotation: remaining true hamstrings, adductor magnus, abdominal muscles

For knee flexion: remaining hamstrings including short head of biceps femoris, sartorius, gracilis, popliteus and (weakly) gastrocnemius

Antagonists: To hip extension: mainly iliopsoas and rectus femoris and also pectineus, adductors brevis and longus, anterior fibers of adductor magnus, sartorius, gracilis, tensor fasciae latae

To medial rotation of the thigh: long head of biceps femoris, the deep six hip rotators, gluteus maximus, sartorius, posterior fibers of gluteus medius and minimus and psoas major

To adduction: gluteal group, tensor fasciae latae, sartorius, piriformis and (maybe weakly) iliopsoas

To posterior pelvic rotation: rectus femoris, TFL, anterior fibers of gluteus medius and minimus, iliacus, sartorius

To knee flexion: quadriceps group

Semimembranosus

Attachments: From the ischial tuberosity to the posterior surface of the medial condyle of the tibia

Innervation: Sciatic nerve (L5–S2)

Muscle type: Postural (type 1), with tendency to shorten when chronically stressed

Function: Extends, medially rotates and adducts the thigh at the hip, posteriorly rotates the pelvis on the hip, flexes and medially rotates the leg at the knee

Synergists: For hip extension: gluteus maximus, semitendinosus, biceps femoris, adductor magnus and posterior fibers of gluteus medius and minimus

For medial rotation of the thigh: semitendinosus, the most anterior fibers of gluteus medius and minimus, tensor fasciae latae and (perhaps) some adductors

For adduction: remaining true hamstrings, adductor group, quadratus femoris, obturator externus and portions of gluteus maximus

For posterior pelvic rotation: remaining true hamstrings, adductor magnus, abdominal muscles

For knee flexion: remaining hamstrings including short head of biceps femoris, sartorius, gracilis, popliteus and (weakly) gastrocnemius

Antagonists: To hip extension: mainly iliopsoas and rectus femoris and also pectineus, adductors brevis and longus, anterior fibers of adductor magnus, sartorius, gracilis, tensor fasciae latae

To medial rotation: long head of biceps femoris, the deep six hip rotators, gluteus maximus, sartorius, posterior fibers of gluteus medius and minimus and psoas major

To adduction: gluteal group, tensor fasciae latae, sartorius, piriformis and (maybe weakly) iliopsoas

To posterior pelvic rotation: rectus femoris, TFL, anterior fibers of gluteus medius and minimus, iliacus, sartorius

To knee flexion: quadriceps group

Indications for treatment of hamstring group

• Posterior thigh or knee pain

• Pain or limping when walking

• Pain in buttocks, upper thigh or knee when sitting

• Disturbed or non-restful sleep due to posterior thigh pain

• Sciatica or pseudo-sciatica

• Forward head or other postures forward of normal coronal alignment

• Inability to fully extend the knee, especially when the thigh is in neutral position

• ‘Growing pains’ in children

• Pelvic distortions and SI joint dysfunction

• Tendinitis or bursitis at any of the hamstring attachment sites

• Inability to achieve 90° straight leg raise

Special notes

To be defined as a ‘true hamstring’, a muscle must originate on the ischial tuberosity, act on both the hip and knee joint and be innervated by the tibial portion of the sciatic nerve. The true hamstrings include the biceps femoris long head, semitendinosus and semimembranosus. The short head of the biceps femoris is not considered to be a true hamstring (Travell & Simons 1992), since it crosses only the knee joint and therefore does not influence hip extension. The hamstrings as a group (as well as the short head of biceps femoris) and their influences on the knee joint are further discussed in Chapter 13 on pp. 492–495.

The proximal tendon of the long head of biceps femoris shares a common tendon with the semitendinosus, which attaches to the ischial tuberosity as well as merging with the sacrotuberous ligament. The tendon of semimembranosus attaches to the ischial tuberosity deep to this common tendon and some of its tendinous fibers may intermingle with those of biceps femoris and semitendinosus (Gray’s anatomy 2005). The anatomy details of the distal tendons are described in relation to the knee on pp. 456–459.

