John Gibbons
Bodymaster Method
Putting maximus back into the gluteus
rhomboids and serratus anterior)
• Upper lobe of left lung, referring to
the trapezius
• Diaphragm - this is innervated by
the phernic nerve that originates
from the level of C3, 4, and 5, which
could relate to the shoulder via the
neurological dermatome.
You can see there are many
possibilities that could be causing
the pain. Although this list is not
exhaustive, it highlights the many
avenues to consider with a common
complaint of ‘shoulder/trapezius
pain’.
Taking a holistic approach
Let us now assess the client globally
rather than locally, remembering that
the pain only comes on after running
four miles.
John Gibbons looks at a case study that
demonstrates how pain does not always
present itself at the site of the problem
The client was a woman of 34 and a
physical trainer for the RAF, presenting
with pain in the superior aspect of her
left scapula. The pain was intense and
would come on four miles into a run,
forcing her to stop. The discomfort would
then subside, but quickly return if she
attempted to keep running. This was the
only activity that caused the pain. Her
complaint had been ongoing for eight
months, worsened over the past three,
and was starting to affect her work.
There was no previous history or related
trauma to trigger the complaint.
After seeing different practitioners, who
all focused their treatment on the ‘upper
trapezius’, she visited an osteopath who
treated her cervical spine and rib area.
The treatments she had received were
biased towards soft tissue techniques of
the affected area - the trapezius, levator
scapulae, sternocleidomastoid, scalenes,
and so on. The osteopath had also used
manipulative techniques on the facet
joints of her cervical spine - C4/5 and
C5/6. Muscle energy techniques and
trigger point releases were used in a
localised area, which made it feel better
at the time but had no impact when she
attempted more than four miles’ running.
She had not undergone any scans (e.g.
MRI or x-ray).
Assessing the symptoms and cause
Tissue(s) that seemed to be causing
the client’s pain/symptoms:
• Upper trapezius
• Levator scapulae
• Scalenes
• Thoracic rib
• Cervical rib (extra rib forming from the
transverse process of C7).
Potential causes of the problem:
• Referral pain from cervical facet
C4/5 or C5/6
• Protective spasm/strain of upper
trapezius or levator scapulae
• Dysfunction of the gleno-humeral
joint (or even the acromio-clavicular or
sterno-clavilcular joint)
• Inter-vertebral disc bulge
of C4/5 or C5/6
• Elevated first rib
• Tightness of the scalenes
• Positional - due to upper crossed
syndrome (forward head posture and
rounded shoulders due to tight pectorals
and sternocleidomastoid, and weak
When I see a new patient, I normally
assess the pelvis for position and
movement, as I feel this is the
‘foundation’ for everything that connects
to this part of the body. I often find that
when I correct a dysfunctional pelvis, my
client’s presenting symptoms settle down.
However, when I assessed this client, I
found her pelvis was level and moving
correctly. I went on to test the firing
patterns of the gluteus maximus (or gmax), which I often do with athletes who
participate in regular sporting activities,
but only if I feel the pelvis is in its correct
position. The logic is that you often get a
positive result that the muscle is mis-firing
when the pelvis is slightly out of position.
I found a bilateral weakness/misfire of
the g-max, but it seemed a bit slower to
fire on the right side. As I hadn’t found
any dysfunction in the pelvis, I pursued
this avenue further.
So how does a right side weakness of the
g-max cause pain in the left trapezius? Is
there a link, and if so how is this possible?
What can be done to correct this and
why has it happened in the first place?
To answer these questions, we need to
look at the anatomy of the function of
the g-max and its relationship to other
anatomical structures, as detailed on
reverse.
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Piecing it all together
So what do we know? We know that
the right side of the g-max is slightly
slower and that this muscle plays a role
in the ‘force closure’ of the SIJ. This tells
us that if the g-max cannot do on of its
functions, then something else will assist
in stabilising the joint. The left latissimus
is the synergist to help stabilise the right
g-max and, more importantly, the SIJ.
As the client runs, every time her right
leg contacts the ground and goes
through the gait cycle, the left latissimus
contracts. This causes the left scapula to
depress and muscle that resists this is the
upper trapezius and the levator scapulae.
Subsequently, these muscles start to
fatigue and for this client, it occurs at
approximately four miles, at which point
she feels pain.
Treatment
You might think the easy way to treat
the weakness in the g-max is to simply
add in ‘strength’ biased exercises.
However, in practice this is not always
the case, as sometimes the tighter
antagonistic muscle is responsible for
the apparent weakness. The muscle in
this case is the psoas (hip flexor) and
this, when shortened, can result in a
weakness inhibition of the g-max.
My answer to this puzzle was to stretch
the client’s right psoas muscle to see if it
promoted the firing activation of the gmax, while at the same time introducing
strength exercises for the g-max.
