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5 minutes: Attendance and Breath of Arrival
50 minutes: Problem-Solving: Pelvis and Legs
Punctuality- everybody's time is precious:
o Be ready to learn by the start of class, we'll have you out of here on time
o Tardiness: arriving late, late return after breaks, leaving early
The following are not allowed:
o Bare feet
o Side talking
o Lying down
o Inappropriate clothing
o Food or drink except water
o Phones in classrooms, clinic or bathrooms
You will receive one verbal warning, then you'll have to leave the room.
Piriformis syndrome Entrapment of one or both divisions of the sciatic nerve by the piriformis muscle in the gluteal region.
Divisions of the sciatic nerve Tibial and peroneal nerves.
o Greater sciatic notch of the ilium (superior and lateral)
o Piriformis (superior)
o Other 5 deep lateral rotators (inferior)
o Sacrospinous ligament (inferior)
o Pain or paresthesia in the gluteal region that radiates down the posterior lower extremity
• Paresthesia Sensation of pins and needles.
o Low back pain is also a common symptom. Treating it also is wise.
o Sitting for long periods of time (sciatic nerve compression and local tissue ischemia)
o Sitting with a wallet in the back pocket (nerve compression)
Superior gluteal nerve entrapment o Also passes through the greater sciatic notch.
o Travels superior to the piriformis.
o Innervates the gluteals.
o Nerve entrapment leads to aching buttock pain and weak hip abductors.
Myofascial trigger points in the piriformis
Sacroiliac joint dysfunction o Similar, but no radiating pain down the lower extremity
o 10% of the population: one division of the sciatic nerve goes through the piriformis muscle. The other division passes inferior to the muscle.
o 2-3% of the population: one division passes superior while the other division passes inferior to the piriformis.
o 1% of the population: both divisions pass through the piriformis.
o Note: it is not necessarily true that an individual with the sciatic nerve passing through the piriformis would be in serious discomfort all the time.
o Diffused pain felt in the lumbar or sacral region
o Caused by a number of problems at the sacroiliac joint with similar symptoms
o Pain may be referred to the groin or posterior leg
o Can be mistaken for lumbar disc pathology
o Acute injury such as an automobile accident
o Chronic dysfunctional biomechanics such as gait alteration or leg length discrepancy
o Sprain Ligament fiber stretching (permanent) or tearing.
o Friction between the articular surfaces
o Joint misalignment or joint “locking”
The sacroiliac joints: o Are the joints between the sacrum and ilia of the pelvic bones
o Have no muscles that directly span the joints
o Use lumbosacral muscles, ligaments, and fascia to control motion
o Have rough surfaces to help produce stability
The sacrum: o Acts as a wedge between the two pelvic bones
o Holds the weight of the upper body
o Is held firmly in place by a tight webbing of ligaments
o Has very slight movement called nutation and counternutation
Nutation and counternutation of the sacrum: o Nutation Forward tipping of the superior surface of the sacrum
o Counternutation Backward tipping of the superior surface of the sacrum
o Has a total range of 7-8° in the sagittal plane
o Is essential for proper mechanics (walking, bending over, etc.)
Ligaments of the S.I. joints: o Anterior sacroiliac
o Posterior sacroiliac (fascially connect to Piriformis)
o Iliolumbar
o Sacrotuberous (fascially connected to G. Max and Biceps Femoris)
o Sacrospinous
o Reduction or cessation of exacerbating activities • Effective
o Stretching and joint mobilization • Variable effectiveness: don’t take the stretch too far for too long.
o Anti-inflammatory medication • Variable effectiveness: inflammation may not be present
o Surgery • Variable effectiveness
o Cryotherapy • Variable effectiveness: only effective to a depth of 1 cm.