The efficiency of the true hamstrings at the hip is influenced by knee position as their extension power is greater when the knee is locked in extension (Kapandji 1987). When the knee is extended, biceps femoris can also produce lateral rotation of the femur while semimembranosus and semitendinosus antagonize that effort. In order for the group to produce pure extension of the hip (without any axial rotation), the hamstrings must work simultaneously as synergists (in producing extension) and as antagonists to each other (to prevent rotation in either direction).

Local and distant influences on the hamstrings during running

Geraci & Brown (2005) note that the hamstrings are subjected to high tensile load given their extensive eccentric role in running.

• During the initial swing, the knee and hip are flexing requiring simultaneous eccentric and concentric activity of the hamstrings.

• During the latter portion of swing, the hamstrings control knee extension while extending the hip.

• During running the hamstrings work synergistically with the gluteals to stabilize, decelerate, and propel the hip.

• During the propulsion phase, the medial hamstrings assist in decelerating hip external rotation, so maintaining gluteus maximus at its ideal length to act as an accelerator, along with the hamstrings.

• The hamstrings, along with the rectus abdominis, also are decelerators of pelvic anterior tilt throughout stance.

• These functional relationships strongly suggest that hamstring strain or rupture may have its source in the inhibition and weakness of its closest synergists, the gluteals and abdominals.

Travell & Simons (1992) note that:

• Although the hamstrings are ‘quiescent during quiet standing, even when standing on one foot…Okada [1972] found that any form of leaning forward activated the biceps femoris and semitendinosus muscles’

• raising the arms also activates them

• sudden voluntary trunk flexion vigorously activates them

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• the true hamstrings are activated at the end of the swing phase to decelerate the limb and reach peak activity in walking just before or at heel strike

• carrying a load of 15–20% of body weight in one hand significantly increased the activity duration of the ipsilateral semimembranosus and semitendinosus

• the hamstrings are active on ascending and descending stairs, although the medial and lateral muscles’ activities were more diverse when ascending the stairs

• as a group, they are ‘more active during a straight-knee lift than during a flexed-knee lift’

• loss of hamstring use results in a ‘tendency to fall forward when walking, and that they instinctively move the center of gravity posteriorly to maintain extension of the trunk… and, thus, avoid falling. The individuals cannot walk rapidly, or on uneven ground, cannot run, hop, dance, jump, or incline the trunk forward without falling’

• tenosynovitis, bursitis, tendon snapping syndromes at the proximal and distal attachments, strain and/or partial tear of the muscles as well as articular dysfunction of the lower lumbar and sacroiliac joints may each be associated with hamstring pain, spasm and/or dysfunction (see Travell & Simons 1992 for expanded details on these observations).

Deep to the hamstrings lies the adductor magnus. Its uppermost fibers (including the adductor minimus) course almost horizontally while its lowermost fibers course almost vertically. Those fibers lying in between vary in their range of diagonal orientation. Sandwiched between adductor magnus and the overlying hamstring muscles is the sciatic nerve. Knowledge of the course of this nerve is especially important when treating the hamstrings and adductor magnus, especially when incorporating trigger point injections, deep tissue palpation or deep transverse strumming (sometimes used with fibrotic adhesions). Caution should be exercised to avoid pressing on or strumming across the sciatic nerve deep to the hamstrings as well as to avoid entrapping the peroneal portion of it against the fibular head where it lies relatively exposed. Caution is suggested when assessing injured hamstrings. (See Box 12.9)

Box 12.9 Assessing the injured hamstring

For a fuller version of these notes see Chapter 5.

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If the hamstrings are injured the entire kinetic chain with which they are involved should be evaluated.

• Is there weakness or imbalance between hamstrings and quadriceps? The hip extension test (Chapter 10) provides evidence of this.

• Is there relative shortness in the hamstrings? Leg straightening and straight leg raise tests will provide evidence of this (see previous page).

• Is there an associated joint restriction (knee, hip or pelvis)? Motion palpation and assessment would offer evidence of this.

