Tips of proximal quadriceps stretch for strong stiffness with lower back pain

Ref: https://www.bicycling.com/

Quadriceps muscle is bi - articular joint muscle of hip and knee. Its function includes straight knee joint and flex hip joint that stretch the lower back, gluteal and hamstring. Normally, tightness of the quadriceps develops knee bending limitation that when bending the knee, the patient will feel tension at the muscle belly.

My physiotherapy experience, I have seen tightness of the proximal quadriceps in IT band syndrome, upper gluteal pain, and low back pain sometimes. If I take care of these cases, I will add on the proximal quadriceps assessment for more information. Mention to anatomy, this muscle can irritate pelvic posture due to the origin of attachment on a part of the pelvic where is AIIS. 

Quadriceps origin (red mark)
(Ref: https://compedgept.com/blog/)

Sometimes, I have found tightness of the proximal quadriceps following tightness of TFL. Perhaps, their origins are very near and they are located like a neighborhood. Sometimes, I have found only one of them gets tight. However, I would like to recommend stretching the proximal quadriceps if it demonstrated tightness. It can help to release rear side pain and improve posture. 

Strong stiffness of proximal quadriceps that cannot straight hip joint from flexion position.

Previously, I presented the way to stretch quadriceps. I have seen some patients had very strong stiffness of that tissue that would be the threat of recovery. Some of them have done the stretching difficulty. The patients alway compensate i.e. arch lower back or cannot upright hip and torso. 

Arching at lower back to compensate

I found one tips of proximal quadriceps stretch for strong stiffness as this VIDEO

Exercise #1: Half kneeling with toe stand stretch: the target leg is on the knee with set ankle at neutral. Lean back and pelvic backward slightly without arching the lower back. We need hip joint to be neutral or extension.

Case sample 1

Case triathlon athlete who has got both lateral groin pain after cycling training. The patient denied low back pain and gluteal pain. The muscle length assessment found tightness of both proximal quadriceps and slight tightness of TFL. This case did not has gluteus medius weakness that did not persuade me to think of IT band syndrome. One of my treatment processes was isometric contraction of quadriceps before proximal quadriceps stretching as demonstrated VIDEO. 

Cycling posture demonstrates prolonged hip flexion with prolonged gluteal and lower back stretch
(Ref: https://www.giant-bicycles.com/)

Case sample 2

Case swimmer who has got one side of the upper gluteal pain that was worse pain by crawl stroke and butterfly stroke. The patient did not has low back pain and knee pain. Gluteal muscles got pain from pressing and weakness which was gluteus maximus. The gluteus medius was a normal strength that  did not persuade me to think of IT band syndrome. QL and back extensor muscle were not spasms. I almost concluded only inflammation of gluteus maximus muscle, but I have seen slight hip flexion in supine lying. Additionally, the quadriceps muscle mass looked massive that illustrated the groove between ASIS and quadriceps belly.

Middle posture demonstrate quadriceps look like massive and groove between ASIS and quadriceps. Right posture demonstrate neutral posture that not demonstrate groove between ASIS and quadriceps.
(Ref: https://www.kateskinnerpt.com/posture-and-positioning) 

            This groove was only on the pain side and not on the other one. I did more evaluation for quadriceps muscle length, then it showed tightness of the proximal quadriceps. One of my treatment processes was stretching proximal quadriceps and gluteus maximus facilitation. I gave a home program assignment for stretching as demonstrated VIDEO and exercise gluteus maximus. 

Case sample 3

Case of a computer office worker who has got one side of upper gluteal pain and neck pain with radiation to the lateral thigh and tibia from forward reaching to put something on the shelf 2 months ago. The patient was treated by medicine, physiotherapy modalities, and stretching of the gluteus and hamstring. Firstly, I considered about piriformis syndrome. The job characteristic is prolonged sitting at the working desk. The standing posture showed a torso shift forward. There was severe pain and hypersensitivity that felt pain at the gluteus maximus, gluteus medius, TFL, and quadriceps. Torso forward bending was limited by pain with a very narrow range. Torso backward bending was limited by worse pain and radiated to the lateral foot. It was not only pain but also numbness on some range of motion that made me think about nerve irritation.

