Techniques For The Gluteal Region And Coccyx

As the glutei are such strong muscles and are in close proximity to the sciatic nerve they may play an important role in production and maintenance of sciatic pain syndromes. Hypertonic glutei can affect posture and prevent normal mechanical relationship of the hips to the rest of the body. There may be a tendency for the hips to rotate outwards and thus upset locomotion, sitting and standing postures. Lumbar origin pain syndromes will often present as tense painful areas in the glutei, piriformis and gamelli, and work on these can be helpful in treatment of such cases.

Particular caution is rarely necessary in working on the glutei except that a Ewing's tumour in the bone or the ilium itself can present as gluteal pain. Due to the sensitive nature of the area, particular care needs to be taken with the treatment here so that no accusations of improper handling can occur. Informing the patient of the purpose or a particular procedure should eliminate this problem.

The coccyx is commonly a site of pain although many cases are due to referred pain from the lumbar spine. It is, however, possible to have a dysfunctional junction between the sacrum and the coccyx. There are techniques that approach the joint through the rectum, but external techniques are generally preferred by patients and operators alike!

Particular precautions include the possibility of fracture if there has been direct trauma, and rare cases of referred pain from the rectum in the presence of a space-occupying lesion.

15.1 • Kneading prone Use your thumb to apply cross-fibre kneading to the ischial tuberosity and lower part of gluteus maximus. The other hand applies a counter-force, partly to limit the forces to a specific part of the muscles, and partly to reduce the discomfort of direct pressure.

Tips: Most useful in cases of ischial tuberosity bursitis, muscle strains and residual sciatica. Least useful where prone lying might be a problem. Extra considerations: The pillow under the abdomen is for patient comfort. Try using varied degrees of abduction in the thigh, or a pillow under the tibia to flex the knee and reduce stretch on the posterior thigh muscles.

15.2 • Kneading prone Apply a kneading force to the glutei, gamelli and piriformis on the opposite side of the patient. The other hand monitors the stretch produced, and spreads the effect of the hold to reduce any discomfort.

Tips: Least useful where prone lying may be a problem. Exquisite tender areas will often be found in the glutei in lumbar dysfunction syndromes, and although these are often due to referred pain, they can be maintaining factors. Recovery can be enhanced if these muscles are relaxed to allow freer pelvic movement. Extra considerations: The pillow under the abdomen will usually aid patient comfort. Try abducting the leg by varied amounts to find the optimum.

15.3* Kneading prone Work on the lower part of the glutei and the piriformis while holding back on the belly of the muscle with the other hand, to localize the force. The lateral muscles of the thigh can also be addressed in this position.

Tips: Most useful in cases of residual sciatica where there is a muscular component as a maintaining factor. Least useful where prone lying may be a problem. Extra considerations: The pillow under the abdomen will usually aid patient comfort. Try varying the abduction of the thigh to find the optimum for the technique.

15.4 • Inhibition prone Apply a direct pressure over the piriformis with your thumb. Maintain a steady pressure and internally rotate the hip until tension is felt. Inhibition implies a steady pressure, usually while a lever is applied, and a finite time must elapse until a sense of release is attained.

Tips: Most useful in cases of persistent piriformis tension as in some sciaticas. Least useful where prone lying is a problem. Extra considerations: Try varying the hip abduction in the initial set-up for the technique. This may be a very uncomfortable procedure, but within about 10-15 seconds the muscle will be felt to relax, often accompanied by an immediate relief of symptoms.

15.5 • Inhibition prone Carefully apply the tip of your elbow to the piriformis while maintaining the internal rotation of the hip with the other hand applied to the ankle.

Tips: Most useful in cases of severe, long-term spasm of piriformis. It is also the method of choice when the operator's thumbs are not strong enough. Least useful where prone lying may be a problem. Extra considerations: The pillow under the abdomen is to increase patient comfort. This is clearly a powerful technique, and needs sympathetic care in handling to avoid excessive pain; however, it can be extremely useful.

15.6 • Inhibition prone Apply a double thumb pressure to the piriformis with the pads of the thumbs overlaid. This has the advantage over the elbow hold of being a little more gentle, yet very specific.

Tips: Most useful in cases of sciatic nerve irritation where the piriformis is involved, and inhibition alone is required, without stretch. The previous holds for working on piriformis use some longitudinal stretch. Least useful where prone lying is a problem.

15.8 • Articulation of sacro-coccygeal joint prone

Internally rotate the hip with varied degrees of knee flexion as suitable for the case. Hold back on the coccyx with the other thumb. The technique is performed with either a pressure on the coccyx, a circumduction of the leg, or both simultaneously.

Tips: Least useful where prone lying is a problem. This hold is more suitable than the one in photograph 15.7 if a gentler procedure is required as it avoids stressing the hip.

15.7 • Articulation of sacro-coccygeal joint prone

Abduct and internally rotate the hip carefully, as this is potentially a very strong hold. Hold back on the coccyx with your thumb. The technique can be performed as a force with either hand, or both simultaneously.

Tips: Least useful where prone lying is a problem. Extra considerations: Try asking the patient to temporarily hold the breath to assist in firming up the pelvic floor.

15.9 • Articulation of sacro-coccygeal joint prone

Spring alternately on the sacrum and the coccyx. Different lateral pressures can be introduced if required to find the optimum barrier for the articulation.

Tips: Most useful where it is desired to avoid using the hip as a lever. Least useful where the prone lying position may be a problem. Extra considerations: To make the technique more effective try using patient breath-holding to drive the pelvic floor down and firm up the area.

15.10 • Articulation of sacro-coccygeal joint prone Hold the coccyx toward yourself while internally rotating the opposite leg.

Tips: Most useful where one hip has a dysfunction making it unusable as a lever, so the contralateral side is used. Least useful where prone lying may be a problem or where the reach may be too great for a small operator. Extra considerations: Try using varied degrees of hip abduction to amplify the technique.

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