o Joint mobilization and manipulation • Variable effectiveness: it’s not clear why it reduces pain
o Strength training and exercise programs • Effective: stabilizes the joint
o Proliferant injections • Variable effectiveness: encourages growth of stabilizing fibrous tissue
Soft-Tissue Manipulation: Overview Prone
Draping: uncover the back Myofascial release lower back
Draping: fold sheet diagonally to access upper and lateral gluteals Myofascial release gluteals Lower back (thoracolumbar fascia, latissimus, and erectors) Swedish Deep longitudinal stripping
S.I ligament deep transverse friction *Draping: cover the back, and uncover one leg Deep Massage The Lauterstein Method Gluteus Maximus Hamstrings
Swedish Gluteal Hamstrings
Deep longitudinal stripping hamstrings Piriformis Deep longitudinal stripping Pin and stretch Active engagement deep longitudinal stripping Contract-Relax stretch Draping: cover the leg and uncover the low back S.I ligament deep transverse friction Repeat starting at the * above to treat the other leg
Draping: uncover the back
Lower back myofascial release o Assess the fascia before and after to track effectiveness o Arms crossed: place hands 10 inches apart on either side of the spine o Apply a light degree of pulling force between the hands o Hold. Wait for a subtle sensation of tissue release or a working sign o Slowly release and repeat (between the sacrum and T10)
Draping: fold sheet diagonally to access upper and lateral gluteals
Gluteal myofascial release o Use a light and slow force to lengthen the superficial fascia o Using two loose fists, stroke medial to lateral o Do not neglect the uppermost gluteal fibers
Lower back Swedish o Address thoracolumbar fascia, latissimus dorsi, and erector spinae o Effleurage, wringing, pulling, and Lift and Roll BMT o Tissues must be thoroughly warmed and softened before proceeding
Lower back deep longitudinal stripping o Address thoracolumbar fascia, latissimus dorsi, and erector spinae o Use thumbs or fingertips with hands stacked for stability o Work superiorly in 2-4 inch sections o Pause and repeat in areas of tension o Progressively work more deeply as tissues soften
S.I. ligament deep transverse friction o Use thumbs or finger tips with hands stacked for stability o Use moderate to deep pressure for 1 minute o Address all ligaments between ilium and sacrum
Draping: cover the back and uncover one leg
Deep Massage the Lauterstein Method o Use lighter pressure since the tissues are not deeply warmed yet o Gluteus Maximus o Hamstrings
Gluteal and Hamstring Swedish o Effleurage o Fulling o Kneading o Gluteal and Hamstring compression BMT o Note: be extremely thorough in warming and softening the tissues
Hamstring deep longitudinal stripping o Start with a very broad forearm stroke o Progress to thumb or fingertip stripping working proximally o Work superiorly in 2-4 inch sections o Pause and repeat in areas of tension o Progressively work more deeply as tissues soften
Piriformis deep longitudinal stripping o Check in with the client. This may feel intense. o Piriformis runs diagonally from the greater trochanter toward the
center of the sacrum o Using two loose fists focusing on 1 or 2 knuckles, strip laterally o Progress from medium to deep pressure
Piriformis pin and stretch o Holding the client’s ankle, flex the knee to 90° o Shorten the piriformis: take the hip into full lateral rotation o Pin the piriformis: use a thumb or finger to melt into it o Lengthen the piriformis: maintain the pressure. Medially rotate the hip o Repeat several times for maximum benefit
Piriformis active engagement deep longitudinal stripping o Check in with the client. This may feel intense. o Holding the client’s ankle, flex the knee to 90° o Instruct the client:
• “Use 50% of your strength to hold your leg in this position as I
try to pull it toward me” (isometric contraction) • “Slowly release that contraction as I continue to slowly pull
your ankle toward me”(post-isometric relaxation, PIR) o As the client releases, pull the ankle toward yourself o Simultaneously use the knuckles of a loose fist to strip the piriformis o Repeat the Contract-Relax-Passive Movement and Stripping
Piriformis Contract-Relax stretching o Use this for clients whose symptoms are exacerbated by pressure o Check in with the client: lateral rotation may aggravate the knee joint o Holding the client’s ankle, flex the knee to 90° o Joint mobilizations: hip medial and lateral rotations o Instruct the client:
• “Hold your leg in this position for 5-8 seconds as I try to rotate it toward me” (isometric, piriformis lateral rotation)
• “Slowly release the contraction” (post-isometric relaxation) • “Let me know when this is a good stretch for you”
o Medially rotate the hip by pulling the ankle toward yourself o When the client says its good, hold for three of your breaths o Slowly release the stretch and do joint mobilizations of the hip
Repeat on the other side starting with: S.I. ligament deep transverse friction
End with: S.I. ligament deep transverse friction
o Reduce exacerbating activities such as prolonged sitting or sitting with a wallet in the back pocket.