One sample of stand and reach function in normal life living that can stress to lower back and gluteal
(Ref: https://depositphotos.com/)

            I started treatment with a gentle massage on my iliopsoas and quadriceps because firstly my aim was improve posture. It was a good response that pain intensity was decreased significantly. Then I started stretching iliopsoas and proximal quadriceps gradually where pain and numbness free. After the hip extension range increased, I started gluteus maximus facilitation to the hip stability function. Finally, the pain intensity decreased 70 - 80% with improved standing posture. The torso range of motion and all tenderness of gluteal muscle were improved. I gave a home program assignment for stretching as demonstrated VIDEO and exercise gluteus maximus. Moreover, the patients was recommended not to be prolonged sitting because proximal quadriceps may be tight together with prolonged stretch gluteal region. I concluded this case was upper gluteal strain with proximal quadriceps spasm.  

Prone hip extension exercise for strengthen gluteus maximus
(Ref: https://www.saintlukeskc.org/)

 

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following a demonstrated VIDEO. 

My secret of TFL stretching from my physiotherapy experience

       

Tensor fascia lata (TFL) muscle
(Ref: https://learnmuscles.com/glossary/tensor-fasciae-latae-tfl/)

      I have taken care of many patients with ITB syndrome (IT band syndrome) for many years who were soccer players, tennis players, runners, cyclists, triathletes, the most. One of my routine treatments was ITB stretching as Ober’s maneuver that I have felt does not satisfy the outcome.  

Ober's stretch
(Ref: https://www.aafp.org/pubs/afp/issues/2005/0415/p1545.html)

Then, I changed stretching to be another TFL (Tensor fascia lata) stretching because I found some factors from TFL related to ITB tightness which was demonstrated in exercise #5. However, I still have not felt stretched enough. Moreover,  the TFL muscle stretching in standing position is difficult to apply to subjects who have unstable knee joints or have leg pain with the weight bearing.  

Exercise #5: Stand TFL stretching: Step target leg backward, then put it behind the fore - leg. Then rotate the hip external rotation as the toe out. Final, shift pelvic forward like over - pressure hip extension.  

Finally, I would like to present one normal stretching that may stretch TFL directly. Due to, TFL is one joint muscle that passes only the hip joint; additionally, IT band stretching is not the way to release IT band tension. Therefore, I focus on stretching only the TFL at the hip joint by reversing all its muscle action. 

“To perform TFL stretch, the main direction consists of hip extension, hip external rotation and hip adduction.” 

4 options to stretch Tensor fascia lata (TFL) muscle

Exercise #1: Single leg stand TFL stretch

Exercise #2: Half kneeling TFL stretch

Exercise #3: Prone TFL stretch

Exercise #4: Supine TFL stretch

Anatomically, TFL muscle is located on the lateral portion of the femur. TFL merged into the IT band, So do gluteus maximus. The fasciae of these two muscles join the iliotibial band just distal to the greater trochanter forming a triangular ‘‘pelvic deltoid”.

TFL originates from the outer lip of the iliac crest, the anterolateral iliac fossa just below the iliac crest, the deep surface of the fascia lata, the iliac tubercle, the lateral aspect of the anterior superior iliac spine and a notch below the anterior superior iliac spine. TFL attaches to two layers of the IT band of the fascia lata and ends usually around the greater trochanter.

The major muscle action of TFL includes three directions that are hip abduction, hip internal rotation, and hip flexion. By mechanical, the gluteus medius and minimus are at a major disadvantage to act as the primary hip abductors, whereas the tensor fasciae latae is at a major advantage to exert the necessary force to counterbalance the force of weight during the full stance phase of the gait cycle. TFL function depends on the position of the hip. It helps the gluteal abductors prevent the Trendelenburg gait and stance so that we can conclude that it is one of the posture muscles. The anterior fibers flex the hip and the posterior fibers abduct and internally rotate the hip. 

