A newly recognized problem of the tensor fascia lata (TFL) may be affecting your patients’ ability to respond to customary treatments
By Gary V. Humphrey, D.C.
Soft tissue syndromes may have more important effects on the human body than
most realize regarding in terms of the treatment protocol for other primary
conditions.
All chiropractic practitioners have at one time or another experienced various
patients that seem to be slow to respond to our usual and customary methods
of treatment. We should become aware of the possible effects of soft tissue
involvement, for this may be the additional contributing factor to many other
primary symptomatic complaints. Many times I have found that a soft tissue involvement
has blocked some patients’ symptomatic recovery. To this extent, the above
referenced systemic effects of soft tissue effects is provided herein for consideration
as an adjunct remedy for other primary musculoskeletal conditions. It is in
this detection that many times the underlying effects of soft tissue anomalies
are the final correction needed to resolve the stubborn conditions that were
previously reluctant to respond to our usual and orthodox methods of treatment.
Consequently, this insight is offered to help expand the parameters of our professional
knowledge by sharing the unorthodox clinical findings that are frequently discovered
only through clinical practice.
At one point during my past 26 years of practice, I inadvertently, through the
regular use of a G-5 vibrator apparatus, discovered a subtle underlying soft
tissue syndrome that seemed to produce a distinct effect on a large number of
patients. I noticed several patients were experiencing unusual symptoms of acute
pain and tenderness in the soft tissues of the tensor fascia borders of one
or both thighs from nothing more than common pressures from a standard application
of a G-5 vibrator unit. The prevailing symptoms were not normal, and the repeated
phenomenon soon became a curious mystery, as painful discomfort typically should
not be felt in these regions with the standard applications of a G-5 vibrator
unit.
None of the patients’ case histories reflected any evidence of physical
trauma or systemic diseases being present to affect the area that might warrant
these peculiar symptoms.
My first thought was perhaps that this was something that might exist, but with
which I was unfamiliar, however subsequent research revealed nothing that would
specifically identify or characterize the symptoms displayed from these anomalous
findings. Consequently, after many years of personal evaluation and experience
with this phenomenon, I present it here for professional scrutiny.
Introduction: TFL Syndrome Discovered
In my many years of practice, I always have used a G-5 vibrator unit on patients
prior to administering any spinal manipulations. In most instances, this brief
procedure usually would provide the patient with a pleasant relaxing stimulus
that would help increase soft tissue circulations and provide an additional
comfort zone to the paraspinal muscles and other corresponding tissues. On various
occasions however, during the application of the G-5 unit to the patient’s
low back and gluteal musculatures, the procedure was additionally extended for
maximum benefit directly to the tensor fascia lata (TFL) muscle tissues and
the lower extremities.
It was in this specific area that I frequently would note the inability of various
patients to be able to tolerate standard G-5 pressures for any length of time
to their thigh fascia tissues without expressing complaints of substantial pain
and discomfort.
The question arose as to why certain patients were experiencing pain in TFL
tissues and why others were not.
After many years of evaluating this phenomenon, I found that the fascia tissues
additionally seemed to have some means of involvement with the underlying effects
already related to other conditions affecting many low-back and lower-extremity
problems. The tensor fascia tissues in some patients appeared to have definite
involvement in the amount of pain many patients would experience, and seemed
to relate to the duration of the patient’s recovery period.
I also found that when systematically administering a continued regimen of specific
G-5 applications to the offending tissues, the overall symptomatic complex would
verily improve at a substantially faster rate.
The regimented G-5 application to the TFL soft tissues seemed to indeed offer
a viable dispensation and release of some form of toxic substances within the
appurtenant structures.
It was still unknown as to why this syndrome existed, so I continued to evaluate
the different types of patients that seemed to be most affected.
It appeared that people middle-aged or above with decreased amounts of regular
exercise were the greatest candidates. Clinical statistics revealed that TFL
Syndrome would affect both males and females, but had a greater predilection
for females. Females over the age of 40 seemed to be the most affected and were
more likely to experience the condition by as much as a 10:1 ratio over men.
The sensitive condition seemed more inclined to be present in those with poor
muscle tone and those with a more lethargic lifestyle.
After many years of treating and evaluating this phenomenon, it seems that this
fascia illio-tibial syndrome produces an underlying effect on many lower-musculoskeletal
and lower-extremity physical fatigue-type conditions.
