Author: Sam Visnic

Name: Massage Therapist
Brand: Release Muscle Therapy
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Hamstring Tendinopathy | How To Identify And Manage

Written by Sam Visnic on October 25, 2023. Posted in Deep Gluteal Pain Syndrome, Hamstrings.

It can be a mysterious source of discomfort, especially in runners and other athletes. It can be the covert culprit behind a precipitous drop in physical performance. For many, it’s a little-known adversary causing chronic pain. It is often triggered by seemingly innocuous activities such as sitting.

We’re talking about hamstring tendinopathy. This is an entity of deep gluteal pain and insidious discomfort associated with the sciatic nerve. But if you were recently diagnosed with this condition, many questions may arise.

What exactly is hamstring tendinopathy? How does your physical therapist diagnose and manage it? Is there anything you can do at home?

Let’s dive deep into understanding this pathology to answer these questions.

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Understanding Hamstring Tendinopathy: Definition and Causes

Hamstring Release - Semitendinosus Temecula Myofascial Release — Semitendinosus

The medical community initially recognized hamstring tendinopathy as hamstring syndrome in 1988. Since then, many athletes and seniors have been diagnosed over the years. It is common in runners, dancers, and endurance athletes.

Hamstring tendinopathy occurs when hamstring injuries affect the soft tissue of proximal hamstring tendons. You will also find it as proximal hamstring tendinopathy (PHT) or high hamstring tendinopathy.

According to some authors, the formal definition is a lesion in the myotendinous junction of the hamstring with concomitant damage to the adjacent hamstring tendon, resulting in buttock pain, and pain in the posterior thigh, among other symptoms.

Surprisingly, up to 51% of dancers may encounter this problem. The primary cause? A muscle injury in the section where the hamstring muscle meets the tendon (1).

But why does it happen (1)?

Overexertion: It may happen in sprinters at the terminal swing phase of the gait cycle. At that time, the hamstrings contract to decelerate the lower limb and can be subject to soft tissue injury.
Active stretching: Hamstring tendonitis can also develop after active stretching of the muscle. This cause is less frequent and takes place in response to hip flexion with knee extension.
Incorrect technique: It may also follow an overstretching move associated with sports. This may be the case in dancers or individuals attempting a high kick without the correct technique.
Overuse & overload: Some authors also suggest overuse and overload hamstring injuries as possible causes. These more commonly affect the semimembranosus hamstring tendon.

Risk factors

In addition to the known causes, some risk factors increase the chance of proximal hamstring tendinopathy (PHT). For example:

Older age.
Reduced flexibility of the hamstring and quadriceps.
Weakness of the hamstring muscle.

Some systemic factors may also influence the prevalence, such as:

Diabetes.
Hypertension.
Obesity.
Genetic predisposition.

Although the latter are not direct causes, they may contribute to proximal hamstring tendinopathy.

Spotting the Symptoms: Key Indicators of Hamstring Tendinopathy

The most notable symptoms of high hamstring tendinopathy are (1):

Unilateral tendon pain in the posterior thigh or lower buttock.
Neuropathic symptoms if the sciatic nerve is involved.
Pain in ischial tuberosity worsens with repetitive contraction of the hamstring (uphill running, walking fast).
Pain in ischial tuberosity worsens with direct pressure on the hamstring muscles when sitting.
When sitting for long periods, patients may describe a boggy mass sensation around the ischial tuberosity.
Symptoms develop gradually without a clear cause.
In the case of avulsion hamstring injuries (a severe tendon tear), the tendon pain in the ischial tuberosity is sharp and very intense after trauma.
In the above case, there may also be an audible popping sound at the time of trauma.
Swelling may be seen in the tendon area in some cases.

Besides considering the symptoms of hamstring tendinopathy, how they came on, and where they radiate, your physical therapist will also look for signs. Signs are different from symptoms because your therapist can see and measure the health of your proximal hamstring tendons. They help detect proximal hamstring tendinopathy.

To that end, they will perform some clinical tests. These are maneuvers that may feel a bit uncomfortable, but they serve to identify the root of the problem (2).

These are available maneuvers your therapist may try on you (1,2):

Straight Leg Raise Test

This is an important test to examine the range of motion in proximal hamstring tendinopathy. It is an active assessment, meaning that the therapist will ask you to do it without help.

Keeping your leg straight, you should raise a single leg as far as possible. This will assess flexibility and whether the movement triggers hamstring tendon pain.

Slump Test

This maneuver is essential to identify radiculopathy in proximal hamstring tendinopathy. That is, to test if the sciatic nerve has been affected along with the proximal hamstring tendon. It is a neural tension test performed in a seated position.

The therapist will ask you to slump forward. If this does not cause pain in the ischial tuberosity, they will ask you to extend your knee as far as possible. A positive pain trigger means your sciatic nerve is likely involved.

Bent-knee stretch

This is a passive maneuver, in which the examiner will do the movement for you. The physical therapist will ask you to lie on your back on a stretcher.

They will take a single leg and bring your knee and hip to their point of maximum flexion and then slowly extend the knee. If this maneuver causes pain in the problem area, it is positive for proximal hamstring tendinopathy.

Modified bent-knee stretch

This maneuver is very similar to the previous one. It also requires the assistance of your therapist. Similarly, they will ask you to lie on your back. The examiner will take a single leg, flexing the knee and hip to the maximum, and then quickly extend the knee.

Similarly, the result is positive for proximal hamstring tendinopathy when this triggers pain in the ischial tuberosity. Some reviews describe this as the most sensitive and specific maneuver.

Puranen-Orava test

To perform this test, your therapist will ask you to stand up and keep your knee extended. The foot is placed on a support, raising it until the hip is flexed at a 90° angle.

It is positive for proximal hamstring tendinopathy if it reproduces the patient’s pain in the proximal hamstring area.

Hamstring loading movements

One of the main clinical tests involves load evaluation. This is done with different exercises focused on the hamstring muscle. The most common is the Romanian deadlift.

Tests are positive for proximal hamstring tendinopathy when they elicit the characteristic pain in the ischial tuberosity during exercise. To confirm, the therapist may decide to slightly increase the load, which also increases pain intensity.

Diagnostic Procedures

As with other causes of deep gluteal pain, high hamstring tendinopathy can be difficult to detect. Symptoms are often insidious at first. Because they are mild, inconsistent, and difficult to describe, many patients do not seek immediate consultation. And if they do, they often do not receive a proper diagnosis on their first attempt.

Basic assessment

In most cases, the pain is associated with mechanical loading of the hamstrings. It is almost always located in the ischial tuberosity. In most cases it does not change location or spread to other anatomical sites.

In the case of irradiation, this is usually due to a sciatic nerve entrapment. Almost always the radiating pain involves the hamstring muscles but rarely goes beyond the knee.

The hamstring tendon pain is aggravated by provocative activities. For example, running uphill, lunging, and during hamstring stretches. Even sitting can cause deep buttock pain, due to compressive loads across the hamstring.

All these data are important to have an initial diagnostic suspicion of proximal hamstring tendinopathy.

It is also important to check the symmetry of the lower limbs and palpate the ischial tuberosity and the proximal hamstring tendons.

Differential diagnoses

In some cases, imaging studies may be used to arrive at a diagnosis of proximal hamstring tendinopathy. This is not always performed in the setting of a physical therapist.

It is usually reserved for cases in which the tendinopathy does not respond to treatment. Also, when the specialist suspects another condition masks the symptoms of high hamstring tendinopathy.

In the diagnostic process, it is very important to consider differential diagnoses. These are other diagnoses with similar deep buttock pain or associated with hamstring tendinopathy.

One of the main conditions is sciatic pain. Any pain originating from the sciatic nerve can cause symptoms similar to hamstring tendinopathy.

Moreover, high hamstring tendinopathy is often complicated by neuropathy. Thus, although it is not automatically a deep gluteal pain syndrome, the possibility remains.

For the differential diagnosis of sciatica, your therapist may perform some maneuvers. For instance, the lumbar extension and flexion, straight leg raise, and slump test.

Similarly, it will also be important to test for the presence of systemic inflammatory disease. For example, psoriatic arthritis and ankylosing spondylitis (2).

Treatment and Management Strategies

Several treatments and management strategies exist for proximal hamstring tendinopathy. These include oral anti-inflammatory and analgesic medications, and targeted exercise. Other strategies include corticosteroid injections, platelet-rich plasma injections, shockwave therapy, and surgery.

Nevertheless, most people get better with conservative treatment. That is, most do not need surgery and other invasive treatments. Similarly, corticosteroid and platelet-rich plasma injections are rarely used.

The most important treatment and management strategies are as follows (2)

Patient Education

The main therapeutic tools available are education and exercise. Patient education is essential to identify the symptoms and their origin. This helps avoid recurrences in the future.

It is important to emphasize that pain does not always mean structural or biological damage. Patients and therapists can use pain intensity to measure advances. Pain determines how the proximal hamstring tendon functions and how well it can tolerate certain activities.

In this way, patients learn about their organisms, limitations, and precipitants throughout the treatment of proximal hamstring tendinopathy.

Rehabilitation

Focused hamstring muscle rehabilitation is also important. The usual rehabilitation period is three to six months. However, some patients may need longer rehabilitation, up to 12 months.

From an early stage, the programmed exercises aim to provide a load to the hamstring muscle-tendon unit in a progressive manner. From exercises with low load to exercises with higher load.

The individual patient’s response to deep buttock pain will determine what type of exercise to use, and what the progression will be. Pain symptoms are assessed 24 hours after exercise to make modifications to the intensity of the next exercise.

Some athletes begin with heavy slow resistance training. A senior by comparison requires starting with very low loads.

In some cases, it will also be necessary to rehab other muscles, as in an ankle sprain, triceps surae wasting problem, or any other injury in the past.

Rehabilitation also takes into account biomechanics. These can increase the load on the hamstring muscles and tendons. For example, we may need to correct the femoral-pelvic position, the anterior and posterior pelvic tilt, or an excessive forward trunk inclination, among others.

As the exercises progress the intensity increases in different ways:

Incrementing the load
Accelerating contraction speed
Extending the hip flexion range
Incorporating more complex exercises.
Other conservative interventions

Other conservative measures

Besides performing these exercises and their evaluation, there are also passive interventions for proximal hamstring tendinopathy. These involve movements guided by an expert or manual therapy.

Corticosteroid injection therapies may also work but are best avoided, and platelet-rich plasma injections are becoming more of a popular trend.

Massage therapy is widely used in the early stages, and may help in getting the proximal hamstring tendon into the correct position. This is especially true is the work is neuromuscular therapy or myofascial release, which is far more specific than generalized massage.

Return to sports and prognosis

A concern in athletes is the return to sports quickly. In most cases, athletes will be able to continue their activities while completing their rehabilitation. Only your specialist can make that decision after examining your case.

Rushing rehabilitation is a common mistake, especially given the competitive nature of sports.

Prognosis is also a frequently asked question, especially about sitting pain. But sitting pain may improve over time, and can often take up to a year to be completely resolved.

Recovery will be more difficult in patients with other associated diseases, and athletes who rush to return to the playing field.

