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May, 2011, Vol. 11, Issue 05

Pseudo-Sciatica and Gluteus Minimus Trigger Points

By David Kent, LMT, NCTMB

Knowing the specific pain patterns of each muscle gives you many advantages over your competition and allows you to most effectively apply your specialized skills. This knowledge allows you to efficiently assess, educate and design treatment plans tailored to your patient's complaints.

The gluteus minimus can be easily overlooked since the referred pain from this muscle is felt so deep and remotely from the location of the trigger points. Let's examine the gluteus minimus muscle, its anatomy and trigger point pain referral patterns and ways to help build your practice.

The gluteus minimus is the deepest of the three gluteal muscles, is also the smallest in length and lightest in weight. It attaches proximally to the external surface of the ilium and distally to the anterior surface of the greater trochanter of the femur. (Image 1A). The muscle fibers of gluteus minimus and gluteus medius run in the same direction and produce the same action.

When the lower extremity is free to move and all fibers of the gluteus medius contract they produce abduction of the thigh. When just the anterior fibers of gluteus minimus contract, and the lower extremity is free to move, they produce medial rotation of the thigh. When the lower extremity is in a fixed position, as during the weight bearing phase of gait or when balancing on one leg, the gluteus minimus, along with the gluteus medius, and tensor fascia lata, keep the pelvis level when the opposite limb is raised off the ground.

The superior gluteal nerve arises from L4 through S1 and innervates the gluteus minimus, gluteus medius and tensor fascia lata. When the nerve is compromised due to trauma, disc involvement or other factors, the supporting action of these muscles are diminished. When the patient tries to balance on one limb, the pelvis falls on the side of the raised limb indicating a positive Trendelenburg sign. The referred pain from trigger points in the gluteus minimus may be constant in duration, severe in intensity and may cause the patient to limp when they walk. The discomfort may also interrupt their sleep if they roll onto the effected side.

When active trigger points are present in the anterior fibers of gluteus minimus, patients will have pain and difficulty getting up out of a chair or standing up straight, following periods of hip flexion, as when seating in a car, watching TV, working at a computer or sleeping in a fetal position. Intake forms will help you ask the right questions to uncover all of the patient's symptoms.

Zones and Trigger Points

Gluteus Minimus - Copyright – Stock Photo / Register Mark In images 1 - 3, "X" indicates the common location of trigger points. Solid red indicate Essential Pain Zones or the regions of referred pain that is present in nearly every person with active trigger points. The dotted red regions indicate Spillover Pain Zones or the regions of referred pain on some, but not all, patients with active trigger points.

Trigger Points (TrPs) in the anterior fibers of gluteus minimus refer into the lower buttock and down the lateral aspect of the thigh into the fibular region of the leg. Rarely do the referrals cross the ankle, but on occasion will refer into the dorsum of the foot. (Image 1B). Trigger points in the posterior fibers tend to refer more medial into the lower buttock (then the anterior trigger points) and into the posterior thigh and proximal calf (Image 1C).

These trigger points form for numerous reasons from direct trauma, inter muscular injections, postural distortions, running, swimming, walking too far and/or too fast over uneven terrain, and sporting activities such as tennis, handball or cycling.

Resolve & Distinguish

Piriformis - Copyright – Stock Photo / Register Mark First identify, then eliminate or modify the factors that perpetuate the existence of trigger points. These may include periods of prolonged immobility such as seating in a car, watching a movie, working at a desk, sleeping in a fetal position or sitting on a wallet.

It will be easy to distinguish gluteus minimus trigger points from others, like the piriformis or the overlying gluteus medius, based on their referral patterns and the location of the trigger points.

Piriformis trigger points refer into the posterior thigh distally to the knee (Image 2), whereas the gluteus minimus trigger points also include the lateral thigh and calf (Images 1B,C).

Gluteus medius trigger points are less likely to involve the thigh (Image 3).

Gluteus Medius - Copyright – Stock Photo / Register Mark Range of motion is another way to determine which muscles are involved. Trigger points in the gluteus maximus restrict hip flexion, while trigger points in the piriformis restrict medial rotation of the thigh.

Trigger points in the gluteus minimus and gluteus medius will restrict adduction of the thigh.

Professionalism

The success of your practice is influenced by your ability to educate your patients. Set your self apart and reinforce a professional image by using visual aids like trigger point wall and flip charts to show patients their pain referral patterns. Postural analysis photos make it easy for you to assess, show patients imbalances in their musculoskeletal system and document postural improvement over a series of treatments. Read "Getting Inside Your Patient's Head" (MT, January, 2011).

Knowing the specific pain patterns of each muscle gives you the knowledge to efficiently assess, educate and design treatment plans tailored to your patient's complaints.

I wish great success in the treatment room.


Click here for more information about David Kent, LMT, NCTMB.

 

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