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Discover Nonsurgical Solutions for Hip Pain and Plantar Fasciitis

Discover Nonsurgical Solutions for Hip Pain and Plantar Fasciitis

Can plantar fasciitis patients incorporate non-surgical treatments to reduce hip pain and restore mobility?

Introduction

Everyone is on their feet constantly as it helps people stay mobile and allows them to go from one location to another. Many people are constantly on their feet from childhood to adulthood. This is because the feet are part of the lower musculoskeletal extremities that stabilize the hips and allow sensory-motor function to the legs, thighs, and calves. The feet also have various muscles, tendons, and ligaments surrounding the skeletal structure to prevent pain and discomfort. However, when repetitive motions or injuries start to affect the feet, it can lead to plantar fasciitis and, over time, cause overlapping risk profiles that lead to hip pain. When people are experiencing these pain-like conditions, it can significantly affect their daily activities and overall quality of life. When this happens, many people seek various treatments to reduce the pain-like symptoms caused by plantar fasciitis and restore hip mobility. Today’s article looks at how plantar fasciitis correlates with hip pain, the connection between the feet and the hips, and how there are non-surgical solutions to reduce plantar fasciitis. We talk with certified medical providers who consolidate our patients’ information to assess how to mitigate plantar fasciitis and restore hip mobility. We also inform and guide patients on how numerous non-surgical treatments can help strengthen weak muscles associated with plantar fasciitis and help with restoring stabilization from hip pain. We encourage our patients to ask their associated medical providers intricate and important questions about incorporating small changes to reduce the pain-like effects caused by plantar fasciitis. Dr. Jimenez, D.C., includes this information as an academic service. Disclaimer.

 

How Plantar Fasciitis Correlates With Hip Pain

Do you experience pain in your heels constantly after a long walk? Do you feel stiffness in your hips when stretching? Or do you feel your shoes are causing tension and pain in your feet and calves? Often, many of these pain-like scenarios are due to people dealing with plantar fasciitis, characterized by heel pain due to inflammation or degenerative irritation of the plantar fascia, a band of thick tissues is running across the bottom of the foot and connecting to the heel bone to the toes in the lower extremities. This band of tissues plays an essential role in the body, providing normal biomechanics to the foot while supporting the arch and helping with shock absorption. (Buchanan et al., 2024) Plantar fasciitis can affect the stability of the lower extremities since the pain affects the feet and causes hip pain.

 

 

So, how would plantar fasciitis correlate with hip pain? With plantar fasciitis, many people are experiencing pain in their feet. It can lead to abnormal foot posture, lower extremity muscle weakness, and muscle stress that can reduce the stability of the legs and hip muscles. (Lee et al., 2022) With hip pain, many people can experience a gait dysfunction that causes muscle weakness in the lower extremities and causes the accessory muscles to perform the primary muscles’ jobs. To that point, this forces people to scrap the ground when walking. (Ahuja et al., 2020) This is because normal conditions like natural aging, muscle overuse, or trauma can cause pain-like symptoms to the hips, including discomfort on the thighs, groin, and buttock region, joint stiffness, and reduced range of motion. Hip pain can cause overlapping risk profiles that may include repetitive strain on the feet, thus leading to symptoms of sharp to dull aches on the heel.

 

The Connection Between The Feet and The Hips

It is important to understand that foot problems like plantar fasciitis can affect the hips and vice versa, as both body regions have a beautiful relationship within the musculoskeletal system. Plantar fasciitis on their feet can alter their gait function, potentially leading to hip pain over time. This is due to many environmental factors that can affect the hips and feet over time, leading to plantar fasciitis correlating with hip pain. From excessive weight-bearing activities to microtrauma in the hips or the plantar fascia, many people will often seek treatment to reduce the effects of plantar fasciitis correlated with hip pain by addressing how their range of motion is affecting the plantarflexion and their load on the force-absorbing plantar surface structures could be good starting points in the prevention and treatment of plantar fasciitis correlated with hip pain. (Hamstra-Wright et al., 2021)

 


What Is Plantar Fasciitis?-Video


Non-Surgical Solutions To Reduce Plantar Fasciitis

When it comes to reducing plantar fasciitis in the body, many individuals will seek non-surgical treatments that can alleviate the pain from plantar fascia. Non-surgical treatments are cost-effective and can reduce the pain from plantar fasciitis and its associated symptoms, like hip pain. Some of the benefits of non-surgical treatments are promising, as they have a low risk of complications, good accessibility, and even a high capacity to relieve the mechanical load on the plantar fascia when doing regular activities. (Schuitema et al., 2020) Some of the non-surgical treatments that many people can incorporate include:

  • Stretching exercises
  • Orthotic devices
  • Chiropractic care
  • Massage therapy
  • Acupuncture/electroacupuncture
  • Spinal decompression

 

These non-surgical treatments not only help reduce plantar fasciitis but also help alleviate hip pain. For example, spinal decompression can help restore hip mobility by stretching the lumbar spine and relieving the lower extremities from numbness while strengthening tight muscles. (Takagi et al., 2023). Electroacupuncture can stimulate the body’s acupoints to release endorphins from the lower extremities to reduce inflammation of the plantar fascia. (Wang et al., 2019) When people begin to make small changes in their routine, like wearing proper footwear and not carrying or lifting heavy weighted objects, it can go a long way to prevent plantar fasciitis and hip pain from reoccurring can go a long way. Having a personalized treatment plan can ensure many individuals seeking non-surgical treatments have a better outcome on their health and mobility while preventing long-term complications. 