Surgical treatment

When conservative treatment does not work, surgical treatment may be necessary. In most cases, it consists of nerve debridement and release of the proximal tendon. Likewise, if there are any bands between the nerve and the hamstring tendon, doctors can remove them in surgery.

Tips for Preventing Recurrence

Despite treating tendon pain, one of the problems of high hamstring tendinopathy is the potential for recurrence. Some studies have reported up to 30% recurrence in cases of hamstring strain.

It is even theorized that tendon tears and damage to hamstring muscles cause changes in the long-term architecture of the hamstring tendon. It leaves a scarred section that replaces the normal fibers and tendons (2).

Thus, hamstring tendinopathy pain may return after some time, or have relief and reoccurrence periods. Some retrospective studies even show that more than 50% of patients with high hamstring tendinopathy experienced recurrences and failed to have a complete long-term symptomatic resolution (1).

Here are some recommendations to avoid a recurrence (1,2):

Strengthen the hamstring muscles. This is one of the most important recommendations. The best prevention is working out the hamstring muscles according to their strength and endurance. The nordic hamstring curl is a super popular, although extremely challenging exercise for athletes.
Strengthen the entire kinetic chain. That is, all the muscles associated with hamstring function. These muscles, even if they are accessory, relieve the hamstring load and decrease the risk of recurrence.
Resolve deficits from past injuries. Often a past injury can be a trigger for high hamstring tendinopathy. If the injury is not resolved, the pain will return sooner or later.
Avoid the use of corticosteroids. Although helpful in preventing or relieving pain, corticosteroids can lead to a greater recurrence of symptoms. This does not happen with other injections such as platelet-rich plasma.
Ongoing evaluation. Even if you feel recovered from hamstring tendon pathology, it is essential to continue visiting your therapist. Only in this way will you be able to determine the actual degree of muscle recovery beyond the reduction in pain. They will also assess the limits of functionality to which you must adhere.

References:

Argo, L. R., Selley, R. S., Tjong, V. K., & Ihm, J. (2021). Proximal Hamstring Tendons. In Tendinopathy: From Basic Science to Clinical Management (pp. 103-127). Cham: Springer International Publishing.

Nasser, A. M., Pizzari, T., Grimaldi, A., Vicenzino, B., Rio, E., & Semciw, A. I. (2021). Proximal hamstring tendinopathy; expert physiotherapists’ perspectives on diagnosis, management and prevention. Physical Therapy in Sport, 48, 67-75.

Piriformis Trigger Points | How To Find And Self Treat

Written by Sam Visnic on October 25, 2023. Posted in Glutes, Pain, Piriformis.

Dealing with persistent hip or buttock pain?

You might be experiencing the effects of piriformis trigger points. These sensitive spots within the piriformis muscle, located deep in the buttock region, can cause a myriad of symptoms, ranging from localized discomfort to radiating pain mimicking sciatica.

Armed with my personal experience as a neuromuscular therapist with over 20 years of expertise and practical knowledge at my clinic Release Muscle Therapy, I’ll guide you here on how to identify, self-treat, and prevent piriformis trigger points and related issues.

Piriformis Muscle Anatomy And Function

Location: The piriformis muscle is located deep within the buttock, situated beneath the gluteal muscles.

Origin: It originates from the anterior surface of the sacrum, which is the triangular bone at the base of the spine.

Insertion: The muscle fibers run from the sacrum and converge to attach to the greater trochanter of the femur, which is the large bony prominence located on the outer side of the upper thigh.

Relation to the Sciatic Nerve: The piriformis is closely associated with the sciatic nerve, which either runs beneath or, in some individuals, through the muscle. This close proximity is the reason why the piriformis is often implicated in sciatic pain.

Function of the Piriformis Muscle:

Lateral Rotation of the Hip: When the hip is extended, the piriformis acts primarily to laterally rotate the femur (thigh bone) in the hip joint. This means it helps turn the leg and foot outward.

Abduction of the Thigh: When the hip is flexed to 90 degrees, the piriformis acts to abduct the thigh, meaning it helps move the leg away from the midline of the body.

Stabilization: The piriformis also plays a role in stabilizing the hip joint, especially during walking or running. It helps keep the head of the femur securely within the hip socket, preventing dislocation or excessive movement.

Restraining Medial Rotation: The piriformis helps to control and limit the medial (inward) rotation of the thigh, especially during the early stance phase of gait when the foot first hits the ground during walking.

Given its role and its relation to the sciatic nerve, any dysfunction or tightness in the piriformis can lead to a range of symptoms, the most notable being “piriformis syndrome.” This syndrome arises when the muscle compresses or irritates the sciatic nerve, leading to symptoms like buttock pain that can radiate down the leg, mimicking classic sciatica.

What Are Trigger Points And Why Do They Matter?

Trigger points, often referred to as “muscle knots,” are hypersensitive, tight areas or nodules within muscle fibers. They can be felt as small, tender lumps in the muscle and are usually the result of muscle overuse, strain, or injury.

There are two main types of trigger points:

Active Trigger Points: These cause pain at rest and when the muscle is used. The pain is usually felt at the site of the trigger point and can also radiate to other areas. This referred pain can sometimes follow specific patterns.
Latent Trigger Points: These are dormant and don’t cause spontaneous pain, but they can restrict movement and cause muscle weakness. When pressed or stretched, they can become painful.

Active trigger points are notorious for causing persistent pain, which can manifest as sharp, dull, burning, or aching sensations. This pain is sometimes so unique that it’s mistaken for other conditions, leading to potential misdiagnosis. But the implications of trigger points don’t stop at mere discomfort.

They can significantly impact the range of motion in joints due to the pain and muscle tightness they induce. Over prolonged periods, this limitation can escalate into joint stiffness and a noticeable decline in functionality.

Moreover, muscles plagued with active trigger points don’t operate at their best, resulting in muscle weakness and quick fatigue. One of the hallmark features of trigger points is their capability to refer pain to distant regions of the body.

For example, those present in the neck might be the culprits behind recurring headaches. Chronic presence of these trigger points, especially in pivotal muscles like those in the back and neck, can lead to postural anomalies as the body constantly tries to adjust and compensate for the pain and imbalance.

To add to this, the consistent pain and discomfort stemming from these trigger points can be a significant disruptor of sleep, causing conditions like insomnia or sporadic sleep patterns.

Main Complaints Related To Trigger Points in The Piriformis

Trigger points in the piriformis muscle can lead to a variety of symptoms and complaints. The piriformis muscle, due to its proximity to the sciatic nerve, can have a profound impact when these trigger points become active. Here are the main complaints related to trigger points in the piriformis:

Buttock Pain: One of the most common complaints is a deep, aching pain in the buttock on the affected side. This pain can sometimes be sharp or radiating.
Sciatica-like Symptoms: The sciatic nerve runs very close to or even through the piriformis muscle in some individuals. When the piriformis muscle becomes tight or inflamed due to trigger points, it can compress or irritate the sciatic nerve. This can lead to symptoms that mimic sciatica, such as radiating pain, tingling, or numbness that travels down the leg, sometimes reaching as far as the foot.
Reduced Range of Hip Motion: The tightness and discomfort caused by the trigger points can lead to a reduction in the range of motion of the hip joint, making movements like hip rotation painful.
Referred Pain: Trigger points in the piriformis can also cause referred pain to other areas, such as the lower back or the other regions of the buttock.
Difficulty Sitting: Due to the location of the piriformis, sitting for extended periods, especially on hard surfaces, can exacerbate the pain and discomfort.
Pain While Walking: Walking, especially for long distances, can become painful due to the involvement of the piriformis in hip stabilization and movement.
Piriformis Syndrome: This is a condition where the piriformis muscle compresses the sciatic nerve, leading to a range of symptoms including pain, numbness, and tingling. While piriformis syndrome can have other causes, trigger points in the piriformis are a common culprit.
Pain During Certain Activities: Activities that put strain on the piriformis, such as climbing stairs, running, or even crossing legs, can become painful when there are active trigger points in the muscle.

Causes Of Piriformis Pain And Trigger Points

Piriformis pain and the development of trigger points in the muscle can arise from various causes. One of the primary culprits is muscle overuse or strain, often seen in athletes or individuals who engage in activities requiring repetitive hip rotation or sudden changes in direction.

Direct trauma or injury to the buttock area, such as from a fall or a car accident, can lead to inflammation and tightness in the piriformis, fostering the formation of trigger points. Prolonged sitting, especially on hard or uneven surfaces, can put constant pressure on the muscle, leading to discomfort and potential trigger point development.

Furthermore, anatomical variations where the sciatic nerve runs through the piriformis muscle, rather than beneath it, can make some individuals more susceptible to piriformis syndrome, with the muscle compressing the nerve when it becomes tight or inflamed.

Additionally, imbalances in posture or gait, often stemming from issues in adjacent muscles or joints, can place undue stress on the piriformis, contributing to pain and the onset of trigger points.

It’s also worth noting that other conditions, like lumbar spine issues or hip disorders, can refer pain to the piriformis region, making it essential to obtain a comprehensive diagnosis to pinpoint the exact cause of the discomfort.

Piriformis Trigger Point Locations

piriformis trigger points — Image reference: David G. Simons, Janet G. Travell, Lois S. Simons. Myofascial Pain and Dysfunction: The Trigger Point Manual

The piriformis muscle, given its relatively small size but significant depth, can house multiple trigger points. The exact number and precise location can vary among individuals, but typically, the trigger points in the piriformis muscle are found in the following areas:

Medial Trigger Point: Located closer to the sacrum, this trigger point is found near the muscle’s origin on the anterior surface of the sacrum. It’s often the most medial of the piriformis trigger points.
Central Trigger Point: Positioned roughly in the middle of the muscle belly, this trigger point is typically the most prominent and can be the primary source of referred pain patterns associated with the piriformis.
Lateral Trigger Point: Located closer to the greater trochanter of the femur where the piriformis inserts, this trigger point is the most lateral and can sometimes be the source of pain that radiates down the leg.

When palpating (feeling) for these trigger points, one might feel taut bands or nodules within the muscle, which are hypersensitive to pressure. Applying pressure to these points can reproduce the pain or refer pain to other areas, a characteristic feature of trigger points.

It’s essential to approach piriformis trigger points with care, given the muscle’s proximity to the sciatic nerve. Proper assessment and treatment by trained professionals can ensure that the nerve is not inadvertently irritated during the process.

How To Self-Release Piriformis Trigger Points

VIDEO

For those grappling with the discomfort of piriformis trigger points, several self-release techniques can provide relief right at home. One of the most popular methods involves using a foam roller.

By sitting on the foam roller and positioning it under the buttock of the affected side, individuals can gently roll back and forth, applying sustained pressure on tender areas to help release muscle tightness.

Another effective tool is a tennis or lacrosse ball.

By placing the ball under the buttock and leaning into it, one can target specific trigger points more precisely, applying pressure and making small circular movements to aid in the release.

Follow Up Stretching The Piriformis

VIDEO

Stretching the piriformis after trigger point release is vital. The process not only ensures the muscle retains its relaxed state, preventing re-tightening, but also boosts blood flow, speeding up recovery and delivering essential nutrients.