• Are there active trigger points present in the muscles associated with the injury? NMT evaluation would provide evidence of this.

• Are posture and gait normal? See Chapters 2 and 3 for full discussion of these key functional features.

A model of care for hamstring injuries

Reed (1996) suggests:

The physical examination of the athlete with an injured hamstring starts with a postural screening. Examination of the patient should begin with the observation of the patient’s posture standing, sitting and lying down. Observing the patient’s movement from sitting to standing, or other alterations of position is [also] important.

Additionally, evaluate the following elements from a position posterior to the patient: foot status, muscle contractures of the legs, iliac crests levels, pelvic rotation and flare status, femoral rotation, lumbar curve, knee varus or valgus status.

And from the lateral aspect of the body, check: tilt of the pelvis, lumbar lordosis, abdominal protrusion, degree of knee extension/flexion.

Reed then suggests:

Examination of the hamstring includes placing the athlete in a supine position and performing straight leg raise, noting the position of pain or painful arc. This should be performed bilaterally. While the athlete is still supine, the hip should be flexed to 90°with the knee flexed. With the foot in a neutral position, the knee is then extended to the point of pain. This test is repeated with both internal and external tibial rotation. Internal tibial rotation will place more stretch on biceps femoris. External tibial rotation will place a greater stretch on the semimembranosus and semitendinosus. Once again, there should be bilateral comparison. The area of pain should be noted and followed by palpation of the area. Palpation is important to determine if there are any defects in the muscle. Palpation should be performed with the athlete’s thigh in a position of comfort… The thigh should also be observed for haematoma. This may not be present initially, but may take several days [to emerge].

Trigger point target zones for the hamstring muscles include the ischium, posterior thigh, posterior knee and upper calf for the medial hamstrings while the lateral hamstrings primarily refer to the posterior thigh and strongly to the posterior knee (Fig. 12.40). Trigger points in the hamstrings primarily occur in the distal half of the muscles and are particularly activated and perpetuated by compression of these muscles by an ill-fitting chair (Travell & Simons 1992).

Figure 12.40 Trigger point target zones of hamstring muscle. Referred patterns of semimembranosus and semitendinosus are shown on the left leg and patterns for biceps femoris are shown on the right leg

(adapted with permission from Travell & Simons 1992).

Should obviously tight hamstrings always be ‘released’ and should active trigger points in the hamstrings always be deactivated? Van Wingerden et al (1997), reporting on the earlier work of Vleeming et al (1989), remind us that both intrinsic and extrinsic support for the sacroiliac joint derives, in part, from hamstring (biceps femoris) status. The influence occurs between biceps femoris and the sacrotuberous ligament, which are frequently attached via a strong tendinous link.

Force from the biceps femoris muscle can lead to increased tension of the sacrotuberous ligament in various ways. Since increased tension of the sacrotuberous ligament diminishes the range of sacroiliac joint motion, the biceps femoris can play a role in stabilisation of the SIJ.

In low back patients, forward flexion is often painful as the load on the spine increases, whether flexion occurs in the spine or via the hip joints. If the hamstrings are tight, they effectively prevent pelvic tilting. ‘An increase in hamstring tension might well be part of a defensive arthrokinematic reflex mechanism of the body to diminish spinal load’ (Van Wingerden et al 1997).

The decision whether or not to treat tight hamstrings should therefore take account of why they are tight and consider that in some circumstances they might be offering beneficial support to the SIJ or reducing low back stress. And trigger points within the muscle may be a part of the method used to produce increased tone. We are not implying that these features should permanently remain but rather that steps should be taken to correct the primary dysfunctions that have given rise to these secondary features.

Tests for shortness/overactivity in hamstrings

Functional balance test

This is a prone hip extension test to evaluate relative balance between hamstrings, erector spinae and gluteus maximus (Janda 1996). See Figure 10.65 in Chapter 10 and Volume 1, Fig. 5.3

• The patient lies prone and the practitioner stands to the side at waist level with the cephalad hand spanning the lower lumbar musculature and assessing erector spinae activity.

• The caudal hand is placed so that the heel of the hand lies on the gluteal muscle mass with the finger tips on the hamstrings.