 


References

Ahuja, V., Thapa, D., Patial, S., Chander, A., & Ahuja, A. (2020). Chronic hip pain in adults: Current knowledge and future prospective. J Anaesthesiol Clin Pharmacol, 36(4), 450-457. doi.org/10.4103/joacp.JOACP_170_19

Buchanan, B. K., Sina, R. E., & Kushner, D. (2024). Plantar Fasciitis. In StatPearls. www.ncbi.nlm.nih.gov/pubmed/28613727

Hamstra-Wright, K. L., Huxel Bliven, K. C., Bay, R. C., & Aydemir, B. (2021). Risk Factors for Plantar Fasciitis in Physically Active Individuals: A Systematic Review and Meta-analysis. Sports Health, 13(3), 296-303. doi.org/10.1177/1941738120970976

Lee, J. H., Shin, K. H., Jung, T. S., & Jang, W. Y. (2022). Lower Extremity Muscle Performance and Foot Pressure in Patients Who Have Plantar Fasciitis with and without Flat Foot Posture. Int J Environ Res Public Health, 20(1). doi.org/10.3390/ijerph20010087

Schuitema, D., Greve, C., Postema, K., Dekker, R., & Hijmans, J. M. (2020). Effectiveness of Mechanical Treatment for Plantar Fasciitis: A Systematic Review. J Sport Rehabil, 29(5), 657-674. doi.org/10.1123/jsr.2019-0036

Takagi, Y., Yamada, H., Ebara, H., Hayashi, H., Inatani, H., Toyooka, K., Mori, A., Kitano, Y., Nakanami, A., Kagechika, K., Yahata, T., & Tsuchiya, H. (2023). Decompression for lumbar spinal stenosis at the intrathecal catheter insertion site during intrathecal baclofen therapy: a case report. J Med Case Rep, 17(1), 239. doi.org/10.1186/s13256-023-03959-1

Wang, W., Liu, Y., Zhao, J., Jiao, R., & Liu, Z. (2019). Electroacupuncture versus manual acupuncture in the treatment of plantar heel pain syndrome: study protocol for an upcoming randomised controlled trial. BMJ Open, 9(4), e026147. doi.org/10.1136/bmjopen-2018-026147

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The Benefits of using Electroacupuncture for Osteoarthritis

The Benefits of using Electroacupuncture for Osteoarthritis

Can individuals with osteoarthritis find the relief they deserve through electroacupuncture to restore knee and hip mobility?

Introduction

The lower extremities provide movement and stability to the body, allowing people to be in motion. The hips, lower back, knees, and feet each have a function to do, and when traumatic issues start to affect the spinal structures, it can cause numerous symptoms to pop up and cause pain-like symptoms. Additionally, degenerative factors are natural to the joints of the lower extremities as many people make repetitive motions to their bodies that lead to the degenerative process. One of the most common degenerative issues that affect the lower extremities is osteoarthritis, which can make many people feel miserable. Today’s article looks at how osteoarthritis affects the lower extremities and how treatments like electroacupuncture reduce inflammation associated with osteoarthritis and restore knee and hip mobility. We talk with certified medical providers who consolidate our patients’ information to understand better how osteoarthritis affects their lower extremities. We also inform and guide patients on how electroacupuncture therapy can help reduce the inflammatory effects of osteoarthritis affecting the hips and knees. We encourage our patients to ask their associated medical providers intricate and important questions about reducing the progression of osteoarthritis through non-surgical treatments. Dr. Jimenez, D.C., includes this information as an academic service. Disclaimer.

Osteoarthritis Affecting The Lower Extremities

Have you been dealing with stiffness in your knees, hips, and lower back in the mornings? Do you feel like you are wobbling a bit too much when walking? Or do you think radiating heat and swelling in your knees? When people experience these inflammatory pain issues in their joints, it is due to osteoarthritis, a degenerative joint disorder affecting the cartilage between the bones and the tissue components surrounding the joint. Osteoarthritis is multifactorial, meaning it can be idiopathic or secondary while influenced by heredity factors. (Bliddal, 2020) The most common places where people experience osteoarthritis are the lower back, hand, hips, and, most commonly, the knees. Some of the major environmental factors that contribute to the development of osteoarthritis include:

  • Obesity
  • Age
  • Repetitive motions
  • Family history
  • Injuries

When people are dealing with osteoarthritis, environmental factors can lead to weight overloading on the joints, which results in compression and inflammation. (Nedunchezhiyan et al., 2022

 

 

When inflammation is associated with osteoarthritis, it can cause the joints and surrounding muscle tissues to swell and feel hot to the touch. At the same time, osteoarthritis is one of the leading causes of disability that can become a socio-economic issue for many people. (Yao et al., 2023) This is because many individuals with osteoarthritis have comorbidities that are associated with the effects of inflammatory cytokines, which can cause them to be physically inactive and miserable. (Katz et al., 2021) However, there are various ways to reduce the progression of osteoarthritis and reduce the inflammatory effects on the joints. 

 

Electroacupuncture Reducing Inflammation Associated With Osteoarthritis

When it comes to inflammation reduction associated with osteoarthritis, many people seek out surgical and non-surgical treatments that can help decrease the progression of this degenerative joint disease. Many people will do aqua therapy to relieve pressure off the joints and improve their mobility. At the same time, others use spinal decompression to create negative pressure on the joint space. However, many people have found that electroacupuncture can help reduce the inflammatory effects of osteoarthritis. Electroacupuncture combines electrical nerve stimulation and acupuncture by highly trained professionals that can help decrease the pain intensity in the joints and provide functionality. (Wu et al., 2020) Additionally, since osteoarthritis is associated with inflammation, electroacupuncture can promote blood circulation and adjustment of muscle tension on the joints, and improve mobility. (Zhang et al., 2023)

 

Electroacupuncture Restoring Knee & Hip Mobility

Electroacupuncture can help with hip and knee mobility as this non-surgical treatment helps promote pain limitations and muscular atrophy from biomechanical overloading, thus improving cartilage viscoelasticity. (Shi et al., 2020) This allows the joints to retain mobility in the hips, knees, and lower back. When people go through consecutive treatment for osteoporosis, they can recover their muscle strength over time to restore their mobility and reduce the progression of osteoarthritis. (Xu et al., 2020) By doing so, many people can find the relief they are looking for with electroacupuncture, which can enable them to make small changes in their daily routine to ensure they can function throughout the day. 


