Darren is a 34-year-old male who works in a big home-improvement store. His job involves restocking building materials and retrieving large orders for customers. Consequently, he does a significant amount of heavy lifting in his job and also drives a forklift.
For several months now, Darren has been having some low-back tightness and pain extending down his right leg. At first, he brushed the problem off as something that comes with the job and he assumed it would be temporary. However, the condition has persisted. He is concerned that the problem is getting more severe and may affect his ability to keep working. He wants to try a noninvasive procedure like massage first, hoping that this will prevent a need for more serious interventions like back surgery.

Key Considerations
Let’s take a look at some of the key anatomical and biomechanical considerations in this area and then explore Darren’s case in greater detail. A tremendous amount of low-back and lower-extremity pain originates from muscle overuse and dysfunction, so it makes sense to look at muscle structures as a potential cause. However, not all conditions have muscle tissue involvement, so it is always important to keep an open mind in the beginning.
We know that Darren spends a lot of his day lifting heavy items. He is also frequently on a forklift, where he must turn his upper body around while in a seated position to look behind him as he is driving. These occupational motions and activities place a significant load on many low-back muscles. The key stabilizing muscles of the low back that are frequently injured from occupational overwork include the quadratus lumborum and the different divisions of the paraspinal lumbar extensors. These muscles are not designed for power-lifting activities. They also respond poorly to being held in a static position for long periods.
A key concern in Darren’s case is the fact that he reports pain going down his right leg. In reports of radiating lower extremity pain, disc herniation and nerve root compression are often suspected. However, there are several conditions that produce similar symptoms, so deeper investigation is definitely required.
Myofascial trigger points in the gluteus minimus closely replicate the neurological-type symptoms of sciatic nerve compression. It is common for these trigger points to develop in people who sit for long periods during the day (as Darren does when driving the forklift). Of course, massage therapy is one of the most effective ways to address muscle injury that occurs from chronic overload or extreme tightness (hypertonicity), so if this turns out to be the primary issue, we can likely help him a great deal.
The intervertebral disc is a key structure involved in low-back mechanics, and for many years was considered a primary cause of low-back pain, especially if there was pain radiating down the lower extremity. When exposed to high compressive loads over time, such as long periods of sitting or heavy lifting, the disc will partially flatten and protrude to the side. Unfortunately, the structures in closest proximity to the protrusion are the lumbar nerve roots.  
Massage therapists might be reluctant to work on individuals with disc herniations because they fear further compressing the nerve roots. Further nerve root compression can result from movement in the spine due to treatment and it is advisable to be cautious when working in this region if disc compression is suspected. However, it would be very difficult to put direct pressure on the nerve roots where a disc is compressing them because this is prevented by the transverse processes of the lumbar vertebra and soft-tissue structures in this area.
Other conditions such as facet or sacroiliac joint dysfunction, where there is irritation between the contact surfaces of adjacent joints, may also produce similar symptoms. Piriformis syndrome, which is a compression of the sciatic nerve in the gluteal region, is another potential cause of these same symptoms. All of these conditions can produce radiating pain down the lower extremity that mimics sciatic nerve compression symptoms. Further investigation is necessary to identify which tissues are involved in Darren’s problem, as our treatment will be different for each of these potential conditions.