• The person is asked to raise the leg into extension as the practitioner assesses the firing sequence.

• The normal activation sequence is (1) gluteus maximus, (2) hamstrings, followed by (3) erector spinae contralateral, then (4) ipsilateral. (Note: Not all clinicians agree with this sequence definition; some believe hamstrings fire first or that there should be a simultaneous contraction of hamstrings and gluteus maximus.)

• If the hamstrings and/or erectors take on the role of gluteus maximus as the prime mover, they will become shortened and further inhibit gluteus.

• Janda (1996) says: ‘The poorest pattern occurs when the erector spinae on the ipsilateral side, or even the shoulder girdle muscles, initiate the movement and activation of gluteus maximus is weak and substantially delayed …the leg lift is achieved by pelvic forward tilt and hyperlordosis of the lumbar spine, which undoubtedly stresses this region’.

• If the hamstrings are stressed and overactive (having to cope with excessive functional demands), they will shorten, since they are postural muscles (Janda 1982).

Functional length test

• The patient is seated on the edge of the treatment table.

• The practitioner places one thumb pad onto the inferior aspect of the PSIS on the side to be tested and the other thumb alongside it on the sacral base.

• The patient is asked to straighten the knee.

• If the hamstring is normal the knee should straighten fully without any flexion of the lumbar spine or posterior rotation of the pelvis (Lee 2004).

• If either of these movements is noted then shortness can be assumed and the degree of that shortness is evaluated by means of the leg straightening test (below).

Leg straightening test

• The patient lies supine, hip and knee on the side to be tested flexed to 90° with the practitioner supporting the leg at the ankle.

• The non-treated leg should remain on the table throughout, as the test is performed. The practitioner slowly straightens (extends) the knee until the first sign of resistance to this movement is noted.

• By rotating the hip medially or laterally before performing the same test, the medial and lateral hamstring fibers may be evaluated.

• This test assesses shortness in the hamstrings, as well as nerve root syndromes (which would elicit marked pain down the leg during the test).

• If the hamstrings are tight, in spasm or chronically shortened, there should be no pain during the test, unless the barrier of resistance is exceeded. However, straightening will be to a point short of the normal range, which involves an extended knee with 80° of flexion at the hip according to Lewit (1999), but only 70° according to Lee (2004), quoting Kendall et al (1993).

• Shortness or excessive tightness of the hamstrings is likely to produce extreme sensitivity at the attachments on the ischial tuberosity

• As noted earlier, Lewit (1999) points out that hamstring spasm can derive from blockage of L4–5, L5-S1 or the sacroiliac joint.

Straight leg raising test

• The straight leg raising test, commonly used as a hamstring assessment, is more appropriately focused on evaluating nerve root restriction/joint blockage (as mentioned immediately above).

• The supine patient’s lower extremity is slightly adducted and externally rotated, with the knee maintained in extension, as the leg is raised to its barrier (i.e. the hip is flexed).

• Muscular spasm and pain will usually reduce elevation to between 30° and 60°, if nerve root restriction is present (Lee 2004). The normal leg should raise to at least 90°.

• If both pain and restriction are noted and if marked external rotation of the hip eliminates the pain, then entrapment of the sciatic nerve by piriformis may be responsible, rather than a spinal or pelvic joint blockage (see piriformis discussion in Chapter 11).

Note: The evidence derived from a standing flexion test as described in Chapter 11 would be invalid if there is concurrent shortness in the hamstrings, since this will effectively give either:

• a false-negative result ipsilaterally and/or a false-positive sign contralaterally if there exists unilateral hamstring shortness (due to the restraining influence on the side of hamstring shortness, creating a compensating contralateral iliac movement during flexion), or

• false-negative results if there is bilateral hamstring shortness (i.e. there may be iliosacral motion that is masked by the restriction placed on the ilia via hamstring shortness).

Hamstring length tests should therefore always be carried out before standing flexion tests are performed to evaluate iliosacral dysfunction. If shortness of hamstrings can be demonstrated these structures should be normalized as far as possible, prior to iliosacral function assessments.

