lying As it is impossible to adduct the thigh more than a small amount to stretch the lateral tissues, direct stretch with pressure is sometimes the only way to get to these tissues. Here the operator has adducted the patient's thigh as much as possible, and then while holding back on the superior part, is applying a longitudinal stretch with the other hand. As the ilio-tibial band is largely non-extensible, very little stretch can be produced, and this procedure can be very uncomfortable. This is one of the few osteopathic techniques where the use of a lubricant oil or cream may make the technique more effective.
Tips: Most useful in severe cases of osteo-arthrosis of the hip where it is not possible to mobilize the hip directly. Least useful when there are fibrous bands in the fascia lata which are very tender. Extra considerations: Change the angle of the hip flexion to find the optimum in each case.
30.3 • Kneading lateral and anterior muscles of thigh From behind the patient the operator has grasped the muscles on the lateral side of the thigh and, while applying a pushing force with the thumbs, is pulling with the fingers to produce a cross-fibre kneading to the area. There are many variations of hand hold that can be used here.
Tips: Most useful where the patient can take direct kneading on the muscles and where the fascia is mobile enough to accept stretch in this way. Least useful where the patient has any problems with the other side making sidelying difficult. Extra considerations: Vary the angle of the hip for optimum tension, fix hands and use body movement rather than hand movement alone.
30.4 • Kneading medial or posterior muscles of thigh supine With the patient's knee and hip flexed and firmly held against the operator's abdomen, a cross-fibre kneading action is being performed. The more the work is shared by both hands, the less the discomfort of the movement, and the deeper the technique can be applied to produce a better and quicker result. With the hip and knee flexed, the muscles are off tension and therefore easier to work in most cases.
Tips: Most useful in cases where the patient cannot extend the hip fully. Least useful when the patient is very ticklish. Extra considerations: It may be necessary to experiment to find whether it is better in a particular case to fix with one hand and move with the other or to work both hands.
30.5 • Kneading thigh supine Here the operator has fixed the anterior part of the thigh to himself, and is holding the patient's foot into the table at varied angles of flexion of the knee to optimize the technique. The other hand is applying the cross-fibre kneading to the adductor muscles. In this position it is possible to reach well up to the origin of the muscles.
Tips: Most useful where there are tight bands in the adductor muscles, particularly close to the pubis. Least useful when the patient may feel threatened by this position. Extra considerations: Sometimes the kneading hand can be held still and the operator and his other hand moved against it.
30.6 • Kneading thigh sidelying The operator is in front of the patient and is working on the medial aspect of the leg on the table. Both hands are working in opposite directions to minimize the amplitude of force in each. In this position the upper thigh 'protects' the groin area and it is possible to reach very high up into the origins of the muscles; this also allows the pubic ramus to be reached without excessive embarrassment to the patient.
Tips: Most useful where it is necessary to apply the technique high in the adductors. Least useful where the patient has difficulty sidelying. Extra considerations: Changes in the angle of flexion of the knee and hip can make it possible to reach different parts of the muscles.
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