Case of the Week 2-27-12: The Ectomorph | Modern Manual Therapy Blog

Case of the Week 2-27-12: The Ectomorph

This week's case is a dancer I had seen in the past with lumbar derangement who improved quickly with postural correction and a repeated extension program. This second time I saw her a few years later, she was studying more and dancing less.

History: 19 yo formerly very active ballerina with subacute onset of bilateral anterolateral thigh pain. Tried previous HEP (and never really stopped) which was ineffective. Sx were constant, worse in standing and walking. Sitting had no effect.


  • lumbar repeated motion exam negative
  • Hip ROM WNL in all planes (hypermobile) except hip extension which was 0 bilaterally with hard end feels
  • Thomas test revealed severe restrictions in bilateral hip flexors, psoas, rectus femoris, and ITB
  • Ober's test also severely restricted, and also increased her hip pain
Assessment: Signs and Sx consistent with subacute femoral nerve entrapment with hip extension dysfunction

Treatments 1-3: focused on IASTM to ITB, psoas and iliacus releases and gluteal strengthening. HEP was self psoas stretching.

Treatment 4-5: She was about only 50% better. I decided to check neurodynamics, specifically femoral nerve, this was completely negative for Sx reproduction and ROM was almost normal in prone. I then tried the sidelying femoral slump test. Her hips were even more limited than the first visit in the Thomas test. Her mother had to hold her upper thoracic spine and cervical spine in flexion. 

The interesting points about positives with this test were:
  • if it were hip flexor limitation, flexing the trunk toward the hips would improve hip extension, a positive test had marked decreased hip extension
  • cervical extension increased hip extension

Her mother helped with a combination of femoral slump tensioners (mother would flex trunk and head) and I would bring her into hip extension, adduction, and IR, which was severely restricted and then mother would extend her head while staying slumped, which increased her hip mobility. After only 2 more treatments, of this combined with the previous functional release and IASTM approach and she was pain free! She ended up doing her own femoral slump tensioners actively in hip extension and adduction while her mother kept her head and trunk flexed for HEP.

I was reminded of this case I saw several years back after reading Dr. Brence's great post on the Reliability and Diagnostic Validity of the Femoral Slump Test.

Discussion: Possibly dancing less and sitting/studying more shortened her hip flexors which then entrapped the femoral nerve. May have been shortened also due to the frequent anterior pelvic tilt in dancing and also from sitting with a lumbar roll. This became sensitized to mechanical stretching and needed excessive trunk/cervical flexion to challenge it's mobility within the neural container. I am not sure how she would have done if the first few treatments did not include hip flexor functional release and IASTM to the hip flexors, but it most likely sped up the progression and decreased the total number of treatments overall.


  1. Erson,
    Thanks for this post. I an about 90% sure that this is what's happening with a pt. I am treating. I will test it Monday and update. Could you provide more info regarding dosage og the femoral neurodynamic tensioner?

  2. No problem Mike! Typical dosage is sets of 30 seconds or so of oscillations, but of course I've done up to a minute or so depending on how they respond. It is normal to increase complaints or peripheralize, but they should not remain worse for more than 5 minutes after 1 set. If they cannot handle tensioners, you could try sliders with cervical extension to improve motion and decrease CNS sensitivity to motion, then progress to tensioners.

  3. I think a complicated case. After I had assessed femoral nerve slump in sidelying last Thursday, pt noted increased peripheral symptoms. I had performed several 30 sec sets of oscillations on/off symptoms with pt. maintaining CS and TS flexion.
    He presented yesterday with new complaints of R sided lumbar pain. Previously all complaints had been in the R leg (entire lateral thigh, anterior knee and distal 1/3 medial thigh) always worse with walking. I retested repeated movement and back symptoms worsened with REIS, no change with RFIS (previously repeated movements had not affected symptoms). He also c/o difficulty with transitional movements such as bed mobility. I place pt in prone and manually rocked sacrum into flexion and symptoms were abolished both in leg and LS. LS intervertebral mobility markedly restricted for PA at lower LS and for rotation to left with reproduction of LS pain with this mobilization (grade III). Retested femoral nerve in sidelying and LE symptoms were still easily reproduced with femoral slump. Hip extension on affected side is approximately 15 deg greater with CS and TS in neutral vs in flexed position for sidelying test.

    As treatment, I again performed tensioners as oscillations, decompressed lower lumbar with supine lying over 1/2 foam roll at sacrum (forcing sacrum to flex) followed by DKC over 1/2 foam roll in this position. Postural ed to avoid excessive lordosis.

    Anything else jump out at you??

  4. Have you released the psoas/ilicus? Also, looks like the MDT you're assessing is only the sagittal plane, try sidegliding in standing to see if there is a loss to the R. Could be a far lateral derangement, which is why extension peripheralizes and worsens it. If that is restricted, you can release the QL, and give repeated sidegliding in standing to the R for HEP as well.

  5. Side gliding to close the left: increased back pain but no worse. No significant ROM or postural defects in frontal plane.
    Released quadratus and that reduced pain significantly. Also began femoral sliders. Pt. left with only c/o of infrapatellar pain (I think still related to femoral nerve). Gave repeated side glides as HEP.

  6. Does he have a hip capsular pattern on the involved side? Have you released the ITB for lateral femoral cutaneous entrapment?

  7. No capsular pattern and no have not done any soft tissue work at ITB. Actually was referred for "IT Syndrom"

  8. Pt returned after a week away. He has improved ROM and pain levels throughout. His femoral nerve no longer seems entrapped as femoral neurodynamics are no longer provocative. Standing lateral glides are still increased and after 3 sets of 10 worse for patellar tendon area pain. Did have moderate restriction in distal ITB.
    Flexion-rotation MDT next???

  9. Mike, what about glut strengthening on that side? Does he have Trendelenburg, or restricted ankle dorsiflexion? Both often cause knee pain.