Deep Buttock Pain: Causes and Treatment

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It can be difficult to determine the cause and to treat deep gluteal pain.  The piriformis muscle is often suspected, but rarely the source of the pain.  The muscles below the piriformis often need treatment: superior gemellus, obturator internus, inferior gemellus , obturator externus and the quadratus femoris.  A thorough differential diagnosis, Active Release Techniques (ART) and specially tailored exercises should be considered to help alleviate deep gluteal pain. Read more ›

Posted in Active Release Techniques, Myofascial Release, Obturator Internus, Quadratus Femoris

“Trochanteric Bursitis” is often Gluteal Enthesopathy

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Patient guide to Greater Trochanteric Pain Syndrome

My approach has evolved in how to treat and prescribe exercises to patients with lateral hip pain or greater trochanteric pain syndrome (GTPS). In the majority of GTPS cases, the gluteal tendons and their attachment sites to the hip are causing pain not a bursitis.

Gluteal Tendinopathy and Enthesopathy Treatment

If you are reading this you probably have been diagnosed with a gluteal tendinopathy or enthesopathy (the attachment site of the tendon to the bone).  I hope this post helps provide some helpful information, and if you are in my area make an appointment. Through the decades, I have refined my approach to the point where I now have  great success treating gluteal enthesopathy:

  • myofascial release of the gluteus medius, with a focus on the anterior fibers and the TFL
  • hip abduction exercises starting with low pain isometrics ( contract the muscle against something, with no movement)
  • manage the load on the tendons through exercise and education on the underlying pathomechanics
  • Gluteal enthesopathies (GE) are treated differently than a bursitis!  An exercise approach of high load isometrics progressing to eccentrics, is recommended for GE.
  • strengthen the hip stabilizers
  • address any weakness or tightness of all lower extremity muscles and joints

Evidence:
  • evidence that gluteal tendinopathy is more common than trochanteric bursitis. A research review was published in 2015
  • often imaging tests do not reveal any obvious abnormality in patients with lateral hip pain
  • after one year 36% (29% after five years) of GTPS cases are still symptomatic
  • 2015 study found that patients with glute tendinopathy on one side had weakness of the glutes on both side
  • high prevalence of cases have leg length discrepancy, ITB syndrome or OA at the knee, suggesting a lower limb biomechanical link
  • 2016 study revealed, “Individuals with gluteal tendinopathy exhibit greater hip adduction moments and alterations in trunk and pelvic kinematics during walking. Findings provide a basis to consider frontal plane pelvic control in the management of gluteal tendinopathy.”

“The cause of lateral hip pain is usually some combination of pathology involving the gluteus medius and gluteus minimus tendons as well as the iliotibial band. Bursitis is present in only the minority of patients. These findings have implications for treatment of this common condition.” 2013 study of 877 patients

Make an appointment at Whitley Bay Chiropractic 0191 251 9892
For more fitness, rehab, and wellness news, follow us on Facebook and Twitter.

You may also like:

High Hamstring Strain: Best Low Compression Exercises

Best Glute Medius Exercises for Runners

Research Based Hamstring Therapy – FIT Institute

The New Age of Golf Training is Creating Stronger and More Athletic Golfers Than Ever Before – STACK

Performance Therapy: Greg Rutherford’s StoryAthletics Weekly

The ART of Active Release Techniques Telegraph

How is ART different from Sports Massage  220 Triathlon

Transform Performance  Vigour Magazine

Golf Performance Therapy Titleist Performance Institute

Follow Manual Therapy UK  for all my material for health providers.

Posted in Active Release Techniques, exercises, Myofascial Release, steroid injections Tagged with: ,

Exercises to prevent a hamstring re-injury

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After a hamstring injury, what is the best way to judge if an athlete is ready to return to play? Researchers have found that after the pain of a hamstring injury (HSI) is gone that does not mean all is ok:

  • strength is slow to return
  • muscle fascicles ( a bunch of fibers) are shortened
  • reinjury rates are very high

My approach-is to combine soft tissue work and exercises (see below)

Soft tissue work myofascial therapy increases hamstring flexibility (see below). It probably does this through a neurophysiological effect.  