Trendelenburg sign (Ref: https://www.pinterest.com/)

Mechanism of TFL shortening happened after hip abductor fatigue. The TFL muscle was in spasm, it is pulling hard on ITB and developing pain at the insertion point on the outside of the knee. Shortening of the TFL and ITB can pose problems in the behavior of walking and running. Additionally, they often develop clinical symptoms such as the iliotibial band syndrome or the patellofemoral syndrome.

Patellofemoral pain syndrome
(Ref: https://www.enzopierromassagetherapy.it/)

IT band syndrome
(Ref: https://www.kaizo-health.com/)

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

"However, I would like to recommend strengthening exercise for gluteus maximus and gluteus medius. It is very crucial part of treatment and be able to release IT band tension, afterward".

Reference:

https://www.researchgate.net/publication/337228717_Detailed_Morphological_Study_of_Tensor_Fasia_Lata_TFL_and_its_Clinical_Significance 

https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.908.4975&rep=rep1&type=pdf 

https://www.researchgate.net/publication/322583917_Morphometric_properties_of_the_tensor_fascia_lata_muscle_in_human_fetuses 

https://www.ijsr.net/archive/v7i10/ART20191686.pdf 

https://www.koreascience.or.kr/article/JAKO202018436566234.pdf 

Physiotherapy with 5 options of the sartorius stretching exercise which we always neglect.

Ref: https://www.yoganatomy.com/sartorius-muscle/

 

The incidence of upper thigh injuries include the adductor (23%), hamstring (12– 37%) or quadriceps (19%), whilst  sartorius muscle injuries occur in 31–46%. The pathogenesis of muscle injuries is divided into extrinsic and intrinsic injuries. 

Intrinsic injuries are caused by contraction or elongation of the muscle that mainly involve type II muscle fibers which rapidly contract. It extends between two joints, contracts eccentrically and has a fusiform muscle fiber arrangement, leading to destruction of the internal muscle fiber. There are 3 grade injuries categories based on the extent of the lesion: grade I involves a few muscle fibers within a bundle; grade 2 involves up to three/fourths of the affected muscle portion; and grade 3 involves more than three/fourths, and the lesion may then involve the entire muscle belly.

Extrinsic injuries include factors such as contusions and penetrating wounds that can involve all types of muscle fibers.

5 options of the sartorius stretching exercise

Exercise #1: Sartorius stand wall stretch: Hands are on the wall for maintain balance. Step target leg backward, then adduct as behind front leg, then medial rotation as toe in, then move pelvic forward.

Exercise #2: Sartorius stand leg curl stretch: Bend target knee with hand support, then situate target shin laterally, then extend hip joint without arch lower back.

Exercise #3: Sartorius semi side lying stretch: Lying on the side to the opposite side of the target leg that makes the target leg is behind. Target leg was pushed by hand forward. Then rotate the torso to mid line again. 

Exercise #4: Sartorius side lying stretch: Shin should be lateral to thigh in the end of pose setting.

Exercise #5: Sartorius supine stretch: For beginners, you should supine on the elbow. For advances, you can lie on the back. 

I hardly have seen patients with sartorius injury. Most of my rare cases always complained e.g. proximal anteromedial tibia pain which was pes anserine, VMO pain, fore - thigh pain, proximal lateral groin pain, MCL pain. I had to evaluate carefully to clear the root curse and site of injury. 

One sample case, He was overlapped by one soccer player on the leg  while his knee was bending. He went to see a doctor and he was diagnosed with a knee tendon or ligament injury. A few days later, he came and saw me at physio clinic for more investigation and needed some advice. After subjective examination and physical evaluation, they indicated sartorius tendon more than MCL. To answer the question was how long should he rest? I investigated him by sonography, then the injured site demonstrated grade I. So, we can say his injury was the result of an extrinsic factor.

