Case of the Week 10-14-13: Running Out of Breath | Modern Manual Therapy Blog

Case of the Week 10-14-13: Running Out of Breath


I saw a good friend of mine last week who is a triathlete and recently opened a dog running business this summer. He had to stop running in the past month and has difficulty training due to thoracic pain and difficulty breathing while running.

History in a nutshell:
  • early 30s male with c/o moderate and intermittent right mid thoracic pain
  • Sx worse with thoracic rotation right, deep breath, coughing
  • unable to run his normal 7 minute mile pace due to fatigue and trouble breathing - always feels out of breath too early in the run
Objective findings:
  • cervical screen negative
  • MSR was FN to the left, and DP, mod loss to the right
  • seated trunk rotation left FN, right DP, sev loss
  • hip and tibial motion FN bilaterally
  • apical expansion (unilateral rib expansion with breathing - PRI test) left FN, right severely limited, DN - yes I use SFMA grading with other systems, it's easier
Treatment:
To improve thoracic rotation right
  • right pec minor release
  • right psoas release
  • right QL release
  • IASTM to thoracic paraspinals
  • supine thoracic thrust manipulation
This improved his thoracic rotation to the right to DN, mild loss, an improvement from severe loss, DP. Apical expansion was still limited, so I instructed him on the hooklying balloon breathing with right UE in flexion. I manually held his left ribcage in depression after the first exhale to facilitate right rib expansion during inhalation. This was very difficult for him during the initial 3-4 repetitions. However, after 3 more repetitions of 4 deep breaths, right rib expansion improved significantly.

Thoracic rotation to the right was still DN compared to left, but improved over prior to the breathing exercise/manual correction. 

Homework:
  • thoracic ballistic whips to the right, 10 times/hourly
  • hooklying balloon breathing with right UE overhead, feet propped on 2-3 inch bolster, 4 sets of 4 breaths, 2-3 times/daily
Thoughts:
  • I have blogged about this patient before, for various ankle, knee, and posterior tibialis issues
  • after changing his running form to a mid foot strike, working on his symmetry and increasing his cadence, he was able to go from 5ks to marathons within 6 months
  • the entire last year, he only came for a few maintenance visits here and there, but was largely pain free - a difference of regular visits every 2-3 months for 4-6 visits to work on nagging issues
  • this year, starting the dog running business, he mostly holds the dogs on the right and is either being pulled into thoracic rotation left, or actively limited that by preventing trunk rotation
  • he does try to switch leash holding sides, but apparently is not doing it enough, thus limiting his thoracic rotation left
  • the active holding and bracing eventually limited his rib expansion, this limiting difficulty breathing during running
  • a facebook follow up told me that he is rotating better, but is still having pain because he has to run dogs daily, so this is something we will be working on in terms of rotation, trunk mobility, etc... - any thoughts or ideas?
Keeping it Eclectic...

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