Chiropractic Care For Leg Instability- Video


References

Bliddal, H. (2020). [Definition, pathology and pathogenesis of osteoarthritis]. Ugeskr Laeger, 182(42). www.ncbi.nlm.nih.gov/pubmed/33046193

Katz, J. N., Arant, K. R., & Loeser, R. F. (2021). Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review. JAMA, 325(6), 568-578. doi.org/10.1001/jama.2020.22171

Nedunchezhiyan, U., Varughese, I., Sun, A. R., Wu, X., Crawford, R., & Prasadam, I. (2022). Obesity, Inflammation, and Immune System in Osteoarthritis. Front Immunol, 13, 907750. doi.org/10.3389/fimmu.2022.907750

Shi, X., Yu, W., Wang, T., Battulga, O., Wang, C., Shu, Q., Yang, X., Liu, C., & Guo, C. (2020). Electroacupuncture alleviates cartilage degradation: Improvement in cartilage biomechanics via pain relief and potentiation of muscle function in a rabbit model of knee osteoarthritis. Biomed Pharmacother, 123, 109724. doi.org/10.1016/j.biopha.2019.109724

Wu, S. Y., Lin, C. H., Chang, N. J., Hu, W. L., Hung, Y. C., Tsao, Y., & Kuo, C. A. (2020). Combined effect of laser acupuncture and electroacupuncture in knee osteoarthritis patients: A protocol for a randomized controlled trial. Medicine (Baltimore), 99(12), e19541. doi.org/10.1097/MD.0000000000019541

Xu, H., Kang, B., Li, Y., Xie, J., Sun, S., Zhong, S., Gao, C., Xu, X., Zhao, C., Qiu, G., & Xiao, L. (2020). Using electroacupuncture to recover muscle strength in patients with knee osteoarthritis after total knee arthroplasty: a study protocol for a double-blinded, randomized, and placebo-controlled trial. Trials, 21(1), 705. doi.org/10.1186/s13063-020-04601-x

Yao, Q., Wu, X., Tao, C., Gong, W., Chen, M., Qu, M., Zhong, Y., He, T., Chen, S., & Xiao, G. (2023). Osteoarthritis: pathogenic signaling pathways and therapeutic targets. Signal Transduct Target Ther, 8(1), 56. doi.org/10.1038/s41392-023-01330-w

Zhang, W., Zhang, L., Yang, S., Wen, B., Chen, J., & Chang, J. (2023). Electroacupuncture ameliorates knee osteoarthritis in rats via inhibiting NLRP3 inflammasome and reducing pyroptosis. Mol Pain, 19, 17448069221147792. doi.org/10.1177/17448069221147792

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Spinal Decompression: How to Relieve Hip Pain Easily

Spinal Decompression: How to Relieve Hip Pain Easily

Can individuals dealing with hip pain, find the relief they are looking for from spinal decompression to reduce their sciatica pain?

Introduction

When it comes to individuals doing everyday movements, the body can be in weird positions without pain or discomfort. Hence, people can stand or sit for prolonged periods and feel all right when doing strenuous activities. However, as the body ages, the surrounding muscles and ligaments can become weak and tight, while the spinal joints and discs start to be compressed and wear and tear. This is because many individuals make repetitive motions on their bodies that cause pain-like symptoms in the back, hips, neck, and body extremities, leading to referred pain in different body locations. When individuals are experiencing musculoskeletal pain in their bodies, it can cause overlapping risk profiles that can hinder the individual and cause them to be miserable. Additionally, when people experience musculoskeletal pain in their bodies, many will seek treatment to reduce the referred pain-like symptoms associated with the musculoskeletal pain. Today’s article will examine one type of musculoskeletal pain on the hips, how it can cause sciatica pain-like problems, and how treatments like decompression can reduce the pain-like effects of hip pain correlated with sciatica. We talk with certified medical providers who consolidate our patients’ information to provide numerous treatments to relieve hip pain associated with sciatica. We also inform and guide patients on how decompression can help reduce pain-like symptoms like sciatica and restore hip mobility. We encourage our patients to ask their associated medical providers intricated and important questions about the pain-like symptoms they are experiencing from hip pain. Dr. Jimenez, D.C., incorporates this information as an academic service. Disclaimer.

 

Hip Pain Associated With Sciatica

Do you often experience stiffness in your lower back and hips after sitting down for an excessive period? How about feeling radiating pain running down from your lower back to your legs? Or do you think your hip and thigh muscles become tight and weak, which is affecting your gait stability? Many individuals experiencing these pain-like issues are experiencing hip pain, and it can be an issue when it is not treated over time. Since hip pain is a common and disabling condition that is challenging to diagnose, many individuals often express localized pain in one of the three anatomic regions: the anterior, posterior, and lateral hip sections. (Wilson & Furukawa, 2014) When individuals are dealing with hip pain, they will also experience referred pain in their lower backs, which causes them to be in distress and miserable. At the same time, simple ordinary movements like sitting or standing can affect the muscles and ligaments surrounding the hips and can be damaging. This can cause hip pain to be referred from the lumbar spine and spine problems, which then cause musculoskeletal issues in the lower extremities. (Lee et al., 2018

 

 

So, how would hip pain be associated with sciatica and causing pain in many lower extremities? The hip areas in the musculoskeletal system have numerous muscles surrounding the pelvic bone area that can become tight and weak, causing referred musculoskeletal pain from intrapelvic and gynecologic issues. (Chamberlain, 2021) This means that musculoskeletal disorders like piriformis syndromes associated with hip pain can lead to sciatica. The sciatic nerve travels down from the lumbar region and the buttocks and behind the leg. When a person is dealing with sciatica and is going to their primary doctor to get treated for the pain, their doctors will do a physical examination to see what factors are causing the pain. Some of the common findings during a physical exam were tenderness and palpation of the greater sciatic notch and the reproduction of pain along the hips. (Son & Lee, 2022) This causes associated symptoms that correlate with sciatica and hip pain, including:

  • Tingling/numbing sensations
  • Muscle tenderness
  • Pain while sitting or standing
  • Discomfort

 


Is Motion The Key To Healing- Video


Spinal Decompression Reducing Hip Pain

However, many individuals will find non-surgical treatments to help reduce sciatica associated with hip pain. Non-surgical treatments are customized to a person’s pain and are cost-effective while being gentle on the spine. Spinal decompression can help reduce hip pain associated with sciatica. Decompression on the spine allows gentle traction to stretch out weak muscles along the lower back and hips while the spinal discs are experiencing negative pressure. When a person is dealing with sciatica pain associated with hip pain and trying decompression for the first time, they are provided with the relief they deserve. (Crisp et al., 1955)

 

 

Additionally, many individuals who incorporate decompression for their hip pain can begin to feel its effects as it helps improve blood flow circulation back to the hips to start the natural healing process. (Hua et al., 2019) When people begin incorporating decompression for their hip pain, they can relax as they feel all their aches and pain gradually disappear as mobility and rotation are back on the lower extremities.

