Background and History

Mrs B is a 58 year old nurse who recently presented to our clinic with a 9 month history of right buttock, posterior thigh and calf pain, as well as intermittent numbness in the calf and bottom of foot.
The pain had developed slowly without any specific incident. Of note, Mrs B had suffered a period of left heel pain 3 years prior. At the time, Mrs B had been managed in a moon boot on the left side for 8 weeks to reduce pressure on the foot for what had been diagnosed as plantar fasciitis. She had also been experiencing left hip pain, but these 2 pains had resolved before her more painful right buttock and leg pain had started.
Mrs B had trialed treatment with Physios, Osteos and had been having Pilates, the latter she felt actually aggravated her condition. She had also had cortisone injections into the facet joints of her lower back, which had not helped.

Investigations

Mrs B’s MRI, taken 5 months previously, showed forward displacement of the L4 segment, disc bulging, facet joint degeneration, as well as compression of lumbar nerve roots (see excerpt below).

How Mrs B Was Impacted By Her Condition

Mrs B’s pain was worse in the mornings, and she often waked on turning in bed. She could not sit for more than 20min before the pain worsened, and she was also unable to walk for longer than 10-15min.
She had struggled to maintain her part time nursing, and had taken afternoon shifts because the pain was not as bad at that time of day. She was not able to do as much for her family and her children were helping her out with most of her home duties (not necessarily a bad thing!).
Mrs B had also stopped her regular walks around the Maribyrnong River with her friend due to the pain.
She was taking 2-3 Panadeine daily and also 2 x Nurofen.
She rated her functional ability at 50%.

Assessment

Mrs B presented with some postural compensations, ie she was standing in an altered state due to her pain. The anterior pelvic tilt posture was placing more stress on her lower back.
She had reduced reflexes on the right side (S1), but no loss of power in the specific nerve supply areas (myotomes). Her lumbar range of movement was restricted by muscle guarding, as was her right hip flexion, hamstring range and thoracic rotation. The latter 4 movements formed the basis of her key movement signs, the tests we use to measure her response to treatment and her progress. These were all tested to the first point of reactivity, which is a more sensitive and reliable way to test movement, as it tests the protective response within the nervous system and is not reliant on a patient’s symptoms.
Mrs B also exhibited adverse nerve tension in the left upper limb, and both lower limbs.

We performed a whole body assessment (WBA) for Mrs B as part of our systematic whole body problem solving process. We found many areas of muscle knots and stiff hypomobile joints in the neck, thoracic and lumbar spines.

The Treatment and Problem Solving Process

We first needed to clear Mrs B’s adverse neural tension, so that she would then respond to treatment more readily and it would be easier to find her primary contributors to her condition.

We then performed treatment trials on all of the unhappy muscles and joints we found on the WBA, using Mrs B’s hamstring as the main movement test. That is, we released the relevant muscle or joint while Mrs B actively straightened her hamstring (hip in 90deg flexion). Any improvements in hamstring range were recorded as percentage improvements for the particular structure on which we trialing treatment. We would retest all of Mrs B’s movement signs at the start and end of each session, so that we could plot a progress graph.

Process of Elimination

We came up with a list of 16 structures which were all affecting Mrs B’s key movement tests related to her sciatica and back pain. We then worked more on each of these to release them further and test if they were still part of her condition, again using her key movement tests, until the tests reached an optimal range without muscle guarding or reactivity.

We arrived at 3 structures that were having the most effect on Mrs B’s movements. They were the left Piriformis muscle, the left plantar fascia and the T8 segment, with a left to right bias on the transverse process. These were the primary contributors to her condition as they all improved her key tests related to her sciatic condition.

We also started Mrs B on a range specific exercises for her Tr Abd, as she was not activating this well, and also the right gluteal muscles. They were also activating poorly.