Assessment and Evaluation
We established in the initial history that Darren was experiencing some low-back discomfort, but primarily pain down his right lower extremity. Yet, we also now know that this information alone is not sufficient to point us to the proper cause. A description of sharp or radiating symptoms could come from any of the possible causes described earlier. Consequently, physical examination is essential for determining if we can help Darren or if we need to refer him to another health professional.
The physical examination will focus on his back and lower extremity regions. Our palpatory investigation reveals tight muscles throughout his lumbar and thoracic regions. There is also significant tightness in the gluteal muscles, hamstrings, and calf muscles. He also reports that deep palpation in his low-back region reproduces some of the common pain sensations in his low back. However, nothing in the initial palpatory examination reproduces his lower extremity pain.
Assessment shows he has range of motion restriction in forward flexion and lateral flexion of the lumbar region to each side. This restriction is present in both active and passive movements. However, none of our simple range of motion movements produce the primary pain complaint Darren has been experiencing. He does mention that his back feels tight and there is mild discomfort with some of these motions as he stretches his back, but it’s not the same pain he’s been experiencing.
In a supine position, he has limited hip flexion and says he can feel the hamstrings pulling taut as his fully straightened leg is raised in a hamstring stretch position. This same stretching position is used with a special orthopedic test called the straight leg raise and will often reproduce neurological sensations in individuals who have disc protrusions pressing on a nerve root. However, Darren has no radiating neurological-type lower extremity symptoms aggravated by this stretching position.
To investigate the possibility of sacroiliac joint dysfunction, several special orthopedic tests are used that stress the sacroiliac joint to see if any symptoms are reproduced. It is challenging to identify if the sacroiliac joint is involved with a single physical examination test. Greater accuracy comes if several tests are performed together and then the results are cumulatively considered. Darren describes no discomfort with any of these procedures except for the side-lying compression test, where he is lying on his side and his lateral hip region is pressed with the palms. However, there is also pressure on his hip abductor muscles as this test is performed, so I want to make sure this is a sacroiliac joint response and not a muscle response.
To investigate further, I try using significant pressure with just a thumb pressed into the gluteus medius and minimus muscles. By using a small contact surface of pressure, I can apply more compressive load to the muscles and very little to the sacroiliac joint region for better assessment of those tissues. Darren reports that this reproduces the pain he’s been feeling down his lower extremity.
At this point, I am suspicious about involvement of the gluteus medius and minimus muscles in Darren’s lower extremity pain. While maintaining pressure on these muscles with a thumb, I ask him to abduct his thigh. Immediately, he responds that this really causes discomfort and he feels a sharp aching sensation down the lower extremity. By combining deep, specific pressure with this muscle-resistance test, any existing pathology within the muscle will become much more apparent.
The physical examination revealed significant tightness in muscles throughout the lumbar, gluteal, and lower extremity regions. These muscles form a long and continuous myofascial chain, and it is very common to see tightness patterns that exist throughout. None of the other evaluation procedures we performed strongly pointed to a potential cause for Darren’s pain. However, that doesn’t mean there isn’t another simultaneous, underlying pathology. In fact, it would be very helpful to have additional evaluation and high-tech diagnostic procedures performed by another health professional, just to rule out any potential neural structure involvement in the lumbar region. However, we have established that there does not appear to be any contraindication to performing massage treatment, and with the extensive muscle tightness Darren is demonstrating, massage would be helpful for addressing his problem.

Treatment Considerations
Having established that a primary component of Darren’s pain complaint is muscle dysfunction and trigger-point activity throughout his low-back and gluteal region, a treatment strategy can be created for him. The primary focus will be on techniques to encourage muscle lengthening and deactivation of the involved trigger points.
The hypertonic muscles through his low-back region will be most effectively addressed with deep stripping techniques. Static compression methods will address the specific trigger points. The focus with the deep stripping techniques will likely be on the lumbar paraspinal muscles, as well as the quadratus lumborum. Because of the role in maintaining spinal stability, it is important to treat the deep intrinsic spinal muscles that lie in the lamina groove as well.
Because of the muscular and fascial connections throughout this region, one should be comprehensive and thorough in treating all of the superficial and deep layers of the gluteal muscles, hamstrings, and posterior calf muscles. Specific attention should also focus on the hip abductor muscles, because that is where the key trigger points reproduced Darren’s primary pain complaint. One way to effectively address the trigger points in the hip abductors is to modify the assessment method used during the evaluation process by pressing on the trigger points during active concentric and eccentric contraction.
Compression with active engagement is very effective for addressing trigger points in these thick muscles. To perform this procedure, have the client in a side-lying position and locate the primary trigger points in the lateral hip abductor muscles. Apply pressure to those muscles and then have the client actively contract the muscles by lifting the leg in abduction. It is likely to feel quite sore when he does this, so do not use too much pressure at the outset.
Another effective variation for addressing this muscle group and trigger points is to perform a reverse method, where pressure is applied during the eccentric elongation. This is essentially a pin and stretch technique. Have the client bring the leg up into abduction, then apply pressure to the hip abductors and instruct the client to slowly lower the leg as far as possible while you maintain pressure. The eccentric activation of those muscles while pressure is maintained can be painful for the client, so be sure to gradually measure your progress and pressure level.

Conclusion
Darren’s case illustrates how important it is to be thorough in the evaluation process, because it is common for different conditions to have similar symptoms. Also, the key point illustrated here is the importance of clinical reasoning using analytical skills to go outside of traditional evaluation methods. In this case, it was the application of deep pressure applied with a contraction of the muscle that revealed deep trigger points in the gluteus minimus that were not immediately evident during the initial evaluation. By developing your analytical skills and your technique, you will become a far more effective clinical practitioner for your clients.

Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. You can find more ideas in Lowe’s free enewsletter—and his books, course offerings, and DVDs—at www.omeri.com.

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