Click here to see the full post: http://www.athletestreatingathletes.com/self-muscle-massage-series/self-muscle-massage-pt-10-low-back/

Click here to see the series: http://www.athletestreatingathletes.com/category/it-band/

In the first part of the series, the post talks about what PFS is, what causes it, and how to differentiate it from other possible diagnoses. The second part of the series focuses on how to treat it and offers tips for managing initial post injury symptoms, muscle massage and stretching.

Click here to see both posts: http://www.athletestreatingathletes.com/category/patellofemoral-pain/

Click here to read more:

http://www.athletestreatingathletes.com/self-muscle-massage-series/self-muscle-massage-pt-9-the-foot/

http://www.athletestreatingathletes.com/self-muscle-massage-series/self-muscle-massage-pt-8-shinouter-ankle/

http://www.athletestreatingathletes.com/self-muscle-massage-series/self-muscle-massage-pt-7-adductors/

For this weeks installment we’re moving south from the hip to talk about the quad muscles. With this blog post, we’ll also be moving the series to it’s new home “Athletes Treating Athletes”. We will be posting links to new posts and series here as well, but hope that you will take a peek at the new website to see what we have planned for you. Here is the link to this weeks installment!

http://www.athletestreatingathletes.com/self-muscle-massage-series/self-muscle-massage-pt-6-quads/

Potential Causes of Injury

1) During normal ambulation, the hip flexors are active during the swing phase (meaning they pull the leg through to start the stance phase all over). With normal push off at the big toe, knee, and hip, part of this motion is passive (meaning the hip flexor can use that momentum to lesson the load on itself). If the push off is incomplete ( as is the case with chronically tight gastrocs and hamstrings for example), the hip flexors must pick up the slack and actively pull the leg through. This can result in a tendon/muscle overuse injury or an acute injury due to a forceful contraction.

2) Due to their location, the muscles in the front of the hip are prone to contractures due to prolonged sitting. As the muscles adapt to that shortened position, they limit hip extension and subsequently push off. This can result in tendon/muscle injuries.

3) In the presence of an anterior pelvic tilt (when the front of the pelvis tips down towards the ground), the anterior muscles are kept in a shortened position and can lead to contracture over time. The hamstring muscles in the back of the thigh are then weakened by being kept in a lengthened position. As the back of the hip is unable to extend, the hamstrings are also unable to compensate, and the hip flexors are left to do all of the work.

4) Combine any of the above scenarios with a deviation from mid-line (when the the whole leg is pulled in towards mid-line) and it is not uncommon for the tight and overworked anterior muscles to get pulled out of their grooves and begin sliding/snapping over the hip bones. This is commonly referred to as snapping hip syndrome.

Anatomy:

Landmarks

In the front of the hip there are two landmarks used to navigate the muscles. One is bony and the other is soft tissue.

#1 The ASIS (anterior superior iliac spine)- while the PSIS is at one end point of the iliac crest towards the back, the ASIS is the end point towards the front. To find it, start with your hands on your hips and your fingertips pointing towards your stomach. Unlike the other two bony landmarks that are small bumps, the ASIS are larger and easily palpable when you follow the iliac crest forward. Visually, when you lay on your back, they are the two hip bones sticking out towards the ceiling.

#2 The groin line- this is a visible soft tissue landmark. When you flex  your hip (lift your knee up towards the ceiling), it is the line/crease between your thigh and pelvis.

Muscles

#1) The TFL- the TFL is a small muscle that originates from the ASIS and inserts into the ITB itself. To find this muscle, lay on your back with your hand on the ASIS. With your knee bent, flex your hip (bring your knee towards your chest like you were sitting in a chair) and rotate your whole leg IN (think opposite motion of crossing your ankle over your knee). As you rotate the leg, the knee will move in slightly and the outside of your ankle will come up. You will feel the TFL move under your hand.

#2) The Sartorious- this muscle is a s small rope like muscle that originates on the ASIS and wraps across the thigh to insert just below the inside of the knee. Like the TFL, to find this muscle, bend your knee and flex your hip (bring the knee up towards the ceiling). Rotate your whole leg OUT (like you’re trying to prop your ankle up on your other knee). You will feel the Sartorious move under your hand.

