Case of the Week 6-25-12: The Quad "Strain" | Modern Manual Therapy Blog

Case of the Week 6-25-12: The Quad "Strain"

This is a quick COTW, and one who has already been featured twice due to the nature of his athletic endeavors!

History: Male, early 30s, was running to catch a pop fly in the outfield. Another fielder was also running to the ball, who he did not see until (the other player screamed) "got it!" The patient tried to slide under him to avoid hitting him head on, with his right leg was flexed at the hip and extended at the knee while his left leg was slightly extended. The other player fell on top of him in this position. This occurred 1 week ago. He was able to finish the game. The next few days he noticed severe right quadriceps pain with sprinting but not running. He is able to walk and all other ADLs are pain free. 

Objective:

  • MS Flexion - FN
  • MS Extension - DP
    • hip flexed on right - MS Ext now FN
  • MS Rot - FN bilaterally
  • SL stance left eyes open, right DN eyes open
  • SL swing left DN, also with mod loss of hip extension, right FN
    • AROM hip ext in prone left FN, right DP, mod loss
    • PROM hip ext in prone left FN/firm, right DP, mod loss, hard end feel
  • myofascia: mod restrictions in right psoas, iliacus, QL, hamstring gluteal junctional zone
MMT
  • hip flexion, 4/5 painful
  • hip extension, 5/5, but limited on right in ROM
  • knee flexion, 5/5
  • knee extension 4/5, painful
A quick check of his "usual culprits" were all FN, tibial IR, ankle df, hip abduction strength, ITB mobility. He had been keeping up on his HEP! 

Assessment: Signs and Sx consistent with acute quadriceps strain

If you can only focus on thing, treat one dysfunction at a time and re-test the dysfunctional, non-painful movements.

Treatment:

I first focused on my good ol' tried and true psoas release, also his favorite technique to hate. It was restricted, but released quickly, along with diaphragm and iliacus. This did not improve his AROM hip extension or hip swing tests. 

I next tried hamstring IASTM with the EDGE and found this!

There wasn't a halo around his restrictions, but there may as well have been one! The actual white graphic outline was the treatment area of superficial light assessment and release with my EDGE tool. Only the middle portion of the treatment area felt restricted and actually because very red, like a triple response of Lewis test very quickly. After only 5-7 minutes of light treatment both proximal to distal and distal to proximal, the tissue quality had normalized. I did not have to progress in depth or use any functional release.

Since he was already prone, I checked AROM and PROM hip extension, completely normal! Hip swing test was also now FN and SL stance tests were also now FN. MMTs for hip flexion and knee extension were also pain free and 5/5.

I had him try a few sprints in the clinic and they were mostly pain free. He had a game later that night and I gave him the ok to play.

For HEP, I showed him a dynamic hip flexor stretch into backward lunge with UEs raised overhead, with spine and head/neck also going into extension. 

I received a text later that night stating he was able to play, performed some hip flexor stretches to warm up for a few minutes, only the first two felt tight, and the rest felt great. He was able to sprint with no quad pain!

Discussion:

The hamstrings tried to compensate for the loaded quick eccentric deceleration during the sliding attempt to avoid the other player. This caused a holding pattern in the proximal and lateral hamstring tissues, that was released easily with light IASTM, or "reset." The hamstring restrictions caused agonist inhibition and antagonist compensation resulting in overactivity of the quadriceps; this was limiting more rapid and active pulling and pushing hip flexion and extension movements of sprinting vs forefoot running, which was pain free for him.

It was a quick case, and when I got the word from his brother, fiance and the patient himself that he injured his quadriceps pretty badly at a baseball game, I was certainly expecting more than a 1 visit fix. I think there are most likely many other solutions to this case, but the hamstring IASTM was what I chose at the time.


11 comments:

  1. what is " a triple response to Lewis test"?

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  2. great case, had a similar one with a soccer player with quad strain, his biggest problem was tight hamstrings, causing excessive forces in quads when kicking the ball.
    Could you please elaborate on some of your abbreviations? MS/DP (deep pain?) FN (functional?)

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  3. If you scratch the back of your nail bed lightly on the skin, it should turn red, then white, then the redness should slightly spread, but not much. If it excessively turns read, it sometimes helps you determine facilitated spinal segments (when done along the erectors).

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  4. I once had to google those when I was reading another blog, I will write a post quickly sometime in the next few days with my abbreviation key.

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  5. Interesting case, just had a couple of questions regarding your thought process.

    What made you target the hamstrings with a FN toe touch and FN MS rotation bilaterally?

    When classifying MSE as FN, are you including restoration of normal spinal curvature (without hinging) in addition to spine of scapula past heels and asis past toes?

    Thanks!

    Andy

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  6. Well, I don't look for issues in the tissues as only antagnonists limiting motion. After SFMA or other movement assessments, I look for my "patterns" of dysfunction, so for lower quarter that would be QL, psoas, HS/gluteal junctional areas.

    And yes, MSE was FN with R hip flexed, not without originally, and after treatment, uniform spinal curvature as well. I try to stick to the criteria for grading.

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  7. Is it not the SFMA Abbrevs?
    MS -Multisegmental,
    D - Dysfunctional
    F - functional
    P - painful
    N - Non-painful
    so when you put them together...

    From what I gather, and this is despite SFMA not making it to Australia, the principle is to use the DNs (which there is likely to be one or two I suppose) as retests as you address more specific impairments, and work your way up from there. I'm sure that's not 100% correct, but it fits well with me.

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  8. You got it Jack! I use SFMA and MDT abbreviations along with standard medical ones. I googled them after seeing them on another blog before I was familiar with the FMS and SFMA, and learned, so I was hoping others would too. I figure it's also just as easy to make a key and make a link to it somewhere on the sidebar.

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  9. Quite Unusual Case, it is most difficult case in my opinion you should go through some expertise for the regular checkup, because these type of problem would create great effect into your upcoming life .

    Pilates London

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  10. Good case study, thanks for posting. I'm a PT myself and it's always helpful to get inside other practitioners mindsets during evaluation and treatment. Keep 'em coming!

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  11. No problem! Keep reading, got another interesting case for next week already planned!

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