Hamstring pain is posterior thigh pain. Quadriceps pain is anterior thigh pain. IT band pain is lateral thigh pain. Adductor pain is groin pain.

Of course it fits that people who aren’t clinicians would label pain using structures they know. And it’s obvious most people can name big muscle groups! My issue is when clinicians inappropriately do it.

If the patient uses this language, in an effort to create rapport, I may use it with interactions with that patient as well. Mimicing language can be a nice therapeutic tool that is easy to implement. (I typically will adopt the patient’s word for describing his or her own symptoms, for example; my favorite instance being my patient who referred to his radiating leg pain as his “lightning bolt.”) I’d prefer, however, to use the correct language if possible since accurate patient education regarding his or her problem is key to a successful outcome.

I do not use these terms to refer to these parts of the body outside of that specific patient context, though. Yes, if the patient has true hamstring, quad, ITB, or adductor pathology, these words are clearly apropos. But those patients (especially among non-athletes) are rare. In most cases a patient’s posterior, anterior, or lateral thigh pain or groin pain is referred pain from the spine or hip. --Laura

​It takes many weeks for tissue to form adhesions and become tight. And when it is indeed tight, it does NOT vary day to day or week to week. I understand that the sensation patients report is one of “tightness,” but if there is variability, then the source of this tight feeling is not the tissue itself.

When I say tissue, what do I mean? I subdivide it into two main categories: contractile tissue (muscles and tendons) and non-contractile tissue. In the second group, most of the time we’re talking about joint capsular tissue, but there could also be problems with skin, fascia, etc.

Tissue can become tight for many reasons. Think of a simple cut on your skin. If you don’t move the affected tissue, over time the tissue will become tight as scar tissue lays down haphazardly, restricting normal, fluid motion. (This is a good thing - you want scar tissue to be strong! But consistent movement in the right direction will make it flexible.) Surgery is like a simple cut writ large. Many tissues are cut and repaired and, without proper re-integration of movement, often are tight months or years later. Some tissues get tight because they don’t get moved properly. That could be from life habits, patterns after a prior injury, or from 8 weeks in a cast, for instance. A frozen shoulder is another example of tight tissue - which, in the absence of an instigating trauma, usually comes on insidiously.

In these examples, it’s clear that tissue can certainly get tight - and that it can restore to normal length (with informal or formal therapy). It’s also obvious from these scenarios that this process doesn’t allow for a patient to report, “Well, some days it feels really tight, but then some days I’m fine.” Tissue does not behave like that. But joints do ... and they refer that tight feeling to nearby tissue. When I take a patient’s history, I ask very specific questions that narrow my possible diagnoses. If the patient describes variability, local tissue tightness is not the cause. --Laura

A tight flexor muscle will be apparent with extension. End-range extension will be limited, painful, or both. Other motions are not commonly as affected, if at all. For certain, flexion won’t be limited because, with flexion, the tight flexor muscle is on slack.

As I’ve stated before, muscles are incorrectly incriminated as someone’s problem way too often. While I see tendinopathies (a contractile issue, not usually a length or tightness issue), I can’t remember the last time I diagnosed a “tight muscle” or had a patient stretch a muscle. What I typically find are joint derangements - joint problems which refer symptoms to muscles. Joint derangements are fixed (often very quickly) with directional preference exercises.

Tight muscles exist, but they are very rarely the source of someone’s complaints. The better we are at diagnosing a problem, the better we are at fixing it. ​-- Laura

​Can we at least agree that a muscle spasm creates a shortening of the muscle as it performs its action? When you have a true calf cramp your foot starts to plantar flex (point down). When your hamstring spasms, your knee bends. When your toe flexors cramp, your toes curl. And so on. (There can be many causes of these muscle spasms including musculoskeletal, nutritional, and others.)

So, if your low back muscles were in true spasm, they (primarily extensors which extend - or backward bend - your low back) should pull you into backward bend. Why don’t they? Because while you feel muscular symptoms, it’s rarely (I want to say never) a true muscle spasm. Instead, it’s pain referred from the nearby low back joints. These muscular symptoms can be horrendous, but they are driven by the joint; and once you start to get the joint moving correctly again, the muscular symptoms calm down.

