Case of the Week 8-29-11: Pressups Til the Cows Came Home | Modern Manual Therapy Blog

Case of the Week 8-29-11: Pressups Til the Cows Came Home

Several years ago, a doc referred a very nice older gentleman over for some help. He had chronic LBP that was central, and had no radiation. He had had a congenital deformity of his right foot and wore custom shoes to compensate for the leg length discrepancy it made. It was also very stiff in dorsiflexion with -10 degrees of dorsiflexion. He was in between custom shoes, and his PCP sent him over for some "temporary" relief until he received his shoe. For some reason, there was a delay and he would not get it for four weeks.

History: He presented with 8/10 complaints of severe LBP. Duration was approximately 3-4 months, but worsened since not having his custom shoe in the past two weeks. Sx were worse in sitting, with bending, and in the morning. Sx were better with standing, and as the day progressed.

Objective: Fair sitting posture. His right hip had a hard end feel in IR and was limited to about 15 degrees. Lumbar flexion in standing was moderately limited and had pain during movement. Repeated flexion was painful, increased his complaints, and worsened as a result. Lumbar extension in standing was severely blocked, had pain during movement, decreased complaints, but was no better as a result. (Freshen up on your MDT Terminology if the increase/decrease, better/worse is throwing you for a loop!) When repeated flexion in standing makes Sx worse, I don't bother with repeated flexion in lying. Seems redundant to me. I felt like he could get more extension in lying; in prone he was severely blocked at first. After several repetitions, his extension improved, but only to moderate loss. His LBP decreased, and was better as a result. He had a severe loss of hip extension bilaterally with hard end feels, which did not change with 2-3 sets of repeated extension in lying. Lumbar spine had moderate restrictions in fascial mobility in a distal to proximal direction, plus medial to lateral along the bony contours of the posterior iliac crest.

Assessment: Signs and Sx were consistent with a chronic lumbar posterior derangement with accompanying hip dysfunction.

Discussion: The derangement gave good prognosis because he could rapidly not only his Sx intensity, but also his range of motion. Anything that changes quickly falls into the derangement category because it doesn't have to be remodelled. I don't use the MDT method for dysfunction because as a manual therapist, we can do better than just having the patient go home and stretch it on their own. In this day and age of up to $50 copays, I'm not going to tell a patient they have to do it all themselves, especially if I can do some manual work to speed up the process. Hips fell into the dysfunction category, which required manual therapy for the tissue remodelling process.

Plan: The patient was to do repeated extension in lying, 10 times/hourly, use a lumbar roll in sitting, and avoid forward bending as much as possible. STM was applied to the paraspinals on the first visit along with hip long axis distractions. This improved hip extension but not significantly, indicating the dysfunction. The pt did note that repeated extension in lying was more comfortable for him with less pain during motion after the manual therapy.

Follow up 2: He was originally seen for a 7 am evaluation, and he was one of the most compliant patients ever!  He estimated doing at least 150 pressups that day and stated that his chest and arms were REALLY SORE! He was very pleased though. He told me his lower back was at least 75% improved in pain intensity and duration. Flexion was still painful, but extension was greatly improved. I added hip mobilizations with a belt and mobilization with movement (Mulligan) for his limited right hip. Psoas release was performed to increased bilateral hip extension. STM was again performed to his lumbar paraspinals. His repeated extension in lying was greatly improved to only moderate to minimal loss.

Follow up 3: Almost 100% better. Hips still limited in extension, but now with a more firm end feel, right hip IR improved to about 20 degrees with a hard end feel. Kept up with the same tissue techniques. Repeated hip IR was instructed for HEP

Despite the pt being 100% pain free by visit 4, I still treated him for 3 more visits to clear up his remaining hip dysfunction. He was very pleased and his PCP became one of my top referring docs as a result! Mr. Compliant still comes to me once a year for a little soft tissue work and a quick manip to his right talocrural joint to help with his ankle stiffness and pain for 1 visit, but hasn't had LBP in years as a result. He still performs press-ups 10 times/hour after 10 years!


  1. Sorry I'm confused..."
    When repeated flexion in standing makes Sx worse, I don't bother with repeated extension in lying. Seems redundant to me. " Is there a typo in here?

  2. Yeah, and you caught it! I will edit and change to repeated flexion in lying.