Case of the Week! Running Regional Interdependence | Modern Manual Therapy Blog

Case of the Week! Running Regional Interdependence

Reading Movement by Gray Cook made me look a bit higher than my normal area screening for patients with lower back/SIJ type complaints.

History: Pt is a 28 yo female soccer player/runner I treated last year for right hamstring and hip pain. That resolved well, but like most, she did not keep up with her HEP and noticed onset of right lower back pain and lateral thigh pain 3-4 months later at the end of soccer season. That was six months ago, and she relatively unchanged, but her Sx are currently only rated 3-4/10 as opposed to 7-8/10 before treatment last year. Her Sx are worse with fast running and walking > 1 hour. They are better with rest, but not resolved. The complaints are felt 90% of the day and intermittent.

Objective: Normally I would screen similar patient's thoracic spine, hips, and ankles as well as ruling out lumbar with repeated motions. I still did these, but since I'm reading Movement, I also looked at the other "big 7" movement patterns.

Relevant findings: (only listing limitations)

  • shoulder extension/IR mod limited on right/hard end feel, painful 
  • thoracic rotation mod limited right/hard end feel, painful
  • hip extension mod limited on right/hard end feel
  • mod restrictions right ankle in dorsiflexion
  • single leg stance on right reveals medial knee tracking
  • single leg stepdown on right reveals mod medial knee tracking
  • deep sqaut functionally limited due to ankle df, thoracic extension and right shoulder limits
Myofascia: mod restrictions along right > left posterior superior iliac crest bony contours, right QL, right psoas, right pec minor, right ITB

Repeated motion exam negative for Sx reproduction

MMT: inhibition of the gluteus medius and maximus on the right

Assessment: Signs and Sx consistent with lumbar dysfunction with accompanying thoracic, hip, and shoulder hypomobilities

Discussion: What I found interesting about this case is that not only was her hip and thoracic spine restricted, which I expected, but her right shoulder was functionally limited in a direction that would cause further stress during arm extension and trunk rotation right. The only area that moves well is her lumbar spine, which most likely needs a bit more stability to compensate for the lack of mobility all around it. The ankle dorsiflexion and hip weakness further causes the genu valgus with stance phase. I only saw her once, and her condition is rather mild compared to last time I saw her, but perhaps the addition of shoulder work to her QL, psoas, ITB, pec minor, ITB will drop a few visits off of her total time spent. I'll post updates in a few weeks on how she is doing.

Treatment for eval included releases to the QL, psoas, ITB, pec minor, and iliac crest bony contours posteriorly. Thoracic manipulation was performed. She was instructed on open book thoracic rotation for HEP along with eccentric step downs focusing on knee tracking.

Plan: Manual therapy, corrective exercise strategies biw for 3 weeks.


  1. Is your PT dx of lumbar dysfunction an MDT classification or just a "dysfunction." I would be hard pressed to classify this as lumbar dysfunction with MDT rules given lack of symptom reproduction with repeated mvt exam. Sounds like MDT thoracic / hip dysfunction?

  2. I used it broadly as "dysfunction." It would most likely classify as derangement since it will be rapidly changed, but not necessarily by position or repeated motion. It's really closer to thoracic dysfunction and shoulder, hip, and ankle derangements for MDT classification.