Pollard & Ward provided evidence of increased range of motion (ROM) of hamstring muscles when cervical suboccipitals were stretched (1997) and when upper cervicals were manipulated (1998). Aparicio et al (2009) also produced increased ROM of hamstrings in subjects to whom they applied suboccipital muscle inhibition technique (pressure applied for 2 minutes at posterior arch of atlas). They suggest three possible hypotheses that relate to both structures (suboccipital and hamstring muscles) - postural control, the dura mater, and the myofascial chains. Although it remains to be clarified as to which of these mechanisms, or others, are responsible, length of hamstrings may be enhanced by concepts such as those discussed in Box 12.10 or with techniques for the suboccipital region, as discussed in Volume 1, the companion to this text.

Box 12.10 Therapeutic horizons: the many ways of releasing a tight hamstring

The exercises described below evaluate whether MET applied to the suboccipital region, MET applied to the shortened hamstrings or isotonic stretching of the quadriceps offer appropriate ways of modifying tone in these muscles (Pollard & Ward 1997). Also listed are a variety of ways in which the hamstrings might be released. The objective is to widen therapeutic horizons.

• In this first exercise the hamstrings of one leg are treated using MET applied to the shortened hamstrings and then retested to see whether any length has been gained.

• The suboccipital MET release is then performed and the hamstrings of the other leg are evaluated.

• Following that, an isotonic stretch is used offering another way of achieving similar ends.

The objective is to evaluate which method, if any, produces the greatest benefit in terms of hamstring release.

Before applying these methods three brief evaluations are necessary.

• Imbalances between hamstrings, erector spinae and gluteus maximus are identified (see functional balance test on p. 437) (Janda 1986).

• Relative shortness in the hamstrings is identified (see leg straightening and straight leg raising tests in this chapter, p. 438) (Janda 1996, Reed 1996).

• Possible shortness in the neck extensors and suboccipital musculature is identified (below).

Test for shortness of neck extensors and suboccipital muscles

CAUTION: This procedure should not be performed if ligamentous and disc structures of the neck are weak or dysfunctional, particularly posteriorly.

• The patient is supine and the practitioner stands at the head of the table, or to the side, supporting the neck structures and the occiput in one hand with the other hand on the crown/forehead.

• When the head/neck is taken into flexion, it should be easy to bring the chin into contact with the suprasternal area, without force.

• If there remains a noticeable gap between the tip of the chin (ignore double chin tissues!) and the upper chest wall, then the neck extensors are considered to be short.

Treatment of short hamstrings using MET

This exercise is performed on one leg only.

Lower hamstrings

• The treated leg is flexed at both the hip and knee and then straightened by the practitioner until the restriction barrier is identified (one hand should palpate the tissues behind the knee for sensations of bind as the knee is straightened).

• An isometric contraction against resistance is introduced at the first barrier of resistance.

• An instruction is given: ‘Try to gently bend your knee, against my resistance, starting slowly and using only a quarter of your strength’.

• It is particularly important with the hamstrings to take care regarding cramp and so it is suggested that no more than 25% of the patient’s effort should ever be used.

• Following 7–10 seconds of contraction and after complete relaxation, the leg should, on an exhalation, be straightened at the knee toward its new barrier with a mild degree of (painless) stretch, with the patient’s assistance.

• This slight stretch should be held for up to 30 seconds.

• Repeat the process one more time.

• Antagonist muscles can also be used isometrically, by having the patient try to extend the knee during the contraction, rather than bending it, followed by the same stretch as would be adopted if the agonist (affected muscle) had been employed.

Upper hamstrings

• Treatment of the upper fibers is performed in the straight leg raising position, with the knee maintained in extension at all times.

• The other leg may be flexed at hip and knee, if needed for comfort.

• In all other details, the procedures are the same as for treatment of lower hamstring fibers except that the knee is kept in extension.

• Now the hamstrings are retested for hypertonicity, shortness, on both the treated and the non-treated legs.