Visit www.fht.org.uk/g-max
exercises to find information
about using a core ball to
activate the g-max.
The g-max, and form and force closure
The main action of the g-max is as a
powerful hip extensor and a lateral
rotator, but it also plays a part in
stabilising the sacroiliac joint (SIJ) by
helping it to ‘force close’ while going
through the gait cycle.
Part of the g-max is attached to the
sacrotuberous, a ligament that runs from
the sacrum to the ischial tuberosity. It is
the ‘key’ ligament that helps to stabilise
the SIJ.
To help us understand this action, we
need to consider ‘form closure’ and
‘force closure’, which are both associated
with the stability of the SIJ (see diagram
1). The shape of the sacrum - along with
its ridges and grooves, and the fact that
it is wedged between the ilia - helps to
bring natural stability to the SIJ. This is
known as ‘form closure’.
If the articular surfaces of the sacrum
and the ilia fitted together with
perfect form closure, mobility would be
practically impossible.
When working efficiently, the forces
between the innominate and sacrum are
adequately controlled and loads can be
transferred between the trunk, pelvis
and legs.
However, form closure of the SIJ is not
perfect and mobility is possible, which
means stabilistation during loading is
required. This is achieved by increasing
compression across the joint at the
moment of loading.
So how do we link this to the client’s
complaint? In one of my previous articles
on training the Oxford rowing team (IT
March 2008), I wrote about the posterior
oblique ‘sling’. This directly links the right
g-max into the left latissimus dorsi via the
thoracolumbar fascia.
The surrounding ligaments, muscles and
fascia are responsible for this. When the
SIJ is compressed, friction of the joint
increases and consequently augments
‘form closure’.
The latissimus had its insertion onto
the inner part of the humerus, and one
of its functions is to keep the scapula
against the thoracic cage and aid in the
depression of the scapula.
Diagram 1: Form closure and force closure (Schamberger, 2002)
Prognosis and conclusion
I advised the client to abstain from running and to get
her partner to assist in stretching the psoas twice a day.
Strength exercises were also advised twice daily until the
follow-on treatment.
I reassessed her 10 days later and found normal firing of
the g-max on the hip extension firing pattern test, and a
reduction in the tightness of the associated psoas.
Due to these positive results, I advised her to run as far as
it felt comfortable.
I wasn’t sure if it was going to correct the problem, but
she reported that she had no pain during or after a sixmile run.
The client is still pain-free and continues to regularly use
the g-max exercises and psoas stretch.
This case study demonstrates that very often, the
underlying cause of a condition or problem may not be
local to where the symptoms/pain presents, therefore all
avenues need to be fully considered.
John Gibbons, BSc (OST), is a registered osteopath, author, sports therapist and a lecturer in sports
medicine at the University of Oxford. Call 07850 176600, visit www.johngibbonsbodymaster.co.uk
or email [email protected]
John Gibbons
Bodymaster Method
Gluteus Maximus
From a functional perspective, the Gmax
performs several key roles in controlling
the relationship between the pelvis,
trunk and femur. This muscle is capable
of abducting and laterally rotating the
hip, which helps to control the alignment
of the knee with the lower limb. For
example, in stair climbing, the Gmax
will laterally rotate and abduct the
hip to keep the lower limb in optimal
alignment, while at the same time the
hip extends to carry the body upwards
onto the next step. When the Gmax is
weak or misfiring, the knee can be seen
to deviate medially and the pelvis can
also be observed to tip laterally.
The Gmax also has a role in stabilising
the sacroiliac joints (SIJs) and has been
described as one of the force closure
muscles. Some of the Gmax fibres attach
to the sacrotuberous ligament and the
thoracolumbar fascia, which is a very
strong, non-contractile connective tissue
that is tensioned by the activation of
muscles connecting to it. One of the
connections to this fascia is the latissimus
dorsi.
Posterior Oblique Sling
connection is known as the posterior
oblique sling. This sling increases the
compression force to the sacroiliac joint
during the weight-bearing single-leg
stance in the gait cycle. Misfiring or
weakness in the Gmax reduces the
effectiveness of the posterior oblique
sling, which will predispose the SIJs to
subsequent injury. The body will then
try to compensate for this weakness by
increasing tension via the thoracolumbar
fascia by in turn increasing the activation
of the contralateral latissimus dorsi. As
with any compensatory mechanism,
‘structure affects function’ and ‘function
affects structure’. This means that other
areas of the body are affected: the
shoulder mechanics are altered due to
the attachment of the latissimus dorsi on
the humerus and scapula. If the latissimus
dorsi is particularly active due to the
compensation, this can be seen as one
shoulder appears lower than the other
during a step-up or even a lunge type of
motion.
