Hip and Thigh Pain: The Tensor Fascia Latae Connection
Great article by David Kent, LMT, NCTMB
Patients will describe referral patterns from myofascial trigger points in the tensor fascia lata muscle, as pain in the hip and down the front side of their thigh (Images 1A and 2).
Other symptoms include tenderness and pain, from the pressure of the patient’s own body weight, which prevents them from laying on the affected side. Patients can lay on their opposite side by placing a pillow between their knees. The pillow prevents the tensor fascia lata, and the other hip abductors on the painful side from being lengthened, which can activate trigger points. If both sides are too painful, the patient will sleep on their back with a pillow under their legs or in a reclining chair.
Patients will also report experiencing pain when standing up straight after being in a hip flexed position from activities such as driving, sitting, sleeping in a fetal position, or on their back with support under their legs. Movements of the hip, including walking, will also produce pain in the hip and or lateral thigh. They may have received a diagnosis of trochanteric bursitis or iliotibial band friction syndrome.
Educate
While you may know the location of trigger points and their specific pain referral patterns, your patients do not. They are in pain and looking to you for answers and relief. It only takes a minute to educate your patients about trigger points and it’s a great way to build your practice. Explain to patients that if you press on a trigger point, it will produce a referred phenomena that is typically described as pain, burning, tingling, or pressure in a region away from the location of the trigger point.
Charts are great visual educational tools (Images 1 and 3). Show patients how your charts work and what they may expect if you palpate a trigger point. For example, in image 4, “X” indicates the common location of trigger points within the muscle. Solid red areas indicate an essential pain zone or area of pain experienced by every patient that had that trigger point activated during research studies. The red dots indicate spillover pain zones. These are areas of pain experienced by some, but not all, patients outside of the essential pain zones.
Check
Besides the tensor fascia lata, there are numerous other muscles that commonly have trigger points that also refer to pain in the hip and lateral thigh. Laminated charts allow you to use a wet-erase marker to circle trigger points that may be involved. This process lets you educate the patient while creating a visual checklist of the muscles you will isolate during the treatment. After the therapy session, you can wipe the chart clean with a little water on a towel (Image 3).
Deep to the tensor fascia lata, the anterior fibers of the gluteus minimus can have trigger points (Image 4a). (See “Pseudo-Sciatica and Gluteus Minimus Trigger Points,” MT, May 2011). Trigger point 2 (TrP2) in the gluteus medius is positioned just belong the iliac crest, mid-way along the crest (Image 5b). (See “Back Pain: Often a Pain in the Gluteus Medius,” MT, March 2009). All five of the trigger points in the vast lateral can refer to pain into the hip, the lateral thigh, and lateral knee (Images 6 and 7). Trigger points in the more lateral fibers of quadratus lumborum also refer pain in the hip (Image 8)
Anatomy
The shape of the tensor fascia latae is wide in the middle and tapered on each end (fusiform). It is approximately 15cm (5.9 inches) long. The tensor fascia latae attaches proximally to the anterior superior iliac spine (ASIS) and the anterior part of the external lip of the iliac crest. Distally it attaches into the iliotibial tract which continues to attach into the lateral condyle of the tibia (Image 1). These attachment points allow the muscle to abduct, medially rotate, and flex the thigh. It also helps to keep the knee extended and to stabilize the trunk on the thigh.
Findings
Trigger points and the pain they refer are symptoms, our goal is to treat the causes. Trigger points form for many reasons, from direct trauma during an accident, to poor posture habits, and more. Information from the patient history forms, subjective complaints, postural analysis, orthopedic assessments and tests (Ober’s), joints range of motion (ROM), length and strength of muscles, and palpation exam will guide us to design the most effective treatment plan.
Photos
A picture is worth a thousand words and a great way to document posture while educating the patients. Posture photos are simple, cost-effective tools that set your practice apart from your competition and should be included as part of the initial treatment or package of treatments.