Eccentric exercise- There is strong evidence that eccentric exercises can prevent hamstring re-injury.   Read more ›

Posted in exercises, Hamstrings Tagged with:

Buttock pain: Obturator Internus

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The Obturator Internus (OI) is a deep gluteal muscle, which can cause pain that is often confused with hamstring pain.  For pain either side of the ischial tuberosity (sit bone) a soft tissue technique called ART is effective in treating.

Patients with deep gluteal pain near the ischial tuberosity are often told they have a high hamstring strain.  Often the hamstring is not involved, but the obturator internus or the sac beneath it called a bursa is.  About 20 different bursae have been identified near the hip and pelvis(1).  A bursitis under the OI should always be considered.

..the obturator internus tendon makes a right-angled bend over the grooved surface of the ischium, between the ischial spine and tuberosity, and then passes horizontally across the posterior to the hip joint before it inserts into the greater trochanter. Moreover, the obturator internus bursa is located between the obturator internus tendon and the grooved surface of the ischium(1) (anatomy video).

A bursa can get irritated and become inflamed (bursitis).  If tendinopathy is suspected but bursitis is also possible, it is wise to do exercises that load the tendon without compressing the bursa against the bone underneath it.  Avoiding compression of tendons where they pass over bones during loading is covered in this video.

Obturator internus EMG amplitude was greatest during hip extension, then external rotation then abduction, with minimal to no activation in other directions (2)

Therefore to shorten the OI, the thigh goes backward, rotates outward and is moved away from the body.  Once the muscle is shortened and it is contracted against resistance the tendon will be loaded without extra pressure on the bursae.

My approach:

1. Check hip range of motion.

2. Activate the core with planks and recheck the hip.

3. Treat with researched based-  Soft Tissue Therapy 

4. Prescribe exercises which maintain good hip function.

Articles I wrote or contributed to:

Telegraph  The ART of Active Release Techniques for Injuries

STACK  New Age of Golf Training is Creating Stronger and More Athletic Golfers

Athletics Weekly  Performance Therapy for Greg Rutherford

220 Triathlon  ART- How is it different from sports massage

Vigour Magazine  ART can release tight muscles to improve performance

Progenex  ART for CrossFitters

FIT Institute  Research based hamstring therapies

TPI  What Performance Therapy Looks Like For Top Golfers

Posted in Active Release Techniques, Obturator Internus, Uncategorized Tagged with: ,

Best Glute Medius Exercises for Runners.

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Glute medius weakness lower back pain link:

Two recent studies 1 2 found a weak gluteus medius was linked to lower back pain!  This study found – Active Release Techniques (ART) soft tissue therapy of the glute medius was effective in treating patients with chronic lower back pain. Find an ART provider near you.

Even pros who train loads need to add glute exercises:

If a four-time Ironman World Champion triathlete like Chrissie Wellington and marathon world record holder Paula Radcliffe can have glute and core weakness issues, it shows that training in varied planes / directions is necessary. 

“My last coach, Dave Scott, integrated strength and conditioning work into my programme and it helped no end, especially towards the end of a race. Dave knew that my drop-off in the marathon wasn’t due to glycogen deficiency or lack of energy – it was because my glutes, core and hamstrings weren’t strong enough, so my form would disappear. So we worked on those by including exercises like lunges, squats, single-legged squats and hip flexion exercises. Simple bodyweight-bearing stuff really. 

“Three times a week, each for about an hour, I’d undertake a strength and conditioning session. That’s not realistic for the amateur athlete, but even doing 2 x 20mins will have an effect. And you can always incorporate the exercises into your everyday life. For instance, when brushing your teeth or making porridge, do it while standing on one leg and squatting. Just take care to do the exercises correctly or your time will be wasted.” Chrissie Wellington 

Read more ›

Posted in Active Release Techniques, exercises Tagged with:

Guru$

I was talking with a pal who devotes a lot of her life to training others. I asked her how we would make any money out of a plan we were hatching. Her reply, “Oh there isn’t much money in it  we do this because we love to do it”.  Unfortunately she’ll never be a guru, because guru$ are all about the business plan.