 


References

Chamberlain, R. (2021). Hip Pain in Adults: Evaluation and Differential Diagnosis. American Family Physician, 103(2), 81-89. www.ncbi.nlm.nih.gov/pubmed/33448767

www.aafp.org/pubs/afp/issues/2021/0115/p81.pdf

Crisp, E. J., Cyriax, J. H., & Christie, B. G. (1955). Discussion on the treatment of backache by traction. Proc R Soc Med, 48(10), 805-814. www.ncbi.nlm.nih.gov/pubmed/13266831

www.ncbi.nlm.nih.gov/pmc/articles/PMC1919242/pdf/procrsmed00390-0081.pdf

Hua, K. C., Yang, X. G., Feng, J. T., Wang, F., Yang, L., Zhang, H., & Hu, Y. C. (2019). The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. J Orthop Surg Res, 14(1), 306. doi.org/10.1186/s13018-019-1359-7

Lee, Y. J., Kim, S. H., Chung, S. W., Lee, Y. K., & Koo, K. H. (2018). Causes of Chronic Hip Pain Undiagnosed or Misdiagnosed by Primary Physicians in Young Adult Patients: a Retrospective Descriptive Study. J Korean Med Sci, 33(52), e339. doi.org/10.3346/jkms.2018.33.e339

Son, B. C., & Lee, C. (2022). Piriformis Syndrome (Sciatic Nerve Entrapment) Associated With Type C Sciatic Nerve Variation: A Report of Two Cases and Literature Review. Korean J Neurotrauma, 18(2), 434-443. doi.org/10.13004/kjnt.2022.18.e29

Wilson, J. J., & Furukawa, M. (2014). Evaluation of the patient with hip pain. American Family Physician, 89(1), 27-34. www.ncbi.nlm.nih.gov/pubmed/24444505

www.aafp.org/pubs/afp/issues/2014/0101/p27.pdf

 

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Assessing Hip Flexors With MET Therapy

Assessing Hip Flexors With MET Therapy

Introduction

The hips play a crucial role in maintaining stability and mobility in the body. However, incorrect actions can lead to misalignment and pain in the hip muscles, causing discomfort and affecting other muscles and joints. This article focuses on the hip flexor muscles and how assessing them with MET therapy can reduce pain and restore hip mobility. We utilize and incorporate valuable information about our patients to certified medical providers using MET therapy to relieve chronic muscle pain associated with the hip flexor muscles. We encourage and refer patients to associated medical providers based on their findings while supporting that education is a remarkable and fantastic way to ask our providers the essential questions at the patient’s acknowledgment. Dr. Alex Jimenez, D.C., comprises this information as an educational service. Disclaimer

 

What Are The Hip Flexor Muscles?

 

Do you have any pain in your hips? Does shifting your weight from one side to the other help relieve the pain? Do you feel pain shooting down from your hips to your legs? These symptoms may be due to pain in your hip flexor muscles. Research studies reveal that these muscles support other muscle groups like the trunk and legs, allowing for proper muscle activity when lifting your legs straight during functional tests for the hips and pelvis. The hip flexors in your hips consist of six muscles that aid in stability and mobility:

  • Psoas Major
  • Iliacus
  • Rectus Femoris
  • Sartorius
  • Adductor Longus
  • Tensor Fasciae Latae

Additional studies have revealed that the hip flexor muscles are crucial in supporting the lower back and maintaining stability. These six muscles aid in hip movements such as deep flexion, adduction, and external rotation, among other functions. The relationship between the hip flexors and the lumbar spine is particularly strong. However, if these muscles become tight, it can negatively affect performance and lead to other issues.

 

Hip Pain Associated With The Musculoskeletal System

Hip pain can be caused by tight hip flexor muscles, which can be affected by various factors such as health issues, injuries, or environmental factors. Research studies have shown that lower extremity injuries can reduce performance and cause pain-like symptoms associated with the musculoskeletal system. Tight hip flexors can be caused by prolonged sitting, incorrect lifting, or repetitive actions, leading to stretched or shortened muscles and the development of nodules. This can contribute to musculoskeletal disorders and uneven hips. Various treatments are available to realign the body and strengthen the hip flexor muscles.

 


Non-Surgical Solution: Chiropractic Care- Video

Do you struggle with instability while walking or find yourself leaning more on one leg than the other? Perhaps you experience constant hip pain. Misalignment in the hips caused by environmental factors can lead to instability and pain-like symptoms associated with tight hip flexor muscles. These issues can cause musculoskeletal disorders that overlap and result in spinal subluxation. Research studies mentioned that it could be difficult to diagnose hip pain because it often presents as referred pain from the lumbar spine or knee joint. This means uneven or tight hips could cause low back or knee pain. Treatments are available to reduce hip pain and gently stretch flexor muscles. The video above demonstrates how chiropractic care can offer non-surgical solutions to realign the body and relieve stress in the surrounding muscles.


Assessing The Hip Flexors With MET Therapy

 

If you are experiencing stiffness or pain in your hips due to tight hip flexors, you can improve your mobility and prevent future issues in several ways. Studies have revealed that physical therapy involving RICE (rest, ice, compression, and elevation) can help restore muscle strength and range of motion. Soft tissue treatment combined with physical therapy can also be effective in restoring hip mobility. In their book “Clinical Application of Neuromuscular Techniques,” Dr. Judith Walker DeLany, L.M.T., and Dr. Leon Chaitow, N.D., D.O. explain that Muscle Energy Techniques (MET) can gently stretch the hip flexor muscles and restore mobility and range of motion in the hip joint. MET therapy can lengthen tight hip flexor muscles, reduce referred pain, and improve the hip’s function.

 

Conclusion

When the hips and the muscles around them start to cause pain that spreads to the rest of the body, it can lead to uncomfortable symptoms that cause people to shift their weight to compensate for the pain. This can happen because of environmental factors like sitting for too long or overstretching the muscles, which makes the hip flexors tight and can lead to pain in the hips and lower back. However, physical therapy combined with muscle energy techniques (MET) can help relieve the pain and realign the hips with the body. These treatments let the body naturally heal the affected muscles so that people can be pain-free.