**Note: the TFL and Sartorious form a “V” at the front of the hip. Start with your hand on the ASIS and move down towards the groin line. As you rotate the leg in and out, you will be able to feel both muscles moving and sink your thumb right in between them into the “V”. The floor of the V is where the next muscle is, your rectus femoris (RF).

#3) Rectus Femoris (RF) - the RF is one of the four quadriceps muscles and is responsible for extending the knee. Because it is the only quad muscle to cross the hip joint, it also aids in hip flexion. As stated above, to find this muscle, locate the V and sink down into that groove between the sartorious and TFL. There you will find the RF as it moves towards its insertion point.

#4) Psoas/Illiacus - The Psoas and Illiacus muscles are the large hip flexor muscles. They insert into the front of the femur and then move up into the abdominal cavity. The Illiacus muscle inserts into the inside of the pelvic bone and the psoas move up to insert into the lumbar spine. Due to the deeper location, working on the upper portions of the muscles is difficult, specific due to the presence of internal organs, and should be left to professionals. There are a few ways you can work on them however. First, you can work on them at their distal insertion onto the femur. To do so you will need to work your way down the groin line.

In the picture above, the blue lines represent your two landmarks. The one at midline is your belly button and the other is your ASIS. The red lines represent your abdominal muscles. To find the distal portion of the psoas and illiacus, start on the blue lines and work your fingers in until you find the outer edge of your abs. Move just outside of them (towards the hip) and follow that down to the groin line (this is the green line in the picture).

The other area that you can access the psoas is to work on it’s upper insertion into the lumbar spine. To locate the lumbar spine, palpate your last rib and trace it around to your back. This is the level of the last thoracic (midspine) level (T12). Each subsequent bump is the lumbar spine. In the case of the psoas muscle it inserts into levels two through four.

To work on the upper levels, you then want to target just to the side of the lumbar spine. The further away from the spine you move, the less likely your are to be on the right spot.

#5 Pectineus and Obterator Externus- these muscles are furthest down the groin line towards mid-line of the body. Due to their location they work with the adductors to move the leg in to the body. As you find the psoas and iliacus muscles, move medial (towards the mid-line) and feel for a pulse. The femoral artery moves through this area. The muscles are medial (towards mid-line) to the the artery and insert right into the pubic bone. The pectineus is the more superficial and lays directly over the obterator. Note: if you ever feel any numbness/tingling while trying to locate these muscles, move closer to the pubic bone. You’re hitting the femoral nerve.

Soft Tissue Techniques

Key Area’s to Work On:

1) The trick with the front of the hip is to work the entire groin line from the ASIS to the pubic bone.

2) Due to the deeper nature of the muscles, cross friction and trigger point works best on this area. However, the foam roller can still be used to loosen things up and desensitize the area prior to using the tennis ball.

Here’s a video demonstrating the different techniques for the anterior hip:

References:

1) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

Potential causes of injury:

1) On a muscular level, tension is increased on the outside of the hip any time that the knee is pulled in towards the mid-line of the body (sometimes called knock knee or genu valgum). This can happen with chronic tightness (or contracture) of the adductors and internal rotators. When this occurs, the gluteus medius and minimus muscles are held in a lengthened position and subsequently weakened.

2) On a structural level (meaning bones and joints), the knee joint can be pulled in towards the mid-line when there is over-pronation at the foot and ankle. Indirectly, the outside of the hip can also be affected by the presence of an anterior pelvic tilt (when the front of the pelvis rotates down towards the ground). This results in tight hip flexors and weak hamstrings/glutes which alters normal propulsion during gait. The result is commonly that the inner hamstrings and adductors work harder to extend the hip and over time shorten due to the repetitive stress; the knee is pulled in towards the mid-line due to the resulting muscle contracture and the lateral hip muscles overloaded.

Anatomy:

Bony structures

Like the posterior aspect of the hip, working on the outside will require you to know and find a few bony landmarks. There are four: 1) the greater trochanter, 2) the PSIS, 3) the ASIS, and 4) the head of the fibula.

#1 The Greater Trochanter- the GT is a common muscle insertion point on the outside of the hip. To find it, start with your thumb on top of your hip bone at the highest point of the iliac crest. From there, simply lay your hand down over the outside of your hip with your fingers pointed down towards the floor. The GT can be found under or close by where your middle finger is (it will be a small bump).