One author found that injuries of the sartorius muscle most often occur in the area of proximal and distal attachment. At the proximal part, common activity of the sartorius muscle and TFL can cause ASIS avulsion that may be observed. At distal insertion, frequently repetitive movements leading to micro injuries and tissue loads in this area are met. In the result of this, inflammations of bursa anserina, tendon strains and rupture may take place in what was pes anserinus. Such injuries happen to: i.a. athletes, runners, jumpers and football players.

Pes anserine bursitis site
(Ref: http://therundoctor.com/pes-anserine-bursitis/)

The sartorius muscle is the longest muscle in humans. Its name derives from a Latin word “sartor” that did mean “a tailor”. 

The sartorius muscle is situated superficially, moreover, it is distinguished by an original shape and a course. It has got a transverse section in the shape of a triangle with the base upturned. The proximal tendon of the sartorius arises from the anterior superior iliac spine. The muscle belly is like an S-shaped running obliquely across the upper anterior third of the thigh in an inferomedial direction and tape twists around the anterior to the medial surface of the thigh. The belly of the sartorius constitutes the anterior wall of the adductor canal. Then the belly turns slantwise forward at the medial epicondyle of femur which together with quadriceps — its medial head — serves as a “trochlea” for the sartorius muscle. Its distal insertion onto the anteromedial proximal tibia as a flat divergent tendon creating in its further section superficial part of the pes anserinus. 

Sartorius muscle
(Ref: https://www.pinterest.com/)

The sartorius muscle is a biarticular muscle or two joint muscles. It is the only muscle of the thigh which bends both hip joint and knee joint. The sartorius is mainly a flexor of the hip  with the accessory function of lateral rotation and abduction of the hip as well as flexion and medial rotation of the knee. So, there are 4 directions of muscle activity including hip flexion, hip abduction, hip lateral rotation, and tibia medial rotation with knee flexion which action is like a cross single leg chair sitting. 

Ref: https://quizlet.com/

Moreover, it has worked as a hip and knee flexor starter that initializes the movement of flexion in both joints from the phase of full extension. Although the sartorius muscle is a weak external rotator and a weak abductor of the hip joint, it plays an important part in stabilization of the pelvis, especially in women. 

In my physiotherapy experience, stretching this muscle was not as easy as many muscles because it did not provide obvious tension. However, the principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hole at the point for 30 seconds of 3 - 5 reputations as demonstrated VIDEO.

Reference: 

https://www.researchgate.net/publication/266027219_Anatomy_of_sartorius_muscle 

https://theultrasoundjournal.springeropen.com/track/pdf/10.1186/s13089-019-0132-9.pdf 

https://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000843_web.pdf 

Physiotherapy with 6 tips to stretch iliopsoas muscle

Ref: https://www.rowperfect.co.uk/

     

        Hip flexion or anterior hip bending was caused by hip flexor muscles contraction. A group of hip flexor muscles consist of iliopsoas, sartorius, tensor fascia lata, and rectus femoris which work as prime - mover, and, pectineus, adductor longus, adductor brevis, and the most anterior fibers of the adductor magnus and the gluteus (medius and minimus) which work as accessory muscle. 

My experience in the physiotherapy clinic, I have seen tightness in some or all of the hip flexor muscles in patients with IT band syndrome, groin pain, and low back pain. One muscle which differs from others is “iliopsoas” because its origins connect to the spine. 

“To stretch the tightness of iliopsoas is used in my physiotherapy session to improve the symptoms often.” 

6 options to stretch iliopsoas muscle

Exercise #1: Standard half kneeling stretch where the target muscle is on the rear leg. The pose need keep back straight with shift pelvic in front that no need to arch the back.

Exercise #2: Supine leg off the side bed

Exercise #3: Basic Thomas stretch that the target muscle is straight leg

Exercise #4: Advance Thomas stretch that the target muscle is off bed

Exercise #5: Upward - Facing dog pose. The pose need elevation of pelvic.