Many patients with low back problems actually lean forward or are stuck forward due to the joint derangement, which further disproves the common theory that muscle spasm is the problem and is what needs to be treated. -- Laura

Regularly sitting for prolonged periods, especially slouched, can lead to orthopedic problems. But the problems arise almost always from joints, not muscles. I continually hear people (health professionals, notably) declare that sitting’s “shortened” position of the hip flexors can cause painful, tight hip flexors. Granted this doesn’t affect all sitters (nothing does), but if large amounts of time in shortened states can lead to painfully tight muscles, then where is the observable pattern? Why aren’t more biceps affected secondary to prolonged elbow bending? Where’s the complaint of painful anterior neck muscles as our heads are so often forward?
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Though I make my case verbally, people won’t budge. It’s likely the only way to prove my point would be to demonstrate an evaluation and treatment of someone with this given “diagnosis.”  In the absence of that, I put forth that, one, we have ways of clinically determining if this is occurring, which, importantly, involves ruling out joints and nerves. Two, if we consider joint mechanics, deranged upper-mid lumbar segments and hip joints can send referred/radicular pain to the hip flexor area. Deranged elbows usually refer pain to the medial, lateral, or posterior elbow. And neck derangements typically send pain posteriorly and laterally – rarely anteriorly. The deranged joint pattern is observable. --Laura

In orthopedics, the core comprises a specific group of muscles in the trunk/pelvis. (Others use core generally to mean trunk.) Core muscle strength is beneficial. Just as arm, chest, and foot strength are beneficial! Core muscles are not exemplary. They’re no more our “foundation” than our foot muscles or those running the length of our spine.

Many erroneously treat orthopedic low back pathology by strengthening the core. Assuming core muscle strength can be accurately assessed, if one or more of them is weak, the question is why. Muscles become weak (and painful) from pulls/tears. However, these are very rare when it comes to the large muscles of the core. (Tears follow a consistent, predictable pattern, too, which should make them obvious to an attentive clinician.) Pain can create weakness, but absent a clear tear, the pain usually originates from something other than the muscle.
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The number one reason any muscle is weak (the large majority of cases) is because its electricity from nerves has been inhibited – either at the spine or extremity joints. It’s a joint problem. Therefore, in most cases strengthening a weak muscle (or entire group!) is simply attacking a symptom, which won’t fully resolve the problem. -- Laura

This topic has been coming up a lot with my patients recently. Many patients report that they don’t feel pain exactly - they feel tight, or, more usually, really tight. This can apply to the neck, low back, and extremities. Determining the reason a patient feels tight (the diagnosis) and helping fix it is, of course, my job.

True muscle tightness certainly exists. What do I mean by “true muscle tightness?” I mean that the reason you feel tight in a muscle, say the hamstring muscle, is because the hamstring muscle is actually tight. This is most typically a result of an increased or altered load on a muscle – like a workout - and sets in 1-2 days after the change in demand. This tightness may be called soreness, and is a result of normal breakdown in the muscle itself and/or inflammation in the muscle. While people might choose to intervene to reduce this tightness (such as going for a walk, stretching, getting a massage, etc.), it is imperative to note that this tightness is normal, and will pass within a few days on its own. People don’t usually seek medical care for this.

True muscle tightness can come from less strenuous events too. For example, if you wear a new pair of shoes while walking around a city for hours, you might experience tightness in a muscle or two the next day since your muscles experienced a new load due to the different position of your feet. Alternatively, if you were in a cast for 8 weeks, your muscles may also feel tight while they are immobilized. And, of course, if you tear a muscle, if will feel tight as inflammation and then immature scar tissue replaces the torn muscle tissue. In all of these scenarios, the cause of the tightness is normal, obvious, and reversible.

Again, patients usually don’t come to me reporting tightness of the normal variety (since normal muscle tightness will pass on its own). So what makes patients feel tight if it’s not normal true muscle tightness? There are two possibilities:

1.  The abnormal sensation of tightness is referred from a joint, either nearby or distant.

A common situation here is a spine joint being out of place and referring a feeling of tightness to a separate area. It can be nearby, like the neck joints sending tightness signals to the upper shoulders. Or it can be more distant, like the low back joints sending tightness signals to the calf. Extremity joints can also send tightness signals. With extremity joints, the signal usually stays close to the problematic joint. The hip joint may send a feeling of tightness down the thigh a bit, for instance. This tightness can be constant or it can come and go.