Meralgia Paresthetica
The condition known as Meralgia Paresthetica (MP), classified as Bernhardt’s
disturbance of sensation and noted in 1895, presents similarities but should
not be mistaken as being the same as TFL syndrome. MP typically results from
a neurological insult primarily to the lateral femoral cutaneous nerve, characterized
by marked stabbing pain and severe burning sensations with numbness and paresthesia
extending into the outer cutaneous borders of one or both thighs.
MP may frequent young patients in their teens who repeatedly wear waist-tight
clothing. The condition seems to affect men more than it does women. It is quite
common in construction workers who wear tight-fitting and heavy tool belts that
sustain prolonged pressures to the lateral femoral cutaneous nerve in the hip
regions. Additionally MP can result from obesity, pregnancy and sometimes diabetes
mellitus surfacing as a diabetic neuropathy. It primarily exists as a distinct
neurological offense, and surgery is rarely required to remedy the condition.
However, on few occasions, the affliction has been caused by an internal growth
or tumor, at which time surgery then may be implemented.
The primary goal in treating MP is usually to eliminate the offending neurological
pressures. Even with this accomplished, numbness occasionally may continue for
a substantial length of time and may even never abate depending on the residual
damage to the LFC nerve. MP typically surfaces as a moderately fast onset of
distinct symptoms for which the patient will usually seek treatment.
On a broader scale, MP should not be confused with TFL syndrome. TFL syndrome
presents as an insidious and obscured condition, and exists in a more chronic
manner than MP. TFL syndrome occurs without offending cutaneous nerve root pressures,
and exists with greater underlying, yet less noticeable, symptoms than MP.
Whereas MP usually results from some form of prolonged, pressured neurological
involvement, TFL syndrome appears to derive from some type of metabolic soft
tissue toxicity, a congestive accumulation (a form of striated bio-toxic pooling
effect) in the tensor myofascia regions, like that of a lactic acid or some
other bio-toxic substance build-up. TFL syndrome does not appear to involve
the LCF nerve like MP does.
The sciatic notch and the sciatic nerve do not appear to be directly affected,
and neither is TFL syndrome like Periformis Syndrome. TFL syndrome seems to
be a contributing entity on its own but usually remains substantially more discreet
in presence. It becomes widely diffuse on a broader scale, and reflects longer
chronic periods to reach any sub-acute stage. TFL Syndrome also seems to occur
without foreign pressures or any other neurological encroachment like that of
MP.
Identifying TFL Symptoms
As previously stated, TFL Syndrome usually is subtle and lies latent until it
is profoundly awakened, primarily by some kind of manual pressured stimulus.
In general, the condition surfaces mostly as a fatigued muscle sensation, and
gradually begins to migrate into one or both hips and, to a lesser degree, into
the SI joints. The patient frequently complains of body fatigue with occasional
episodes of low-back and hip pain.
Cutaneous examination reveals no external lesions, skin discolorations, abrasions,
contusions or tissue effusion. For the most part the tissues appear normal and
are unremarkable to reveal any visible abnormalities. Though muscle tone may
frequently be diminished, muscle atrophy is not visibly apparent.
In referencing the tenderness grading scale, depicted in Cipriano’s Regional
Orthopedic and Neurological Tests (fourth edition), the level of acute tenderness
may vary between patients, but in retrospect I find it may actually encompass
any one of the following grades:
• Grade I — Patient complains of pain.
• Grade II — Patient complains of pain and winces.
• Grade III — Patient winces and withdraws.
• Grade IV — Patient will not allow palpation or pressure to the
immediate area.
Thus far, TFL symptoms have not been noticed in children or young adults, and
I suspect this may reflect a hormonal contribution of systemic balance to these
age groups, which prevents or inhibits the development of any toxicity or element
reflecting those of TFL effects.
Currently it is not known how long the condition may exist before any sub-acute
stages may begin to appear. Experience has revealed that over a substantial
length of time the condition may gradually worsen, and eventually come to a
level that is minimally or indirectly noticed by the patient, at which time
the patient’s general complaint at the sub-acute stage may be of typical
low-back and lower-body fatigue, and perhaps slight aching sensations (Grade
I) and minimal burning paresthesia in one or both lateral thighs and/or hips.