Enhanced circulation reduces the risk of future trigger points, while a flexible piriformis functions more efficiently, reducing potential injuries. Additionally, while the release targets specific muscle knots, stretching provides overall muscle relaxation.

This combined approach not only addresses immediate discomfort but also promotes long-term muscle health and reduces referred pain, offering a comprehensive solution for muscle care.

Follow Up Exercises For Piriformis

Post-trigger point release, follow-up exercises for the piriformis are paramount to ensure sustained muscle health and functionality. While the release targets immediate tension and discomfort, exercises play a pivotal role in reinforcing muscle strength, endurance, and coordination.

By actively engaging the piriformis and its neighboring muscles, these exercises foster muscle memory, ensuring the piriformis operates in harmony with surrounding structures.

This not only reduces the risk of muscle imbalances, which can be a precursor to injuries and strain, but also supports optimal hip and pelvic mechanics during daily activities. Moreover, consistent exercises act as a preventive measure, deterring the re-emergence of trigger points by keeping the muscle active and well-circulated.

In essence, while trigger point release provides immediate relief, follow-up exercises lay the foundation for long-term piriformis health and optimal biomechanical function.

Trigger Points For Plantar Fasciitis | How To Find And Release

Written by Sam Visnic on October 18, 2023. Posted in Plantar Fasciitis.

Myofascial trigger points are a controversial topic, especially when it comes to chronic pain. Keep this in mind when setting expectations for learning about trigger points for plantar fasciitis.

Trigger point therapy can be helpful if muscular dysfunction is a contributing factor in your individual case. In some situations it is possible that trigger points can mimic plantar fasciitis type pain, and upon resolving them, the problem may go away completely.

There is rarely a single pressure point to relieve plantar fasciitis pain, but instead, a collection of them that can be found in the surrounding muscles of the foot and ankle.

In this article, I’ll show you the most relevant trigger points, but keep in mind this is NOT an exhaustive list. There are other trigger points found further up the leg that have the potential to refer sensations down to the foot, and therefore may also contribute to this trigger point pain phenomenon.

So, with that said, let’s get started on finding these little pressure points.

Locating Plantar Fascia Trigger Points

The Science Behind Trigger Points

Trigger points are often referred to as “knots” in your muscles that form when fibers are unable to relax. While the actual concept of a muscle knot is highly debatable, these sensitive points can contribute to pain and limit your range of motion. In the case of plantar fasciitis, trigger points often form in the calf and foot muscles, which can exacerbate the pain in your foot. Treating these trigger points can provide improved muscle performance and facilitate the rehabilitation process.

Foot Trigger Points

Plantar fasciitis occurs when the plantar fascia, a thick band of tissue running from your heel to your toes, becomes inflamed. This band acts like a shock absorber for your foot, and when it’s strained, you feel pain, especially while walking or standing. Understanding the anatomy of your foot can help you grasp why trigger points are so crucial in treating plantar fasciitis.

There are a lot of small muscles in the foot, commonly referred to collectively as the “instrinsic” foot muscles. Many of these muscles can harbor trigger points that can be sensitive right where they are located, OR, can refer sensations to the most common pain point near the heel.

It is possible that in some cases an individual’s entire problem is not actually the plantar fascia, but instead the problem being generated by these local trigger points.

These muscles are generally easily accessible, but one common issue in self-treating them is hand fatigue. I do recommend using a appropriate tool (which I’ll cover down below) in order to effectively work these key trigger points.

Calf Trigger Points

Trigger points located in the calf muscles can create either local dysfunction or refer sensation down to the foot. There is a pressure point in the medial calf that can refer directly into the commonly painful spot on the heel, so it is worth investigating.

There are 2 calf muscles: the gastrocnemius and the soleus. The gastrocnemius rests on top of the soleus, so this muscle will need to be addressed first. As tension and sensitivity is reduced, you will have a better chance at influencing the deeper soleus muscle.

While you won’t be able press straight down through the gastroc muscle, you will be able to access the soleus at the inside and outside parts, near the shin bone.

Trigger points are challenging for therapists to find (and agree on!), so for most people, you aren’t likely to “feel” anything specific under your finger, but you will be able to notice an area that seems very sensitive, and even more importantly refer sensations down the leg.

In my opinion, the areas that refer sensations are most important to address. Since these tender points are challenging to locate to begin with, you might consider using a simple skin marker to make a dot or “X” so that you can easily locate the spot again with ease. This can also be helpful when showing a professional massage therapist where your trigger points are.

Peroneal Trigger Points

The peroneal muscles are found on the outside part of the shin. Even though there are not any common trigger points that refer to the bottom of the foot, this muscle has an important role in function.

Its main job is plantar flex (think calf raise) and evert the foot, so effectively stabilizing the outside part of the foot + ankle.

Trigger points are fairly common in this muscle and alleviation can often make the foot feel as if it’s “moving better”.

Tibialis Trigger Points

The tibialis, both anterior and posterior parts, could be strong contributors to plantar fasciitis. The tibialis functions as a sort of “stirrup” for the foot, and therefore is involved in pronation.

When you consider that over-pronation may be one of the factors that leads to excess stress on the plantar fascia to begin with, it would sense to address this muscle.

Trigger points in the anterior muscle refer directly to the big toe, while pressure points in the posterior muscle can refer directly to the achilles tendon. (Also interesting to note the common relationship between achilles issues and plantar fasciitis!).

Anterior tibialis trigger points are easy reach, but the posterior is far more difficult because of its deep location under the larger calf muscles. While it is somewhat possible to access a portion of it coming in from the side of the shin, it’s best to work with a professional therapist to get better access to this one.

Trigger Point Release Techniques

Trigger point massage for plantar fasciitis muscle work can involve a number of different techniques. Any of them can be effective, but all of them may not work for everyone. Some experimentation may be needed.

Static Pressure Release

Static pressure is the classic method for trigger point therapy. Once the tender pressure point is located, pressure with a thumb or tool is added and held until the sensitive spot reduces in intensity.

There isn’t a lot of agreement by therapists in how hard to press, but generally if we use a 1-10 scale, a 5, which is midway, would be a good place to start when self-massaging.

Kneading

Kneading can involve a number of different movements, but generally the idea is to grab, pinch, roll or stretch the tissues in varying directions, which often increases blood flow to the area and helps de-sensitize the trigger point.

Muscle Energy Techniques

Muscle energy techniques (MET) involves a series of osteopathic-based techniques aimed at triggering the nervous system to relax muscles that have increased muscle tension.

The two primary techniques are called:

Post Isometric Relaxation (PIR) – This technique involves a very low intensity contraction of the muscle that contains the trigger point, with a controlled inhale + exhalation, then subsequent relaxation of the contraction. This process is repeated 3-5 times until full relaxation is achieved.

Sample Technique:

Reciprocal Inhibition (RI) – This techniques involves a contraction of the OPPOSITE muscle that contains the trigger point. In doing so, there is a degree of reduced activity in the target muscle, which can reduce the sensitivity of trigger points.

This technique also involves a breathing component, and the intensity of the muscle contraction may vary depending on individual ability.

I’m a big fan of these techniques, because they are easy to perform, relatively gentle, and can rapidly reduce trigger point activity in the host muscle. Covering these techniques would require an entire blog post to itself, but I wanted to mention them here due to their immense value.

Sample Technique:

Does self release with a trigger point roller help?

While not a technique itself, I wanted to address the most common version of self massage, which is rolling on a foam roller. The roller can help you with static release and a simple version of repeated compression of tissues.

While simple and can generally hit some easy to reach trigger points, it’s not very efficient for dealing with more specific trigger points. This is because the broad contact surface of the roller will often miss the precise trigger points mentioned in the areas above.

Massage tools attempt to help fix this problem, and they can be useful as well, but only after examining the tissues with your hands and locating the trigger points that need to be treated.

Important Tip: Follow up with stretching

Locating and releasing trigger points for plantar fasciitis needs to be a multi-step process. This means you can’t just massage them away.

It’s important to re-train your muscles (+ nerves) on how to change their behavior. An easy way to do this involves stretching the muscles right after treating the trigger points. Kinesiology taping for plantar fasciitis is also helpful in reducing trigger point sensitivity.

As trigger point sensitivity is reduced, there is a sort of window-of-opportunity to teach the nerves how to keep the changes. It doesn’t take much. 2-3 repetitions of a stretch, held for 30 seconds can effectively get the job done.

Lastly, be sure to note exercises for plantar fasciitis to avoid.

Alternative Treatments for Plantar Fasciitis

While trigger point therapy can be very helpful in some cases, it’s not the only treatment out there. Here are some alternative treatments you might consider that are often utilized:

Acupuncture: This ancient Chinese technique involves inserting needles into specific points on your body, including your foot, to relieve pain.
Physical Therapy: Exercises can strengthen your foot and calf muscles, improving your condition over time.
Orthotic Inserts: Custom-made shoe inserts can provide the extra support your foot needs.

A Comprehensive Treatment Plan for Plantar Fasciitis

When it comes to dealing with issues like plantar fasciitis, it is VERY important to utilize a multi-disciplinary approach to achieve the best results. Its crucial to rule out any potential underlying serious pathology, and also identify and address any contributing factors that exist in one’s lifestyle.

Consult a Specialist: Always start by consulting a healthcare provider for an accurate diagnosis.
Trigger Point and/or Myofascial Release Therapy: Schedule regular sessions with a certified therapist.
Home Exercises: Perform stretching and strengthening exercises as advised by your therapist.
Lifestyle Changes: Consider weight loss and proper footwear to reduce strain on your plantar fascia.
Follow-up: Regularly consult with your healthcare provider to track your progress and make necessary adjustments to your treatment plan.

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Article Image Note: I have pulled images from online for utilization in this post, and while I’m not sure exactly where they are from, I do believe they are from Travell and Simon’s Myofascial Trigger Point manuals. If you know, I’m happy to properly attribute these images.

Article Research:

Trigger Point Therapy and Plantar Heel Pain: A Case Report

Quad Trigger Points | How To Find And Treat

Written by Sam Visnic on October 17, 2023. Posted in Massage Therapy, Quadriceps.

If you’re dealing with quadricep or knee pain, then identifying and addressing quad trigger points is an important step in a comprehensive therapy program.

We delve into identification of trigger points, self-treatment strategies, and techniques for stretching and muscle energy. By offering a scientific, analytical perspective, we aim to aid practitioners and patients alike in effectively managing quad trigger points.

Here is what we are going to cover in this guide:

-Overall anatomy and function of the quadriceps muscles

-Location of quad trigger points

-Typical symptoms that are experienced and overlapping conditions

-Potential causes, and how to self-treat these trigger points

The Quadriceps Muscles And How They Work

The quadriceps muscles, often referred to as ‘quads’, play a crucial role in carrying out the hinge-like movement of your knee, enabling walking, running, and jumping with ease.

They originate from various quadriceps attachment points, including the femur and the hip bone, before inserting onto the tibial tuberosity through the patellar ligament, which lies just below the knee joint. There are 4 muscles that form the group:

-Rectus femoris (this is the only one that moves the hip and knee!)