“Meet the new boss, same as the old boss”.

The guru biz plan:

  1. Over complicate something, get paid to decipher it.
  2. Be expensive, it makes some folks think it must be good.
  3. Be controversial on social media, get followers, teach therapists to give out therabands.
  4. Claim you’ve read old studies in multiple languages.
  5. Be arrogant, it usually comes with the territory.
  6. Be difficult to get in touch with, create the illusion of scarcity.
  7. Never move on from the original big idea that made your name, ignore contrary evidence.
  8. Become an expert in functional anatomy, dazzle those too lazy to do the same.
  9. Write a book so heavy in detail, it must be read 4x to grasp.
  10. Build a team who will deliver your product for peanuts, just to be associated with you.

All names have been changed to protect the innocent. :)

 

 

 

Posted in Uncategorized

Treat Hamstring Injuries with Active Release Techniques

Active Release Techniques soft tissue therapy and Nordic Hamstring Curls!

For almost twenty years, I’ve worked with professional athletes who make a living by running really fast. In this article, I will detail the approach used to help them get speed and strength back.

  • HSI have increased by 4% annually in men’s pro European soccer since 2001 source
  • the increase in HSI have occurred in training not during games
  • eccentric strength does not return, even after symptoms abate source
  • short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football source
  • most HSI are of the long head of the biceps femoris (BFlh) source
  • flexibility may not return

What might cause this?

  • after the HSI, pain causes the athlete to avoid strengthening the muscle at longer lengths
  • this is called neuromuscular inhibition source
  • the hamstring atrophies and the muscle fascicles shorten
  • knee flexor torque joint angles change
  • traditional rehab (leg curls) doesn’t address the shortened fascicles 
  • re-injury risk remains high

Active Release Techniques (ART)

The two big factors that are faced after an HSI mentioned above are NI and the shortened hamstring fascicles.  ART has been proven to be very effective at increasing hamstring flexibility (see below). ART is a movement based soft tissue therapy. A patient shortens a muscle and then fully lengthens the muscle, while the provider maintains a manual tension on the muscle. The provider’s hands provide a fixed tension as the muscle slides under the contact.  Does ART play a role in lengthening the shortened hamstring muscle fascicles after a HSI? Possibly 

Focussed Structural Rehabilitation

Rather than using “functional” exercises, focus is put on the structural muscular composition of individual muscles. Eccentric hamstring exercises performed with the hamstring in a lengthened position are used to address the structural damage post HSI.  Eccentric hamstring exercises have been shown to prevent first time and recurrent HSI (source). These exercises are a vital part of breaking the cycle of pain, atrophy, weakness, and re-injury of the HSI. Read more ›

Posted in Active Release Techniques, exercises, Hamstrings, High Hamstring Strain Tagged with:

Breaking the cycle of recurrent muscle injury

Every sports fan gets frustrated by that player on his/her favorite team who gets soft tissue injuries again and again. The cycle goes like this: muscle or tendon injury, rehab, comes back and lasts a few games, and then back to rehab. Too often the chronically injured player rests too much and never builds up a base of heavy training which reduces injury risk. A new paradigm is now changing the way professional teams use the information they get from GPS data.

Dr Tim Gabbett, the world’s leading researcher on training loads and injury, research has changed  way rest and hard training are recommended. Here are some of the highlights of his research:

Read more ›

Posted in exercises, Hamstrings

Increase Ankle Dorsiflexion with Myofascial Release

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Shannon Turley, the Stanford University Strength Coach, was profiled in New York Times and Bleacher Report articles recently. When asked what N.F.L. scouts should focus on, he said,ankle mobility, the ankle begins the chain of movement.  Ankle mobility is often limited in athletes without the athlete even being aware of it.  Dorsiflexion is the movement of the foot towards the shin.  If one side is particularly limited then it is vital to address this issue before the body starts to compensate, which can cause dysfunction elsewhere.

A 2014 study of infantry recruits doing intense training found a link between decreased ankle dorsiflexion (with knee bent) and Achilles tendinopathy.  Backman et al tested basketball players for decreased ankle dorsiflexion, the players with decreased dorsiflexion were much more likely to have knee pain within a year.

