Vastus Lateralis Vs. the IT Band

Our last muscle to cover from the quadriceps femoris group series is vastus lateralis, fondly named by Dr. Janet Travell, the "hornets' nest" along with "stuck patella muscle." The problem is this muscle is often overlooked as causing symptoms that are common among runners and avid exercisers. Lateral thigh pain is almost always diagnosed as Iliotibial (IT) band syndrome.

The conclusion is usually an assumption based on a runner doesn't stretch enough and the IT band has become short over time which is producing their symptoms. However, I rarely find this to be the case when treating runners. They end up in my office because what they were told to do, foam roll and stretch the IT band, isn't relieving their symptoms.

The Wrong Diagnosis

The reason their symptoms are not being alleviated is they are not treating, or stretching the right muscle—the vastus lateralis. While pain from the other quadriceps trigger points is focused only on the knee joint, the vastus lateralis trigger points may also project pain to the outside of the thigh, which may be confused with IT Band syndrome.

Here, I will explore how to relieve your client's pain and discomfort no matter what their lateral thigh diagnosis is. I will also be sharing how one of my clients, a mid-reliever in baseball, formed this famous "hornets' nest."

The biggest component of the confusion is overlooking the fact that the fascia forming the IT band is woven into the muscle fibers of the vastus lateralis. So when the vastus lateralis tightens from overuse, the IT band extending over this muscle gradually shortens, preventing the vastus lateralis from relaxing to its resting length.

This tight compression can activate the latent trigger points along the lateral thigh. As the muscle tightens and the fascia becomes more restricted blood flow is also restricted along with lactic acid and other muscle byproducts that will accumulate in the tissues. This of course creates pain which is worse after an activity that demands a lot of the vastus lateralis (like running).

Let's talk about the function of vastus lateralis. In everyday life, the quadriceps muscle group functions together to allow a person to squat into a chair, get up from the chair, bend backwards and walk up or down stairs. These muscles are not active while standing with the knees locked, but become active during the heel-strike and toe-off phases of walking.

Understanding Function

According to Dr. Travell when vastus lateralis TrPs refer pain and tenderness to the proximal thigh region, the clients may be unable to lie on that side, or may have disturbing sleep at night. Dr. Travell also states that a distinctive feature of TrP1 in this muscle is a "stuck patella." A more anteriorly placed "hornets' nest" of TrPs at midthigh level in the TrP4 region is not uncommon and is likely to cause severe pain over the entire length of the lateral thigh, slightly anterior to the pain of TrP3 and extending upward almost to the pelvic crest.

Another thing to note is that the lateral thigh pain characteristic of proximal vastus lateralis TrPs is commonly misdiagnosed as trochanteric bursitis because of referred pain and referred tenderness in the area of the greater trochanter. The following are some of the ways a client can produce TrPs in vastus lateralis:

• Eccentric overload cause by "catching oneself" after stumbling or unexpectedly stepping into a hole.

• A new exercise program that includes squats or deep knee bends.

• Unaddressed trigger point activity in the hamstrings can cause chronic tightness in these muscles.

• As the biomechanical counterpart to the hamstrings, the quadriceps will frequently develop trigger point activity in response to the chronic muscle tension in the hamstrings.

• Clients that have tension in their soleus muscle will often need to compensate when trying to squat down and lift something heavy. The tight soleus prevents them from ankle dorsiflexion which then overloads the quadriceps muscles.

• Sitting with a leg tucked underneath the buttocks for long periods.

• Skiing is particularly hard on the quadriceps muscles.

• Direct physical trauma to the lateral thigh.

I was very lucky to treat a mid-reliever for 11 years of my massage career. On one occasion he got himself into a real mess. He couldn't squat down, he couldn't lie on that side to sleep, and he was in a great deal of pain and dysfunction. My client had developed the "hornets' nest" in his right leg. No matter how many times I told him not to go heavy on the leg press and not to do the leg extension machine he wouldn't listen. To make matters worse when he could no longer squat down and the leg press started to hurt, he increased his leg extensions. Yikes!

My Treatment Protocol

The following is a treatment protocol using the ATM system you can do with anyone complaining of lateral thigh pain. Compare their function in and out of gravity. More tests may be necessary depending on your client's health history.

1. Perform a functional movement screen squat test to see how well the client can or cannot squat down.

2. Break down the screen if necessary and take a look at gastrocnemius and soleus length.

3. Evaluate the range of motion of the knee using the Thomas Test that we previously discussed in the first part of this article.

4. Perform a forward bend test and rule out hip and lumbar versus hamstring tightness.

5. Perform a straight leg test to evaluate the hamstring out of gravity.

6. Second exam all along the lateral thigh for TrPs by flat palpation. The leg should be slightly flexed at the knee provided by a knee bolster or towel.

After determining it was in fact the "hornets' nest" that was giving him all the pain with a contributing factor of a tight soleus. I first applied heat for 10 minutes to loosen up the fascia over vastus lateralis. Next I used the manual cups to release the fascia. The cupping was performed in multiple directions, going with the muscle, across the muscle, and directly on top of the trigger point.

I then performed a 15 percent isometric contraction to the quadriceps group followed by manual stretching of the quadriceps group. I did manual treatment with my fingers slowly and deeply to feel and help break up the bundles in the tissue. I also used a gua sha tool at an oblique angle to help break up the fibers.

I treated the gastrocnemius and soleus the same way. I retested the squat, Thomas test, and soleus test to give me an indication how the progress of the therapy was coming along. I repeated all of the above until I was happy with the result. I then treated the entire leg front, back, inside, and again outside with the cupping to release the remaining fascia. To help with the stabilization we needed to reset the core and turn psoas back on.

At the end of one-and-a-half hours he was able to perform the squat test perfectly. I did spend three days with him performing the above manual therapy. At the end of the three days, I barely needed to work on him, and his squat, sleep, and pitch delivery was back to normal.

I hope this helps you the next time you have a runner in your office complaining of IT band syndrome. Together let's get out there and educate the public that there is a "hornets' nest" among us, sometimes mistaken as IT band syndrome. Happy therapy, Debbie.