 

References

Ahuja, Vanita, et al. “Chronic Hip Pain in Adults: Current Knowledge and Future Prospective.” Journal of Anaesthesiology, Clinical Pharmacology, 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC8022067/.

Chaitow, Leon, and Judith Walker DeLany. Clinical Applications of Neuromuscular Techniques. Churchill Livingstone, 2003.

Konrad, Andreas, et al. “The Influence of Stretching the Hip Flexor Muscles on Performance Parameters. A Systematic Review with Meta-Analysis.” International Journal of Environmental Research and Public Health, 17 Feb. 2021, www.ncbi.nlm.nih.gov/pmc/articles/PMC7922112/.

Mills, Matthew, et al. “Effect of Restricted Hip Flexor Muscle Length on Hip Extensor Muscle Activity and Lower Extremity Biomechanics in College-Aged Female Soccer Players.” International Journal of Sports Physical Therapy, Dec. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4675195/.

Tyler, Timothy F, et al. “Rehabilitation of Soft Tissue Injuries of the Hip and Pelvis.” International Journal of Sports Physical Therapy, Nov. 2014, www.ncbi.nlm.nih.gov/pmc/articles/PMC4223288/.

Yamane, Masahiro, et al. “Understanding the Muscle Activity Pattern of the Hip Flexors during Straight Leg Raising in Healthy Subjects.” Progress in Rehabilitation Medicine, 16 Feb. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC7365227.

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Different Stretches To Improve Hip Mobility

Different Stretches To Improve Hip Mobility

Introduction

The hips in the lower portions of the body allow the legs to move the host from one location to another and provide stability to support the upper body’s weight. The hips will enable the torso to twist and turn without feeling pain. This is due to the various muscles and ligaments surrounding the pelvic bone and hip joint socket that allow the motion to be possible. However, when various injuries or factors start to affect the multiple muscles surrounding the pelvis or there is a chronic condition like osteoarthritis that causes wear and tear on the hip joints can cause underlying symptoms associated with the hips and cause many individuals to have difficulty when moving around. Luckily there are ways to improve hip mobility and the surrounding muscles in the hip and pelvic region of the body. Today’s article looks at the causes of the development of tight hips in the body and how different stretches can release tight hip flexor muscles. We refer our patients to certified providers that incorporate techniques and multiple therapies for many individuals suffering from hip pain and its correlating symptoms that can affect the musculoskeletal system in the hips, legs, and lumbar region of the spine. We encourage and appreciate each patient by referring them to associated medical providers based on their diagnosis when it is appropriate. We understand that education is a fantastic way when asking our providers intricated questions at the patient’s request and understanding. Dr. Jimenez, D.C., only utilizes this information as an educational service. Disclaimer

What Causes The Body To Develop Tight Hips?

 

Have you been dealing with hip mobility issues? When you sit, do you feel uncomfortable, and your hip muscles become tight? Or do you have a decreased range of motion when moving your hips? It could correlate with your hips if you have been experiencing muscle pain issues in the lower extremities. The hips help stabilize the upper and lower portions of the body while providing the full leg’s range of motion. When a person begins to sit for long periods or twist their body in a weird position, it can cause the muscles that surround the hips to become shortened. Other issues, like chronic conditions, can play a role in developing tight hip flexors. Studies reveal that various pathologies affecting the hips, lumbar spine, and lower extremities could strongly correlate with restricted hip mobility that can cause harmful effects that can affect the hips. To that point, some of the symptoms associated with tight hip flexors include:

  • Instability
  • Hypermobility
  • Limited range of motion
  • Reduce muscle strength in the groin
  • Muscle cramps
  • Sharp, sudden pain in the hips, pelvis, or groin
  • Low back pain
  • Piriformis syndrome

Other research studies mentioned that hypermobility disorders could affect the hip joints. Hypermobility disorders like EDS (Ehlers-Danlos syndrome) could cause micro or macro-trauma on the hip joint and affect the ligaments surrounding the hip joint. To that point, it can cause the hip flexor muscles to become tense and potentially affect how a person moves, which then causes soft tissue injuries and chronic pain.


Hip Flexor Stretches-Video

Do you feel tight along your hips? Do you see yourself hobbling around when walking? Or do you feel aches or strains when stretching? Many of these issues correlate with tight hip flexors that could result from hip pain in the lower extremities. When a person has tight hip flexors, it could be due to them constantly sitting down, causing the hip muscles to be shortened, or chronic conditions that can affect the hip joint and muscles. However, there are various ways to prevent tight hip flexors and regain mobility back to the hips. Studies reveal that stretching combined with core stabilization can help improve the hip’s range of motion while ensuring core endurance exercises can help strengthen the surrounding muscles in the hip area. The video above shows stretches targeting the hip flexor muscles and helps improve hip mobility.


Different Stretches To Release Tight Hip Flexors

Studies have shown that the hip flexor muscles are the main contributors to lumbar spine stability when releasing tight hip flexor muscles. So when there are tight hip flexors, it can cause overlapping risk profiles to the lumbar spine, which leads to pain and impairment in performance. The best way to reduce the pain-like symptoms associated with tight hip flexors is by stretching the lower half of the body to reduce muscle strain and tightness in the hip flexors. Additional studies have found that stretching combined with exercises targeting the low back can reduce the pain caused in the low back and help improve stability and strengthen the surrounding muscles located in the hips. Now it is important to remember that stretching for at least 5-10 minutes before and after working out allows the muscles to warm up and improve flexibility. Below are some different stretches that can release tight hip flexors.

 

High Crescent Lunge

 

  • While standing on the mat, take a step forward to allow your right foot to be in a staggard stance *Think in a lunge position.
  • Bend the front knee gently while keeping the back leg straight, as this allows the heel in the back leg to be lifted off the mat; the bent front knee enables the thigh to be parallel to the floor, and the right foot is pressed flat on the mat.
  • Square up the hips, so they face toward the mat’s front.
  • Extend the arm up towards the ceiling to stretch upwards while pressing into the mat to feel the hips stretch
  • Hold for five breaths before slowly rising out of the lunge position and repeating on the other side. 

This stretch helps release tension in the hip flexors and quads while warming up the muscles and increasing blood flow to the legs.