#2 PSIS (posterior superior iliac spine)- To find this one, you’re going to start with your hands on your hip bones (iliac crest) so that your thumb is pointing towards your back and your fingers are pointing forwards towards your stomach. As you reach behind with your thumbs, you’re looking for two small bumps on either side of your spine. Visually, you can see them. They are the two “dimples” at the small of your back.

#3 The ASIS (anterior superior iliac spine)- while the PSIS is at one end point of the iliac crest towards the back, the ASIS is the end point towards the front. To find it, start with your hands on your hips and your fingertips pointing towards your stomach. Unlike the other two bony landmarks that are small bumps, the ASIS are larger and easily palpable when you follow the iliac crest forward. Visually, when you lay on your back, they are the two hip bones sticking out towards the ceiling.

# 4 The fibular head- I’m including this landmark to point out that your ITB runs all the way down the outside of your leg and inserts BELOW your knee. To find it, while sitting with your knee bent, wrap your hand around the upper part of your calf so that the space between your thumb and index finger are directly behind the knee and your fingers are wrapped around towards the front of your knee. The fibular head will be the large, bony bump under your index finger.

Soft Tissue Structures

1) GM (gluteus medius + minimus). These two muscles lay one on top of the other and are two fan shaped muscles that originate on the outside of the ilium (hip bone) and insert onto the greater trochanter. The larger medius muscle is the more superficial of the two. Together these muscles abduct the hip (move the leg out to the side and away from vertical midline). They also contribute to rotation of the hip. With the hip in flexion they rotate the knee out (external rotation) and with the hip in extension, they rotate the knee in (internal rotation).

2) TFL (tensor fascia latae). The TFL is a small muscle that originates from the ASIS and inserts into the ITB itself. To find this muscle, lay on your back with your hand on the ASIS. With your knee bent, flex your hip (bring your knee towards your chest like you were sitting in a chair) and rotate your whole leg IN (think opposite motion of crossing your ankle over your knee). As you rotate the leg, the knee will move in slightly and the outside of your ankle will come up. You will feel the TFL move under your hand.

3) ITB (iliotibial band). The ITB starts at the greater trochanter and runs all the way down the outside of the leg to the fibular head.

Soft Tissue Techniques

What you’ll need: a foam roller and trigger point ball.

Key Areas to Work On:

1) The Gluteus Medius and Minimus take up the whole “fan” on the outside of the hip. Be sure to work the whole fan to get a full release of the muscles. Cross friction and trigger point (sustained pressure) work best on the is area.

2) The TFL is slighly in front of the GM “fan” and below the ASIS. Use the foam roller to release general tension and trigger point any muscle knots or spasms.

3) The ITB is best worked with the foam roller. Use the elongation technique to warm up the area and then cross friction with the roller. Be sure to work from the greater trochanter all the way down below the knee.

Video

Here’s a video to help demonstrate the techniques specific to the lateral hip.

References:

1) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

]]> http://pinnaclept.wordpress.com/2010/04/05/self-muscle-massage-pt-5-lateral-hip/feed/ 1 leighpt lateralhipbone greatertroch psis asis fibhead1 fibhead2 lathipmuscles mssgchart2 http://pinnaclept.wordpress.com/2010/03/29/self-muscle-massage-pt-4-posterior-hip/ http://pinnaclept.wordpress.com/2010/03/29/self-muscle-massage-pt-4-posterior-hip/#comments Mon, 29 Mar 2010 11:49:22 +0000 Leigh Boyle http://pinnaclept.wordpress.com/?p=338 ]]> Of all the areas I’m asked about, the hip is easily one of the most popular. It’s also one of the most complex in terms of it’s muscle/mobility and joint structures.

On a muscular level, there are multiple layers working together to move the hip through three different planes of motion:
1) flexion and extension-forward and back
2) adduction and abduction- in and out from the vertical midline of the body
3) internal and external rotation- rolling the leg so that the outside of ankle is up towards the ceiling (internal) and rolling the leg so that the inside of ankle is up towards the ceiling (external).