Results

As we got towards the end of the problem solving process, and not earlier, Mrs B’s symptoms finally began to ease, which coincided with her movement test improvements. Her leg pain started to reduce and she was no longer experiencing the catching pain that had troubled her intermittently over many months.
She began to sleep better, then walk further without pain. She also started to reduce her medications.
On her last review, she was extremely happy with her progress and most of her pain had resolved. She was off all her medications, and had resumed walking around the river with her friend, who had commented that she was struggling to keep up with Mrs B!
She was waking up in the mornings feeling great, and was now happy to resume morning shifts at work.
She self rated her functional capacity at 85-90%!

Mrs B’s progress above shows a steady improvement in her key movement tests, with some regression between sessions.

Summary

This was a very satisfying result both for Mrs B and her Physiotherapist. The protective responses that made the most change in her condition were on the opposite leg. It was theorised that the episode of plantar fasciitis she had last year had contributed to the tension on that leg, and she was most likely placing more weight on the right side.This would have loaded the structures on the right more, leading to her pain.
This case highlights the benefits of using a systematic whole body problem solving approach, as where your pain is may not be where the problem is.
It also highlights the fact that MRI scans don not always correlate with a patient’s symptoms. If Mrs B had a repeat MRI on her lumbar spine, it is unlikely to be any different, yet her pain has resolved. Pain is an output sign created by the brain, and when we address the primary protective responses in the body, there is no need for the brain to create the pain. It is dependent on tissue pathology in many cases.
Careful and thorough assessment and problem solving is needed for each person because each case is individual. People with the same symptoms may have totally different primary sources of their pain.

To ensure the problem does not recur, we have taught Mrs B self management strategies and corrective exercises that she can do at home.

A few years ago I started to notice some mild tingling in my feet, which would come and go, but was more apparent after a long run or a hard training session around Princess Park( I was in a running group back then, and our coach liked to push us!).

As a Physio, I sort of knew what this may be, but it wasn’t affecting me much so I just kept doing what I was doing.

Then in 2019 we renovated our house. Most people who’ve been through this know how stressful it can be, and although we had a great builder, I was quite involved in the whole process. There was a lot of physical work to do, like moving and getting rid of furniture, putting together flat packed furniture( I will outsource this next time!) painting and landscaping, as well as the stress of moving out temporarily and managing the budget. I was still running a lot at this time, because I felt it helped me relax and I enjoyed it.

But soon I started to develop back pain, which would often radiate down the back of my legs on both sides. I remember coming home from work back then, and feeling much worse than the clients I was treating! I also remember umpiring at my son’s tennis games and having real difficulty standing for a set of tennis…my back and legs would be aching, and often my feet would be tingling.

The pain was also affecting my running, in fact I had to stop completely and go to walking on several occasions due to acute episodes. I remember one weekend after a flare up, I couldn’t walk more than 2 km, whereas 1 week earlier I had run 18km! ( 18km is not that far when you’ve done 6 marathons!). I was often tired and cranky at the end of the day, and it was even affecting my relationship with my wife and kids… mainly because I was tired and in pain… and a pain to live with!
 

I had an xray in 2019 and later in 2020 an MRI of my lumbar spine. The results of the latter are below. It looks pretty bad doesn’t it? Essentially I had a forward slip of the L4 vertebral segment on the L5, severe facet joint degeneration at that level, and stenosis(narrowing) of the spinal canal due to disc bulging and swollen facet joints. This really did explain most of my symptoms, especially the tingling in feet and legs, which was nerve irritation.

My doctor had referred me to a spinal surgeon, and cortisone injections were on the cards.

So what did I do:

1. I didn’t panic or catastrophise! With my knowledge of pain and the body, I knew there are a lot of contributors to pain signals being created by the brain, and stress/anxiety is a big factor!
2. I made more time for meditation and managing my mental health, and was more conscious of overdoing and overthinking! This calmed my central nervous system( completing the renovation and settling into a beautiful house also helped!).
3. My colleagues assessed my posture at work and found that I was over straightening my thoracic spine(mid back) when  was leaning over to treat. My back was too straight because I thought this was the right thing, but it was placing more load on my spine, contributing to my pain. Making some postural changes here, working on motor control (thoracic flexion movements) and having my thoracic spine treated regularly made a big difference.
4. I reduced my running volume, slowed down my pace, focussed on more recovery between sessions and worked on my core, back and gluteal strength.( I also started drinking Mangosteen juice daily, known for its anti- oxidant and anti inflammatory properties).
5. I had regular tune ups with the team and regular massage, which prevented strain in my body accumulating, and allowed me to slowly build more strength and capacity for load.
 

