Nagging Hip Pain and its Connection and Implications for Accompanying Foot Pain

hip stretches

photo credit: http://funkroberts.blogspot.com/2008/04/bad-hips-here-is-some-therapy.html

Are you experiencing hip pain that seems sometimes constant and excruciating, which causes a limp while walking, or problems while lying on your side at night, or perhaps difficulty rising from a chair and/or the inability to stand up straight?
Are you struggling with finding a stretching movement or change of position that succeeds in relieving the pain, or having trouble lying down comfortably and walking normally?
Have the outside edge/s of your feet (or has one individual foot) been feeling tingly, weak or painful, but you haven’t yet been able to pinpoint or name one particular activity or incident that you can attribute the bizarre pattern to?
Then this article may be for you!
Before this discussion gets underway, please allow me to brief you on the definition and general nature of trigger points,
those hyper-irritable spots in muscles, that when pressed on often refer a sensation distant to the area of contact.

Osteopath Richard Bachrach of the Center for Sports and Osteopathic Medicine explains..
Trigger points (TrP) are foci of hyperirritability in muscle, fascia or ligaments (connecting bone to bone as in joints). They are characterized by taut fibrous bands, a twitch response when stimulated, and constant areas of referred pain. The pain patterns thus produced are called myofascial pain syndromes.
Active TrPs are always tender. They prevent full lengthening of the muscle and weaken it. Direct compression, stretching, or other sources of irritation such as accumulation of the toxic chemical byproducts of muscle metabolism, or lack of oxygen, will ignite the TrP. From it, localized pain is produced in a specific area with associated autonomic changes. These may include increased or reduced skin temperature, sweating or dryness. The area of referred pain is often distant from the TrP.

Let’s first explore the possible symptoms arising from gluteus minimus  (outer hip muscle) trigger points..

The superior gluteal nerve arises from L4 through S1 and innervates the gluteus minimus, gluteus medius and tensor fascia lata. When the nerve is compromised due to trauma, disc involvement or other factors, the supporting action of these muscles are diminished. When the patient tries to balance on one limb, the pelvis falls on the side of the raised limb indicating a positive Trendelenburg sign. The referred pain from trigger points in the gluteus minimus may be constant in duration, severe in intensity and may cause the patient to limp when they walk. The discomfort may also interrupt their sleep if they roll onto the effected side. -Nationally Certified Therapeutic Massage and Bodywork massage therapist David Kent writing on Pseudo-Sciatica and Gluteus Minimus Trigger Points in a May of 2011 Massage Today issue.

The gluteus minimus can be easily overlooked, says David, since the referred pain from this muscle is felt so deep and remotely from the location of the trigger points.  An analysis of the gluteus minimus muscle’s anatomy and trigger point pain referral patterns clarifies how the function of this thigh abductor helps keep the pelvis level during single limb weight bearing and hints at the potential for a spillover connection (or the satellite nature of gluteus minimus trigger points) by way of the peroneal muscle tendons that attach into the foot.   Trigger points harbored in the anterior fibers of the gluteus minimus can refer into the lower buttock, down the lateral aspect of the thigh, and then further into the fibular region of the leg where the peroneal muscles are found.


Activation of Trigger Points (in the gluteus minimus muscle)
Myofascial trigger points in the gluteus minimus muscle may be activated or perpetuated by sudden acute or repetitive
chronic overload, SI joint dysfunction, injection of medications into the muscle, and nerve root irritation. Perpetuating factors may include prolonged immobility, tilting the pelvis by sitting on a wallet, postural distortions and unstable equilibrium when standing.  Gluteus minimus TrPs may be activated by an acute overload imposed by a fall; by walking too far or too fast, especially on rough ground or over uneven terrain; or by overuse in running and sports activities, such as swimming, tennis and handball.