Just like doctors use x-rays and MRIs to give a report of findings, you can use pictures to show and tell patients how their posture is causing the pain. Simply take postural analysis photos using the camera in your iPhone, smartphone, tablet or iPad and show the obvious distortions to your patients on the screen. Visual aids help patients see how their posture is perpetuating the formation of trigger points and how their treatments can help. No special software is needed, you just take the pictures and look at them. A postural analysis grid chart makes it easier for the patient’s untrained eyes to see the distortions in the photos (Image 3). (See “Practice Building with Postural Analysis,” MT, January 2012 and “Practice Building: Getting Inside Your Patient’s Head,” MT, January 2011).
Hip pain can be a result of several things including arthritis, injury from overdoing various activities, or problems in the muscles in the legs, gluteal muscles, abdomen, and low back. While massage will not eliminate pain from arthritis directly, it can often reduce it by releasing tight muscles affecting the area, eliminating them as a source of pain. The gluteal muscles are the largest in the body, and the hamstring and quadriceps (front and back of thigh) are also large muscle groups. Trigger points or spasms in these muscles, therefore, can cause significant pain in the muscles themselves as well as referred pain in the hips and low back.
When pain is a result of spasms or trigger points in the muscles affecting the hips, massage has been proven to offer significant relief, even allowing distorted gait and movement patterns to return to normal. Massage can reduce tightness and tension, and increase circulation which reduces trigger points and allows for improved muscle recovery after exertion. It also reduces scar tissue from tears and injuries, allowing for normal, smooth movement of muscle fibers. Read more about “Six Massage Techniques to Remove Scar Tissue.”
Leg Muscles
Muscles in the legs can often cause hip pain because they can impact the way we move, walk and even sit. For example, flat feet (especially common in women) can result in the foot over-pronating (rolling in). This force is then transferred to the knee, and finally, the hip, as the muscles attached at each joint are either pulled or shortened depending on the angle and location of attachments.
Massage can help release overtight muscles that result from this problem, especially the gastrocnemius muscles. With the client prone, use the heels of your hands to grab the muscle and compress, lifting it up from the bone. The compression provides flushing of the muscle tissue while the stretch lengthens fibers.
Tight Hamstrings and Quadriceps
Another common hip problem that originates in the leg is the result of overly tight hamstrings or quadriceps. If the hamstrings are overly tight, they pull the pelvic bone down from the attachment on the ischial tuberosity (sit bones). When the quadriceps are overly tight, they pull the pelvic bones forward and down, anteriorly tilting the hips.
As large muscle groups, both the hamstrings and the quadriceps respond wonderfully to massage therapy. Both the hamstrings and quadriceps may benefit from slow, deep gliding strokes to lengthen muscle fibers and release restrictions. Friction, especially a few inches inferior of the ischial tuberosity attachment of the hamstrings (a common location for muscle tearing), is great for freeing uptight, restricted muscles. Read “How Bodyworkers Can Identify a Pulled Hamstring.”
Gluteals
As mentioned, the gluteal muscles are the largest in the body, so when they are tight, in spasm or contain active trigger points, they can cause a tremendous amount of pain! Find out if “Your Client’s Low Back Pain Is Caused By Weak Glutes.” Tears and injuries also create significant pain in these muscles, and in the hip. Elbow work is an excellent way to release these large muscles. By controlling the angle of pressure and the degree of flexion of the elbow, you can control how much pressure you apply, as well as how fine a ‘point’ you are applying pressure with. The elbow can be used to apply static pressure or to friction deep muscle fibers, freeing up the hips.
Lateral Rotators
Lesser known are the six deep lateral rotators, which run from the sacrum to the upper femur. These muscles, including piriformis, rotate the leg laterally (toes out). The sciatic nerve runs between them (at the piriformis), so when they are tight or there is inflammation, there can be a significant impact on the sciatic nerve, causing various levels of sciatic pain in the hip and down the leg. Using your elbows is a great way to apply pressure and release tightness in the rotators, especially piriformis. A great way to enhance this is to use a pin and stretch technique; with the client prone, pin the hip just medial of the greater trochanter and bend the knee so the leg is at 90 degrees. Then with the hip pinned, move foot medially and ‘pin’ with your elbow the piriformis. Then, move foot laterally, applying a stretch of the piriformis against the pressure of your elbow. This gives the rotators a great stretch. For more information, read “False Sciatica: Detecting and Easing Piriformis Syndrome.”