o If the client reports an exacerbation of symptoms during the treatment, modify the treatment. Here are some options: • Work near the origin and insertion to avoid compressing the site of nerve entrapment which can be in the muscle belly • Use Contract-Relax stretching techniques
o Completely and fully reduce hypertonicity in the gluteals prior to treating the piriformis so that treatment does not feel invasive.
o After increasing tissue pliability, stretching is key to improving flexibility and resetting the resting length for the muscles.
o Clients with S.I. joint dysfunction may need accommodations to lie comfortably on the massage table. Have several options available.
o Modify treatment if it exacerbates symptoms
o Post-treatment sensations: o Proprioception and joint position can change substantially when in
a non-weight-bearing position after treatment.
o Encourage clients to move slowly when getting up from the massage table.
o Bearing weight through the S.I. joint again after treatment could be painful.
o Overuse condition that causes lateral knee pain
o Caused by repetitive knee flexion and extension
o Similar symptoms can also be caused by restrictions in local fascia and myofascial trigger points in the vastus lateralis
o Runners and cyclists commonly experience this condition
o Friction can cause irritation and inflammation to the distal posterior IT band and the bursa between it and the lateral epicondyle of the femur.
o In knee extension, the IT band is anterior to the lateral epicondyle of the femur
o As the knee moves into flexion, the IT band moves posteriorly, rubbing across the lateral epicondyle
o Reduction of offending activities o Effective: decreased distance or not running on sloped surfaces
o Orthortics o Variable effectiveness: can address biomechanical patterns
o Anti-inflammatory medication (corticosteroid injection) o Variable effectiveness
o Surgery o Variable effectiveness: incision allows it to slide more smoothly
Soft-Tissue Manipulation: Overview Supine
Lateral thigh Swedish Effleurage, full, wring, knead, and BMT to the TFL Deep Massage the Lauterstein Method Just the TFL part of TFL, G. Medius, G. Minimus IT Band
Prone Lateral thigh Swedish Effleurage, fulling, and wringing Figure 4 position: Lateral thigh Kneading Deep longitudinal stripping Trigger point deactivation Lateral thigh deep transverse friction
Side-Lying TFL pin and stretch
Lateral thigh Swedish o Effleurage, fulling, wringing, kneading, and BMT to the TFL
Deep Massage the Lauterstein Method o Just the TFL part of TFL, G. Medius, G. Minimus0 o IT Band
Lateral thigh Swedish o Effleurage, fulling, wringing
IT band deep transverse friction o To stimulate fibroblasts to repair collagen and remodel scar tissue o Alternate degrees of knee flexion and extension to address the IT band
without directly pressing on synovial tissue deep to it. o In knee extension, the IT band is anterior to the lateral epicondyle of
the femur o As the knee moves into flexion, the IT band moves posteriorly,
rubbing across the lateral epicondyle
Lateral thigh Swedish
o Kneading
Lateral thigh deep longitudinal stripping
o Work proximally in 2-4 inch sections
o Begin using a loose fist o Then progress to thumbs or fingertips with hands stacked for stability o Pause and repeat in areas of tension
o Progressively work more deeply as tissues soften
Lateral thigh trigger point deactivation o Use client report and palpation to locate trigger points o Melt in using the steps of the fulcrum. Hold points for 8 seconds o Use thumbs to hold points for 8 seconds
TFL pin and stretch o Instruct the client:
• “Extend your leg behind you and lift it toward the ceiling.” (hyperextend and abduct at the hip)
o Support the weight of the leg with one hand o Use your forearm to compress and hold (pin) the TFL o Instruct the client:
• “Take the weight of your leg and slowly lower it toward the ground behind you.”
o Repeat several times. Shift to using thumbs to be more specific
o If the condition is severe, adjust techniques to avoid exacerbation.
o It is not a treatment goal to make the IT band as pliable and flexible as the surrounding tissues.
o Address soft-tissue tension in all of the lower extremity muscles, especially the quadriceps.
o Thermotherapy on the lateral thigh tissues may enhance stretching and massage treatments through increased connective tissue pliability.
o Use caution with any technique that aggravates symptoms.
o If the tissues are tight and sensitive but produce no characteristic referral patterns, then myofascial treatments can be effective
o Address tension in the TFL and gluteus maximus to reduce IT band tension
Piriformis Syndrome, S.I. Joint Dysfunction and IT Band Friction Syndrome
