the abdominal muscles and shortening of the hip flexor muscles. The erector spinae muscles tighten and shorten and the gluteal muscles often waste. Soft tissue therapy is aimed at reducing pain within the erector spinae and encouraging contraction of the gluteals using muscle facilitation techniques. To use facilitation, the patient consciously tries to contract the muscle as you stimulate the skin over the muscle using tapotement. Following back pain there are two main reasons that a muscle does not contract. The first is inhibition (pain inhibition), whereby the body tries to protect itself by deliberately not moving. The second reason is poor recruitment, where nervous impulses are not getting through to a muscle because it has been inactive for so long. To manage pain inhibition the physiotherapist targets the cause of the pain, but for poor recruitment we can use tapotement as muscle facilitation and combine this with exercise. Over time, facilitation is reduced and exercise increased as the muscle recovers its contractile ability. Tapotement techniques including tapping, flicking, hacking and shaking are traditionally used to facilitate contraction of low-tone (hypotonic) muscle. When contraction occurs, isometric actions (tense and hold) are used, building up the holding time (3–5 seconds initially) to encourage postural endurance. Effleurage and petrissage may be

used to increase muscle blood flow and reduce lactate build-up within the muscle, which is a cause of ischaemic pain. Focal pressure techniques such as ischaemic compression (pressing

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Figure 4: Stretching tight hip flexor muscles in lying (Thomas test position)

an area for 20–30 seconds and then releasing to allow fresh blood to rush back in and flush the area) and fascial stretch (stretching the skin and underlying fascia lengthways for 10–20 seconds until resistance reduces) may be used to reduce local trigger points. The abdominal muscles are shortened using inner range actions such as a trunk curl exercise from a raise (wedge or cushion) (Figure 4). The tight hip flexor muscles are stretched using static stretching (stretch and hold for 20–30 seconds) while maintaining lumbopelvic alignment. A half-kneeling lunge action (Figure 5) is used, pressing the pelvis forwards to encourage hip extension with the knee flexed to target the rectus femoris muscle. Care must be taken not to allow the lumbar lordosis to increase.

Swayback posture In the lordotic posture the greater trochanter stays on the posture line but the pelvis tilts. In the swayback posture the pelvis remains more or less level, but the whole pelvis is thrust forwards, so that the greater trochanter lies anterior to the posture line. In an optimal posture the sternum is the most anterior bony point of the body, but with a swayback the ASIS is the most anterior. The swayback is often called the “slouch posture” as it occurs with prolonged standing when relaxed. Essentially the patient is balancing on the elasticity of their anterior hip tissues, and the posture often favours one leg (asymmetrical swayback). Now, if the left leg is locked out straight and the right bent at the knee, the patient presses their pelvis forwards and to the left, placing their body weight

EXTENSION AND SIDE FLEXION (MORE ACCURATELY SIDE SHIFT), LEADING TO TISSUE SHORTENING ON ONE SIDE AND LENGTHENING ON THE OTHER

THE POSITION OF THE SPINE IS ONE OF

Figure 5: Hip flexor stretch – half lunge position

Figure 6: Swayback posture position

over the straight leg. The body is now supported by the hip abductor muscles straight (left) leg and the elasticity of the anterior hip structures of the same leg. The bent (right) leg plays little part in taking body weight, acting more for balance (Figure 6).

Clinically it becomes obvious that problems will ensue because most of the body weight is taken on only one leg over a long period. Hip and knee pain are the classic conditions seen, with the powerful hip abductor muscles (gluteus medius) becoming fatigued and the patient relying on the tensor fascia lata muscle and iliotibial band (ITB) instead. The ITB presses against the greater trochanter at the hip and the lateral epicondyle at the knee, sometimes giving rise to ITB friction

sportEX dynamics 2011;29(July):15-18