Hello. I'm Brett DeGoyer. I'm a primary care sports medicine specialist working for Samaritan Healthcare in Moses Lake, Washington. So now I'd like to demonstrate some manual treatment techniques or osteopathic treatment techniques specific to the area of the gluteus medius tendinitis or tendinopathy. This is not meant to be comprehensive or extensive or complete, but a way of presenting some simple techniques that can be done in the office to help your patient feel better and progress through their other treatments as well. It is also important to keep in mind that with manual techniques, you are using your hands on the patient. So you need to be very clear and very direct with the patient on what you're doing, where you will be touching, and why you're doing what you're doing in order to accomplish the treatment that you're offering the patient at the time they are in your clinic. For this specific treatment, the deep muscle inhibition, we're going to find the area on the gluteus medius that is most tight, most spastic. And the treatment is to put your thumbs and push deep into the muscle. The idea is with that inhibition, you want to release that tension and get those muscles to relax. And as they relax, that will reduce the pain. It will also help to treat the other connective tissues, specifically the fascia surrounding that area that also house the lymphatics, vasculature, and other nerves that are running in these regions to eliminate their tightness and congestion and allow for more pain relief. So as we compress down with our thumbs, we hold that compression until we feel that relaxation. Once that is achieved, you retest the area, of course, asking the patient for their feedback as well if pain and tenderness has been relieved. Or if that pain has moved to another spot. If it's moved to another spot, you repeat the same treatment. Now I demonstrated with my thumbs, but you can also use your elbow if it's a much bigger area. The way you do this is find that area and gently put your elbow into that spot and gently compress down until you feel that tightening and ask the patient if it is tolerable to be that deep. One of the other pearls I'll add in here is to help guide and make sure you're not going too deep with your elbow, I'll cup the region with my other hand and fit my elbow right into the crux here where the webbing is between the thumb and the index finger. And that will help give me another gauge to know that I'm not too deep. But it also gives me another hand to induce any amount of rotation that will help speed along the relaxation. As that relaxation occurs, I let off and then retest, just as we did before with the thumbs. So this next treatment with manual treatment, osteopathic manipulative treatment, is to use a technique called counter strain. The idea of counter strain is to take the muscle that's tight or spastic or in pain and shorten the muscles. In shortening the muscles, the idea is to get the nervous system input to reset or relax. Once that relaxes, then the muscle fibers will also relax and then, as the goal of the treatment is to get them out of pain. That's what we're trying to accomplish. So for the gluteus medius and the gluteus region in general, we find the spot that is most tender. And this is where we need, again, clear communication with the patient on what we're doing, where we'll be touching, and with the positioning that we'll need to put the patient in for the treatment. But it's also very important for this treatment to get the patient feedback on just how much pain is present at that area that is being treated. So along the gluteus medius, I'll push in with my fingers and ask the patient to remember that level of pain. So you can remember that level of pain, call it 100% of pain, call it $1 worth of pain. Just remember that level of pain. I put my fingers back to monitor that area. The positioning is to bring the hip into extension. And then I can add in adduction or a little abduction, as well as some external rotation or internal rotation, adjusting my body area in order to make sure that I'm not hurting myself. I want to adjust those to find the place that is most relieving to the pain underneath my monitoring fingers. So I come to this point, and I ask the patient, how much of that pain is still there? So 50%. So we're not quite to the level that I would like to hold this treatment. So I'm going to make some more micro-adjustments, maybe bring her into a little bit more of abduction. And also important in this is to make sure that the patient is as relaxed as possible and make sure that you, as the physician, are doing most of the positioning, if not all of it, so that they can stay as relaxed as possible. So I fine-tune that positioning and then ask again, how much pain is there? 20%. So typically, at 20%, this is where I would hold. We like to have it 30% or less. We'd actually like it to be zero, if we can get it there. Once you find that area, then you hold for about 90 seconds. It's about like singing happy birthday three times in your head, if you need a time gauge. Once 90 seconds has passed, then you slowly bring the patient back into the neutral position and then retest and ask the patient, how much pain is there, if any at all? None. So that's a treatment area for the gluteus medius. Different areas of the gluteal complex can be treated with this same technique. You just fine-tune the positioning of the leg in order to target the area of treatment. Now, this holds true for almost every muscle except the piriformis muscle. So that particular treatment positioning is best demonstrated on the side of treatment. I'm going to have the patient scoot towards the edge of the table, and I'm going to bring the leg off of the table and flex the hip up. And I'm going to bring the leg out into abduction. This is what's going to shorten those piriformis fibers. I'm going to monitor at the piriformis, which is almost directly in the center of the gluteus maximus. So palpate deep and find that tender point. Now, of course, we've tested before we've done the setup in this manner to find out how much pain was there before she even moved. Now that she's moved and we've positioned, I push on that area and ask how much pain was left. And? 80%. So we're going to bring the hip into more flexion, more abduction, and maybe a little bit of internal or external. So this would be external or internal rotation to see if we can fine-tune the muscle relaxation. So we're going to go actually into more external rotation and then ask how much pain is left. So 20%. And again, we'll keep it here for 90 seconds. Once 90 seconds has passed, then we will bring everything back into the neutral position and then retest that spot to find out how much pain is left. An approach to a patient who has problems with the gluteus medius or even the gluteus complex altogether, but in this case, the gluteus medius tendinopathy, we want to make sure to also address the other main muscle groups that are surrounding that area. This would include the lumbar spine. So this technique is muscle energy targeted at the lumbar spine to help reduce the tension in that region, which then will also help to reduce the tension across the gluteal muscles. In this case, again, the gluteus medius. The treatment side is going to be this side. So I'm standing on the opposite side. The positioning for the patient is going to be in this manner, where she is going to have her hand holding her head, her other hand holding her elbow that's bent. So as she does that, and the elbow is going to be right in front so that it's 90 degrees at the shoulder relative to the chest. I'm going to reach in with my hand and grasp her upper arm, as you can see right through here with my hand. I'm going to monitor at the paraspinal musculature in the lumbar spine, particularly this treatment side, which would be the patient's right, to help induce a stretch, I'm going to turn the patient until I feel tightness in this region, and also get feedback from the patient that tightness has been achieved. I can also add in any amount of side bending to also accentuate that tightness. Once I've reached the positioning, the patient is going to contract against my resistance, or in other words, trying to sit back up straight. So go ahead and contract. With this contraction, she's going to hold this for two to five seconds and then relax. And the amount of strength that she's putting in here is gentle to moderately gentle. Once she releases that contraction, I'm going to take up the slack and find that area of tightness once again and repeat two to five times. Again, a treatment for muscle energy is targeting those tight muscles to try and release the areas of tightness not only in the area of treatment, but in the surrounding areas using isometric contraction. This will also help to treat the other connective tissues, such as the fascia, to help release areas of congestion with lymphatics, vascular, or even the nerves that are running in those planes.

2nd Edition, CASE 24

2nd Edition

Hip

osteopathic techniques

gluteus medius tendinitis

muscle energy techniques

counter strain technique

deep muscle inhibition