Abdomen
The abdominal muscles can impact the hips by pulling the hips forward and up when they are tightened and shortened. If they are unbalanced or uneven in strength due to postural habits, they can pull the hips off balance as well. Stripping, friction, and trigger point work will release the abdominal muscles, but ‘pulling’ the muscle works well, too. It is important to move slowly as abdominal muscles are sensitive when tight.
Hip Flexors
Located in the abdomen, the hip flexors are what enable you to lift your legs. Spending a lot of time seated with hips flexed can result in shortened hip flexors, which may result in hip pain. Massage therapy techniques to stretch and lengthen these muscles may reduce the problem, and regular stretching may help eliminate hip flexor pain altogether. For a great stretch of the hip flexors, begin with the client prone and pin the hip to support the low back. Then bend the knee to 90 degrees and lift the leg by grabbing the knee, extending the hip. Be sure to support the low back while doing this stretch.
The Psoas
Another muscle in the abdomen is the psoas or iliopsoas. This muscle runs from the transverse processes of the lumbar vertebrae and inserts deep in the groin on the lesser trochanter of the femur. This is one of the deepest muscles in the body and stabilizes, joining upper and lower body, and flexes the hip. While it is possible to access part of the psoas on the medial side of the pelvic muscles, this is an extremely sensitive area. Any work on the psoas must be done slowly and with steady pressure, giving the client time to react and respond. The psoas is a muscle that ‘holds’ a lot of our fears in life, and clients may become very agitated if we work on it too aggressively. Learn more about “The Mind/Body Connection.”
Low Back
Improper lifting or posture can result in uneven development or tightening of the postural muscles of the back. The deep erector muscles which run between ribs and vertebrae account for our ability to move and remain upright. Large muscles over them such as the trapezius and latissimus dorsi allow us to move, lift, and pull ourselves up. When they are unbalanced or uneven in strength, they begin to affect our posture and movement. They also begin to pull on the pelvic bones and this tension often results in pain in the hip.
Swedish and deep tissue massage techniques can reduce muscle tension, balancing the muscles of the back releasing the hips to return to balance. By using a combination of effleurage, friction, and compression we can release the back – a major objective in almost every massage.
Massage therapy can have an enormous impact on many postural and muscle imbalances due to uneven workload, habit, or injuries. A comprehensive plan of massage therapy, stretching and appropriate strengthening can go a long way to eliminating hip pain.
Hip-related pain is common in young to middle-aged active adults (usually aged 18–50 years) and has a significant impact on physical activity and quality of life (Kemp et al., 2020).
Pathophysiology
The presentation of hip pain does not always mean that the joint is the primary contributor to pain. Another peripheral generator that is often overlooked is peripheral nerve irritation, namely, sciatic, pudendal, obturator, femoral, and lateral femoral cutaneous (Martin et al., 2017). There are also twenty-one muscles that cross the hip providing both movement and stability between the femur and acetabulum, all of this contributes to the complex clinical picture of hip pain.
Classification of hip-related pain
Osteoarthritis Related Hip Pain – Osteoarthritis of the hip is a common finding in the general population, and in a majority of cases, these degenerative changes are asymptomatic. However, in some cases, this condition involves sensitization of nociceptive pathways, which may result in patients with osteoarthritis perceiving relatively low-level stimuli as being overtly painful (Hunter & Bierma-Zeinstra, 2019).
Gluteal Tendinopathy – Tendinopathy of the gluteus medius and gluteus minimus tendons is now recognized as a primary local source of lateral hip pain. Many cases of hip “bursitis”, should be more correctly classified as non-inflammatory insertional tendinopathy of the gluteus medius or gluteus minimus tendons, that attach just deep to the greater trochanteric bursa. This condition interferes with sleep (side-lying) and common weight-bearing tasks. The cardinal sign for this diagnosis is pain on palpation of the soft tissues over the greater trochanter.