-Vastus lateralis

-Vastus medialis

-Vastus intermedius

The quadriceps are responsible for knee extension and hip flexion (only the rectus femoris does this one) – crucial movements in everyday activities.

Quad Trigger Points – Where Are They Located?

Trigger points in the quads are typically found in four key areas within the muscle group.

The vastus medialis and vastus lateralis, found on the inner and outer aspects of the thigh respectively, often contain very tender trigger points. Similarly, the rectus femoris and the vastus intermedius, located centrally, can also hold some important points.

Understanding the precise location aids in effective quad trigger point release, alleviating pain and improving muscle function. It’s crucial to remember that each individual may have a unique distribution of quadriceps trigger points, requiring a personalized approach to treatment.

Symptoms Associated

Recognizing the symptoms associated with quad trigger points plays a vital role in both getting to the root cause of the problem, as well as selecting the right therapy protocols.

The manifestation of a trigger point in quad muscles typically results in localized pain or discomfort. This may be accompanied by muscle stiffness or a palpable “knot”, often referred to as a quad muscle knot.

It’s important to note that the severity of symptoms can vary greatly from individual to individual. Some individuals might experience mild discomfort, while others may report deep aching pain. Furthermore, these “knots” in quads can lead to limited mobility in knee flexion, muscle weakness, or even muscle twitching.

In some cases, quads trigger points could also cause referred pain that radiates to other areas. This is especially the case when it comes to anterior knee pain and patellar tendon.

Causes And Treatment Options

Overuse, trauma, or strain are common causes for trigger points in quads. A sedentary lifestyle can also lead to de-conditioning and tension in the quadriceps.

To relax the quad muscles, physiotherapy, stretching, and massage are often generally recommended. Trigger point therapy or myofascial release techniques can be used to release quads, focusing on specific quadricep trigger points.

If symptoms persist even after these interventions, the trigger points themselves may not be the primary contributor to the issue, and additional sources should be ruled out.

Differential Diagnosis – What Else Could It Be?

Differential diagnosis plays a crucial role in ruling out other potential causes of discomfort in the quadriceps.

A detailed clinical examination often reveals tense bands of muscle fibers, often associated with trigger points in the thigh. However, the presence of a muscle knot in the quad does not necessarily confirm a trigger point.

It’s essential to differentiate between simple trigger points and other pathologies such as strains or tears.

Hence, a comprehensive differential diagnosis is paramount in accurately identifying and treating quad trigger points. This should be performed by your primary healthcare provider.

How To Self Treat

Self-treatment methods for quad trigger points, when applied correctly, can effectively alleviate discomfort and enhance muscle function.

The first step in how to self-treat these muscle “knots” is identifying the specific trigger points. Once identified, you can use various techniques to release them.

These techniques can include self myofascial release with a tool such as a foam roller, tennis ball, lacrosse ball, etc., muscle energy techniques, or ice therapy with stretching.

VIDEO

Stretching quadriceps muscles aids in relaxing the tense muscle fibers and promoting blood circulation. It’s vital to maintain a gentle, consistent stretch for maximum benefit.

Stretching The Quadriceps

Incorporating regular quadriceps stretching into your routine can significantly assist in relieving the tension from quad trigger points. The standing quad stretch, for instance, is very easy to perform, and get the job done efficiently.

https://vimeo.com/805256199

The standing quad stretch can be done for 2-3 repetitions on each side, holding for 30 seconds each. This can repeated 1-3 times per day.

Regular practice of this stretch can help get the self massage work to “stick”, improve range of motion, and reduce likelihood of the issue in returning.

Muscle Energy Technique For The Quads

Muscle Energy Technique (MET) is a type of manual therapy that uses the patient’s own muscle energy (i.e., their force) to improve joint mobility and muscular function. Here’s how it works:

Isometric Contractions: The therapist positions the quadricep into a lengthened position. The patient is then asked to contract the quad against a counterforce provided by the therapist. This is done in a controlled and gentle manner. Only about a 15% effort is generally required.
Relaxation & Stretching: After the isometric contraction, the muscle is allowed to relax for a short period. The therapist will then move the tissues to their new range of motion, effectively stretching the muscle a bit further.
Repetition: This process is repeated 5 or more times, until no further range of motion is achieved.

At the end of the technique, the previously tender trigger point is retested, for reduced sensitivity or de-activation.

Conclusion

Effective management of trigger points in the quadriceps encompasses various treatment options, including self-myofascial release, stretching, massage, and muscle energy techniques. However, a differential diagnosis is vital to rule out other conditions with similar manifestations.

Thus, comprehensive knowledge and appropriate intervention strategies are paramount for optimal outcomes.

Pectoralis Trigger Points | How To Find And Release

Deep Gluteal Pain Syndrome MRI – What Can It Tell Us?

Written by Sam Visnic on October 16, 2023. Posted in Deep Gluteal Pain Syndrome, Glutes.

Deep gluteal syndrome (DGS) features symptoms such as pain after prolonged sitting, muscle weakness, posterior hip pain, among others. It can sometimes be problematic for doctors and physical therapists to unravel, not to mention patients.

Besides identifying the symptoms, professionals must dig into the deep gluteal space to find the root cause of the problem. This can be tiring for patients who constantly experience sometimes debilitating buttock, hip pain and sciatica symptoms.

But the diagnosis is a multi-step process. You’ll usually need confirmation after a physical examination with an imaging study. Magnetic Resonance Imaging (MRI) is the most commonly used tool by physicians to see what’s compressing or irritating the sciatic nerve, causing buttock pain and sciatic nerve entrapment. It is invaluable to investigate deep gluteal syndrome anatomy.

But, like other diagnostic tools, it can also have limitations.

How accurate is an MRI? Will it reveal the source of pain? What will happen after the study?

Stay around, and we’ll unpack the questions step by step.

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Evaluating the Accuracy of MRI

MRI is essential in the gluteal syndrome anatomy imaging arsenal. But this clinical test is not a solitary act. In addition to the imaging study, a physical examination and a previous interview with the patient are paramount. All data collected forms the basics of the diagnosis.

The first step of the diagnosis is examining the symptoms such as pain after prolonged sitting. Then, comparing them with an MRI identifies the location of sciatic nerve entrapment. But how reliable are the results of this study?

To answer this question, a team of researchers pooled 239 cases of sciatica of non-disc origin (meaning a disc issue was ruled out). They revealed a sensitivity of 64% and a specificity of 93% of MRI studies (1).

In other words, false positives are very uncommon with an MRI. But it also indicates a high incidence of false negatives.

Simply put, many patients could have deep gluteal syndrome anatomy issues, even if they don’t show up on their MRI. Thus, an MRI should confirm the diagnosis or rule out other causes. It is not a screening test.

MRI scans confirm a physical examination and the assessment of the patient’s symptoms. As a second step in the diagnostic process, the combination will yield the best results.

Adding to the arsenal, the new buttock pain and sciatica screening protocols include other procedures. One is known as response-to-injection study and the other is a sciatic nerve-specific exam. The former features an injection of corticosteroids and local anesthetics. The second involves the use of electromyography of the sciatic nerve.

This way it is possible to detect a non-discogenic sciatic nerve entrapment more accurately. It also narrows the search to the deep gluteal space. Altogether, this makes up the definition of the syndrome (2).

How does MRI results affect treatment?

Anatomy imaging and management often belong together to explore the most likely cause of your pain. It can be a piriformis syndrome, ischiofemoral impingement, or sciatic nerve compression. There are many other deep gluteal space problems, and MRI is an excellent aid to detect the trigger.

Depending on the MRI findings, we understand the cause of buttock pain. This shapes the treatment plan, which may include drugs or a physical therapy course. In some cases, doctors may even practice interventional magnetic resonance imaging to release entrapments in the subgluteal space.

So yes, the MRI can change the treatment approach. It can also guide the exercise course your physical therapist will implement in your case. Here are examples of how anatomy imaging and management meet in a clinical scenario (3,4):

Piriformis syndrome

MRI findings

Hypertrophy and some anatomical variants of the piriformis muscle can point to piriformis syndrome on MRI. A local anesthetic infiltration test can confirms these findings. It appears piriformis syndrome is the most common cause of deep gluteal pain.

Treatment

In this case, treatment usually consists of anti-inflammatory medications, muscle relaxants, and rest. Your physical therapist may recommend a 6-week course of exercises. If this approach does not ease deep gluteal pain, others may work better for piriformis syndrome. Botulinum toxin injection and surgical resection of the piriformis muscle are commonly used.

Variants of the sciatic nerve

MRI findings

Magnetic resonance neurography (MRN) show an abnormal course of the sciatic nerve inside the deep gluteal space. Around 16-17% of the population has this anatomical variant. Yet, not everyone will have sciatic nerve symptoms or any other clinical features. This may sometimes be included as a subtype of piriformis syndrome.

Treatment

In the presence of deep gluteal syndrome symptoms, the infiltration test may work as diagnosis and treatment. If this fails, an endoscopic tenotomy of the piriformis muscle is the treatment of choice.

Variants of the piriformis muscle

MRI findings

This is another subtype of piriformis syndrome. An anatomical variant in the deep gluteal space can also alter the interaction between the piriformis muscle and the sciatic nerve. For example, the insertion zone can be different, or we can have an enlarged piriformis muscle. This variant causes a misalignment of the anatomical components and may trigger deep gluteal pain.

Treatment

Pain may improve with physical therapy and other conservative treatments. But these sciatic nerve entrapments are usually more difficult to resolve. They will likely require an intervention such as endoscopic muscle resection to resolve sciatic nerve entrapments in the subgluteal space.

Deep gluteal syndrome triggered by trauma and overuse conditions

MRI findings

In these cases, MRI can also detect fibrous bands in the piriformis muscle. These adhesions form in response to inflammation. They push structures and cause sciatic nerve entrapment and deep gluteal syndrome.

Treatment

In this case, the most effective treatment is an endoscopic sciatic nerve decompression in the deep gluteal space.

Hamstring tendinopathy

MRI findings

MRI is also essential to diagnose deep gluteal syndrome triggered by the hamstring muscle. Hamstring tendinopathy is often associated with inflammation, which can be acute or chronic. The images may feature acute inflammation and edema affecting the sciatic nerve. In chronic inflammation, bands and fibrotic tissue form in the deep gluteal space.

Treatment

Many cases of acute inflammation have a successful resolution with physical therapy and other conservative treatments. On the other side, chronic causes usually respond only to surgery.

What are the limitations of MRI in evaluating Deep gluteal pain syndrome?

As practical as MRI is, it also has limitations. Despite showing all the anatomical parts in detail, some of them escape the examiner’s view. It usually happens when the problem is associated with a movement, not with the anatomical structures in question.

Moreover, there’s also a psychosocial aspect of buttock pain. It can affect your quality of life to a great extent. Even if MRI shows nothing at all, you will probably want to do something about it.