The Gmax significantly increases the
stabilisation of the SIJs during early
and mid-stance phases through the
attachments of the posterior oblique
sling.
The Gmax plays a significant role in the
gait cycle, working in conjunction with
the hamstrings. Just before heel strike,
the hamstrings will activate, which
will increase the tension to the SIJs via
the attachment on the sacrotuberous
ligament. This connection assists in
the locking mechanism of the SIJs for
the weight-bearing cycle. From heel
strike to mid-stance of the gait, the
Gmax increases its activation and the
hamstrings decrease their activation.
The hip extension firing pattern test is
very unique in its application. Think of
yourself as a six- cylinder engine: basically
that is what our body is – an engine. The
engine has a certain way of firing and so
does our body. For example, the engine
in a car will not fire its individual cylinders
in the order 1–2–3–4–5–6; it will fire in
the sequence, say, 1–3–5–6–4–2.
Weakness or misfiring in the Gmax
will cause the hamstrings to remain
active during the gait cycle, to maintain
stability of the SIJs and the position of
the pelvis. The resultant overactivation of
the hamstrings during the gait cycle will
subject them to continual and abnormal
strain.
Hip Extension Firing Pattern Test
The figure below indicates the correct
firing pattern of hip joint extension. The
normal muscle activation sequence is:
1. Gluteus maximus
2. Hamstrings
3. Contralateral lumbar extensors
4. Ipsilateral lumbar extensors
5. Contralateral thoracolumbar extensors
6. Ipsilateral thoracolumbar extensors
If we have our car serviced and the
mechanic mistakes two of the leads
The Gmax forms a partnership with
the contralateral latissimus dorsi via the
thoracolumbar fascia – this partnership
If we have our car serviced and the
mechanic mistakes two of the leads
and puts them back incorrectly, the
engine will still work but will not be very
efficient; over time, the engine will start
to break down. Our body is no different:
in our case, if we are particularly active
but have a misfiring dysfunction, our
body will also break down and eventually
cause us to experience pain.
Psoas & Rectus femoris
Modified Thomas Test: shortness of psoas and rectus femoris.
The patient is asked to lie back on the edge of a couch while holding onto their
left knee. As they roll backwards, the patient pulls their left knee as far as they can
towards their chest, as shown in figure. The full flexion of the hip encourages full
posterior rotation of the pelvis and helps to flatten the lordosis.
In the figure below the therapist is demonstrating with their arms the position of
the right hip compared to the right knee. You can see that the hip is held in a flexed
position and that the lower leg is held in extension, this confirms the tightness of the
right iliopsoas and the rectus femoris in this case.
In my experience I find that the
hamstrings and the ipsilateral erector
spinae are generally first to contract and
the gluteus maximus is number four in
the sequence. This will mean that the
erector spinae and the hamstrings will
become the dominant muscles in assisting
the hip in an extension movement. This
can cause excessive anterior tilting of
the pelvis with a resultant hyperlordosis,
which can lead to the lower lumbar facet
joints becoming inflamed.
To correct the misfiring sequence, the
answer is not to strengthen the so-called
‘weak’ muscles, since encouraging
strength-based exercise will not assist
these specific muscles in regaining their
muscular strength.
MET treatment of the Psoas
The patient is asked to contract the right hip (flexion) isometrically for 10 seconds,
on the relaxation phase the therapist applies a downward pressure on the knee, this
will induce a stretch of the psoas.
Remember which muscles are
antagonistic to the Gmax? Well, the
Gmax is a powerful hip extensor so it has
to be the hip flexors – the main muscles
responsible for hip flexion are the psoas,
rectus femoris and adductors.
One way of encouraging a correct
firing pattern is to identify the length
of the hip flexors: if they are tested as
short, an MET can be utilised to assist in
normalising the resting length of these
shortened structures. This theory of
lengthening the shortened structures can
be applied for a period of approximately
two weeks; if the firing pattern has
not improved in this two-week period,
strengthening protocols for the Gmax
can then be incorporated into the
treatment plan.
1. Athlete presents with?
• Tight/painful hamstrings or lumbar paraspinal muscles
• Insufficient forward or upward power production from the legs
• Pelvic position dropped when running
What can it imply?
Faulty posterior chain muscle activation pattern
Likely finding:
GMax weakness or delayed timing on same side
2. Athlete presents with?
• Tight/painful adductor magnus (inner thigh)
• Asymmetrical body orientation
• Better balance one side than the other
What can it imply?
Faulty hip extension pattern: adductor magnus being over used to extend the hip
Likely finding:
GMax function decreased on same side
3. Athlete presents with?
• Excessively tight latissimus dorsi (remembering that the dominant arm will often be slightly less flexible than the non-dominant one)
What can it imply?
Faulty posterior oblique sling
Likely finding:
GMax function decreased on opposite side
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