REFERRED-ORIENTED HAMSTRING CONDITION A referred-oriented hamstring condition is described as pain or an increase in tension referred from the interface between the peripheral nerves and spinal cord with muscular structures in the lumbar or hip regions.

Gluteus medius and minimus Trigger points in these two muscles can be the cause of considerable lumbar, gluteal, sacral and posterior thigh pain (3). Trigger points in the gluteus medius tend to be found along its superior attachment. As well as pain, patients often have restricted abduction. There may also be a positive

BOX 1: STANDING FLEXION TEST ■ Tests movement of the ilium on the sacrum

■ With patient standing, the left and right posterior superior iliac spine are palpated while the patient bends into forward flexion

■ Positive if one side moves higher than the other, indicating hypomobility on that side.

BOX 2: STORK TEST (GILLETS TEST)

■ With patient standing, palpate posterior superior iliac spine and sacrum at same level

■ Patient flexes hip and knee on palpated side while standing on the opposite leg ■ Test both sides

■ Positive if posterior superior iliac spine on the tested side does not move downwards in relation to the sacrum – indicates hypomobility.

BOX 3: REVERSE STORK TEST (THOMAS TEST)

Tests hip flexion contraction. The patient lies supine and hugs one knee to the chest. The positive sign is that the opposite leg lifts off the couch.

The modified Thomas test requires the patient to sit on the edge of the couch and bring one knee to the chest. The patient then assumes the supine position and ensures a posterior pelvic tilt to flatten lordosis, allowing the testing leg to extend off the table. In addition to being an indication of hip flexion contracture, an extended knee may indicate rectus femoris shortening and an abducted leg and TFL tension.

BOX 4: SACROTUBEROUS LIGAMENT

■ With patient supine, flex and adduct the hip by moving knee to opposite shoulder ■ Compare left and right

■ Perform only if no hip joint pathology and full range of movement.

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Trendelenburg sign because of inhibition of this muscle’s function. The gluteus minimus muscle has a

similar anatomical configuration to the medius, but it is less extensive. It arises from the external surface of the iliac, also attaching to the greater trochanter. Its trigger points can be seen in either the anterior or posterior portion of the muscle. The pain that arises is deep

buttock, posterior thigh and calf pain. In the case of the anterior trigger points, pain distribution includes the buttock, lateral thigh and leg regions. The significance of these muscles

in the origins of sacral, buttock and leg pain is that they can mimic radicular sources of pain as well as sacroiliac joint dysfunction. In addition, trigger points in these muscles may be a result of radicular and sacroiliac joint dysfunction.

Referred pain originally from a spinal structure can set up satellite trigger points in these muscles. The myofascial source of pain may well outlast the primary joint dysfunction. Pain from facet joints may overlap

that of the gluteus minimus muscle. Tension generated by trigger points in the gluteus minimus may further block movement of the sacroiliac joint, particularly when involvement of this muscle is seen with piriformis. Activation of these trigger points can be caused by acute overload as a result of a fall, distortion of gait or sacroiliac joint dysfunction. Being located deep to the gluteus maximus and medius and tensor fasciae latae, it is difficult to palpate taut bands here.

Trigger point examination for gluteals

Anterior trigger points

Patient lies supine, with leg extended of fthe side of the couch in hip extension. The tensor fasciae latae is identified. Palpate the deep distal ASIS.

Posterior trigger points

Have the patient lying on their side, with the thigh slightly adducted and slightly flexed to identify the piriformis line. Gluteus minimus trigger points are found above this line between its midpoint and the junction of its middle and lateral thirds.

Associated trigger points These are seen in conjunction with

piriformis, gluteus medius, vastus lateralis, peroneus longus, quadratus lumborum and gluteus maximus. Anterior gluteus minimus and

tensor fasciae latae often develop trigger points together. Vastus lateralis trigger points can develop as satellites. Gluteus minimus may develop as satellites to quadratus lumborum. The connection is so strong that sometimes activation of quadratus lumborum activates gluteus minimus trigger points.

Piriformis syndrome This muscle arises from the inner surface of the sacrum and attaches to the greater trochanter of the femur. It is a stabiliser of the hip and lateral rotator of the thigh in extension and neutral. At 90 degrees flexion it abducts the thigh, producing a strong rotatory force on the sacrum. This tends to displace the base of the sacrum anteriorly while the apex is displaced posteriorly. Pain is referred over the lateral aspect of the buttock, down the posterior thigh and the sacroiliac joint. Neurogenic pain may accompany active trigger points, and this pain can be referred into the back of the leg and the sole of the foot.

Symptoms

Pain and paraesthesia may be felt in the low back, buttock, groin, perineum, hip, posterior thigh, leg, foot and rectum. Symptoms are aggravated by flexion, adduction and rotation. The patient may complain of painful swelling in the limb and sexual dysfunction. The reported incidence of piriformis syndrome is six times more common in females. Travell and Simons identify three components in piriformis syndrome (3): ■ Myofascial trigger point pain ■ Nerve and vascular entrapment ■ Dysfunction of the sacroiliac joints.

As any muscle contracts, its girth increases. Anatomical variations such as a large muscle in a small greater sciatic foramen could lead to neurovascular compression. Therefore, active trigger points in the piriformis could cause displacement of the sacroiliac joint, which in turn could maintain piriformis shortening. Pain due to the myofascial trigger points targets the back, buttock, hip and thigh and is often aggravated by sitting. Compression of the superior

sportEX dynamics 2008;18(Oct):20-23