Similar to MP, prolonged standing often becomes painful and difficult for many,
as low-back, hip and thigh muscles frequently begin to ache. The patient typically
will seek to relieve the weight from their legs by sitting down.
The Enigma
The question continues, however, as to why this syndrome primarily affects the
tensor fascia lata muscle striae and surrounding tissues. It may be hypothesized
that this may result from diminished circulation to the supporting and weight-bearing
tissues of the hip structures, thereby forming an insidious circulatory congestion
affecting muscles, the related muscle tone and neurological distribution.
As scientific study has confirmed, it is at the cellular level, in correlation
with the liver and kidneys, that the body’s biomechanics of systemic function
play an important part in the metabolic removal process of lactic acid from
the muscle tissues, but the question arises, if indeed this might be the cause,
as to how a continued accumulation of lactic acid or any other vascular toxin
would continue to coalesce and affect the TFL and supporting tissues without
ample systemic dispersal.
In addition, the question might also be asked as to what contribution a sedentary
life style and lack of minimal exercise that affect the proliferation of this
disorder.
The specific effects of this little known condition have been evaluated from
many years of practice, and are now being offered as a viable insight as to
what additional effects this syndrome may have on other principal conditions.
This specific anomaly has been found to latently affect many patients who often
were never aware of any additional sensations of pain or discomfort until the
applied pressures of a G-5 vibrator unit were implemented. Patients frequently
would state they never knew how much pain they had in the area until the area
had been stimulated.
Though most patients usually seek attention for common low-back or leg complaints,
typically the doctors and the patients seldom realize there may be corresponding
TFL tissue involvement.
Diagnosis & Treatment
TFL syndrome is easily recognizable by the fascia tenderness and retraction
response that most always seems to be experienced by the patient during G-5
vibrator or by something similar applications. Acute tenderness is the most
identifiable symptom affecting the borders of the lateral gluteus musculatures,
but primarily tissue soreness will extend inferiorly through the Tensor Fascia
Lata tissues, and usually terminates at the distal lateral femoral condyles.
On rare occasions, the discomfort may even extend into the proximal borders
of the lateral malleolus, and may even drift into the hamstrings to a lesser
degree, but mostly is confined to the TFL tissues proper.
To determine the actual presence of TFL syndrome, a sustained manual pressured
application of a vigorous vibrator unit must be directly applied to the major
portions of the TFL tissues. Healthy fascia tissue normally should not produce
pain when pressured contacts are made; this in itself is what immediately helps
determine the assessment of the presence of TFL syndrome.
With the patient usually in a prone or side lying position, a four-inch flathead
G-5 vibrator unit or similar apparatus should be applied directly to the primary
fascia tissues. If the TFL condition is indeed present, the patient will display
an almost immediate painful response, usually at the Grade III level.
The patient will barely be able to sustain the invigorated pressures without
an immediate withdrawal response from the applied stimulus. This reaction ordinarily
reflects a positive indication to the effects of TFL syndrome.
Even though the patient readily reacts to the pressured stimulus with substantial
discomfort, the pain customarily does not begin to abate until several minutes
after the tissues have been sufficiently expurgated.
Treatment and the Effects of Manipulation
Experience shows that SI manipulation offers little if any assistance to remedy
the total effects of TFL syndrome. The primary course of treatment mostly requires
a thorough dispersal of the offending soft tissue bio-toxic element(s).
Diagnosis and treatment play an interrelated part in recognizing this disorder
as each one assists the other. The application of the vibrator apparatus is
first used as a diagnostic tool, and it is also used as a treatment adjunct.
To effect a remedy, it must be in accordance with a regimented schedule of treatments.
Specific direct tissue contact is required. Apply the firm edge of a flathead
surface vibrator unit held at an oblique angle directly to the TFL tissues.
The appliance should be administered with a somewhat aggressive force consisting
of long striated unidirectional strokes. The circumference edge of the vibrator
appendage must be used in a continuous motion, working the tissue from top to
bottom. Begin at the superior borders of the gluteus medius musculatures, and
proceeding inferiorly through the illiotibial band and soft tissues. This process
should be repeated as many times as necessary and as the patient is able to
tolerate, and usually is continued until the painful symptoms begin to abate.
During this procedure, the doctor must use proper discretion in applying the
correct amount of pressure, while remaining consistent to uniformly expunge
the fascia area of lactic acid or other bio-toxic substance from the appurtenant
tissues, thereby replenishing new blood circulations to the area.
