Massage Tutorial: Hip pain (myofascial release)
Hi everyone, I'm Ian Harvey, massage therapist. This is my friend, Summer. Today we're going to be talking about hip pain.
You have a client who comes in your office, they say, "I've got hip pain." The first thing that I want to do is ask them to point it out. People have different concepts of what their hips are. A lot of them might end up pointing here, toward their SI joint. That's a whole other ball of wax if you wanna see stuff about that, look at my gluteal region video. Now, if they point over here, then we're talking about the region of the greater trochanter and there are some likely suspects at play. Just as a couple notes, if they do complain about this lateral pelvis pain, ask them if there is any related pain.
Some types of related pain will be low back. These hips can easily refer pain up into the low back. We'll talk more about that in a second. Or, pain that lives here can be associated with lateral knee pain.
I've also got a video on lateral knee pain if you'd like to check that out. It also talks about the IT band. But if things are tight up here, they can be yanking on some of this lateral thigh tissue. But the main muscles we're going to be talking about here are going to be gluteus medius and minimus and maybe some tensor fasciae latae. So let's have a look at this. Alright, so I am using a more liberal glute draping here, so do you have a conversation with your client if you would like to have this much real estate available to you. Let them know that you'd like them to be completely undressed.
Ask if that's okay with them. If not, there's a lot that we can do through underwear, and through the drape. We'll talk about that in a bit when we're doing stretching. First, let's find out landmarks.
Around the side you'll find the greater trochanter. You'll know that you're on this if you hold some fingers on this knob of bone here and then you rotate the femur just a bit with the other hand. If that knob of bone moves, you're on the greater trochanter. Explore the boundaries of that greater trochanter because a lot of the times the pain that they'll be having with this hip pain will be either at the greater trochanter itself, or just superior to it, and maybe just a little posterior to it. Often you'll find more as you travel up this gluteus medius and minimus.
So, explore the boundaries that greater trochanter. It will kind of meld into the rest of the femur as you go below it, but find those boundaries anterior to, superior to, posterior to that greater trochanter. Then, coming superiorly we'll come up with some nice soft and powerful muscle. This is gluteus medius and minimus. Until we reach a ridge of bone.
This may be higher than you expect it to be, more superior, so keep traveling up into you meet this lip of bone that you can travel past. So if we're able to then sink into muscle, here's where we're sinking into quadratus lumborum. If you come back down, this is the iliac crest.
You'll be able to follow it forward to the ASIS, the anterior superior iliac spine, and you can follow it posteriorly, until it meets the top of the sacrum, and then we're going to get into that SI joint, that sacroiliac joint. So, our two main landmarks here are that greater trochanter, and that iliac crest. Between the two of these, you'll find some dense muscle. This is the gluteus medius, and underlying that is the gluteus minimus. It's very unlikely that you'll be able to differentiate the two, just know that if you're working in this region, you're working with both muscles.
Now as I'm working on this, as always, I'm lounging against the table as much as possible. So this rear leg is leaning against the table, when possible I'll lean this front leg against it, because this keeps me close to my client and it allows me to let a lot of this energy come from my hips, rather than pressing, rather than using a lot of muscle. So, I'm getting in close, I'm relaxing, and now we're going to do just a few steamrolling strokes, up the lateral hips. Notice how I'm anchoring my elbow into my side, and then letting that elbow travel down my leg. At no point am I having to really use my pec muscles. Most of this is coming from the movement of my stance. As always, with myofascial release, we're coming at this from origin to insertion and beyond.
Now our origin is here at the greater trochanter, the insertion is along this ilium, and up toward the iliac crest. So, we're going to start below the greater trochanter using a nice broad surface, and we're going to move superiorly as far as the draping will allow. If you've got a very liberal draping like this, you can come all the way up into the low back, and to these lateral ribs. All this fascia is connected, if you can get this stuff to loosen up and this stuff to loosen up, this will be happier. So just some more general strokes: Just because we're focused on these lateral hips, don't forget about gluteus maximus and all these rotators. Anything that attaches to the greater trochanter can be broadcasting pain to that boney protuberance. I like to switch into open fist. It keeps me at a very neutral wrist.
I'll let my fingers trail behind, and just let the thumb trail behind, its not doing any work. And feel free to pass right over iliac crest. As long as you're not really sinking in with these punching knuckles. As long as you're distributing this weight along the knuckles, and these posterior proximal phalanges, then that shouldn't be painful. It should just feel like a nice steamrolling. Now, as you're warming this, I like to just do a lot of steamrolling.
Some of it up longitudinally like this, some of it down transversely like this, starting near the SI joint. Now, usually I'd be right up against the table here, but I need to stay out of the way, because its TV. So I'm coming out transversely, So this is kind of a broadening move for this muscle. The fibers run in this direction, and I'm coming across them.
And you can incorporate these as a longer stroke that starts in the gluteus maximus, and then comes around into gluteus medius and minimus. Now, you can do other Swedish moves here. You can do petrissage, but some people feel self-conscious about having this area moved around too much, so I like to keep things a little bit slow here. So, after I've done some nice broad moves, I'll move on to more specific tools, like fingertips. In this case I'm going to use reinforced fingertips, so these three are doing the main work, and these other guys here are just on top for support. Again I'm anchoring my elbow into my side, so as my stance changes, as I slide along this table, that's powering this move. And you can use carving knuckles here.