 

Knee-To Chest Stretch

 

  • Lie on the mat with both legs extended out and feet flexed.
  • Pull on the left knee to the chest while keeping the right leg straight, and the lumbar portion of the back is pressed into the mat.
  • Hold the position while taking deep breaths for 30 seconds to 2 minutes.
  • Release slowly and repeat on the right leg *You can lift both knees to your chest and rock slowly from side to side to relieve low back tension as an alternative.

This stretch is extremely helpful for tight hamstrings and allows the tense muscles on the hips and lower back to relax while increasing blood flow back to the muscles.

 

Piriformis Stretch

 

  • On the mat, sit with both legs extended out.
  • Cross the right leg over the left and place the other flat on the floor while the left foot is flexed
  • Place the right hand behind the body while the left elbow is on the right knee.
  • On inhale, press the right leg to the left while allowing the torso to twist on the right.
  • Take five breaths for a deeper stretch and switch sides to repeat the action with the left hand *If you have low back pain issues, the modified version allows you to use your left hand to pull the right quad in and out to the left and vice versa.

This stretch helps loosen tight muscles in the lower back, hips, and glutes. If you have sciatic nerve pain associated with piriformis syndrome, this stretch helps release muscle tension from the piriformis muscle aggravating the sciatic nerve.

Happy Baby Pose

 

  • Lie on the mat with both knees bent and feet on the ground.
  • On inhale, lift the feet off the ground and grab the outer sections of the feet with your hands.
  • Then gently pull the feet towards the chest and allow the knees to lower to the ground, on either side of the body, while keeping the back flat on exhale.
  • Hold the position for at least five breaths.

This stretch helps with the inner thigh muscles or hip adductors and helps them become loose and mobile without feeling any strain or tension.

 

Bridge Pose

 

  • On the mat, lie on your back and sides, and extend your arms while your feet are flat on the floor with your knees bent.
  • Press with your heels to lift the hips and allow the feet to walk a few steps toward the body. *Keep the feet and knees hip-width apart.
  • Clasp hands together underneath the body and press them into the mat
  • Hold the position for five breaths.

This stretch helps take the pressure off the hip muscles while strengthening the glutes and abdominal muscles.

 

Conclusion

When it comes to releasing tight hip flexors after sitting for a long time or having hip issues affecting your low back or pelvis, Doing different stretches that target the hips can reduce the pain and release tight muscles associated with other conditions that can affect the body. The hips are important to take care of since they provide mobility and stability to the upper and lower portions of the body. They support the upper body’s weight while providing a huge range of motion to the legs. Incorporating these different stretches can reduce the pain that they have been under and help warm up the other muscles that surround the lower extremities.

 

References

Lee, Sang Wk, and Suhn Yeop Kim. “Effects of Hip Exercises for Chronic Low-Back Pain Patients with Lumbar Instability.” Journal of Physical Therapy Science, U.S. National Library of Medicine, Feb. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4339134/.

Moreside, Janice M, and Stuart M McGill. “Hip Joint Range of Motion Improvements Using Three Different Interventions.” Journal of Strength and Conditioning Research, U.S. National Library of Medicine, May 2012, pubmed.ncbi.nlm.nih.gov/22344062/.

Reiman, Michael P, and J W Matheson. “Restricted Hip Mobility: Clinical Suggestions for Self-Mobilization and Muscle Re-Education.” International Journal of Sports Physical Therapy, U.S. National Library of Medicine, Oct. 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC3811738/.

Reiman, Michael P, and J W Matheson. “Restricted Hip Mobility: Clinical Suggestions for Self-Mobilization and Muscle Re-Education.” International Journal of Sports Physical Therapy, U.S. National Library of Medicine, Oct. 2013, www.ncbi.nlm.nih.gov/pmc/articlhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027473/es/PMC3811738/.

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Toe Flexors & Trigger Points

Toe Flexors & Trigger Points

Introduction

Regarding different destinations, our feet allow the legs and the lower body to move forward and stabilize the upper extremities from putting so much weight on the body itself. The lower portion of the body contains the hips, pelvis, legs, and feet. Within each section of the lower body, various muscles surround the joints and skeletal features of the lower half. For the hips, multiple muscles and tendons help support hip mobility and pelvic function. The legs work with the thigh as numerous muscles and tendons help the legs have more power to move. The lower portion of the legs works with the knee to allow extension and flexion to move as well. And finally, the ankles and feet work with various muscles to enable movement to the toes. The different muscles in the toes help stabilize the foot from causing issues to the ankles. However, when multiple injuries or factors begin to affect the muscles in the toes, it can lead to myofascial pain syndrome or trigger points to affect not only the toes but the entire portion of the legs and travel up to the hips. 

 

Today’s article looks at the flexor muscles of the toes, how calf pain is associated with trigger points affecting the toes, and how different treatments and stretches can alleviate trigger points along the toe flexor muscles. We refer patients to certified providers that incorporate various techniques and therapies in the lower body extremities pertaining to trigger points affecting the legs, calves, and feet. This helps many people with pain symptoms along the flexor toe muscles, causing pain when doing everyday actions like stepping or walking. We encourage and appreciate each patient by referring them to associated medical providers based on their diagnosis when it is appropriate. We understand that education is a terrific way when asking our providers intricated questions at the patient’s request and understanding. Dr. Alex Jimenez, D.C., only utilizes this information as an educational service. Disclaimer

The Flexor Muscles Of The Toes

Have you been dealing with stability issues that are affecting the way you are standing? How about coping with unquestionable calf or foot pain? Do you feel aches in your big toe? Many of these issues affecting the feet are correlated with the flexor muscles in the toes. The flexor muscles are the flexor digitorum longus and the flexor hallucis longus. These muscles are located in the calf region of the lower leg and travel downwards to the ankle, forming the tendons for the feet and toes. Research studies reveal that the flexor digitorum longus muscle is a thin muscle located in the tibia’s deep posterior muscles and provides operational support to the four different sections of the toes and allows flexion. While other research studies reveal that the flexor hallucis longus muscle is a deep posterior muscle located in the fibula and provides flexion to the great toe while serving to plantarflex and inversion to the foot.

 

Now the flexor muscles work together to allow stability to the foot when a person is walking. Additional studies have shown that the flexor muscles are active as many people push off from the heel to allow movement to the toes and feet when stepping on the ground. This action enables the flexor muscles to contract and exerts much energy to allow the feet to move. However, when the body begins to age naturally, or various issues affect the lower body extremities, it can lead to multiple problems affecting a person’s mobility. 