Exercise #6: Chair stand posterior pelvic tilt

    The iliopsoas is the most powerful of the hip flexors. The function of iliopsoas such as sit up, elevate leg, leg swing during walking, control sitting balance, and control lordotic curve of lumbar spine. 

Ref: https://womencycles.com/blog/

  

    Iliopsoas is a compound muscle which consists of the psoas major and iliacus. The psoas major is placed lateral to the vertebral column. It corresponding intervertebral discs of the last thoracic and all the lumbar vertebrae that originates at  the 12th thoracic vertebrae until to the vertebral body of the lateral surface of the 5th lumbar vertebrae and extends to the transverse process of the lumbar vertebrae 1st to 5th, and, the superior two-thirds of the bony iliac fossa and the iliolumbar and ventral sacroiliac ligaments. It goes down and palpable just deep to the inguinal ligament, where it lies bordered by the sartorius muscle laterally and the femoral artery medially, and, finally attaches to the femur lesser trochanter and the linea aspera medial. 

Ref: https://www.optimaphysio.com/

The iliacus has several points of origin; it starts with the iliac crest, anterior inferior iliac spine, iliolumbar ligament, and anterior sacroiliac ligament. And eventually attaches to femur lesser trochanter and linea aspera medial that seem to be the same tendon of psoas major. 

Ref: https://www.osteopathyny.com/

While sitting or standing, the iliopsoas is constantly active and plays an important role in stabilizing the pelvis and lumbar region along with the erector spinae and quadratus lumborum. Hence shortening or straining of the iliopsoas can cause excessive pelvic anterior tilt or increased spine extension during hip joint motion, thereby acting as a risk factor for low back pain. A shortening of the iliopsoas muscle can result in anterior pelvic tilt and trunk extension. Finally, it is leading to low back pain.

Ref: https://www.pinterest.com/

            Shortening of the iliopsoas muscle was found to be the primary cause of lumbar hyperlordosis and excessive anterior pelvic tilt. This abnormal alignment may inhibit the function of the Transversus Abdominis (TrA). Back muscle guarding from lumbar hyperlordosis resulted from the shortening of the iliopsoas muscle. This is impaired circulation by muscle guarding, leading to increased pain (pain-spasm-pain model). 

Back pain and improved excessive lumbar lordosis angle can be reduced by lengthening the iliopsoas muscle and increasing TrA activation capacity.

The principle of muscle stretching is simple: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations in one muscle as demonstrated VIDEO. 

Reference: 

https://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000843_web.pdf 

https://www.jptrs.org/journal/view.html?doi=10.14474/ptrs.2021.10.2.225 

https://www.thaiscience.info/journals/Article/JMAT/10971199.pdf

Physiotherapy with 6 optionals TFL & ITB stretching in iliotibial band syndrome

 

Ref: https://www.knee-pain-explained.com/lateral-knee-pain.html

    Some of my patients who are with knee pain include lateral pain, fore - knee cap pain, and medial pain. Lateral thigh evaluation is one of my routine standard physical assessments. I have found some patients with iliotibial band syndrome or iliotibial friction band syndrome (ITBS).

My patients with ITBS are distance runners, cyclists, and triathlon, the most. Recently, I found it in an ice hockey player. They have trigger points, high - tension, and tightness on the IT band that stretch IT band uses for prevention and treatment of ITBS. 

6 Optionals of IT band stretching 

Exercise #1: Stand stretch TFL & IT band

Exercise #2: Chop stretch TFL & IT band

Exercise #3: Half cross sitting stretch TFL & IT band

Exercise #4: Half kneeing stretch TFL & IT band

Exercise #5: Side lying stretch TFL & IT band (easy)

Exercise #6: Side lying stretch TFL & IT band (advance)

Anatomically, the IT band is a thick tendinous big band that locates on the lateral thigh. It is a continuation of the tendinous portion of the tensor fascia lata (TFL) muscle with some contributions from the lateral gluteal muscles. The IT band has many distal attachments that span out to the lateral border of the patella (by way of epicondylopatellar ligament and patellar retinaculum), patellar tendon, lateral patellar retinaculum before its insertion on Gerdy’s tubercle of the tibia, the biceps femoris, and vastus lateralis. 