Treatment of short neck extensor muscles using MET

• The neck of the supine patient is flexed to its easy barrier of resistance and the patient is asked to extend the neck (‘Tip your chin upwards, gently, and try to take the back of your head toward the table’) using minimal effort, against resistance.

• After the 7–10 second contraction, the neck is actively flexed further by the patient to its new barrier of resistance, with the practitioner offering light pressure on the forehead to induce lengthening in the suboccipitals while also incorporating a degree of reciprocal inhibition of the muscles being lengthened.

• Repetitions of the contraction, followed by stretch to the new barrier, should be performed until no further gain is possible or until the chin easily touches the chest on flexion.

• No force should be used or pain produced during this procedure.

Hamstring length is now retested in both legs.

Which method provides the greatest release of hamstring hypertonicity? According to research (Pollard & Ward 1997), the suboccipital release should provide the greatest release of hamstring hypertonicity. The mechanisms involved are under debate and possibly include the effects on the dura.

Further evaluation of non-obvious influences on hamstring hypertonicity

This involves using slow eccentric isotonic stretch (SEIS) of antagonists (quadriceps) (Liebenson 2001, Norris 2000).

• The patient is supine with hip and knee flexed (it is equally useful and sometimes easier to perform this maneuver with the patient prone).

• The practitioner extends the flexed knee to its first barrier of resistance while palpating the tissues of the posterior thigh proximal to the knee crease for the first sign of ‘bind’, indicating hamstring tension.

• The patient is asked to resist (extend the knee), using approximately half his strength, while the practitioner attempts to slowly flex the knee fully, thereby stretching quadriceps isotonically eccentrically.

• An instruction should be given that makes the objective clear: ‘I am going to slowly bend your knee, and I want you to partially resist this, but to let it gradually happen’.

• After performing the slow isotonic stretch, the hamstring is retested for length and ease of leg straightening.

• The slow isotonic stretch of the antagonist to the hypertonic muscle should effectively release its excess tone.

Which of the methods used so far offered the best results in terms of hamstring release? In the list below the authors offer their clinical experience of some of the many other ways for modifying hamstring length (see Volume 1, Chapter 10, and Chapter 9 in this volume for details of many of these methods).

1. Straight leg raise is held at the resistance barrier until release ± 30 seconds (yoga effect).

2. Straight leg raise to the first resistance barrier; an isometric contraction of the hamstrings is introduced, which produces postisometric relaxation, then the tissue is stretched.

3. Straight leg raise to the first resistance barrier; an isometric contraction of the quadriceps is introduced, which produces reciprocal inhibition of hamstrings, then the tissue is stretched.

4. Ruddy’s pulsed MET is used. The tissue is held at its barrier and the patient introduces 20 contractions in 10 seconds, toward or away from the restriction barrier and length is reevaluated.

5. Positional release is used; the hamstring is placed into a position of ease (strain-counterstrain) and held for up to 90 seconds.

6. Myofascial release of the superficial tissues is performed; tissues are held at their elastic barrier until release: 1–2 minutes or more.

7. Cross-fiber stretch (‘C’ or ‘S’ bend) is performed until myofascial lengthening occurs – 30 seconds or more.

8. HVT or mobilization of associated joints (knee, SI) is used for reflex influence on muscle and/or to mobilize (articulate) hip and knee joints.

9. Rhythmic rocking is used, the leg is held straight with a very low-grade, rhythmic impulse introduced from heel to hip, using rebound as impetus for developing ‘harmonic’ influence.

10. Muscle belly trigger points (ischemic compression) or periosteal pain points (ischial tuberosity, tibial head) are treated.

11. Muscle tone is reduced by application of firm bilateral pressure (‘proprioceptive adjustment’) toward the belly (influencing the spindles) or toward attachments (influencing the Golgi tendon organs) or the reverse is done to the quadriceps.

12. Massage is used to encourage relaxation and reduce hypertonicity.

13. A golf ball is placed under the foot and the plantar fascia ‘massaged’ by rolling it up and down for 1 minute. Hamstring should release markedly.