The basics:

  1. how to  check if normal using a reliable lunge test
  2. self treatment using a foam roller
  3. mobilization drill
  4. manipulation and mobilization were found effective in this study
  5. using a strap to pull the talus was more effective than static stretching.
  6. PNF stretching which a recent study concluded was very effective after a 6 week program.
  7. prone scoop manipulation works every time, I teach this one at my workshops! 

Read more ›

Posted in Uncategorized

Obturator Internus, Quadratus Femoris and Bursae.

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Therapist guide: Obturator Internus (OI) and Quadratus Femoris (QF) treatment, rehab exercises and more.

Patients with deep gluteal pain near the ischial tuberosity are often told they have a high hamstring issue.  Often the hamstring is not involved,  but the obturator internus,  quadratus femoris or a bursa is.  About 20 different bursae have been identified near the hip and pelvis(1), and should always be considered when prescribing exercises.

..the obturator internus tendon makes a right-angled bend over the grooved surface of the ischium, between the ischial spine and tuberosity, and then passes horizontally across the posterior to the hip joint before it inserts into the greater trochanter. Moreover, the obturator internus bursa is located between the obturator internus tendon and the grooved surface of the ischium(1) (anatomy video).

If tendinopathy is suspected but bursitis is also possible, it may be wise to load the tendon without compressing the bursa.  Avoiding compression of tendons where they pass over bones during loading is covered in this excellent video from Running Reform.

Obturator internus EMG amplitude was greatest during hip extension, then external rotation then abduction, with minimal to no activation in other directions. Paul Hodges. (2)

Therefore to load the OI tendon with less pressure on the bursa,  I shorten the muscle in extension /ext rotation / abduction and apply resistance.

The QF is an easy muscle to treat, but if thigh internal rotation is decreased it is wise to see if doing plank activations immediately increases the lacking ROM. Read more ›

Posted in Obturator Internus, Quadratus Femoris Tagged with: ,

Gluteal Enthesopathy Treatment

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Gluteal Tendinopathy and Enthesopathy Treatment

If you are reading this you probably have been diagnosed with a gluteal tendinopathy or enthesopathy (the attachment site of the tendon to the bone).  I hope this post helps provide some helpful information, and if you are in my area make an appointment. Through the decades, I have refined my approach (focussed on isometric exercises more)  to the point where I now have  great success with gluteal enthesopathy:

  • Active Release Techniques® (ART) soft tissue therapy is effective in treating the gluteus medius (study) focus on the an anterior fibers and the TFL
  • hip abduction exercises starting with low pain isometrics ( contract the muscle against something, with no movement)
  • manage the load on the tendons through exercise and education on the underlying pathomechanics
  • Gluteal enthesopathies (GE) are treated differently than a bursitis!  An exercise approach of high load isometrics progressing to eccentrics, is recommended for GE.
  • strengthen the hip stabilizers
  • address any weakness or tightness of all lower extremity muscles and joints

Read more ›

Posted in exercises, Myofascial Release Tagged with:

Mobility Work Do’s and Don’ts

For more fitness, rehab, and wellness news, follow us on Facebook and Twitter.

Evidence

Chris Beardsley, the author of the Strength and Conditioning Research Review, gave this summary of the evidence:

“Immediately after foam rolling, flexibility increases for about 10 minutes, but how long you need to roll for or exactly how to do it is still up in the air. On the plus side, there is no evidence that athletic performance is affected by foam rolling, so we can do it before a workout if we want. Probably most interesting are the preliminary indications that foam rolling could help improve recovery and reduce muscle soreness after workouts.”

tmag

I wrote about this topic in the print edition of Train Magazine

Read more ›

Posted in Active Release Techniques, High Hamstring Strain

Tennis Elbow Treatment UK

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A Patient Guide to Lateral Epicondylalgia (LE) aka Tennis Elbow.