IT band anatomy picture that has origin near hip joint
and many insertions end around knee joint; ITB: IT band
(Ref: https://www.researchgate.net/figure/The-iliotibial-band-and-site-of-injury-at-lateral-epicondyle-of-the-femur_fig1_51211560)

The site of injury is near the insertion at the lateral epicondyle. Majority of the injury mechanism is repetitive friction and compression of the IT band against the lateral epicondyle. IT band sliding over the lateral femoral epicondyle, moving anterior to the epicondyle as the knee extends and posterior as the knee flexes, and remaining tense in both positions. Repetitive irritation can lead to chronic inflammation, especially beneath the posterior fibers of the ITB, which are thought to be tighter against the lateral femoral epicondyle than the anterior fibers. The critical friction angle of the knee occurs at or at slightly less than 30 degrees of knee flexion which is called  ‘‘impingement zone’’ that associates during walking, running, and cycling. 

Triathlon consists of swimming - biking - running 
Ref: https://www.drjimtaylor.com/

The intrinsic factors consist of leg - length discrepancies that the longer one is more risky, and biomechanics that are very strongly related to muscle performance include strength, endurance, flexibility, and segmental coordination. Strength of  the gluteus medius and gluteus maximus muscles is important to control hip adduction and knee varus and valgus because strength deficits in the hip abductors are believed to play a role in the development of ITBS. 

Extrinsic factors are related to training methods as well as running shoes or cycle fit. Several training factors have been related to ITBS, including excessive running in the same direction on a track, downhill running, a lack of running experience, abrupt increase in running distance or frequency, and running long distances. 

Downhill running
(Ref: https://www.runpacers.org/pasadena/downhill-race-training/)

According to a subjective examination in my physiotherapy clinic, I have heard patients' stories, for example, change speed running immediately, increase distance immediately, not enough recovery, etc. For objective examination some patients never know the cause of pain, for example, weakness of hip abductor muscles, improper running shoes, etc. 

One case came to see me with fore - knee pain who just bought popular and expensive running shoes. She is mid foot strike pattern and her shoes have a narrow outsole at mid and heel section. I informed her of two options; include, change the strike pattern to forefoot strike pattern, or change to new shoes which are wide mid and heel section outsole.    

Clinical present with complaints of a sharp or burning pain roughly 2 cm superior to the lateral joint line. The pain may radiate proximally or distally. There usually is tenderness on palpation of the ITB 2 to 3 cm above to the lateral joint line. There may be local edema or crepitation. The pain always makes it difficult to go up - down stairs, bend knee, and sports performance drop.  

Ober's test use for IT band tightness assessment
(Ref: http://corebalancetherapy.com/wp-content/uploads/2013/09/Iliotibial-Band-Syndrome-review-PMR-2011.pdf)

Michael and Adam (2006) classified ITBS recovery into 4 phases including acure, subacute, recovery - strengthening phase, and Return - to - running phase. Stretching exercises are suggested to start after acute inflammation subsides that mean they should start in the subacute phase. 

The way to stretch is simple: stretch to the point where “tightness without pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 repetitions in one muscle as demonstrated in the video. Stretching exercise is one of the important management parts of ITBS. However, gluteus medius and gluteus maximus strength is very crucial management part for prevention and treatment, as well. 

Reference: 

https://www.researchgate.net/publication/51211560_Iliotibial_Band_Syndrome_Soft_Tissue_and_Biomechanical_Factors_in_Evaluation_and_Treatment/link/59dce6f8458515e59df9eeca/download 

https://www.researchgate.net/publication/7004336_Practical_Management_of_Iliotibial_Band_Friction_Syndrome_in_Runners/link/5665d83208ae192bbf927368/download