14. The suboccipital muscles are stretched to obtain reflex effect (or possibly dural release).

15. Tonic neck reflex: cervical rotation increases ipsilateral extensor tone + contralateral flexor tone while it decreases contralateral extensor + ipsilateral flexor tone (Murphy 2000).

16. If the patient looks (with eyes only) toward the chin, flexor muscles will tone and extensors, including hamstrings, will be inhibited (and vice versa) (Lewit 1999).

17. Vigorous exercises to ‘warm up’ muscles, then they are retested.

18. Have the patient sit onto palms of the practitioner’s hands so that the ischial tuberosities rest on the palms. The attachments can be firmly ‘kneaded’ for a minute or so, to release hamstring hypertonicity (a Rolfing procedure).

19. After testing for shortness of hamstrings, the patient is asked to recline and practice slow rhythmic breathing for a minute or two and then the muscles are retested.

There are many other possibilities and often combinations of the above may achieve an even greater result. The practitioner is also encouraged to uncover the underlying conditions that have led to hamstring tightness and to work with the patient to remove these primary (perpetuating) factors in order to encourage a more long-lasting result.

NMT for hamstrings

The patient is prone with the feet supported on a cushion. The practitioner stands beside the ipsilateral thigh at the level of the lower thigh.

Resisted flexion of the knee will result in a contraction of the hamstrings, which will help the practitioner to identify the most lateral aspect of this muscle group. Lubricated gliding strokes are repeatedly applied in segments, by using the thumbs, palms or proximal forearm. The most lateral aspect of the posterior thigh includes tissues that lie lateral to the hamstrings, that being a portion of vastus lateralis and the gluteus maximus attachment to the gluteal tuberosity. When the thumbs are then moved medially, the biceps femoris are encountered followed by the medial hamstrings (semimembranosus and semitendinosus). A portion of the adductor magnus may be influenced on the most medial aspect of the posterior thigh as well as with deeper pressure through the hamstrings, if appropriate. These repetitive gliding strokes serve to warm the tissues as well as give the opportunity to palpate congested, thickened or dense muscular tissue.

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Once located and duly warmed, any areas of thick, dense muscular tissue can be treated with compression by the thumbs, flat-tipped pressure bar or stabilized elbow. Since the rounded nature of a taut hamstring makes it more easy to slide off the tissues when compressing them (especially if lubricated), the practitioner’s other hand can be used to stabilize the pressure bar or elbow as shown in Figure 12.41 to avoid slippage.

Figure 12.41 The tip of the elbow can be safely used to compress the tissues if stabilized by the opposite hand. Gliding strokes should NOT be applied with the pointed tip of the elbow but they can be applied with the flat proximal forearm.

The proximal attachment of the hamstrings is identified by asking the patient to raise his foot from the cushion by flexing his knee (with or without resistance) while the practitioner palpates the ischial tuberosity. The contraction of the hamstrings attachment at the ischium is readily felt. Compression or friction can be used to assess and treat this attachment site unless excessive tenderness implies bursal or attachment trigger point involvement.

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The distal tendons create the medial and lateral borders of the upper half of the popliteal fossa, a diamond-shaped region of the posterior knee. With the knee in passive flexion, these tendons, once identified, can be grasped in a pincer compression and examined with compression or manipulated between the fingers and thumb so long as the middle portion of the popliteal fossa, where neurovascular structures lie, is avoided (Fig. 12.42). The distal tendons can be followed to their attachments to the tibia and fibula, as long as care is taken to avoid compression of the peroneal nerve. The attachments and surrounding anatomy are described in further detail in Chapter 13 with the anatomy of the knee.

Figure 12.42 Compression of the tendons of the hamstrings. Caution is exercised due to popliteal neurovascular structures.

The practitioner moves to the contralateral side of the table while the patient remains prone. The hamstrings can be approached from this position to more easily access the medial aspect of the muscle group. Gliding strokes can be applied to the medial aspect of the semimembranosus and semitendinosus as well as a portion of adductor magnus.