 

Calf Pain Associated With Trigger Points Affecting The Toes

 

As the body ages naturally, a person’s mobility will eventually begin to decline as they shuffle in their steps instead of picking up their feet to move. Studies reveal that when older adults start to age naturally, they tend to have a decreased foot posture that enables them to have a more pronated foot than a supinated foot. When this happens, it can reduce mobility in their legs while also causing stress to the flexor muscles and have a high occurrence in lower extremity injuries like patellofemoral pain or tendon dysfunction. Stress in the flexor muscles can lead to the potential development of trigger points along the flexor muscles, which can correlate to calf pain. Dr. Janet Travell, M.D.’s book, “Myofascial Pain and Dysfunction,” mentioned that trigger points along the toe flexor muscles could potentially cause impaired mobility and strain to the foot. Since the flexor muscles are located in the calves, many individuals that incorporate running, jogging, or walking as part of their daily lives can be affected. To that point, if a person is walking on uneven ground, it can cause the foot to be hyper-pronated and lead to calf pain. At the same time, trigger points in the flexor muscles can cause symptoms of muscle spasms and cramps which can become overlapping risk profiles for ankle and foot pain.


Treating Trigger Points Along The Flexor Muscles- Video

Have you been dealing with unexplainable muscle spasms in your calves? Do you feel unstable when walking for a long time? Or do you notice you shuffle instead of picking up your feet? Many of these issues are correlated with trigger points affecting the flexor muscles of the toes that are causing pain to the calves and feet. When it comes to trigger points along the flexor muscles of the toes, studies show that it can develop a “trigger toe” where the flexor hallucis muscle that is providing flexion to the great toe, is in pain which leads to foot issues like plantar fasciitis or ankle pain. Fortunately, all is still possible as there are different stretches and treatments to reduce trigger points associated with the toe flexor muscles. The video above explains where the flexor muscles are located in the calve region of the leg and demonstrates how to stretch the flexor muscle to prevent trigger points from returning.


Different Stretches & Treatments For Toe Flexor Muscles

 

When relieving foot and calf pain associated with trigger points affecting the flexor muscles, there are different stretches and treatments to reduce pain-like symptoms associated with trigger points. Studies reveal that incorporating various muscle-strengthening exercises that target the calves could improve postural balance on the feet. Or find the right footwear to prevent trigger points from appearing in the future. Other stretches like toe grasping and flexing the foot allow many pain specialists to locate where the trigger points affect the flexor muscles and develop a treatment plan to reduce the effects of trigger points along the toe flexor muscles. Some of the treatments include chiropractic care. Now, doesn’t chiropractic care only incorporate spinal adjustments on the back? Yes, it does, but it can also alleviate other issues. As stated earlier, the feet provide stability to the lower body extremities. When problems affect a person’s balance can cause limited mobility to the hips, affect the legs and feet over time, and develop trigger points along the way. With chiropractic care, chiropractors can restore hip mobility through mechanical and manual manipulation of the spine and can help loosen the stiff joints and muscles that are causing pain. Chiropractors can pinpoint where the trigger points are located and find ways to reduce the pain in the affected muscle.

 

Conclusion

The flexor muscles of the toes, the flexor digitorum longus, and the flexor hallucis longus allow stability and flexion to the toes. The flexor muscles are located in the calve region and enable the individual to walk without complications. When issues or injuries start to affect the feet, they could develop into overlapping issues that affect the flexor muscles and causes symptoms of instability in a person’s balance. If not treated right away, it could develop trigger points in the calf region and cause pain to the flexor muscles. Trigger points in the flexor muscles can cause stress on the flexor muscles, which then leads to foot issues like patellofemoral pain or tendon dysfunction. To that point cause impaired mobility and muscle strain on the foot. Luckily there are treatments and various stretches to reduce trigger points from developing further and improve stability in the body. To that point, allow the individual to walk without any foot pain.

 

References

Fowles, J V, and N M Newman. “A Case of ‘Trigger Toe.’” Canadian Journal of Surgery. Journal Canadien De Chirurgie, U.S. National Library of Medicine, July 1984, pubmed.ncbi.nlm.nih.gov/6744145/.

Goldmann, Jan-Peter, and Gert-Peter Brüggemann. “The Potential of Human Toe Flexor Muscles to Produce Force.” Journal of Anatomy, U.S. National Library of Medicine, Aug. 2012, www.ncbi.nlm.nih.gov/pmc/articles/PMC3406365/.

Grujičić, Roberto. “Flexor Digitorum Longus Muscle.” Kenhub, Kenhub, 5 Dec. 2022, www.kenhub.com/en/library/anatomy/flexor-digitorum-longus-muscle.

Kusagawa, Yuki, et al. “Toe Flexor Strength Is Associated with Mobility in Older Adults with Pronated and Supinated Feet but Not with Neutral Feet.” Journal of Foot and Ankle Research, U.S. National Library of Medicine, 11 Sept. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7488436/.

Murdock, Christopher J, et al. “Anatomy, Bony Pelvis and Lower Limb, Calf Flexor Hallucis Longus Muscle …” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 25 Aug. 2022, www.ncbi.nlm.nih.gov/books/NBK539776/.

Quinlan, Shayan, et al. “The Evidence for Improving Balance by Strengthening the Toe Flexor Muscles: A Systematic Review.” Gait & Posture, U.S. National Library of Medicine, Sept. 2020, pubmed.ncbi.nlm.nih.gov/32679464/.

Travell, J. G., et al. Myofascial Pain and Dysfunction: The Trigger Point Manual: Vol. 2:the Lower Extremities. Williams & Wilkins, 1999.

