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That tight rectus femoris?
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That tight rectus femoris? - July 27, 2004 5:41:00 PM
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PTupdate.com
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Joined: October 8, 2001
From: Pittsburgh, PA USA
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Hello all,
For years I felt I was the only PT that addressed rectus femoris tightness with low back pain patients, especially older stenotic patients. I really felt it was the key to the great success I was having. The only theory I could muster was that somehow tightness was pulling the pelvis into an anterior tilt, forcing increased lordosis to maintain upright standing, and therefore increasing facet compressive forces.
However, over the past year or two, much of it after reading things from Barrett and postings on NOIgroup, I have wondered if I am more performing a neural mobilization along with the actual muscle stretching. Or, perhaps the muscle isn't tight at all, and the "stretch" is just mobilizing the nervous system as it relates to the femoral nerve, and therefore reducing the above mentioned effects.
Either way, I found that when the patients foot touches that buttock (finally) in a prone position, their pain is usually reduced by 75%. Perhaps it is this treatment, or all the other things I am doing...I just don't know.
What do you all think?
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: That tight rectus femoris? - July 27, 2004 7:09:00 PM
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Synergy
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From: Texas
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Duff,
I know what you are talking about, but I also think that hip flexor tightness can be an even greater culprit! It's origination on the anterior surface of T12-L5 and insertion on the lesser trochanter of the femur tends to create all kinds of problems for LBP patients.
I usually notice a great reduction in pain (after several treatments mind you) after stretching the hip flexors, but like you said Duff, am I somehow facilitating some sort of neural mobilization with this technique?
Coupled with the stretching, I usually follow this up with some MWMs of the psoas or iliopsoas as the patient performs resisted hip flexion or trunk rotation in hooklying.
I'm interested in seeing what everyone else does as well.
_____________________________
Chris Adams, PT, MPT
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Re: That tight rectus femoris? - July 27, 2004 11:27:00 PM
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nari
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From: Australia
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I would definitely think along the lines of neural mobilisation, which will be done in the PKB position anyway. For good measure, RF will be stretched as well, but I would ensure that the stretches are very brief in duration (5 secs) and nor many reps.(no more than 5-8).
Some EIL might be advantageous too.
Nari
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Re: That tight rectus femoris? - July 28, 2004 6:41:00 AM
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PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
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I agree with the hip flexor tightness, but don't see it almost universally like I do the "rectus". I have also found that when treating persons with TKA, where you cannot get the stretch due to limited knee flexion, that the results are never as rapid and successful. ( The same is seen in patients with some other internal derangement that limits knee flexion) I plan on trying that Mulligan technique.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: That tight rectus femoris? - July 28, 2004 7:35:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Duffy,
I appreciate your ability to begin to doubt previously held assertions and work to change your theory and technique. I get around, and this ability seems not all that common.
I've always wondered why people think that certain "muscles" might spontaneously grow short. How could that possibly happen without massive trauma and prolonged immobilization leading to a decrease in sarcomeres in series? That would certainly work, but sitting around isn't going to do it. A little movement ala Feldenkrais will demonstrate quite clearly that the restriction isn't in the muscle-it's in the brain. Of course, this work hasn't exactly caught on.
Anyway, why would a short muscle hurt? It's built to withstand tension painlessly, isn't it? Why would facet compression hurt? Isn't that what they're designed for?
I'm aware of no research demonstrating that "tight hip flexors" cause trouble, but the evidence that neural tension, however acquired, will certainly lead to the picture you describe is overwhelming.
By the way, I wouldn't try to fix that problem with stretching myself. See the "Why such resistance?" thread for more on that.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: That tight rectus femoris? - July 28, 2004 2:24:00 PM
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PTPLUS
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When I worked for a large hospital based group one of the clinics was big on ecentric situps for for certain types of low back pain. The clinic manager had come across this technique for decreasing muscle tone in the hip flexors and was a big part of her treatment for many patients with LBP and she swore by the results.
Sounds like something similar to me, I have used this technique in the past and was literally shocked by how quickly I saw results with some patients.
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Re: That tight rectus femoris? - July 29, 2004 11:24:00 AM
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CarolinaPT
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From: North Carolina
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I don't know whether it may be a part of the healing process involved but there certainly is some LB movement occuring with a RF stretch. Maybe it is the gentle extension mobilization that is helping. Just some thoughts.
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Re: That tight rectus femoris? - July 29, 2004 8:19:00 PM
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coloradojulie
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From: colorado usa
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I agree with your considerations Duffy. At this point in practice my thinking lies more in a "use it or lose it philosophy". I agree with Barret that it is positive to continually re-evaluate thinking and am doing that clinically as well.
Use it or lose it as follows:
The shortening of the rectus femoris and the psoas is adaptive. It is a movement adaptation that occurs over time secondary to a movement pattern that fails to utilize active hip extension in gait. So when these individuals walk, they are not actually extending their hips. So they are not actually using the antagonists (gluts)and they are not actually using their abdominals to prevent excessive lumbar extension or anterior pelvic tilt and voila...over time, they lose hip extension range of motion and their muscle adaptively shortens. Their gluts weaken and their abs lengthen and weaken.
As a result, the lumbar spine must substitute for loss of true hip joint extension by either rotation movements or lumbar extension. OVer time leading to lumbar instability and hypermobile movement segments.
This also leads to overuse of the quadratus lumborum as the primary "hip" extensor during gait. Facet compression becomes excessive...and these joints become irritated (grab a spine and make it extend and rotate to the same side...OUCH!!)...voila belt line pain with the pattern of one sided dominent L5/S1 (often mistaken for SI joint pathology) pain with intermittent contralateral pain (secondary to the rotational instability, as a compensation for loss of hip extension). The schlerotome pattern for facet pain I believe is to follow an angular pattern from the buttock to the anterior medial thigh, never below the knee (yes I say never)
The femoral nerve and the femoral cutaneous primarily have sensory distribution in the anterior (not lateral or posterior hip) thigh (femoral cutaneous) and the femoral nerve continues to the anterior shin with a medial bias.
The agonistic relationship between the gluts and psoas results in an inhibition of the gluts, not necessarily for any other reason than lack of use by the user...use it or lose it.
So we release psoas and rectus, we strengthen gluts and low abs and then make it functional. Works like a charm.
If it was truly femoral nerve entrapment I think we would see more anterior medial shin pain associated with these clients.
To address some of Barrett's questions, I think a shortened muscle may be "overused" with a tendency for the individual to place greater functional demands on the tissue with resultant overuse syndromes. I think facets hurt, because like any other joint with meniscus and articular cartilage eg. the knee, excessive load bearing leads to cartilage breakdown and the degenerative process. Pain arises from this process.
Inherent in muscular structure is the answer to length tension relationships with regards to cross bridge positioning and contractile effectiveness. Either too short or too long, can lead a muscle to less than optimum function.
I don't think muscles spontaneously grow short, I think the user makes them that way over time. When they get short enough or weak enough or imbalanced enough, we cross a functional tolerance barrier and pain ensues...the last straw deal.
I don't think these adaptations are either beneficial or ideal for these individuals. Rather I would seek to remedy this situation by teaching the person how to use these muscles properly again.
I find it hard to believe there would be any research out there that could identify one single variable such as "hip flexor tightness" or "neural tension" as THE defining factor in a patient's pain complaint or recovery. It is simply impossible to rule out all other cause and effects in the chain of muscles involved and how they interact dynamically with each other. Hence the evolution....
But this is where I sit now....
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