We could describe at least two cases in which an MRI can miss the diagnosis:

A type of piriformis syndrome involves a dynamic sciatic nerve entrapment. In other words, the sciatic nerve is only affected when adopting some postures or making some movements. The magnetic resonance neurography will not be able to detect cases of dynamic sciatic nerve entrapment. Sometimes MRI scans show edema associated with hyper-intensity in the sciatic nerve. But even so, the definitive diagnosis is made by endoscopy (4).
Similarly, one of the main limitations of MRI has to do with orthopedic anomalies. When sciatic pain is triggered by orthopedic issues, these are not always visible on MRI. The neuropathy is activated in a specific position or during dynamic motion. Therefore, diagnostic images will often not capture the exact root cause of the problem (4).

As noted, all these diagnostic tools should guide and not replace clinical tests. A postural evaluation, a gait examination, and physical exam maneuvers can lead the diagnostic suspicion to a more accurate location. That’s how we make sure treatment covers the real cause of radicular pain and it will be much more effective.

Conclusion

Diagnosis and management of sciatic nerve entrapments often belong together. MRI is the most common tool in the gluteal syndrome anatomy imaging arsenal. It reveals problems in muscles, ligaments, tendons, and other structures.

However, other tools can complement and confirm suspicions. For instance, electromyography of the sciatic nerve and the response to treatment with corticosteroid injection or local anesthetics.

MRI stands out as one of the main approaches due to its 93% specificity. However, it has a sensitivity of 64%. In other words, abnormalities in these tests are unlikely to be wrong. However, there can be false negatives in many patients.

Moreover, piriformis syndrome can happen due to dynamic causes. There are also orthopedic triggers of deep gluteal syndrome (DGS). They are both unlikely to show up in an MRI. That is why it is a confirmatory tool and should not replace the careful study of symptoms and clinical tests.

The MRI will directly affect the treatment. In many cases of acute inflammation, rest, anti-inflammatory drugs, and muscle relaxants will do the work. In other cases, the patient will find relief with injections of local anesthetics in the deep gluteal region. Even when this doesn’t work, botulinum toxin injection and various surgical techniques can be an option.

MRI results may guide medical treatment and the exercises performed by your physical therapist. It’s a valuable tool to provide specific treatment but also has some limitations. Sometimes, immediate surgical treatment becomes a better option. However, in most cases, it is possible to resolve radicular pain with conservative treatment and physical therapy.

Pectoralis Trigger Points | How To Find And Release

Written by Sam Visnic on October 16, 2023. Posted in Massage Therapy, Pectorals.

Have you ever experienced chest or shoulder pain that seemed to defy explanation? It’s possible that pectoralis trigger points are the culprits. Unlocking pain relief by treating these trigger points can be life-changing. In this blog post, we’ll delve into the world of pectoralis trigger points, focusing on the major and minor muscles and their referred pain patterns.

Key Takeaways

This article explores the characteristics and referred pain patterns of pectoralis trigger points, located in both the major and minor muscles.
Common symptoms include mid-scapular back pain, breast sensitivity, chest pains mimicking cardiac angina, and shoulder/ulnar nerve discomfort.
Treatments involve self massage techniques such as pressure application with fingers or a foam roller, professional therapy options like injections or neuromuscular therapy massage, stretching exercises to increase flexibility & strength. Plus prevention methods for future activation.

Understanding Pectoralis Trigger Points

Trigger points are localized, hyperirritable spots in a taut band of skeletal muscle, and they can cause pain both locally and in a referred pattern. The pectoralis major and minor muscles are particularly known for their trigger points, which can refer pain to the chest region.

We will delve into the specifics of these muscles and their referred pain patterns next.

Pectoralis Major Muscle

The pectoralis major muscle, also known as the pectoralis muscle, is a large fan-shaped muscle located in the chest that can develop trigger points, causing breast and nipple hypersensitivity. It is responsible for the movement and stabilization of the shoulder joint and comprises two heads: the clavicular and sternal heads. The clavicular head lies underneath the collarbone, while the sternal head is situated at the bottom of the sternum, just above the ribcage.

Muscle overload, poor posture, or injury to any of the three portions of muscle fibers that make up the pectoralis major muscle may activate trigger points. Damage to the nerve of the pectoralis major can lead to disruption in its normal functioning. This can result in denervation, atrophy or fibrosis of a section of the muscle. The symptoms associated with pectoralis trigger points may be more intense than the actual severity, giving the sensation of cardiac pain or even a heart attack.

Pectoralis Minor Muscle

The pectoralis minor muscle is a thin, triangular muscle situated at the upper part of the chest, beneath the pectoralis major muscle. It has the following features:

Origin: 3rd to 5th ribs near their costal cartilages
Insertion: Medial border and superior surface of the coracoid process of the scapula
Primary actions: Stabilization, depression, abduction or protraction, internal rotation
Function: Provides a passage for the vascular-nerve brachial system.

Referred Pain Patterns

Referred pain occurs when pain is felt in a different location than the actual source of the pain. In the case of pectoralis trigger points, pain referral may include:

the chest
anterior shoulder
medial arm, which can cause arm pain
inner elbow

These referred pain patterns can be confusingly similar to those of other conditions, such as cardiac pain or thoracic outlet syndrome, and can lead to misdiagnoses.

Before attributing chest pain to trigger points, verify there is no cardiac involvement.

Referred pain from pectoralis trigger points can also be associated with conditions such as mid-scapular back pain, breast pain, and pain radiating in the anterior shoulder and ulnar nerve path.

Understanding these referred patterns can help differentiate between pectoralis trigger points and other underlying conditions.

Identifying Pec Trigger Points

The pec major and minor muscles have unique trigger points that can be found using specific palpation techniques, which we will discuss in the following subsections.

Locating Pec Major Trigger Points

To identify trigger points in the pectoralis major muscle, begin by locating the sternal head of the muscle, situated at the bottom of the sternum, just above the ribcage. Use your fingers to trace up the muscle until you encounter a taut band, which may or may not produce a referral pattern to the shoulder or down the arm.

Locating Pec Minor Trigger Points

To find trigger points in the pectoralis minor muscle, start by identifying the clavicular head of the muscle, situated at the upper portion of the sternum, just under the collarbone. Again, move your fingers along the muscle until you detect a taut band, which may or may not produce a referral pattern to the shoulder or down the arm.

Potential Causes of Pectoral Trigger Points

Pectoralis trigger points can be activated or reactivated due to various factors such as:

Muscle overload or fatigue
Improper posture
Stress
Strenuous lifting
Exposure to cold air from air conditioning
Immobilization of the shoulder or arm in a cast or sling
Excessive training volume in sports like weight training, rowing, boxing, and push-ups

Being aware of these potential causes can help you take preventive measures to avoid recurring pectoralis trigger point re-activation.

Treating Pectoralis Trigger Points

Effective treatment of trigger points (along with an overall integrative approach to pain) can provide significant pain relief and improve overall quality of life.

In the following sections, we will discuss self-massage techniques, professional therapy options, and stretching exercises that can help treat these trigger points.

Self-Massage Techniques

To release pec-based trigger points, you can employ various self-massage techniques such as applying static pressure to the sensitive points with your fingers, using a foam roller, or utilizing a massage ball.

When applying static pressure, hold a light to moderate pressure for 30-60 seconds and release, repeating as needed 1-2 more times. An important note that applying excessively aggressive pressure is NOT needed for results.

Always start with small amounts, and increase as tolerance improves over time.

Professional Therapy Options

Based on the provided text, I have split it into two paragraphs for improved readability:

For more targeted treatment of shoulder pain, particularly front shoulder pain, professional therapy options such as trigger point injections, neuromuscular massage therapy, and muscle energy technique stretching can be explored. Additionally, working with a trained therapist can help you learn effective stretching exercises to enhance shoulder range of motion and strength.

Stretching Exercises

Incorporating regular stretching exercises can help alleviate pectoralis trigger point pain and prevent reactivation. The Pec Major Stretch and Doorway Stretch are two recommended exercises for treating pectoralis trigger points. The Pec Major Stretch involves standing in a doorway, placing your arms on either side, and leaning forward until a stretch is felt in the chest.

The Doorway Stretch also requires standing in a doorway and placing your arms on either side of the doorway, then leaning forward until a stretch is felt in the chest area. Consistently performing these stretches can help to increase flexibility, reduce muscle tension, and alleviate pectoralis trigger point pain.

Preventing Pectoralis Trigger Point Activation

Preventing the activation of pectoralis trigger points can save you from unnecessary pain and discomfort. To avoid pectoralis trigger point activation, consider implementing the following techniques:

Manual therapy
Myofascial release
Gentle stretching techniques
Refraining from activities that put strain on the pectoralis muscles

Keeping a good posture and adding regular stretching exercises to your routine can also ward off the development of pectoralis trigger points.

Pectoralis Trigger Points and Related Conditions

Pectoralis trigger points are not only a source of pain in the chest and shoulder area but can also be associated with other conditions such as Thoracic Outlet Syndrome and Carpal Tunnel Syndrome.

Thoracic Outlet Syndrome is a condition caused by the compression of nerves and blood vessels in the thoracic outlet, resulting in pain, numbness, and tingling in the neck, shoulder, and arm.

Carpal Tunnel Syndrome is characterized by compression of the median nerve in the wrist, resulting in pain, numbness, and tingling in the hand and fingers.

Recognizing the association between pectoralis trigger points and these related conditions can help identify the correct diagnosis and appropriate treatment. Collaborating with healthcare professionals to address both pectoralis trigger points and underlying conditions can improve overall well-being and quality of life.

Summary

In conclusion, understanding and effectively treating pectoralis trigger points can provide significant pain relief and improve overall quality of life.

By learning about the pectoralis major and minor muscles, identifying their trigger points, and employing self-massage techniques, professional therapy options, and stretching exercises, you can unlock pain relief and prevent the reactivation of these trigger points.

Remember to consult with a healthcare professional before initiating any treatment plan to ensure the most appropriate and effective approach for your specific needs.

Managing Deep Gluteal Pain: Guide to Piriformis Syndrome and Buttock Pain

Written by Sam Visnic on October 10, 2023. Posted in Deep Gluteal Pain Syndrome, Glutes.

Buttock complexity is often underestimated. However, they are an intricate web of overlapping muscle layers, nerves, and blood vessels.

What happens when it goes awry? What is deep gluteal pain? Where does it come from?

As the name suggests, deep gluteal pain originates in the intermediate or deep muscle layers. This stealthy intruder often connects to a sciatic nerve entrapment syndrome, such as the notorious sciatica.

Just imagine not being able to sit comfortably for more than 15 minutes. That’s an everyday problem for some people, even athletes (1). So, the importance of treating deep gluteal syndrome becomes evident after experiencing the symptoms.

Deep gluteal pain is not a minor inconvenience. It can become a disabling problem in older adults and a performance killer in young people.

That is why we devoted this hub page to shine a spotlight on this perplexing ailment.

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What is Deep Gluteal Pain?

What is the actual definition of deep gluteal pain?

It’s a sensation of numbness or a distinct pain in the buttocks. But what makes deep gluteal pain different vs regular gluteal pain? It is the nerve entanglement factor.