2. The abnormal sensation of tightness is nerve tension/tightness.

Nerves run throughout our body, passing through and next to muscles. If a nerve is compressed somewhere along its path, it will lose the ability to lengthen, making it indeed tight. The most frequent example of this is the sciatic nerve. When compressed in the low back, it can create a feeling of tightness in the back of the thigh, calf, or foot. Most people, however, just blame the muscle in the area of tightness, not understanding that a nerve is also in that area! This tightness, also, can be constant or it can come and go.
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There are movements and simple tests I use in the clinic to determine what is causing the tightness. A simple slump test is used to help differentiate if a hamstring muscle or a sciatic nerve is tight, for instance. The take home message is this: true muscle tightness is usually normal, but persistent or recurring (chronic) tightness is not normal, and is almost always arising from a location away from the site where the tightness is felt. You shouldn’t be stretching, foam rolling, or massaging your arm, back, or leg muscles all the time. Find the joint or nerve causing the feeling of tightness and fix that to get relief for good. -- Laura

I remember learning about dead butt syndrome (DBS) during a presentation at the clinic where I worked several years ago, two years into my career. I believe the sales rep was there to push taping products, but this topic somehow came up. (Please note: while some refer to all the gluteal muscles becoming weak, others specify the gluteus medius muscle in particular.) This gentleman explained that since people sit all day without using their gluteus muscles, they become weak. Made sense to me! And it had a fun name.

However, when I began using the term with patients whose gluteus medius muscles were in fact weak, and fielding patients' questions regarding the topic, I became skeptical. For one, if sitting dormant all day was the root cause, why wouldn't mostmuscles weaken? And, secondly, if it was sitting combined with lack of daily use of the gluteus medius muscles - lack of moving the hips laterally - that was the trigger, wouldn't the lateral movers of other joints suffer then too?
So I did a bit of "research:" I read a few articles intended for the public. The consensus is that DBS not only affects expert sitters, but also people who exercise, but who don't target the glute muscles enough. That sounds strange. Those could be very different cohorts. Or, the exercisers could also be expert sitters when they're not moving. Here are my two chief complaints with what I found to be the commonly proposed etiology of DBS:

1. Asserting that the glutes are weak because of reciprocal inhibition does not resonate with me. This argument states that, with prolonged sitting, hip flexors get tight and contracted and therefore inhibit the muscles opposite them - the glutes. For starters, tight and contracted are not necessarily the same thing. I'll allow that hip flexors may get tight the more we sit with them maintained in a shortened state, but given they get some stretch with each step we take, pathological hip flexor tightness is a hard sell for me. Very often what is diagnosed as hip flexor tightness is actually femoral nerve tightness. (There are clinical tests to distinguish between the two.) Additionally, hip flexors don't contract, that is, actively work, while you're seated. They're normally pretty quiet as you just sit there. Lastly, my understanding is that reciprocal inhibition is when the body momentarily relaxes an antagonist to allow the agonist to do its work - which in and of itself does not create weakness. In sum, while I certainly agree that many people have weak gluteus muscles (one or more of them) I can't get behind this explanation.
2. One author writes, DBS "can lead to lower back pain and hip pain, as well as knee and ankle issues, as the body tries to compensate for the imbalance." Can weakness lead to pain? Sure. Is it more likely, though, that the weak glutes, low back pain, hip pain, and lower extremity pain are all manifestations of one pathology? That is, most likely a lumbar spine that is a little, or a lot, malaligned? The words "compensate" and "imbalance" are actually my two least favorite words in the world of physical medicine. While it doesn't seem far-fetched to think, "Hey, my left knee has been hurting for awhile and now my right hip is starting to hurt because I'm walking differently," what if we instead asked: What can be causing both left knee pain and right hip pain? You must have a solid diagnosis first. The answer to that question, of course, is almost always the spine.

Another article states, "It may seem bizarre for a muscle to just stop functioning out of nowhere." Yes! It is indeed very bizarre! Except when you recall that nerves send power to muscles ... and when there is a problem with the flow of electricity through those nerves, muscles will stop functioning seemingly out of nowhere! This inhibition-driven weakness, while not normal, is extremely common. (In fact, if I tested the primary muscles of the upper and lower extremities of 100 people, I bet not one person would demonstrate full strength. That means not one person would have uninterrupted flow of electricity from their spine to their muscles.) The good news is, once you restore the flow of electrical power from the spine - I use specific movements with my patients to accomplish this - muscles should immediately regain normal strength.
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So what is going on with DBS? In the large majority of cases, prolonged sitting (the more slouched, the worse) creates a malalignment in the low back which impedes the flow of electricity via the nerves to the glutes, depriving them of their juice to be strong. The same scenario can create pain in the glutes as pinched nerves can carry pain along their path (or any altered sensation such as tingling or degrees of numbness). That'swhy your butt is dead. To fix it, you'll need to address your low back in order to decompress the nerves. And then, once the power is back on, if your gluteus muscle strength doesn't return completely since the muscles had been dead for so long, you can move on to targeted strengthening exercises to rebuild them. -- Laura