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Dealing With Upper Thigh Pain? Could Be Trigger Points In the Hamstrings

Dealing With Upper Thigh Pain? Could Be Trigger Points In the Hamstrings

Introduction

Many individuals utilize their lower muscles to move around and stay active as each muscle does its job and allows mobility to the hips and thighs. In sports, the thigh muscles are utilized constantly to extend the legs and bend the knees, allowing a powerful force to win any sports competition. At the same time, various sports injuries can occur to the hips, thighs, and legs and can affect the muscles causing pain and discomfort to the lower extremities. A hamstring injury is one of the most common injuries that can affect the thighs, which can cause many athletes to be taken out of their favorite sport to recover from the injury. Today’s article looks at the hamstring muscle, how trigger points correlate with a hamstring strain, and how various stretches can reduce muscle strain on the hamstrings. We refer patients to certified providers who incorporate multiple methods in the lower body extremities, like upper thigh and hip pain treatments correlating to myofascial trigger point pain, to aid individuals dealing with pain symptoms along the hamstring muscles. We encourage and appreciate patients by referring them to associated medical providers based on their diagnosis, especially when appropriate. We understand that education is an excellent solution to asking our providers complex questions at the patient’s request. Dr. Jimenez, D.C., utilizes this information as an educational service only. Disclaimer

What Are The Hamstring Muscles?

 

Do you experience pain in the back of your upper thigh? When walking from one place to another, do you hear a popping sound in the back of your thigh? Or are you dealing with muscle tenderness in the back of your upper thigh? Many of these symptoms correlate with issues affecting the hamstrings causing trigger points to affect the upper thighs. As one of the most complex muscles comprising three muscles (semitendinosus, semimembranosus, biceps femoris), the hamstrings play a crucial part in daily activities. From simple actions like standing to explosive movements like sprinting or jumping, the hamstrings are known as posterior thigh muscles that begin from the pelvis and run behind the femur bone and cross the femoroacetabular and tibiofemoral joints. The hamstring muscles in the body play a prominent role in hip extension and is a dynamic stabilizer of the knee joint. To that point, the hamstring muscles are the most susceptible muscle that succumbs to injuries that can lead to disability in the legs and affect daily activities.

 

Hamstring Strain & Trigger Points

 

Since the hamstrings are the most susceptible muscles that can succumb to injuries, it takes a while for the muscle to heal, depending on the severity of the damage. Studies reveal that the hamstrings can occur injuries when a person is running or sprinting due to their anatomic arrangement, which causes the muscles to strain. To that point, depending on how much force has impacted the hamstrings, the injuries can lead to 3 of the following:

  • Grade 1: Mild pain or swelling (no loss of function)
  • Grade 2: Identifiable partial tissue disruption with moderate pain and swelling (minimal loss of function)
  • Grade 3: Complete disruption of the tissue with severe pain and swelling (total loss of function)

The pain that patients experience can be painful when walking, causing them to limp. In “Myofascial Pain and Dysfunction,” written by Dr. Janet G. Travell, M.D., stated that when patients are dealing with pain in their hamstrings, it could potentially be associated with trigger points along the three muscles, causing pain and disability in the upper thighs. The book also mentioned that when trigger points affect the hamstrings, it can lead to muscle inhibition, compromising hip stability. Another issue that trigger points associated with hamstring strain causes in the body are that when individuals are sitting down are likely to experience posterior pain in the buttock, upper thighs, and back of the knees. Luckily, there are various ways to reduce the pain along the hamstring muscles. 

 


Trigger Point Of The Week: Hamstrings- Video

Have you dealt with pain along the back of your upper thighs? Does it feel uncomfortable when you are sitting down? Or do your hamstrings ache or feel tight after running for a long period? People dealing with issues in their hamstrings could be dealing with muscle strain associated with trigger points. The hamstring muscles play a vital role in the body as it allows the individual to walk, run, bend the knees and even extend the legs. The hamstring muscles are also the most susceptible to injury, causing disability to the legs. Studies reveal that trigger points associated with the hamstring muscles can lead to soreness or irritability in the muscle fibers that may interfere with the biomechanics and normal functioning of the lower limbs. The video above explains where the hamstrings are located and how the trigger points can cause referred pain to the hamstrings. To that point, trigger points can affect a person’s ability to walk and affect the surrounding muscles in the lower body while mimicking other chronic conditions.


Various Stretches To Reduce Muscle Strain On The Hamstrings

 

When the hamstrings become injured, the healing rate usually depends on how severe the injury is in the hamstrings. If a hamstring injury is mild, the tears or strains can heal within about three to eight weeks, and if the hamstring injury is severe, the tears or strains could be long as three months. When the hamstrings are tense and on the verge of tearing, many people should stop overusing the muscle. Various stretches can reduce muscle strain on the hamstrings and relieve tension from the hamstrings to allow mobility back to the legs. Studies reveal that manual ischemic compression on the upper thigh muscles can significantly reduce pain in the lower limbs. This allows the individual to manage the trigger points associated with the hamstrings and reduce the chances of them re-occurring in the legs.

 

Conclusion

As the most important muscle in the lower body extremities, the hamstrings play a crucial part in the body as they allow the individual to walk, run, and stand without feeling pain. However, even though they are important muscles, they are susceptible to injuries. When the hamstrings become injured, the recovery process varies depending on the severity and can develop trigger points along the muscle fibers. To that point, it causes referred pain along the upper thigh muscle and affects a person’s ability to walk. Fortunately, incorporating various stretches to the hamstrings can alleviate the pain and reduce the trigger points from re-occurring in the muscle. This allows mobility back to the legs, and many individuals can resume their daily activities.

 

References

Esparza, Danilo, et al. “Effects of Local Ischemic Compression on Upper Limb Latent Myofascial Trigger Points: A Study of Subjective Pain and Linear Motor Performance.” Rehabilitation Research and Practice, Hindawi, 4 Mar. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6425406/.

Poudel, Bikash, and Shivlal Pandey. “Hamstring Injury – Statpearls – NCBI Bookshelf.” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 28 Aug. 2022, www.ncbi.nlm.nih.gov/books/NBK558936/.

Rodgers, Cooper D, and Avaias Raja. “Anatomy, Bony Pelvis and Lower Limb, Hamstring Muscle.” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 29 Jan. 2022, www.ncbi.nlm.nih.gov/books/NBK546688/.

Thummar, Ravindra C, et al. “Association between Trigger Points in Hamstring, Posterior Leg, Foot Muscles and Plantar Fasciopathy: A Cross- Sectional Study.” Journal of Bodywork and Movement Therapies, U.S. National Library of Medicine, 7 Aug. 2020, pubmed.ncbi.nlm.nih.gov/33218537/.

Travell, J. G., et al. Myofascial Pain and Dysfunction: The Trigger Point Manual: Vol. 2:the Lower Extremities. Williams & Wilkins, 1999.

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