It often causes radiation pain along the distribution of the sciatic nerve anatomy (sciatic nerve pain). Deep gluteal pain is considered a sciatic nerve disorder, unlike regular buttock pain. It is untethered from disc issues and features sciatic nerve entrapment in the deep gluteal space (2).

As noted, it is much more complex and goes beyond simple, transient pain. It usually comes with psychosocial consequences, movement limitations, and a plummet in your quality of life.

Causes of Deep Gluteal Pain

The deep gluteal space is complex. Each component can be a pain trigger. The potential cause can be a muscle, tendon, or nerve. Each can generate pain due to different processes. For instance:

Entrapment neuropathy

It features pinching or pressure upon a nerve, which triggers pain. It is one of the most common causes of deep gluteal pain. One example is the ever-troublesome piriformis muscle, which often causes sciatic nerve entrapment (3).

Lesions and fractures

Inflammation is a common trigger of deep gluteal pain. It can originate from an injury or fracture. For example, repetitive movements can cause micro-tears in the muscle tissue. It swells and puts pressure on nerve structures. This cause of deep gluteal pain is common in sports injuries in and around the gluteal triangle region (4).

Enthesopathy and tendinopathy

Tendon disorders such as tendinitis can cause deep gluteal pain. There is also connective tissue connecting tendons and bones (entheses). These ailments can also trigger deep gluteal syndrome. A few potential culprits here include the quadratus femoris muscle, piriformis muscle, and gluteus medius (5).

Uncommon causes

Can ovulation cause deep gluteal pain? Yes, some patients develop deep gluteal pain during pregnancy or ovulation.

However, this is a type of referred pain. The trigger can be intra-abdominal or intra-pelvic inflammatory processes. Endometriosis, irritable bowel syndrome, and even inguinal hernia may also cause these symptoms (2).

Trigger points in the gluteals may also be a contributing factor in some cases.

The triggers are outside the deep gluteal space, which is why some professionals do not include them in the deep gluteal syndrome. Also, it does not feature sciatic nerve compression. Therefore, seeking professional help is essential to rule out a differential diagnosis and alleviate your symptoms.

Symptoms of Deep Gluteal Pain

Deep gluteal pain symptoms may include (2,6):

Buttock pain or numbness
Pain radiated to the knee (sciatic nerve symptoms)
Pain triggered by prolonged sitting
Walking in short strides for pain avoidance
Sensory changes and pain upon palpation
Disturbed sleep due to severe pain at night
Locking or clicking sounds on the hip joint
Limping after prolonged sitting

These symptoms of deep gluteal pain do not follow a set script. For instance, nerve entrapment can be vague and hard to pinpoint. Symptoms may come and go and change location, varying in intensity depending on the cause.

However, in almost all cases, deep gluteal pain features nerve entrapment, Thus, it includes a combination of radiating sciatic pain and limping. Depending on the cause, different signs and symptoms may add up. For example:

Hamstring tendinopathy could make you feel a “boggy mass” in your hips with weight-bearing activities or after sitting.
Gluteal tendinopathy gives you night pain when lying on the affected side.
In pudendal nerve entrapment, using a seat or riding a bicycle increases the pain, but sitting on a toilet might bring some relief.

It’s a complex puzzle, and each piece matters. So, communicating your symptoms can make a difference in the diagnostic process.

Diagnosis

The symptoms of deep gluteal pain are often cryptic. However, your therapist will sort them out and perform a few physical examination maneuvers and tests to reveal the diagnosis.

What exams and maneuvers work to diagnose deep gluteal pain?

Discriminating signs and symptoms

An understanding of deep gluteal space is fundamental. It will help your therapist rule out similar-sounding culprits.

You may drop a big hint that points directly to a diagnosis. In other cases, a workup will help rule out different possibilities and reveal the source of pain.

The most common symptoms are pain in the buttocks and retrotrochanteric regions. This sciatic pain often radiates to the posterior thigh but may also radiate to the perineum or groin (6).

Physical examination basics

Physical therapists may also assess whether hip flexion or rotation worsens the pain and whether it flares up during physical activity or extended sitting.

With a physical examination, paresthesia, numbness, trigger points, and tender areas can also be detected. Different landmarks can guide the way of palpation, such as the greater trochanter, ischial tuberosity, and iliac crest (2).

When signs and symptoms are unclear, a thorough physical evaluation should be performed. It may include the spine, hip, pelvis, and abdomen examination. As tiring as it may seem, it is a crucial piece of the puzzle.

Deep gluteal pain testing

You may need to undergo a series of passive and active movement tests with your provider. Remember these are important to get to the bottom of things, and you should communicate your sensations throughout.

Special tests include internal rotation of the hip, the flexion test, and the seated piriformis stretch test, which can help diagnose piriformis syndrome. The piriformis muscle provocation test is also beneficial to diagnose sciatic nerve entrapment (7).

Diagnostic imaging

Imaging tests may confirm the diagnosis or rule out other potential causes. For example, X-rays can spot bone pathologies, but they are not the most commonly used.

Nerve conduction studies help detect sciatic nerve entrapment. However, an MRI is the most convenient to rule out specific underlying contributors and assist with diagnosing the root cause of deep gluteal pain.

MRI unveils abnormal fibrous bands, atrophy, muscle hypertrophy, and muscle or tendon tears. Magnetic resonance neurography may even show nerve trace abnormalities in the deep gluteal space.

In mechanical neuropathies, MRI can identify the presence of fascicular edema and perifascicular fat abnormalities. Note that MRI will not always serve to confirm a diagnosis. But even when magnetic resonance neurography and similar tools do not confirm a diagnosis, it is always valuable to rule out other pathologies (8).

Ultrasound can also play a crucial role, adding real-time evaluations to the diagnostic arsenal. Doctors may carry out tests such as internal and external hip rotation to evaluate how it looks from deep within. Ultrasound can also guide palpation and identify structures likely to be a source of pain, such as nerves, tendons, and gluteal muscles (9).

Deep Gluteal Pain vs. Other Conditions

Deep gluteal pain has many differential diagnoses. In other words, different conditions can masquerade the signs and symptoms listed above. But there were also terminology changes over time, which is often a source of confusion.

So, when you read about other conditions with the same list of signs and symptoms, remember that deep gluteal pain syndrome is a relatively new term. It started to be used in the literature as new pathologies were added as potential causes of the same syndrome. The new term encompasses all of them.

The best way to explain this is through a few examples (6):

Piriformis syndrome

It is also known as fat wallet syndrome or walled sciatica. The term has been around since the 1930s. It was formally adopted as medical terminology in the literature by 1947. But what’s the difference between piriformis syndrome vs deep gluteal pain?

Today, the term is still used despite the tendency to change it to deep gluteal syndrome. It’s because the term can be misleading. It implies that the piriformis muscle alone is to blame for the symptoms we just described. As a new term, deep gluteal syndrome casts a wider net. It also encompasses new entities health professionals should consider.

Proximal hamstring tendinopathy

Hamstring deep gluteal pain has undergone a name evolution, too. It occurs due to repetitive loading and strain over the hamstring and its tendon.

Repetitive motion causes micro-tears, inflammation, thickening of the tendon, and compression of the underlying nerve (sciatic nerve entrapment). Rupture of the tendon may also occur.

This entity can be a cause of deep gluteal pain. Thus, similar to the piriformis syndrome, it is encompassed in the deep gluteal syndrome.

Trochanteric bursitis

This entity features inflammation in the bursa of the greater femoral trochanter. Thus, trochanteric bursitis can trigger deep gluteal pain, but hip pain is the most common symptom.

People with trochanteric bursitis usually present with pain on the outside of the hip and posterior thigh. It is one of the differential diagnoses to consider in a case of buttock pain.

Treatment Options

Treating deep gluteal pain may require different modalities and strategies. The main highlights are medication and physical therapy. Encouraging relative rest and adjustments in certain activities and habits is also essential.

Medications

Oral analgesics are often the first-line treatment. These reduce inflammation and help manage pain.

These medications can be used along with muscle relaxants when the source of the problem is muscle tension. Oral medication is often replaced with intramuscular or intravenous therapy in more severe cases (2,7).

Physical therapy

Depending on the pain trigger, there are different sets of exercises for deep gluteal pain relief. Some require the assistance of a therapist. You can do others at home.

Consistency and following instructions for the allotted time are the key. Follow the instructions to the letter and ask your physical therapist before trying something new (7).

Most professionals will recommend physical therapy rehabilitation for a minimum of six weeks. It consists of exercises to strengthen hip mechanics, tendons, and muscles involved in lower extremity movement.

Some exercises are designed to mobilize sciatic nerve entrapment in the gluteal region. This sciatic nerve glide improves flexibility and stabilizes your symptoms (2).

Massage therapy

The main massage for deep gluteal pain is neuromuscular massage therapy. It is also referred to as myofascial release or trigger point therapy.

This technique consists of applying pressure for 30 seconds to two minutes with the appropriate intensity on the right trigger point. Therefore, this technique should be administered by a professional (10).

You can also benefit from self-massage at home with foam rollers or replacing them with a tennis ball (2).

Experimental and complementary treatment

Some tough cases can improve with manual therapy, trigger point injections, and acupuncture. However, there is not enough evidence to use these methods systematically.

There are also reports with results with botulism toxin injections in the piriformis muscle. However, this approach can cause complications, such as fibrosis of the sciatic nerve (2).

Surgical treatment

Sometimes, surgery is the only resource to achieve pain relief. There are different surgical approaches, such as open decompression of the sciatic nerve or endoscopic procedures. For severe cases, this can be a game-changer in hamstring or piriformis muscle syndrome, and traumatic causes of deep gluteal syndrome (7).

How to Treat Deep Gluteal Pain at Home

How to treat gluteal pain at home? There are many options out there besides traditional medical treatment. They do not replace medical therapy but may help you find comfort at home. Here’s a summary of the most effective home remedies, stretches, and recommendations (2).

Activity modifications

Pay attention to any activity modifications proposed by your doctor and physical therapist. Depending on the source of the pain, you may need to make some changes.

For example, in hamstring tendinopathy, you should avoid bending activities, especially deadlift exercises. Also, avoid stretching the hamstrings unless directly recommended by your therapist.

In all cases of sciatic nerve entrapment, alternating periods of sitting and standing can make a lot for you. Likewise, doctors and therapists may recommend drivers to move the seat closer to the steering wheel. If you’re a runner, you may need to reduce your stride length.

Additional recommendations

Further changes include shedding excess weight and quitting smoking. Also, anti-inflammatory foods can be suitable home remedies for deep gluteal pain, such as turmeric and omega 3.

Ice and low temperatures can also improve pain temporarily. However, do not apply ice directly to the skin. Use a cloth to keep your skin apart, and use ice therapy for five minutes to avoid ice burns.

Stretches and exercises

There’s a range of deep gluteal pain stretches to try at home. The recommended set of exercises is not the same for all patients. Therefore, always consult your therapist before embarking on any new routine.