  1. Research shows Myofascial Release is better than standard therapies.
  2. Exercises help- try isometric (no movement) and eccentric (negatives) exercises.
  3. There is some inflammation in some tendon problems, ice may help after heavy use.
  4. MRI may be better than diagnostic ultrasound in identifying LE.
  5. Steroid injections don’t provide long-term benefit.

Here is my typical conversation with a patient after I give him or her the diagnosis tennis elbow:

“But I don’t even play tennis.”

Me “You don’t have to be Andy Murray to get it, your repetitive work may be involved”,

“Does that mean you can give me a note so I can quit my job.”

Me “You can quit your job, but without strengthening the wrist tendons it can stick around. The good news is myofascial soft tissue work can help too.”

“So I can;t tell my boss to stuff it.”

Should I ice it? There may be some swelling but in most cases ice is not needed.

Over the last few decades, LE stopped being considered a tendinitis because little evidence of inflammatory markers were found.  Tendinopathy became the new term of choice, but recent research found convincing evidence that the inflammatory response is a key component of chronic tendinopathies like LE.   My take: some inflammation is there, but it may be an important part of healing.  Only ice after heavy use.

What causes the pain?

In a nutshell, tendinosis involves too much tendon breakdown and not enough repair. When repetitive micro trauma damages cells, they create new collagen which is structurally different.

Is exercise the answer?

Exercises helped relieve pain in the short-term compared to no intervention 2011 study.

Exercises should progress from isometrics to eccentrics-

Isometric exercises involve putting a muscle and tendon under tension, but no movement.  In some cases I give this exercise with the wrist and finger in varied positions.

Eccentric exercises with a band for LE are often helpful and easy to do.

Will it go away on its own?

2002 study found in 83% of cases of LE resolved at 52 weeks with no intervention

Does manual therapy help?

Researchers compared Active Release Techniques (ART) and Myofascial Release to therapeutic ultrasound, 1 2 the release techniques were found to be much more effective. 

Two case reports  also found them effective 1 2.  A recent study found myofascial release effective in treating plantar fasciitis, which is similar to tennis elbow.

What about injections?

Steroid injections were found to provide worse outcomes than placebo in a 2013 study.  “There may be a short-term pain relief advantage found with the application of corticosteroids, but no demonstrable long-term pain relief” – 2014 review

Are MRIs or ultrasound scans needed?

2014 review concluded, “power doppler ultrasonography and real-time sonoelastography (is) expensive, and …this technology did not significantly add to the sensitivity and specificity of Gray-scale Ultrasonography”.

There is evidence of MRI signs of oedema on the asymptomatic side of many LE patients. Thickening or partial tearing was not found on the asymptomatic side. Therefore if the non-painful side shows swelling, it may not be important for an MRI to find the sore side has swelling!

Conclusion

Combine manual therapy with an exercise program, before getting an injection.

For more fitness, rehab, and wellness news, follow us on Facebook and Twitter.

 You may also like:

High Hamstring Strain: Best Low Compression Exercises

Best Glute Medius Exercises for Runners

Articles:

Telegraph  The ART of Active Release Techniques for Injuries

STACKNew Age of Golf Training is Creating Stronger and More Athletic Golfers

Athletics Weekly  Performance Therapy for Greg Rutherford

220 Triathlon  ART- How is it different from sports massage

Vigour Magazine  ART can release tight muscles to improve performance

Progenex ART for CrossFitters

FIT Institute  Research based hamstring therapies

TPI  What Performance Therapy Looks Like For Top Golfers

Posted in Active Release Techniques, Lateral Epicondylalgia, Myofascial Release

Hip Bursitis Treatment UK

Health care providers who use therapy and prescribe exercise, like Manual Therapy UK for more original content, and information on my workshops!

Patient guide: Greater Trochanteric Pain Syndrome (GTPS). aka “Hip Bursitis”, but it is often a glute tendon issue.