Greater Trochanteric Pain Syndrome – An umbrella term used to encompass trochanteric bursitis, snapping hip syndrome, and adductor tendinopathy.
Femoroacetabular Impingement (FAI) Syndrome – The diagnosis of FAI syndrome currently includes bony morphological changes in the hip which may cause aberrant joint forces during hip movements and possible damage to the intra-articular structures of the joint.
Ischiofemoral Impingement – Refers to the painful entrapment of the quadratus femoris muscle between the lesser trochanter and the ischial tuberosity. The quadratus femoris acts synergistically with the other short external rotators but also serves as a secondary adductor of the hip.
Snapping Hip Syndrome – (iliopsoas tendinitis, or dancer’s hip) is characterized by a snapping sensation felt when the hip is flexed and extended. This may be accompanied by an audible snapping or popping noise and pain or discomfort. Pain often decreases with rest and diminished activity. Snapping hip syndrome is classified by the location of the snapping, either extra-articular or intra-articular.
- Intra-articular Because the iliopsoas or hip flexor crosses directly over the anterior superior labrum of the hip, an intra-articular hip derangement (i.e. labral tears, hip impingement, loose bodies) can lead to an effusion that subsequently produces internal snapping hip symptoms.
- Extra-articular
- Lateral extra-articular (More common) Occurs when the iliotibial band, tensor fasciae latae, or gluteus medius tendon slides back and forth across the greater trochanter. This normal action becomes a snapping hip syndrome when one of these connective tissue bands thickens and catches with motion. The underlying bursa may also become inflamed, causing a painful external snapping hip syndrome.
- Medial extra-articular (Less common) The iliopsoas tendon catches on the anterior inferior iliac spine, the lesser trochanter, or the iliopectineal ridge during hip extension, as the tendon moves from an anterolateral to a posterior medial position. With overuse, the resultant friction may eventually cause painful symptoms, resulting in muscle trauma, bursitis, or inflammation in the area.
Examination
A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g. low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.
Physical Examination
According to a recent systematic review the most useful clinical finding to identify patients most likely to have osteoarthritis of the hip are (Metcalfe et al., 2019):
- Posterior Pain with squatting
- Groin pain with passive abduction or adduction
- Hip abductor weakness
- Decreased passive hip adduction or internal rotation as measured by a goniometer or compared with the contralateral leg.
Outcome Measurements
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
- Self-Rated Recovery Question
- Patient-Specific Functional Scale
- Brief Pain Inventory (BPI)
- Visual Analog Scale (VAS)
- The Western Ontario and McMaster Universities Arthritis Index (WOMAC)
- Lower Extremity Functional Scale (LEFS)
Treatment
Education
Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.
Manual Therapy
The use of massage therapy has been shown to improve outcomes in post-operative hip patients. One recent randomized controlled trial published in the journal PM&R looked at the use of manual therapy following total hip arthroplasty (Busato et al., 2016). In this study, two treatment sessions were able to significantly improve functional outcomes in patients when used in addition to usual treatment.
Structures to be Aware of When Treating Hip Pain
A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from hip pain may include neurovascular structures and investing fascia of:
- Iliopsoas (iliacus and psoas major)
- Hip Adductors (adductor brevis, adductor longus, adductor Magnus, pectineus, gracilis)
- External Rotators of The Hip (piriformis, gemellus superior, externus and internus obturators, gemellus inferior, and quadratus femoris)
- Quadricep Muscles (rectus femoris, vastus lateralis, vastus medial, vastus intermedius)
- Hamstring Muscles (semimembranosus, semitendinosus, and biceps femoris)
- Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)
- Erector Spinae (iliocostalis, longissimus, spinalis) & Multifidus
- Quadratus Lumborum
- Thoracolumbar Fascia & Latissimus Dorsi
*Disclaimer: This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider.
Please consult your healthcare provider with any questions or concerns you may have regarding your condition.
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