Four Case Histories
Case History #4
Marilyn, a 53-year-old physical education teacher, was demonstrating a round-off dismount from a low balance beam, when she landed hard on her left leg and heard something “snap.” This incident took place a year and a half prior to her doctor’s referral for Myofascial Trigger Point Therapy.
She had been for other therapies including strengthening of the hamstring muscles under the direction of a physical therapist, deep tissue massage and "some kind of injection in the rear of the thigh.” In spite of this, Marilyn continued to have pain in the left buttock and posterior thigh with considerable pain at the proximal, medial thigh, as well. Her pain went as high as a 10/10 if she sat for any considerable period of time.
After taking an in-depth history, I discovered she had a serious trauma to the left foot in 1966 and a “very hard fall” landing on the buttocks in 1977. There was also orthoscopic surgery of the right knee in 1998 for torn cartilage. This current injury occurred 11/97.
It seemed that what we were dealing with were the remnants of more than one injury to the muscles of the lower limbs and pelvis. According to Travell, MD, once trigger points are laid down in a muscle, they can continue to cause referred pain and/or autonomic phenomena indefinitely.
After performing several ROM tests for the pelvic and lower extremity muscles, I found trigger point activity in the right quadratus lumborum and left erector spinae muscle group. Curiously, the Straight Leg Raise test for the hamstrings was nearly normal at 85°, bilaterally.
It was not until the fourth treatment that Marilyn began to experience some relief from her pain. She noticed she could sit for longer periods of time. When her pain did commence it was not as intense as it had been prior to treatment. Up to this point, treatment had consisted of Myofascial Trigger Point Therapy and soft tissue mobilization focusing on the hamstrings and lateral rotators of the hip.
As her pain continued to decrease and she was able to sit for longer periods of time, I began to treat the tensor fasciae latae, quadriceps and the adductors which I felt were secondary to the problem. Although Marilyn reported decreased pain in the left medial proximal thigh, palpation of the left adductor magnus minimus revealed taught bands of muscle that were very painful to treat.
By the sixth treatment, Marilyn was able to sit for a period of up to 3 hours at a time with her pain level at a 2–3/10, at most. She was very excited about this and optimistic that this therapy would be able to resolve her pain after a year and a half of suffering.
By the tenth treatment, Marilyn was still having occasional exacerbation of her left posterior thigh pain. She still had pain in the left buttock just above and below the gluteal fold, as well as three or four points of pain over the proximal half of the left posterior thigh just lateral to the midline. Muscle testing and palpation did not reveal the source of this continued pain.
When Marilyn came in for her eleventh treatment, we reviewed her entire home exercise program. During that time, Marilyn reported an increase in the intensity of pain in the left buttock and posterior thigh while performing an exercise that involved abduction of the hip allowing the gluteus medius to shorten.
When muscles harboring triggers points are shortened, often times the signature pain pattern of that muscle will be revealed or intensified. Such was the case with Marilyn. Deep palpation of the left gluteus medius did indeed recreate Marilyn’s pain pattern. Using Myofascial Trigger Point Therapy and soft tissue mobilization of the gluteus medius and minimus, Marilyn’s pain was decreased to zero.
At the time this case study is written, Marilyn has not completed therapy and is still experiencing pain at a level of 1–3/10, but has been able to return to normal activities such as playing softball, going on light day hikes and playing golf. When Marilyn was leaving my office following her most recent treatment, she said she was on her way to play golf with her daughter and was anxious to see how this most recent treatment would improve her golf score. As Marilyn’s therapist, I share her optimism.