Lisa is an avid recreational runner. During the past six months, she has trained hard for an upcoming marathon. For the last month, she has had a low-level, dull, aching pain in the left-lateral hip region. She did not actively address it, because she thought it was a simple overuse issue associated with her training regimen.
Two weeks ago, when leaving her apartment, Lisa stumbled and fell on the stairs. She landed on her left hip, but was unable to significantly break her fall because her hands were full. That night, she had pronounced pain in her left-lateral hip, and the next day it was swollen and very tender to the touch. Walking was painful for the next two days, and running was out of the question.
After about five days, most of the swelling subsided and the pain was reduced but still present. Lisa resumed a very limited running schedule, but continued to experience prominent left-lateral hip pain and a dull, aching pain in her gluteal region on the same side when running. She was also aware of a sharp pain in her posterior thigh aggravated by her running that was not there previously and seemed to be increasing.

Evaluation
Lisa sought treatment two weeks after her incident. A detailed history from Lisa provided valuable clues and helped direct the physical examination. There was no longer any visible swelling in her lateral hip region or other visible indicators of tissue disruption, nor was there any apparent pathology in the hip, gluteal region, or posterior thigh (the regions where she reported pain).
Palpation revealed significant tenderness in her lateral hip region directly over the greater trochanter of the femur. There was also significant tenderness in the soft tissues superior to the trochanter that have attachments on that bony landmark. The gluteus maximus on each side appeared normal, but there was palpable tightness deep to the gluteus maximus on the left side, which appeared to indicate hypertonicity in the piriformis muscle.
In the active, passive, and resisted movement assessment, Lisa reported lateral hip pain when performing active abduction of the left hip. There was a slight limit to range of motion for active internal rotation on the left side compared to the right. No other active movement caused any discomfort or limited range of motion.
While active abduction reproduced her pain, passive abduction did not. Passive internal rotation performed in a prone position also showed a limited range of motion on the left side compared to the right. This was the same motion limitation that was apparent with active movement. She also reported mild pain sensations in the gluteal region at the end of the passive internal rotation movement on the left side.
Lisa’s lateral hip pain was reproduced with resisted abduction on the left side. There was no similar pain with resisted abduction on the right side, and the right side resisted action was strong and normal. No other resisted movements reproduced any pain or discomfort.
The information derived from the history, observation, and initial physical examination provided further key clues about the nature of Lisa’s hip and gluteal pain. Following the range-of-motion and resistance testing, two other additional testing procedures were performed to help clarify a possible cause for her symptoms.
Lisa described having gluteal pain and neurological sensations down her posterior thigh. In addition, there appeared to be significant limitation to internal hip rotation, which indicated tightness in the external rotators of the hip. This pattern of symptoms is frequently present when the sciatic nerve is entrapped by the piriformis muscle.
The position shown in Image 1 is a familiar one for stretching the piriformis muscle and is also used for assessing neurological involvement of the sciatic nerve. If the position increases or aggravates existing neurological sensations, there may be compression of this nerve. The sciatic nerve runs just adjacent to the piriformis, and fibrous or tendinous bands within the muscle can compress the nerve (Image 2).
The sciatic nerve can also become compressed if the muscle is overly tight. Cadaver dissections show that variations in the position of the two sciatic nerve divisions are not uncommon. In some cases the nerve may separate its peroneal and tibial divisions as it passes the piriformis muscle, and the nerve may even go directly through the middle of the muscle. These anatomic variations can make the nerve more susceptible to compression pathology.
If the piriformis muscle is compressing the nerve and that muscle is stretched, it will often increase neurological sensations. Lisa reported a slight increase in sharp pain and some paresthesia in the posterior thigh when this procedure was performed. This result, along with the findings from the other portions of the assessment, indicates there is some level of nerve compression.
Sciatic nerve compression by the piriformis muscle would likely produce Lisa’s gluteal and posterior thigh pain, but would not likely produce her lateral hip pain. She reported serious lateral hip pain and swelling immediately after falling on the stairs. That swelling subsided shortly after the injury, and she likely sustained an acute trauma to the trochanteric bursa, which caused the swelling. The trochanteric bursa is located over the greater trochanter and under the iliotibial band (Image 3, page 98).

However, she has a lingering pain during palpation of the soft tissues superior to the greater trochanter. Lisa’s lateral hip pain was also reproduced during resisted abduction. The gluteus medius and gluteus minimus muscles are primary hip abductors, so there may be something occurring in those muscles associated with the lateral hip impact. It is also notable that she reported a mild pain sensation in this region prior to the accident, so there may have been an underlying dysfunction in those tissues prior to the fall.
The gluteus medius and minimus play a key role during the normal running and walking gait, and face an interesting biomechanical challenge as the body seeks to accommodate the alternating changes in weight during stride. When weight is fully on one side, like the stage of running stride shown in Image 4, these muscles contract to maintain a level pelvis. Lifting weight off the right leg would cause the pelvis to drop to the right. The hip abductors on the left contract to pull the pelvis level as the non-weight-bearing right leg swings through.
During evaluation, it is helpful to attempt reproduction of this biomechanical challenge for the hip abductors with a procedure called the Trendelenburg test. From a standing position, the client lifts the leg on the side opposite the leg with the potential problem. In Lisa’s case, that would mean she would lift her right leg. If the pelvis drops to the right side, that indicates a weakness in the hip abductor muscles. These muscles might be weak if they were injured in her fall. Often, pain that is produced on the affected side with this procedure indicates damage or dysfunction in the associated tendons of the gluteus medius and gluteus minimus muscles.1 Lisa had a mild pain sensation in the left lateral hip region when this procedure was performed.
If there was damage to the distal tendons of the gluteus medius and minimus, it could also explain why there was some potential tightness developing in the piriformis muscle from the accident. The distal tendon of the piriformis muscle blends with fibers of the gluteus medius and minimus tendons, as they all attach on the greater trochanter.2
Trauma to this area could have caused tendon damage or reactive muscular splinting from the impact. This could aggravate existing tendon pathology that could have already existed from overuse.