It did take some time for things to settle and to build load capacity again, but if you give your body the right conditions(including your positive thoughts and beliefs), and have the right guidance…you can overcome many physical conditions. This also shows that you cannot make decisions about your health based only on scan results, because often they do not correlate to symptoms. There is now lots of evidence to support this. If I had another MRI now the results would not be much different… the same degenerative changes would be there… but I’m essentially pain-free, enjoying my running again…. and my wife and kids are happier!:))
 

If you have recently had a spinal or joint scan and are a little concerned about it, feel free to contact us at the clinic and we’ll be happy to discuss it with you.

Hip pain can present itself in a myriad of ways. It can feel like pinching at the front of your joint, a deep, dull ache in the buttock, or burning pain on the side of the leg. It can even be felt as referred pain in the groin and knee region or present with associated stiffness and tightness across your whole leg. Lateral hip pain is a particularly common problem – prevalent in women between 40-60 years old and in 25% of the general population (Williams and Cohen, 2009).

If you have a hip problem, it can affect many of your day-to-day functions negatively, for example:

• Putting weight on the leg
• Walking, or taking large steps
• Getting in and out of a car
• Sitting or driving for long periods
• Sporting activities like running, change of direction, kicking a ball, etc.

So What Structures Can Be Involved?

Your hip is a ball and socket joint made of the head of the femur sitting in the pelvic acetabulum. While it has good mobility in all directions, it is also one of the most stable joints in the body. There are numerous muscles, tendons, and ligaments crossing the region and if any of them become dysfunctional, it can set off a host of problems in your hip. Here are the common structures that can cause hip pain:

• Glute maximus, which is the main power muscle of the leg and helps generate force in many activities
• Smaller muscles like the glute medius, tensor fascia lata, and piriformis, which help stabilise your hip joint and pelvis
• The gluteal tendon, which is where your gluteal muscles attach to the hip bone itself
• The psoas and iliacus muscles, aka your hip flexors, which originate from the spine and attach the hip bone
• The sciatic nerve, which passes through under the piriformus muscle before it travels down the rest of your leg
• The labrum, which sits inside your joint to help keep the ball in the socket
• The trochanteric bursa, which helps the tendons glide smoothly over your hip joint

However it is important to remember that the hip joints connect closely with the pelvis and spine, so it is common for dysfunctions in these areas to present as hip pain – this is a good reason to make sure you explore thoroughly for the source of the pain before settling on a diagnosis. In our clinical practice, we have found sources of hip pain coming from problems in the spine and trunk, but also areas as remote as the foot or the shoulder. When diagnosing the cause of an injury, it is best to leave no stone unturned!

Let’s Get Specific: Gluteal Tendinopathy

The gluteal tendon connects your gluteal muscles to the side of your femur. When this tendon degenerates, this is called gluteal tendinopathy and can often present as pain and tenderness on the outside of the hip, as well as any number of symptoms mentioned earlier. You might also notice pain and stiffness upon waking up in the morning that improves with activity and then becomes painful again as you cool down.

This degeneration can result from repetitive movements of the hip that cause compressive force over the tendon – typically when the leg crosses the midline of the body (e.g. when crossing your legs or when your knees knock together) (Segal et al 2007). This compressive force, if persistent and beyond the tolerance of the tendon, will cause microtrauma and degeneration (tendinopathy) to occur.

Fortunately, gluteal tendinopathy can be fixed! Read on for info about how.

How Did This Happen To Me?