Here are a few examples of exercise for deep gluteal pain:

Some patients with piriformis syndrome may benefit from a piriformis muscle and glute stretch with a foam roller. To perform this exercise, lie on the floor with your buttocks resting on the foam roller. With the knees bent, move forward and backward to stretch the gluteus muscles.
Another exercise is the glute stretch lying. Lie on the floor bending your knees at 90°. Cross one ankle with the opposite knee. Push until you feel a little stretch. Repeat on the other side.
Sitting exercises can also be done, such as the piriformis muscle stretch sitting. It is very similar to glute stretch lying, but instead of lying on your back, you will sit on a chair. After crossing your ankle with the knee on each side, lean forward until you feel the stretch in your buttocks.

FAQs

Can deep gluteal pain be chronic?

Yes. Chronic deep gluteal pain can develop when a long-standing ailment is causing the symptoms. Some cases of recurrent or refractory pain can reach a chronic state.

That is why doctors leave surgery as a last resort, but there are still patients who are not candidates. They should seek supportive treatment rather than a curative approach and may still experience chronic pain.

How does deep gluteal pain affect leg abduction?

Deep gluteal pain with leg abduction can be a sign of piriformis muscle involvement. This movement can be used in the physical examination as one of the maneuvers to identify the source of the pain. It is a sign of inflammation of the piriformis muscle or sciatic nerve irritation.

When should I consider surgery for deep gluteal pain?

Surgery is the last treatment option for patients who do not respond to medical treatment and physical therapy. In most cases, conservative treatment is sufficient to improve lifestyle and, in many cases, solve the underlying problem.

How long does it typically take to recover from deep gluteal pain?

Recovery may take 6 to 12 weeks, depending on the trigger and the severity of the complaint. During this time you should follow the instructions of your doctor or therapist to speed up the results.

Can deep gluteal pain be a sign of a more serious underlying condition?

Other problems outside the deep gluteal space can also trigger these symptoms. For example, hip joint osteoarthritis may cause referred pain in the buttocks. Something similar can also occur in femoral neck fractures and other serious injuries outside the deep gluteal region.

Conclusion

Navigating the intricacies of deep gluteal syndrome can feel quite challenging. But let’s have a deep gluteal pain summary.

In short, deep gluteal pain syndrome is a localized pain in the buttocks. It often radiates due to sciatic nerve entrapment (sciatic pain). It was known as piriformis syndrome for many years, but the term is being updated to encompass other pathologies of the deep gluteal space.

The pain results from abnormalities in the muscles such as the piriformis muscle, tendons such as the hamstring tendon, and other structures of the deep gluteal space. It features an umbrella of conditions that demand thorough evaluation.

So, if you are grappling with deep gluteal pain, ask your healthcare provider and seek professional help before it becomes unbearable. After a physical examination and some tests, a diagnosis and accurate treatment will be possible.

Do not hesitate to come to a professional for deep gluteal pain. Most patients find relief through conservative treatment and physical therapy, making a profound difference in their quality of life.

References:

Podschun, L., Hanney, W. J., Kolber, M. J., Garcia, A., & Rothschild, C. E. (2013). Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report. International journal of sports physical therapy, 8(4), 462.
Hu, Y. W. E., Ho, G. W., & Tortland, P. D. (2021). Deep gluteal syndrome: a pain in the buttock. Current Sports Medicine Reports, 20(6), 279-285.
McCrory, P., & Bell, S. (1999). Nerve entrapment syndromes as a cause of pain in the hip, groin, and buttock. Sports Medicine, 27, 261-274.
Franklyn-Miller, A., Falvey, E., & McCrory, P. (2009). The gluteal triangle: a clinical patho-anatomical approach to the diagnosis of gluteal pain in athletes. British journal of sports medicine, 43(6), 460-466.
Ohm-Pedersen, K. (2018). Gluteal Tendinopathy. Clinical Practice Guidelines, 357.
Carro, L. P., Hernando, M. F., Cerezal, L., Navarro, I. S., Fernandez, A. A., & Castillo, A. O. (2016). Deep gluteal space problems: piriformis syndrome, ischiofemoral impingement, and sciatic nerve release. Muscles, ligaments and tendons journal, 6(3), 384.
Martin, H. D., & Gómez-Hoyos, J. (2019). Deep gluteal syndrome. Posterior Hip Disorders: Clinical Evaluation and Management, 167-187.
Hernando, M. F., Cerezal, L., Pérez-Carro, L., Abascal, F., & Canga, A. (2015). Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space. Skeletal radiology, 44(7), 919-934.
Chang, K. V., Wu, W. T., Lew, H. L., & Özçakar, L. (2018). Ultrasound imaging and guided injection for the lateral and posterior hip. American Journal of Physical Medicine & Rehabilitation, 97(4), 285-291.
Awan, W. A., & Babur, M. N. (2011). Effectiveness of deep friction massage & stretching exercises in piriformis syndrome. IJCRB, 3(03), 378-383.

What Does Psoas Release Feel Like? – What Most People Experience

Written by Sam Visnic on October 1, 2023. Posted in Psoas.

The psoas muscle is the most powerful hip flexor muscle, and is essential to stability of the hips, pelvis, and spine. It is commonly found to be short and tight on testing (the Thomas Test), but not always.

Just because the muscle isn’t found to be tight on testing, doesn’t mean that it doesn’t FEEL tight.

I frequently have this type of discussion with my personal clients, and it is very often very enlightening for them to understand what a muscle release feels like.

What does a psoas release feel like?

We all know what it feels like to stretch a muscle. For example the hamstrings, or the calves. Its a fairly sharp, pin-point type of feeling at the end of the available range of motion that the muscle has. As we stay in that position, it’s as almost the muscle starts to let go and give way a bit.

This is the same feeling you will feel when stretching your psoas. The easiest position to feel this stretch is in the Thomas Test position. As the upper thigh is allowed to hang, the psoas is put into a lengthened position. As gravity does the work, the upper thigh will descend as the muscle stretches and lets go.

This feeling is a bit different when hands-on techniques are used to release the psoas muscle.

In the following video, I demonstrate a massage technique technique for the psoas.

First of all, its not possible to make direct contact with the psoas without making contact with the tissues on top of it, so the pressure is super gentle, and whatever tissue/s are sensitive will be the target of the technique. You certainly won’t feel a stretch in the muscle, or much tenderness like you would when working another muscle such as the TFL or quadricep.

At the tendon attachment of the psoas on the femur, there is much more of a chance of making contact with it. The insertion point will be much more tender and often sharp.

When working that attachment (as well as many other areas), I usually only press to a 4/10 max intensity on the point. This is confirmed by the client’s input on how sensitive it is. This stimulation is sufficient to bring the person’s awareness to the muscle, but very comfortably.

At that point, I ask them to take a nice deep but comfortable breath in, hold it for a movement, then sigh and exhale fully to relax.

The psoas “release” occurs at this point. What it will feel like is that I have lessened my pressure on that point, but I have not. So, what happened?

My theory here is that the very low level of “threat” or guarding that occurred on pressing the tender spot was essentially discharged or diminished as a result of the deep breath followed by the exhalation. It allows the nervous system to be reminded of safety. The context of being in the therapist’s office, performing low-threat, comfortable techniques for the purpose of relief, helps make the release possible.

After the technique is repeated for a number of repetitions, re-testing is done to check for improvements. This can be done by repeating the Thomas Test, testing the performance of the muscle, or simple standing and walking around to note any differences in the person’s experience.

That is how a psoas muscle release feels like!

How To Stretch Psoas While Sleeping – Is It Possible?

Written by Sam Visnic on October 1, 2023. Posted in Psoas.

So you’ve been told that your psoas muscle is tight and it needs to be stretched.

Certainly this is easy enough to do with proper psoas stretching techniques during the daytime, but is it possible to do at night while sleeping?

Sure, but it may not be a good idea. Let’s dive into this a bit more.

Is it possible to stretch the psoas while sleeping?

The psoas muscle is a hip flexor, so stretching it means placing it into its lengthened position, which is in extension.

The best example of this is the Thomas Test:

As you can see the upper thigh needs to move into extension, which is moving in the direction behind you. This is not the only thing you have to pay attention to. The lower spine needs to be in a stable position, which is either a neutral curvature, OR flat on the table in order to allow for a full psoas muscle stretch.

Now, imagine yourself having to be in this type of position in bed. Sure its possible to maintain this position while awake, but at night?

No way.

And even if you figured out a way to rig this setup so that you could fall asleep in it, your leg would very likely fall asleep in that position. It would be very uncomfortable.

What works better?

The better option is to sleep in a comfortable position which allows the greatest relief in order to get a good nights sleep, and address chronic psoas tension issues in the daytime!

6 Step Guide to Releasing a Tight Psoas Muscle

Written by Sam Visnic on August 27, 2023. Posted in Massage Therapy, Muscles, Psoas, Stretching.

The psoas muscle (also known as the iliopsoas) plays an important role in spinal stabilization and hip flexion. However, chronic tightness in the psoas can lead to low back and hip pain. Releasing the psoas requires a comprehensive approach to address the muscle itself as well as contributing factors.

In this guide, we will cover the key steps to releasing a tight psoas muscle:

Assessing psoas and hip flexor tension
Ruling out underlying issues
Stretching the psoas
Psoas release massage techniques
Releasing other hip flexors
Activating glutes and hamstrings

Read on for details on each step. And be sure to check out our dedicated posts that dive deep into psoas tests, stretches, and release techniques.

Key Takeaways:

Properly assessing hip flexor tension is essential before assuming the psoas muscle is tight. The Thomas Test is commonly used to evaluate hip flexor length.
Rule out underlying pathology, such as hip joint or lumbar spine issues, before focusing on psoas release techniques.
Stretching the psoas involves reversing its action by side-bending the spine away from the side of the stretch.
Neuromuscular techniques like reciprocal inhibition and post isometric relaxation can enhance the effectiveness of psoas release.
Manual therapy, such as massage techniques, can help address chronic tightness in the psoas muscle.
Additional hip flexor muscles, such as the rectus femoris and tensor fascia latae, should also be addressed to reduce overall hip flexor tension.
Facilitating the opposite muscles, particularly the hip extensors, can help relax the tight hip flexors and improve range of motion.
If all steps have been followed and tightness persists, consider seeking manual therapy or addressing other underlying issues that may be contributing to the tension, and be sure to include psoas strengthening exercises.

Step 1: Assess True Psoas and Hip Flexor Tension

Everyday I see people that have been told their iliopsoas muscle is tight, and its causing all their problems. However, most of these people have never actually had their hip flexors assessed for tightness.

Just because someone looks like their pelvis has a bit of increased anterior pelvic tilt does not automatically mean the psoas major is tight.

The “feeling of tightness” or tension isn’t the same as actually having a positive hip flexor tension test. This is why it needs to be assessed properly, and additional psoas myths need to be eliminated.

Thomas Test

The Thomas Test is best way to measure hip flexor length and is commonly performed by physical therapists. It not only tests psoas muscle tension, but also the other hip flexors including the rectus femoris, sartorius, and even the tensor fascia latae (TFL).

Since the psoas connects the lumbar vertebrae to the thigh bone (lesser trochanter), it has an important stabilization function for the lumbar spine, but also acts as a hip flexor.

