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.

Objective:


  • 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.


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