The reasons for why injuries happen are always individual to your lifestyle and activity. A sedentary office worker presenting with hip pain will have a very different cause than the runner who is running a mileage of 80km per week. Among our clients, the most common reasons for hip pain to occur are:

• Sudden increase in training loading
• Poor postures, like slouching or crossing legs
• Asymmetries in strength and stability around the body
• Poor technique in training and sport
• Structural deformities in the ball or socket of the hip which result in impingement with certain movements

Do’s & Don’ts

The basic rule of thumb: do not push through pain. Pain is a warning signal coming from your brain that tells you when your hip is not happy so when you push through pain, you risk aggravating your condition. Here are examples of activities and postures that can put stress on your hip:

• Sleeping on your side
• Sitting with crossed legs
• Standing with uneven weight on each leg
• Stairs
• Wearing heels
• Running
• Overstetching (if you feel more pain after stretching, this is not the intended effect!)

If any of these positions aggravate your problem, do your best to modify or avoid them where possible.

What Can I Do About My Hip Pain?

The good news is that you don’t have to put up with it! If you are experiencing hip pain, there are a few options for you to start fixing your problem straight away. Watch our video series on gluteal tendinopathy – it includes more information as well as key exercises to try at home. Exercise and strength work have been proven to improving function and decreasing pain, so keep moving where possible (Mellor et al. 2018).
If you are not finding improvement on your own, it is best to speak to a health professional you trust and get it checked out. Remember, the problem may not be coming from the place you are experiencing the pain! If you would like more personalised advice, our physios are available to answer your questions so feel free to call our clinic on (03) 9370 5654.

References

1. Segal NA, Felson DT, Torner JC, et al, Multicenter Osteoarthritis Study Group. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil 2007;88:988-92.
2. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. 2009;108(5):1662–70.
3. Mellor R, Bennell K, Grimaldi A, et al. Education plus exercises versus CSI use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BJSM 2018; 52(22):1464-1472.

We can break the elements of correct running biomechanics and posture into key areas:

1. Head straight and shoulders relaxed

While this may seem obvious, we see many people running with their head down and their shoulders tense.  This increases effort and energy expenditure with moving the body forward. Keeping your head upright and your shoulders relaxed also keeps the muscles in your back relaxed, which helps with running efficiency.

2. Elbows bent between 60-90 degrees, kept by your side, with arms moving forward and back

A common biomechanical deficiency seen with runners is the arms moving across the body and/or elbows bent beyond 90 degrees. This creates more rotation force, placing increased pressure through the spine and also decreases the efficiency of moving the body forward.  In addition, holding the arms away from the body further encourages an arm swing across the mid-line and increases tension through the neck and shoulders.  It is important you keep your arms compact, by your side, bent between 60-90 degrees and moving straight back and forth to maximise efficiency.

3. Pelvis in neutral

While a slight forward tilt of the pelvis may help to facilitate a forward lean from the ankles, assisting with forward propulsion, it is best from our experience to keep the pelvis in neutral to maximise efficiency and optimal length/tension relationships for all muscles working off the pelvis. Conversely, the pelvis tilted backwards flattens out the spine and shortens the hamstrings, resulting in increased tension and effort to move forwards. While the pelvis is in neutral, it is easier for the trunk to remain upright, with the forward lean coming from the ankles.
Individual variations of the above guidelines may be required for specific runners with specific issues. For example, if you have a spondylolisthesis ( forward slip of one lumbar vertebra on another) it is more desirable to run with a slight posterior tilt to reduce the load on the vertebral segments. It is best to consult with a health professional to get the best personal recommendations about pelvic posture while running.

4. Footstrike – ideally should occur between rear and midfoot.

It is widely accepted that landing with a heel strike creates increased braking forces and places significantly increased load through the knee.  The majority of runners (80-85%) will land predominantly on their rearfoot, but it is important that this is occurring closer to the midfoot as opposed to the back of the heel.  The key measure for correct foot-strike is that the ankle should sit directly below the knee, with the tibia (lower leg) vertical at footstrike.

5. Optimise knee spring/stiffness in stance phase to approximately 25 degrees of knee flexion

It is important that we achieve a good balance between ‘spring’ and ‘stiffness’ in the knee during the initial part of stance.  This ensures we get good shock absorption, force distribution and support through the lower limb joints throughout this phase. Too much spring / knee flexion is indication of weakness through the lower limb muscles (quads especially) therefore increasing the force through the joints, particularly the knee.  Too much stiffness/reduced knee flexion will decrease the force distribution through the leg and places increased load through the ankle and calf.