Just make sure to keep a straight wrist joint. And this can feel quite sharp, so do track your client and stay in good communication. Now that we've done some general warming up, we can work with some trigger points if that's your thing. Just doing all of these myofascial strokes and doing some slower static holds, like this, and kind of hanging around while that softens under your hand, that will work with trigger points.
But if you want to get more specific, feel for that superior surface of the greater trochanter. This is where a lot of these trigger points will live. Just as a note of caution, all of this lateral hip tissue can be very sensitive. It can be weirdly sensitive. People will say, "Oh wow, why is that like that?" and just let them know that with every step they take, this is acting as a stabilizer. So, just above this greater trochanter is where common sites of trigger points will be.
Search around anteriorly a bit. Search around posteriorly a bit. If you find something that feels extra tense, or if your client reports that you've found a good point, stay in good communication and they'll be able to let you know about stuff like that. I prefer to let the client report when I've found a trigger point. I don't always trust that what I'm feeling, and it feels unusual to me, necessarily feels like anything to the client. So, I let them lead the way there. And I'll continue on northward. You'll find some really good ones right in the belly of the muscle.
There will be ones that are between the greater trochanter and that iliac spine. And again, a little posteriorly, and a little anteriorly. And you'll also find some, and these can be quite sensitive, you may want to actually avoid these if they're too sensitive, that are right up near the iliac crest. And you can follow that iliac crest all the way back, and all the way forward. Just a quick note, if you've got a client who wants or needs a lot of pressure here, you can use your punching knuckles here. You can sink in, step way back away from your table, and then lean in here. And this will allow you to offer significant pressure without having to press really hard with your fingertips.
You can have a straight elbow and a straight wrist, and simply lunge forward. And you can continue that stroke downward, and come anteriorly. As you may be aware, I'm a fan of coming at areas that are in crisis, or that are sticky, and that need work, from a lot of different angles, because that gives the nervous system a lot of different kinds of stimulus, rather than just trying the same thing over and over again, the nervous system can acclimate to that, and you might get no change. So, let's change some angles here. I'm going to apply my elbow to my own side, and give some good pressure to this gluteus medius and minimus region.
Right now I'm in the belly of the muscle. Now, this other hand can be rocking the femur, just subtly, back and forth, as I either continue stripping upwards, or just do a static move here on trigger points. This is a good starting place. It's not to threatening to the nervous system. There's little chance of spasm with something this gentle. You can incorporate client engagement. So Summer, I'd like you to very subtly, just moving by about a centimeter, rock your heel to the left and to the right.
It'll be a very tiny movement. Perfect. If your client does this too quickly, let them know, have them slow it down. This will be them engaging the muscle.
These lateral hip muscles here are internal rotators, so you'll feel them firm up as that heel comes outward, and you'll feel then slacken as the heel comes inward. Both are important. It is cool. As you are doing this, you can come all the way around anteriorly, and incorporate that tensor fasciae latae a bit. I like to use fingertips for this, because if I try to use my soft here that could be a little uncomfortable for my wrist. If you're feeling adventurous, you can also use your elbow here. Anytime that I'm working with hips, I like to incorporate some movement of this femur here.
So I've redraped the glutes, because, by changing the angle of this femur, sometimes it causes the hips to to come up a bit, and I don't want there to be a draft. And also, mostly I'll just be doing static compressions, rather than any sort of gliding move. You could keep the glutes undraped, you'd just need to have some cloth bunched up under the hips so there wouldn't be a draft. So I've got the ankle plucked up, and now I can apply some pressure inward by hooking my elbow into my side, and allowing my body to come up against the table. And then, once again, I just lounge. And now, by changing the angle of this femur, I'm making a big change in this gluteus medius and minimus.
So, you can use your open fist here, you can use fingertips, you can use these carving knuckles, you can use elbow here, if you can figure out how to make you body mechanics do that, but that's a little too slumped over for me, so I'm going to use fingertips. Come around, find your greater trochanter, and your iliac crest, come between them, apply some good pressure, some good static pressure, and then were going to change the angle of this leg. This will create a bigger change just working with hip in a static position. You can also incorporate some stretching. So, bringing the leg very far into internal rotation like this, (you can tell its internal rotation because the knee is coming inward), bringing it very far into internal rotation like this is going to make all of these internal rotators, like gluteus medius and minimus, and tensor fasciae latae, it's going to make them very loose, and slack. Versus crossing the leg over like this, that's going to stretch all these muscles. So, work with these muscles in stretch, work with them while they're slack. Work with them in all sorts of different ways.
If you'd like to get another interesting angle, grab the inside of the knee, bring the leg outward, and now we're still doing internal and external rotation, but this is at a completely new angle this greater trochanter, and for this hip joint. From here you can put the legs into a figure four configuration. Because this brings the hips up just a bit, you can really access tensor fasciae latae this way. Alright, let me know what you think, hit me up in the comments section, consider subscribing, and I'll see you next time.
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