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A myofascial technique intended to free restriction between the hamstrings and underlying adductor magnus can also be applied from this position. To use this technique, the practitioner places her thumbs, positioned with tips touching each other, onto the mid-belly region of the medial aspect of the hamstrings, while remaining superficial to the adductor magnus. A gentle and increasing pressure is applied to the hamstrings as if to lift them slightly and slide them laterally to their first tissue barrier (Fig. 12.43).

Figure 12.43 Laterally oriented pressure applied to the medial aspect of the hamstring muscles may help to free fascial adhesions resulting from injury or from compression while sitting

(reproduced from Journal of Bodywork and Movement Therapies 1(1): 17).

The pressure is then sustained for 30 seconds to 2 minutes or pressure increased as the tissues soften and separate. These steps can be applied more proximally or distally as well to more sections of hamstrings but are usually most effective when applied to the central portion. The person will usually experience relief of a ‘deep ache’ in the posterior thigh. A small portion of the adductor magnus may also be accessed with gliding strokes under the medial aspect of the hamstrings while they are laterally displaced (Fig. 12.44).

Figure 12.44 Gliding strokes can be applied to the adductor magnus while displacing the hamstrings laterally to access a small portion of the muscle normally covered by the overlying tissues

(reproduced from Journal of Bodywork and Movement Therapies 1(1): 17).

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MET for shortness of hamstrings 1 (Fig. 12.45)

• The non-treated leg of the supine patient should either be flexed or straight on the table, depending upon whether hip flexors have previously been shown to be short or not.

• The treated leg needs to be flexed at both the hip (fully) and knee and the knee extended by the practitioner until the restriction barrier is identified (one hand should palpate the tissues proximal to the knee for sensations of bind as the knee is straightened).

• The leg should be held a fraction short of the resistance barrier.

• An instruction is given such as: ‘Try to gently bend your knee, against my resistance, starting slowly and using only a quarter of your strength’.

• It is particularly important with the hamstrings to take care regarding cramp and so it is suggested that no more than 25% of the patient’s effort should ever be used during isometric contractions in this region.

• Following the 7–10 seconds of contraction and a complete relaxation, the leg should, on an exhalation, be taken through the previous restriction barrier, with the patient’s assistance, to create a mild degree of stretching.

• This slight stretch should be held for up to 30 seconds.

• Repeat the process until no further gain is possible (usually one or two repetitions achieve the maximum degree of lengthening available at any one session).

Figure 12.45 Assessment and treatment position for lower hamstring fibers

(adapted from Chaitow 2001).

MET for shortness of hamstrings 2 (Fig. 12.46)

• Treatment is performed in the straight leg raising position, with the knee maintained in extension at all times.

• The other leg should be flexed at hip and knee, or straight, depending on the hip flexor findings, as explained above.

• In all other details, the procedures are the same as for treatment of method 1, except that the leg is kept straight.

Figure 12.46 Assessment and treatment of shortened hamstrings using straight leg raising

(adapted from Chaitow 2001).

PRT for hamstrings

The medial hamstring tender point is located on the posterolateral aspect of the knee joint.

• The patient lies supine with the affected leg at the edge of the table.

• The practitioner sits alongside and palpates the tender point with her tableside hand.

• The hip is abducted to allow the leg to flex over the edge by approximately 40° (thigh remains on the table).

• The practitioner first introduces inversion of the foot to create a slight adduction and then internal rotation of the tibia, in order to reduce sensitivity in the tender point.

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• Once the sensitivity has reduced by 70% or more the position is held for 90 seconds before a slow return to neutral.

The lateral hamstring tender point is located on the posteromedial aspect of the tibia, close to the tendinous attachment of semimembranosus and semitendinosus.

• The patient lies supine with the affected leg at the edge of the table.

• The practitioner sits alongside and palpates the tender point with her tableside hand.

• The hip is abducted to allow the lower leg to flex over the edge by approximately 40° (thigh remains on the table).

• Abduction of the tibia is introduced via a hand contact on the foot (creating a slight valgus force) and either internal or external rotation of the tibia is then introduced (whichever most effectively reduces sensitivity in the tender point).

• Once the sensitivity has reduced by 70% or more the position is held for 90 seconds before a slow return to neutral.

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