6. The foot should land underneath you, with a quick pull back as you land

In line with the ankle sitting below the knee at the onset of stance phase, your foot should also not land too far in front of your pelvis – ie. Your foot should land underneath you, not in front you. At the least, your rearfoot should sit in line with the front of your pelvis as you land – as shown in the photo below.   A common biomechanical issue seen with running is the foot landing in front of the knee and hip/pelvis, which is termed over-striding. This is associated with significantly increased force and loading through the knee.

A quick pull back of the leg as you land engages the gluts and hamstrings effectively, helping to propel you forward.  This also assists in achieving enough knee flexion during swing, which is an important element to prepare the leg effectively for the next stance phase. 

Further information on these key elements can also be found at the following link:  http://www.nwpg.com.au/video-gallery/the-5-elements-of-good-running-posture

>We hope this provides you with some useful information to help guide you in achieving optimal running posture and biomechanics.

If you are unsure whether or not you are achieving some of these key elements, a running assessment with one of our physiotherapists can greatly assist with this.

This will include a comprehensive running analysis and functional screening tests to determine whether there are any factors that may impede your running. A detailed report with recommendations will be emailed to you to clearly identify the steps required for you to run with confidence.

Time for assessment is 1hr and a further 1hr is allocated for compilation of the report.

If you are interested in a running assessment, please contact us at the clinic to make an appointment.

If you would like to discuss further, please email graham@nwpg.com.au.

Mr M’s main goals: (self rated as 10/10 being pain free and full function)

1. To walk without restriction (5/10)
2. To move from sit-stand and in/out of the car without pain and restriction (currently 5/10)
3. To return to Jiu Jitsu unrestricted (currently 0/10)

We performed a systematic assessment of Mr M’s musculoskeletal system and found the following imbalances:

1. No signs of structural dysfunction within the left knee
2. Significant restriction in hip flexion range of movement bilaterally: Left – 85 degrees; right – 80 degrees.
3. Widespread lower limb muscle tension and guarding, particularly of right gluteals, psoas, Iliacus, quads and hamstrings and left psoas, Iliacus and gluteals.
4. Stiffness in the anterior portion of the disc at left L2, 3 and 5 and L3 and 4 on the right.
5. Stiff thoracic segments at T7-10.
6. Significant upper limb muscle tension/guarding at infrapsinatus and subscapularis bilaterally.
7. Restricted to a double leg, ½ squat.

Through a process of treatment directed testing, we found that the primary contributing factor to Mr M’s left knee condition was his left Iliacus (hip flexor) muscle.  Treatment to this improved all of his objective signs significantly and by the end of the initial session he was walking painfree without a limp.  With another 3 sessions over the following week, he had restored all of his movement restrictions to normal and achieved his other goals of sit-stand, in and out of the car and returning to Jiu Jitsu training without restriction.

Mr M was given postural strategies and home exercises to help decrease the load placed on his hip flexor and subsequently prevent the likelihood of a flare up in his condition.  He has been managing well with this and has continued with his training over the past 2 months without any restrictions.

This is another example which demonstrates the primary contributing factor to a client’s condition is not always in the same area as the presenting pain. In this particular presentation, we were able to completely treat the condition without any local treatment to the knee itself.  This gives further indication that without a thorough assessment, we can’t be sure we are treating the main driver of the condition.

It can be felt at the front, sides or behind the knee, with the most common area being the front, around the patella(kneecap). It can affect your walking, going up and down stairs, getting up from a chair, squatting, bending, kneeling and running – particularly up or down hills/inclines.

As physiotherapists, we always look for all possible contributing factors to a client’s condition, and this will often involve testing areas that may be somewhat remote from the area of pain.

There have been several studies that have looked at the role of the gluteal muscles in knee pain, both amongst runners and the general population.

A review of all published research examining gluteal muscle function in patello-femoral pain syndrome (PFPS) by Barton et al(2013) found moderate-to-strong evidence indicating gluteus medius (GMed) activity is delayed and of shorter duration during stair negotiation in PFPS sufferers. In addition, limited evidence indicates GMed activity is delayed and of shorter duration during running.  