This procedure begins the initial treatment process to eliminate TFL symptoms.
However, it must be reiterated that, in the early stages of treatment, the initial
applications may be painful for the patient, and care requires an important
treatment assessment by the practitioner to evaluate proper duration and amount
of force.
As the tissues eventually become more tolerant, pain usually lessens as the
offensive elements begin to dissipate. Gradually with each treatment, additional
manual vibrator pressures may be more generously applied. Though the early stages
of treatment may be somewhat uncomfortable to the patient, it is still necessary
for the practitioner to continue through with the treatment procedure as best
possible. The practitioner should make every effort to remain consistent, but
provide the patient with brief pauses in treatment if the pain is too uncomfortable
to endure.
It is important to try and maintain treatment uniformity until the acuteness
begins to lessen, unless of course the patient is unable to tolerate the treatment
for that day, and is experiencing Grade IV levels of discomfort.
However, it should also be noted that in the event that the pain does not begin
to relent within a reasonable amount of time, the vibrating treatments should
cease, as TFL syndrome may not be the offending disorder. Further investigation
should be implemented accordingly to rule out any other more grave conditions
(e.g., hair-line bone fractures, malignancies, etc.).
Typically after approximately 5 or 10 minutes of sustained rigorous application,
the pain should begin to wane, but this usually depends on the severity and
the length of time the patient has had the condition. During the treatment the
tissues usually become sufficiently expurgated to provide substantial relief
of the patient’s complaints. With each subsequent treatment, the patient
should note considerable improvement.
The duration of therapy usually requires no more than 10 to 15 minutes at each
session, with more aggressive applications continuing thereafter.
In addition, immediately after each vibrator treatment, a two- to three-minute
application of ultrasound to the affected areas with mineral ice or a BioFreeze-type
product as a coupling agent to the related areas may also prove helpful. This
provides a soothing effect to the tender tissues after the painful vibrator
stimulus and serves as an additional adjunct to help reduce tissue congestions
on a cellular level, which provides further relief of pain and additionally
expedites the recovery.
A treatment every three to four days, up to a total of seven treatments is recommended,
and usually suffices within this time limit to effectively eliminate TFL syndrome.
The condition may remiss for several months or even years, or may never return
at all depending on changes in lifestyle, exercise level and/or muscle tone
of the patient.
Additional Recommendations
An additional recommendation is that the patient implement a moderate regimen
of daily walking exercise, which helps to re-establish muscle tone to the appurtenant
muscle tissues and advance the circulatory regions in the lower extremities.
On some occasions, various patients (typically females) have noted capillary
fragility from the rigorous applications of the vibrator unit, which sometimes
may elicit post-therapy ecchymosis (bruising).
In this event, to help prevent bruising, a recommended daily dietary supplementation
of vitamin C with a 1000mg of BioFlavonoid complex should be taken to help strengthen
the connective tissues and reduce petechial capillary hemorrhaging throughout
the body.
Because TFL syndrome, after an extended period of time, may contribute to many
principal conditions, this little known anomaly may very well have an underlying
effect on many resistant low-back, hip and leg case managements. Hence, it should
be within our parameter of patient care to provide patients with a comprehensive
program for detecting these obscure, contributing conditions and advising the
patient accordingly. Patient education and management should consist of proper
exercise, dietary supplementation and should strongly encourage completion of
a course of chiropractic care because, when the condition is treated correctly,
the affected tissues remarkably achieve a restored level of homeostasis as the
innate healing effect resumes.
Discussion and Conclusion
There are no learning capabilities greater than the practical experiences we
derive from our daily clinical environments. It is within these parameters that
we must be afforded the equal opportunity to provide to each other any and all
new information relating to the improvement of the conditions of our patients
for that which our profession may come to treat.
To this extent, practitioners in the field may elect in the future to strongly
consider the valid possibility of the underlying effects of this little known
anomaly, TFL syndrome, as it may be the additional factor of treatment required
to finally correct the many unresolved cases which have resisted responding
to our usual and customary methods of treatments.
About the author: Gary Humphrey, D.C., is a 1977 graduate of The University
of Pasadena College of Chiropractic. He has practiced for 27 years in California
and recently relocated to practice in Winterhaven, Fla. To contact Dr. Humphrey,
email him via logon4gnj@aol.com.
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