To perform the Thomas Test, sit at the edge of a massage table (or bed if you don’t have access to a table), and bring one knee toward your chest.

The goal here is to have enough hip flexion to get a slight posterior pelvic tilt so that your lower back is flat on the table.

The opposite leg is allowed to hang fully in order to assess the degree of hip flexion.

There are a few primary things we are looking for here:

The thigh should rest at least parallel to the floor (optimally about 10 degrees below parallel indicating the psoas muscle has adequate length)
There is no hip pain or knee pain in this position, only a feeling of a upper thigh area or psoas stretch (pain may indicate an underlying hip joint condition)
From the front or top view, the upper thigh should not be excessively externally or internally rotated (this may indicate tightness in the TFL and/or psoas if combined with #1)
The knee is bent near 90 degrees (if more than 90 degrees it indicates tightness of the rectus femoris, which is a quadricep muscle that is responsible for hip flexion)

Here is a video to walk you through this process:

Check out our complete visual guide to properly performing the Thomas Test.

If you find that you pass the above test, then you may be feeling tension/overactivity in your psoas muscle vs it actually being tight. Odds are likely you need on the other hip flexors in this case!

Step 2: Rule Out Underlying Pathology

Before moving on to psoas release techniques or aggressively stretching the hip flexors with the intention of getting pain relief, its important to rule out any underlying causes for psoas muscle tension, especially in the presence of chronic pain or guarding.

Guarding and tension may simply be a way the nervous system is trying to protect things.

Hip joint pathology can be a source of hip pain, and the psoas major is a protector for this region. For example, the psoas muscle may reflexively spasm to guard a labral tear.

Potential Reasons For Psoas Major Tension

Hip joint pathology
Lumbar spine and/or SI Joint pathology
Muscular imbalance elsewhere in the body (resulting in compensation pattern)
Nerve entrapment or irritation

Learn all about the potential reasons for psoas tightness and when you should see a doctor.

Step 3: Stretch The Psoas Muscle

A simple search online will turn up about a dozen different varieties of psoas stretch options. While some are creative and interesting, this muscle isn’t complicated to stretch.

To stretch any muscle, we determine which actions occur when it contracts, and simply reverse it. In the cases of the iliopsoas muscle, when the spine is in neutral, it produces hip flexion.

There are some conflicting views on the contribution of the psoas to rotation of the hip, but it is not that influential in this role. (not enough to spend time doing super duper specific little tweaks in order to get at every little fraction of the fibers anyway!)

We can, however have an influence on the degree of stretch by changing the position of the spine. By side-bending the spine AWAY from the side of the psoas stretch, we can add a little extra bonus to the lengthening of the psoas.

Here is a simple way to accomplish the psoas muscle stretch:

Neuromuscular Techniques For The Psoas Muscle

Beyond basic stretching, we can add what is referred to as neuromuscular release techniques to improve the outcome of our work.

These techniques work on simple principles of the central nervous system. The two techniques I use the most are reciprocal inhibition (RI) and post isometric relaxation (PIR).

Psoas Release Technique – Reciprocal Inhibition

Reciprocal inhibition (RI) technique involves contracting the muscles on the opposite side of the muscle that is lengthened/stretching. In this case, the muscles working on the opposite side of the iliopsoas are the glutes and hamstrings.

This technique is excellent for restoring mind-to-muscle connection in the opposing muscles, as well as improving coordination and strength at the new range of motion after a tight iliopsoas is released.

Psoas Release Technique – Post Isometric Relaxation

Post isometric relaxation (PIR) is a technique that involves a low-intensity contraction of a muscle for a short duration, immediately followed by a stretch.

When this technique is used for hip flexor stretching on a massage table, you can take advantage of gravity for the activation of the muscle (lifting up) and also assistance during the stretch phase.

Step 4: Psoas Release Massage Techniques

Manual therapy techniques are often very helpful for stubborn psoas major chronic tightness issues. Trained massage therapists often offer these techniques, and they should be only be carried out by a careful professional.

While the majority of the psoas is generally inaccessible via direct palpation, it can be contacted at the lesser trochanter attachment point, and influenced through the superficial tissues in the abdomen, just to the side of the rectus abdominus.

Psoas Massage Technique

Learn more about how massage therapists can provide psoas pain relief.

Step 5: Release Additional Hip Flexor Muscles

The psoas muscle (like ALL other muscles in the body) doesn’t work by itself. Other muscles work with it to perform functions. Hip flexion, which is what the psoas major is most known for, involves multiple muscles:

Iliopsoas muscle
Rectus femoris
Tensor fascia latae (TFL)
Sartorius
Pectineus

By addressing chronic tightness in these associated muscles, there will be a positive influence on the problematic tight psoas muscle. When one muscle is overworking relative to the rest of the group, it’s commonly referred to as “synergistic dominance”.

All of these muscles are in a relatively shortened position in the case of excess anterior pelvic tilt, so releasing muscles as a group makes more sense.

The good news is that these additional hip flexor muscles can be stretched and simple tools like a massage ball can be used to release hip flexor restrictions.

Kneeling Hip Flexor Stretch

The kneeling hip flexor stretch is my favorite go-to for addressing chronic tightness in the hip flexors, and to prepare the tissues to progress into the split squat.

The split squat is by far the best exercise to address muscular imbalance in the lower body.

Self-stretching of the hip flexor group can also be accomplished with this stretch. Depending on the amount of bend of the knee, this stretch emphasizes much more of the quadricep muscle (Rectus Femoris) than the TFL, but it works very well for the overall goal in reducing hip flexor tension.

Foam Rolling Hip Flexors

While I’m not a huge fan of foam rolling (I prefer massage as its usually far more comfortable), rolling is cheap, effective, and can be done on a frequent basis.

This checks all the boxes for addressing the hip flexor muscles such as the TFL and sartorius.

These two muscles are easy to access, but just a light warning…they can be VERY sensitive!

Foam Rolling The TFL

Foam Rolling The Adductors + Sartorius

Get the complete guide to foam rolling techniques for hip flexor and TFL release.

Step 6: Engage The Glutes And Hamstrings

If increased activity exists in the muscles that create increased anterior pelvic tilt, then the opposing muscles will contribute to posterior pelvic tilt.

These antagonistic muscles when targeted, will create a neurological “inhibition” effect on the hip flexors. A simple example of this would be doing a bicep curl. The tricep muscle must lengthen in order for the bicep to shorten.

The tricep does not “shut off”, but a different set of nervous system signals has to go to this muscle group in order to perform the activity.

The same type of relationship exists between the hip flexors and hip extensors.

By following psoas release techniques with movement techniques which emphasize the opposite muscles, we can encourage the nervous system to relax the tight muscles, but also train the new range of motion achieved.

Bottom line, this helps to get our work to “stick”.

Glute Bridge

This is an easy go-to exercise for the hip extensor muscle group. One of the main challenges of this exercise is learning how to maintain a posterior pelvic tilt as the hips are lifted, and to sense when to stop at the top.

In the video, I demonstrate how to do this, and in particular, how to reduce any discomfort often felt in the lower back. This is usually due to over-activity in the lower back muscles and extension in the lumbar vertebrae in some individuals that are sensitive to this.

Discover the best hip extensor exercises to relax tight hip flexors.

Step 7: When Psoas Tension Persists

If you’ve gotten to this point, and followed all of the above steps, and still have not been able to reduce the sense of tightness in your psoas and at least improved a bit on your hip extension range of motion, you may need to look elsewhere for the solution.

As mentioned at the top of this post, NO muscle group works alone. Our bodies are meant to compensate in a variety of ways for some times very complicated reasons. Chronic pain in particular can cause us to move in certain ways in an attempt to keep us safe.

The hip flexors in particular are very responsive to this need.

Manual therapy in particular may be needed to address chronic tightness in the psoas muscle. Massage therapy applied directly to the psoas major attachments at the lesser trochanter, along with the other hip flexors may help further relax the psoas muscle and get pain relief.

Why Hip Flexors Won’t Release

Check out my tips on what to do when hip flexors refuse to release.

In Conclusion

Releasing a chronically tight psoas requires patience and a holistic approach. Work through each of these steps – assessment, ruling out pathologies, stretching, massage, releasing surrounding muscles, and strengthening the area. Dramatic change doesn’t happen overnight, but you should notice gradual improvement in mobility and reduction in muscle tension.

For more in-depth information on psoas release, check out the links within each section. And as always, comment below with any psoas or hip flexor questions!e muscles.

Author: Sam Visnic

Understanding Hamstring Tendinopathy: Definition and Causes

Risk factors

Spotting the Symptoms: Key Indicators of Hamstring Tendinopathy

Straight Leg Raise Test

Slump Test

Bent-knee stretch

Modified bent-knee stretch

Puranen-Orava test

Hamstring loading movements

Diagnostic Procedures

Basic assessment

Differential diagnoses

Treatment and Management Strategies

Patient Education

Rehabilitation

Other conservative measures

Return to sports and prognosis

Surgical treatment

Tips for Preventing Recurrence

References:

Piriformis Muscle Anatomy And Function

Function of the Piriformis Muscle:

What Are Trigger Points And Why Do They Matter?

Main Complaints Related To Trigger Points in The Piriformis

Causes Of Piriformis Pain And Trigger Points

Piriformis Trigger Point Locations

How To Self-Release Piriformis Trigger Points

Follow Up Stretching The Piriformis

Follow Up Exercises For Piriformis

Locating Plantar Fascia Trigger Points

The Science Behind Trigger Points

Foot Trigger Points

Calf Trigger Points

Peroneal Trigger Points

Tibialis Trigger Points

Trigger Point Release Techniques

Static Pressure Release

Kneading

Muscle Energy Techniques

Does self release with a trigger point roller help?

Important Tip: Follow up with stretching

Alternative Treatments for Plantar Fasciitis

A Comprehensive Treatment Plan for Plantar Fasciitis

The Quadriceps Muscles And How They Work

Quad Trigger Points – Where Are They Located?

Symptoms Associated

Causes And Treatment Options

Differential Diagnosis – What Else Could It Be?

How To Self Treat

Stretching The Quadriceps

Muscle Energy Technique For The Quads

Conclusion

Evaluating the Accuracy of MRI

How does MRI results affect treatment?

Piriformis syndrome

Variants of the sciatic nerve

Variants of the piriformis muscle

Deep gluteal syndrome triggered by trauma and overuse conditions

Hamstring tendinopathy

Other muscle-related problems

What are the limitations of MRI in evaluating Deep gluteal pain syndrome?

Conclusion

Key Takeaways

Understanding Pectoralis Trigger Points

Pectoralis Major Muscle

Pectoralis Minor Muscle

Referred Pain Patterns

Identifying Pec Trigger Points

Locating Pec Major Trigger Points

Locating Pec Minor Trigger Points

Potential Causes of Pectoral Trigger Points

Treating Pectoralis Trigger Points

Self-Massage Techniques

Professional Therapy Options

Stretching Exercises

Preventing Pectoralis Trigger Point Activation

Pectoralis Trigger Points and Related Conditions

Summary

What is Deep Gluteal Pain?