  • Specific therapy and exercises are effective iexercise
  • “Hip Bursitis” aka lateral hip pain or greater trochanteric pain syndrome 
  •  GTPS is a fairly common condition with 15% of women and 8.5% of men suffering the condition at some point.  
  • Often treated with a corticosteroid injection, but is this wise? I see about two new patients a week with “hip bursitis”, and the following program helps the vast majority of them.
  • Study finds ART muscle therapy effective treating glute medius.
  • Diagnosed with pain on palpation of the greater trochanter, and pain with passive external rotation plus abduction of the thigh.
  • MRI and/or diagnostic ultrasound may reveal swelling, but often these imaging tests do not reveal any obvious abnormality in patients with documented GTPS.
  • After one year 36% (29% after five years) of GTPS cases are still symptomatic.
  • Most commonly one or two of the four lateral hip bursae are injected, with often poor results. Injecting all four (gluteus medius, gluteus minimus, subgluteus medius and subgluteus minimus) bursae has been recommended by some.
  •  A high prevalence of cases have leg length discrepancy, ITB syndrome or OA at the knee, suggesting a lower limb biomechanical link. Given the high recidivism rate and the biomechanical link, could it be that in many (or most) cases bursitis is a misdiagnosis and gluteal enthesopathy is the actual problem?

Research

New evidence that gluteal tendinopathy is more common than trochanteric bursitis. A research review was published in 2015, they concluded, “There is a dearth of evidence for any treatments, so the approach we recommend involves managing the load on the tendons through exercise and education on the underlying pathomechanics.”

“The cause of GTPS is usually some combination of pathology involving the gluteus medius and gluteus minimus tendons as well as the iliotibial band. Bursitis is present in only the minority of patients. These findings have implications for treatment of this common condition.” 2013 study of 877 patients

A 2015 study found that patients with glute tendinopathy on one side had weakness of the glutes on both sides. 

A 2016 study revealed, “Individuals with gluteal tendinopathy exhibit greater hip adduction moments and alterations in trunk and pelvic kinematics during walking. Findings provide a basis to consider frontal plane pelvic control in the management of gluteal tendinopathy.”

Exercise

Gluteal enthesopathies (GE) are treated differently than a bursitis!  An exercise approach of high load isometrics progressing to eccentrics, is recommended for GE.  Because it is difficult to rule out a bursitis it is best not to load an elongated tendon isometrically (or with repeated thigh rotation).  In general, it is probably not wise to stretch a tendon over an irritated bursa or bone. Stretching (and ill-advised iexercises) were found to make proximal hamstring tendinopathies worse.  The same applies when dealing with schial-gluteal bursitis.  Load the tendon, but not with it stretched over the underlying bursa or bone.  Keep the isometrics in a “safer” range.

Of course, it is important to address any biomechanical issues of the foot and/or knee. I find myofascial release is an effective soft tissue method to increase the flexibility of the hips, and any lower limb biomechanical issues.  Chiropractic works well to promote a neurophysiological response to maximize glute activation, and I recommend gentle myofascial release at the enthesis.

You may also like:

High Hamstring Strain: Best Low Compression Exercises

Best Glute Medius Exercises for Runners

Research Based Hamstring Therapy – FIT Institute

The New Age of Golf Training is Creating Stronger and More Athletic Golfers Than Ever Before –STACK

Performance Therapy: Greg Rutherford’s Story Athletics Weekly

The ART of Active Release Techniques Telegraph

How is ART different from Sports Massage  220 Triathlon

Transform Performance – Vigour Magazine

Golf Performance Therapy Titleist Performance Institute

Follow Manual Therapy UK  for all my material for health providers.

Posted in Active Release Techniques, exercises Tagged with:

Hamstring Therapy

Hamstring flexibility research

Kage, Vijay.  Immediate effect of ART versus Mulligan bent lag raise in subjects with hamstring tightness: RCT.  Int J Physiother Res 201, Vol 2(1):301-04

A single session of ART is better as compared to MBLR technique to improve hamstring flexibility and range of motion.

Shah, S and Kage, V.  Comparative Effectiveness of ART and Rolfing on hamstring tightness in normal subjects. RCT  IJPR 

ART showed better improvement as compared to Rolfing in terms of Popliteal angle.

George, JW et al   The effects of ART on hamstring flexibility  J Manipulative Physiol Ther. 2006 Mar-Apr;29(3):224-7.

a single session of ART increased hamstring flexibility in a group of healthy males

Posted in Uncategorized