On a bony/joint level, the hip is part of the lumbo-pelvic-hip complex. This means that the hip joint is part of the pelvic bone and can be influenced by the lumbar portion of the spinal column and vice versa. If one end of the chain is disrupted, the other end will also be affected.

With that being said, I’m going to be talking about the hip over the next three installments in the blog. This will help break down the information and allow focus on each of the major muscle groups in isolation instead of throwing it all together into one big confusing blob of information.

To start, we’re going to talk about the back of the hips first. This is where the large gluteus maximus muscle is located and beneath it, the external rotators (the piriformis being the most popular). This area is susceptible to injury for several reasons. As your leg moves into full extension during the push off portion of the gait cycle, the gluteus maximus is the primary muscle responsible for hip extension. The external rotators assist in providing this extension and take on a much larger role in situations where the leg is rotated and extension is required. If the leg becomes rotated for an extended basis due to muscle imbalances, weakness, or contractures (chronic shortening of a muscle), the smaller rotators can become overused and injured.

To give you some examples of how this might occur:
1) Hyperpronation/Hypopronation at the foot/ankle. Chronic abnormalities at the foot and ankle joints are commonly associated with rotation of the entire lower leg. This rotation occurs over time as a compensation mechanism to maintain propulsion while walking (as the foot rotates in/out the gastroc is unable to provide push off). The result is that instead of push off coming from the calf, quads, and glutes, the workload is shifted up the leg chain to the hip extensors (hamstrings, glutes, external rotators). With the rotation of the leg, the workload is shifted more and more to the small external rotator muscles.
2) Tight Adductor Muscles/Weak Abductor Muscles. In the hip joint, the outer abductor muscles help stabilize the pelvis while walking, keeping it level as you stand on one foot and the other swings through. It is common for these muscles to become weak/overused, resulting in tight adductor muscles that over time can become contracted. In addition to pulling the thigh bone (femur) in towards midline, the adductors can also assist with hip extension and internal rotation. As they become contracted, hip extension will become limited (increasing the workload on the gluteus max) and the tight internal rotators can put the external rotators on stretch (making them more susceptible to injury).

Anatomy:

Unlike the calf and hamstrings where you can see the muscles you’ll be working on, the external rotators are hidden beneath the gluteus maximus. To find them, we’ll use three bony land marks: 1) PSIS (posterior superior iliac spine), 2) Greater Trochanter, 3) Ischial Tuberosity (sit bone).

#1 the PSIS. To find this one, you’re going to start with your hands on your hip bones (iliac crest) so that your thumb is pointing towards your back and your fingers are pointing forwards towards your stomach. As you reach behind with your thumbs, you’re looking for two small bumps on either side of your spine. Visually, you can see them. They are the two “dimples” at the small of your back.

#2 The Greater Trochanter. This landmark is the insertion point for all of the external rotators. To find it, start with your thumb on top of your hip bone at the highest point of the iliac crest. From there, simply lay your hand down over the outside of your hip with your fingers pointed down towards the floor. The greater trochanter can be found under or close by where your middle finger is (it will be a small bump).

# 3 Ischial Tuberosity. Of the three landmarks, the IT is the easiest to find. Simply sit on your hands. You will feel the two “sit bones”. They are in the middle of the gluteal fold on both sides.

The Muscles

An easy way to visualize the external rotators is as a fan. They all insert onto the greater trochanter and then fan out from the PSIS to the IT. The larger gluteus max then lays on top of these muscles.

1) The Piriformis Muscle (Green Line)

2) The Superior Gemelli, Obterator Internus, Inferior Gemelli (Purple Line)

3) The Quadratus Femoris (Red Line)

4) Gluteus Maximus- the glute max covers the rotators. It originates on the sacrum (tail bone) and then inserts into the posterior femur.

Key Areas to Work on:

Unlike the calf and hamstring where there were common points of injury, the trick for working on the back of the hip is to cover all of the fan. When the hip tightens up, you want to release it in all directions. Because the external rotators are deep to the glute max, cross friction and sustained pressure (trigger point) techniques work best on this area. As a general rule of thumb, I start off with the elongation technique using the foam roller. This will help to loosen up the area and to locate any deeper muscle spasms or knots.

Here’s a review of the techniques.

Lastly, here is a video to demonstrate the techniques and how to use them on the posterior hip.

References:

1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

2) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

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