Interpreting the Results
The assessment findings indicate hypertonicity in the piriformis and a likelihood of compression of the sciatic nerve in the gluteal region by the piriformis muscle. In addition, there is likely some muscle-tendon pathology of the hip abductors. Lisa was already experiencing lateral hip pain prior to the accident, so it is unlikely that all of her symptoms result from that accident. There may have been pre-existing, low-level chronic overuse of these tendons, and the accident caused additional damage, further aggravating her pain.
Another factor to consider is the immediate swelling after her fall. It is likely there was acute inflammation of the trochanteric bursa from the impact. Lisa could still be irritating that bursa with repetitive hip motions as she continues training. The gluteus maximus and tensor fasciae latae insert into the iliotibial band (ITB), which courses over the trochanteric bursa. Increased tightness in these two muscles can pull the band taut and increase pressure on the trochanteric bursa during repetitive movements.
In sum, Lisa is experiencing a couple of key issues. The piriformis muscle appears significantly tight and may be compressing the sciatic nerve. And there appears to be dysfunction affecting the distal tendons of the gluteus medius and minimus, causing pain in the trochanteric bursa. The next step is to determine an effective massage treatment approach.

Treatment Strategies
Treatment should begin with the most superficial muscles. The gluteus maximus is the largest and most superficial muscle in this region, and plays an important role because of its attachments into the ITB. While there was no significant hypertonicity in the gluteus maximus, this muscle has numerous fascial connections throughout the area, and treating it will improve overall biomechanics of the entire hip, pelvis, and low-back region.
Treating the gluteal muscle group requires good communication with your client. Asking permission to treat this area is important, and proper and conscientious draping techniques are necessary. Some older draping techniques, like tucking the drape into undergarments, may no longer be appropriate.
The gluteus maximus is tender on most people, but especially so on runners. You can prevent reactive muscle splinting (tightening) by beginning treatment with a broad contact surface. Broad open-fist compressions, sweeping cross-fiber movements, and good compressive effleurage are all very effective for reducing initial tension in the gluteus maximus. Once tightness is reduced, treatment on the underlying piriformis can begin.
One of the most effective ways to address the piriformis without trying to press too deep is with an active engagement lengthening technique. To begin, have the client lie in a prone position, flex the knee, and place the hip in full lateral rotation. Instruct the client to hold as you attempt to gently pull the lower leg toward you (Image 5, page 100). Instruct the client to slowly let go of the contraction as you continue moving the leg toward you (in medial rotation). As you perform this movement, apply a slow specific stripping technique directly on the piriformis, moving forward along the piriformis 3–4 inches with each movement. This technique can be repeated several times until the entire piriformis is addressed. Follow this technique with stretching to encourage full tissue lengthening and advise the client to do home stretches for these tissues.
To address the hip abductor muscles, begin with broad contact techniques for the lateral pelvis. Broad contact techniques can be applied to the gluteus medius and minimus from the edge of the iliac crest to their attachment on the greater trochanter. Once initial muscle relaxation techniques have been engaged, more specific work can be applied to the muscle bellies, as well as the potentially affected tendons.
Lisa had pain just superior to the greater trochanter, so it is possible that there is tissue damage at the musculotendinous junction or possibly chronic tendon overuse of the gluteus medius or minimus tendons themselves. Deep friction massage applied directly to these tendons will help encourage healing of any scar tissue that might be present from a tear, as well as encourage fibroblast proliferation that may help repair the damaged collagen matrix if there is chronic overuse tendon pathology.
After a few treatments, more specific work can be applied to the hip abductor muscles with active engagement methods similar to what was performed on the piriformis. For this treatment, the client is in a side-lying position, with the leg in a fully abducted position. Instruct the client to slowly bring the leg back down as far as possible, even dropping below the level of the table if possible (Image 6). As she brings her leg down in adduction, perform a deep stripping technique on the hip abductor muscles. This technique can be painful, so proceed slowly and with caution, and adjust to appropriate pressure levels. Note that there may be significant tightness or tenderness in small areas of these muscles, and additional attention can be focused on myofascial trigger points with pressure from a thumb, elbow, or pressure tool.
There are other treatment solutions that can be very helpful for addressing Lisa’s injuries. It is helpful to address not only the lateral hip region, but also the low back and lower extremity. See these additional treatment strategies, along with video examples, and home-care solutions on the Resources page of the Academy of Clinical Massage (www.academyofclinicalmassage.com/resources-articles). The Massage & Bodywork digital edition has a video demonstrating one of the active engagement techniques used above.

Conclusion
Lisa’s case is interesting because it shows the importance of an integrated understanding of anatomy, kinesiology, and various types of tissue pathology. The skillful clinician can pick up key factors in the client history, tie those with other responses during the physical examination process, and develop a good understanding for how to proceed. Constructing a beneficial and successful treatment plan for a complex condition such as Lisa’s often involves taking a bit more time in assessment than more straightforward conditions.

Notes
1. R. C. Grumet et al., “Hip Pain in an Athletic Population: Differential Diagnosis and Treatment Options,” Sports Health 2, no. 3 (May 2010): 191–6.
2. F. Michel et al., “The Piriformis Muscle Syndrome: An Exploration of Anatomical Context, Pathophysiological Hypotheses and Diagnostic Criteria,” Annals of Physical and Rehabilitation Medicine 56, no. 4 (May 2013): 300–11.

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