This fan-shaped hip muscle has the potential to refer pain into the lateral calf, AND, according to Travell and Simons’ Myofascial Pain and Dysfunction Trigger Point Manual  (scroll down to Ch. 9 once on this page.  It will be approximately 13 pages beyond the Gluteus Medius referral pattern chart on p. 151 of Ch. 8), this muscle can also refer pain into the lateral ankle, and even to the foot, because of the anterior gluteus minimus muscle’s potential to activate lateral leg trigger points, which can then spill over and induce satellite trigger points in the peroneal muscles located on the outside of the calf.
Note referral zone of Gluteus Minimus in Image 1B   (scroll about 1/3 of way down screen to view).
Trigger points in the gluteus minimus and the gluteus medius will restrict adduction* of the thigh. *Remember adduction is the movement of bringing the thigh towards and/or across the midline of the body.
So, how does one correct a gluteus minimus trigger point pain pattern?  Activities that impose unusual stress on the muscle, such as vigorous sports and hiking, need to be avoided for a time.  Athletic training through incremental conditioning should be integrated and routinely implemented into one’s recreational or sports program.  A person can try using their body weight to achieve deep ischemic compression right on top of the gluteus minimus trigger points located under the tender area at the top of the femur by using a tennis ball to slowly apply a stripping massage. Leaning against a smooth wall while slowly rolling the tennis ball at a rate of about 1 inch every 10 seconds, moving towards either the iliac crest or the sacrum and following the natural layout of the gluteus minimus muscle fibers, can often be quite effective, especially when followed by application of moist heat.

Referred Pain into the Lateral Aspect of the Foot by Peroneal Muscles:
Peroneus longus and peroneus brevis (Refer to page  374 here for an excellent anatomical diagram) trigger points (TrPs) project pain and tenderness primarily to the region over the lateral malleolus of the ankle, above, behind, and below it; they also extend a short distance along the lateral aspect of the foot. A spillover
pattern of the peroneus longus TrPs may cover the lateral aspect of the middle third of the leg.
See: Ch. 20, Peroneal Muscles, Travell and Simons Myofascial Pain and Dysfunction

Consider for a moment the anatomy  of the Peroneal Muscles:

  • Peroneus Longus: The most superficial and the longest of the three muscles, this muscle attachesThe Peroneal Muscles superiorly to the head of the fibula, along the upper half of the lateral aspect of the fibula, and to the intermuscular septa. The tendon of this muscle wraps around behind the lateral malleolus and then across the sole of the foot to attach inferiorly to the medial cuneiform and first metatarsal bones. The Common Peroneal Nerve passes between the two upper attachments of this muscle on the fibula.
  • Peroneus Brevis: This muscle is shorter than the peroneus longus and lies partially underneath it. It attaches superiorly to the lower 2/3 of the fibula, and its tendon joins the tendon of the peroneus longus as it wraps behind the lateral malleous. It then attaches inferiorly on the lateral aspect of the fifth metatarsal bone on the foot.

Note that both the peroneus longus and the peroneus brevis have tendon attachments on the foot.

http://www.triggerpointtherapist.com/blog/peroneous-trigger-points/peroneal-trigger-points-ankle-pain/

Associated Trigger Points

Referred pain that shoots down the leg from gluteus minimus trigger points (side sciatica) may activate trigger points in the peroneal muscles. Additionally, the presence of gastrocnemius trigger points, soleus trigger points, and the tibialis anterior trigger point may weaken their respective muscles and in turn overload the peroneal muscles, causing trigger points to form in them.  Unaddressed trigger points of the quadratus lumborum can act as perpetuators of satellite gluteus minimus trigger points as well.

Writing for the Trigger Point Therapist Network and Information Resource, Dr. Laura Perry, in her article; “Gluteus Minimus Trigger Points: A Small Muscle with a Big Mouth” emphasizes that “Even though it’s a small muscle, its numerous trigger points have a very large distribution of referred pain.”  She states that Dr. Travell (Janet G Travell, M.D. of the infamous Myofascial Pain and Dysfunction trigger point volumes authoring fame) refers to the gluteus minimus as the “Psuedo-Sciatica” muscle because its trigger points can refer pain that mimics the symptoms associated with true neurological sciatica.
If you’ve been experiencing mysterious pain, tingling, or weak sensations on the outside of your foot or lateral leg, you may want to consider the possibility of a false radiculopathy, also known as a pinched nerve:

From pages 173-4, Vol. 2 of Janet Travell and David Simons’ Trigger Point Manual:
The gluteus minimus is a potent myofascial source of pseudoradicular syndromes. [Note that the word pseudo means
false; i.e., not real –athough your subjective pain level may belie this fact.]  The symptoms produced by TrPs (trigger points) in the anterior fibers of the muscle may be mistaken for an L5 radiculopathy, and symptoms from the posterior fibers mimic an S1 radiculopathy. Knee pain that suggests an L4 radiculopathy is not characteristic of gluteus minimus TrPs. Sensory or motor deficits and paresthesias in a nerve-distribution pattern, imaging of the spine, and electrodiagnostic tests   http://www.knowyourback.org/Pages/Treatments/AssessmentTools/ElectrodiagnosticTesting.aspx    http://orthoinfo.aaos.org/topic.cfm?topic=a00270 can distinguish neurogenic from TrP-referred pain.

Corrective actions to restore proper function and flexibility of the peroneal muscles include wearing shoes that provide a good arch and foot support; eliminating under thigh compression when seated, avoiding walking on a slanted sidewalk and/or running on a track or road surface that’s slanted, and avoiding wearing high or spiked heals.  Other hugely therapeutic approaches involve: doing a peroneal stretch while in a warm bath or hot tub, practicing postisometric relaxation techniques, and doing gentle passive stretching of the peroneus longus and peroneus brevis muscles while grasping the forefoot, fully inverting and adducting it, then pulling it upward into dorsiflexion.

Nicole Nelson writing in a November 2012 edition of Massage Today describes

Peroneal Tendonitis (tendinosis) syndrome

http://www.aofas.org/footcaremd/conditions/ailments-of-the-ankle/Pages/Peroneal-Tendonitis.aspx

Although the peroneals are chiefly regarded as everters of the foot, a lesser known, yet very cool fact about the peroneus longus muscle is that it helps in the stabilization of the big toe. This stabilization plays a large role in the appropriate winding of the plantar fascia during gait, known as the windlass effect. Any individual that is forced to move laterally (i.e. tennis or basketball player) places a high demand on these muscles as they act to stabilize and prevent inversion of the ankle. Running or walking on uneven surfaces such as a trail or soft sand will also challenge these muscles. When life is good, the peroneals, along with tibialis anterior and posterior, control inversion and eversion of the ankle and keep the structures of the foot and ankle out of harms way. As we all know, life isn’t always good and injury results. Let’s take a look at the peroneals involvement in ankle instability and go over some massage strategies that will help our clients reduce their pain possibly prevent future injury.
I certainly do suggest relieving trigger points in these muscles with local compression. I would also recommend cross fiber friction to the areas that feel particularly glued down. For this work, I usually position clients in a sidelying position, with the involved leg up and bolstered. Sherrington’s law of reciprocal inhibition states that a hypertonic antagonist muscle may be reflexively inhibiting it’s corresponding agonist. If we consider this law in conjunction with Janda’s insights, it stands to reason that most of the deep stripping should be performed on the posterior tibialis, gastrocnemius and the soleus muscles. Additionally, contract/relax methods of stretching will be helpful in normalizing these overly tightened tissues. Naturally, not everyone fits into the tonic/phasic mold outlined by Janda; therefore, each client should be assessed and evaluated for their unique set of tightness and restrictions.The Peroneals – Anatomy and Function by Nicole Nelson  http://www.massagetoday.com/mpacms/mt/article.php?id=14672

If you’re ready to eliminate once and for all your peroneal and/or gluteus minimus trigger points, or would like to experience myofascial unwinding of the hips and calves, the softening of hypertonic musculature through carefully applied stripping and compression moves, as well as engagement of somatic contract/relax methods and a thorough unwinding of these overly tightened tissues, give Breathe Easy Massageworks’ myofascial and trigger point release therapy trained practitioner a call today!

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~ by charl7 on March 21, 2013.

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