The gluteals consist of 3 muscles –  the gluteus maximus (GMax), gluteus medius (Gmed) and  gluteus minimus (GMin).  GMax is the largest of the gluteal muscles and is the main extensor of the hip, along with assisting in external rotation (outward rotation of hip).  GMed sits between GMax and GMin.  The function of both Gmed and Gmin is to abduct (move leg outwards/away from the midline) and externally rotate the hip. Through these actions of abduction and external rotation, the gluteal muscles help to stabilise the hip and pelvis during walking and running, preventing increased adduction (movement of the leg inwards) and internal rotation (rotation inwards) of the femur. 

Increased adduction and internal rotation of the femur during walking and running also results in an increased valgus angle (angle between the femur and tibia) at the knee, which places increased load through the patello-femoral joint. The gluteal muscles, therefore play an important role in helping to stabilise and unload the knee during running. See photos below:

There is  good evidence to suggest that the strength of these muscles is an important factor in knee pain, and a study by Prins and van der Wurff (2009) completed a review of all the literature on hip muscle weakness in women with PFPS. They found strong evidence of a decrease in abduction, external rotation and extension strength compared with healthy controls. This would correlate with weakness in Gluteus Medius and Maximus.

Other studies have shown that runners with PFJP are likely to have increased hip adduction and internal rotation. Dierks et al (2008) found that runners with PFPS displayed weaker hip abductor muscles that were associated with increased hip adduction angles in running.  More recently Noerhen et al (2012) also found greater hip adduction and internal rotation in female runners with PFPS.

So, if strong evidence supports the role of glutes in knee pain, it is important to assess if this is the case for a specific person, as it is not the case across the board. A physio assessment can accurately determine the role of glute strength and function to a client’s knee condition.  Assessment includes a combination of isolated strength/endurance tests of the glut muscles, along with functional screening tests such as single leg stance, single leg squat and hop.   In conjunction, a running assessment is extremely important to gain greater insight into the relationship between hip/knee control and glute function in running.

If glutes are found to be weak and this is contributing to a client’s PFPS, there is strong evidence to support management with strengthening exercises. Dolak et al. (2011) and Khayambashi et al. 2012  both demonstrated significant improvements in pain and function using hip strengthening exercises for clients with PFPS.

Some examples of good exercises to do if your glutes are contributing to PFPS include:

1.Glute activation in prone:  This is also a good test to see if your glutes are activating well. While lying on your stomach, keep your thigh straight and lift your leg off the ground. Feel for activation(tensing of the muscle) in the glutes as you lift your leg. They should switch on immediately as you lift your leg.  As an exercise, hold the leg lift for 3-5 seconds and repeat up to 3 x 10.

2. Hip abduction in side-lying:  Lying on side, lift top leg up approx. 30cm and hold for 2-3 seconds, then slowly lower back to starting position.  Repeat 3 x 10.

3. Hip abduction in standing: You can progress from side-lying to standing, using weight for increased load/resistance. With cable tied around ankle, move leg out to side (abduction), then slowly move back to starting position. Use a resistance where 3 x 10-12 is difficult and causes fatigue, but you can still maintain correct posture and technique.  Ensure you keep your back straight when moving the leg back and forth, and minimise leaning to one side too much.

4. External rotation (hip): Starting in side-lying, knees bent up.  Keep ankles together and lift top knee. Don’t rotate through spine or hips as you lift leg. Hold 2-3 seconds and repeat 3 x 10-12.

 Weight-bearing exercises such as squats and single leg squats are also important, but these should only be added under the guidance of your physiotherapist and when these movements do not reproduce any knee pain when done repetitively.  

We hope you have found this information useful.  If you are suffering with knee pain during running, or in everyday tasks, it may be worth considering an assessment to test your gluts and determine the main contributing factors to your condition. An appropriate management plan can then be implemented, tailored to your specific needs.

 We also acknowledge running-physio.com for sharing some of the above information.

The pain was localised to the left buttock with some spread into the back of the left thigh. It would also be aggravated by driving immediately after a run. Mrs H’s general health was otherwise good, and there were no other red/yellow flags(cautious signs).

A thorough whole body examination revealed the following main problem areas:

1. Adverse neural tension in the right lower limb and the upper cervical quadrant.
2. Muscle tension/guarding in the right shoulder and neck region( especially infaspinatous).
3. Stiffness(hypomobility) in the neck and thoracic spine left>right.
4. Restricted lumbar movement and early guarding of upper traps with shoulder abduction.
5. Restricted hamstrings range on the left, but no other local signs of tension around the buttock.
6. Good strength and activation of the gluteal muscles, but left hip flexor muscle weaker than right.
7. Running assessment revealed some over-striding, and the shoulders held elevated and abducted(elbows away from body).

Through a systematic process of elimination and clinical reasoning, we found the main area that produced the most change to all of Mrs H’s signs(above) was release of the right infraspinatous(shoulder). This muscle had a large trigger point in it. This cleared the hamstring tension(on the left) and resolved Mrs H’s symptoms so she could run painfree again.

Why was Mrs. H’s  right shoulder so tight? Further discussion revealed that Mrs H often performed Ultrasound testing with her patients, which often required holding her right shoulder away from her body and in awkward extended positions. This had lead to strain building up over time in the shoulder. She also ran with her shoulders in a tense state, which contributed to more accumulation of strain.

So why had this lead to buttock pain? There are a few possible explanations:

a. The tension in the right shoulder affected upper body rotation while running, which was compensated for by increased load on the left hip/gluteal area.
b. Tightness in the right shoulder lead to compensatory tightness developing in the left buttock following a diagonal pattern, a common movement pattern in normal bodily functions(right arm moves with left leg in walking/running).
c. The left buttock pain was an output signal from Mrs H’s brain warning of some imbalance in the body. The area of pain was not necessarily the area of greatest tension in the body, but this was the most effective area of symptoms to cause a behavioural change in Mrs H as it was affecting her running, something that was very important to her general health and well-being.

Whatever the mechanism there was measurable and objective improvement in Mrs H’s condition. Further correction involved teaching postural strategies Mrs H could employ at work to minimise strain from accumulating in her upper body, and some simple corrections to her running mechanics.

What is interesting about this case is that although Mrs H had buttock symptoms, no treatment was performed locally to that area, as there was no measurable signs of tension in the muscles or joints in the area.

Mrs H went on to run a PB (personal best) in the half marathon and is now well on the way to completing her 1st marathon.

Mr T’s main goals:

1. To be able to stretch pain-free after prolonged sitting(self rated 7/10 where 10 is normal painfree function).
2. To be able to sit for 2 hrs without leg pain(4/10).
3. To have no shoulder pain after squash(8/10).

We performed a systematic assessment  of Mr T’s musculoskeletal system and found the following imbalances:

1. Muscle guarding around both shoulders, R>L.
2. Poor sitting posture and weak shoulder stabilisers, R shoulder blade poorly positioned.
3. Restricted R shoulder rotation.
4. Restricted R hip flexion and lumbar flexion(bending forward).
5. Restricted hamstring flexibility R>L.
6. Stiff lower thoracic and lumbar segments L2-4.

Through a clinical reasoning approach, we worked out together that Mr T’s R hamstring flexibility was a good test to measure changes in his condition. Through a process of treatment directed testing, we found the biggest and quickest change in this test occurred with a R subscapularis release, which improved Mr T’s hip and shoulder movement concurrently.

Through further work on the shoulders particularly the subscapularis muscle, postural correction and motor control strategies, we were able to achieve all of Mr T’s goals and resolve his hamstring pain within a few sessions.

This case demonstrates how upper body posture can influence symptoms in the lower body, and how a systematic whole body approach is required to solve these type of problems. In Mr T’s case, he spent long hours sitting for work and also driving, and his poor sitting posture was having a detrimental effect on his musculoskeletal system.

If you would like to learn more about the neuroscience behind the approach we used with Mr T, please click here.