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
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. 

  • 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
  • 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...


  1. Have the LE issues been unilateral or bilateral? What about passive rotation or rolling? Would these add anything to your diagnosis?

  2. Previous LE issues have been unilateral mostly right greater than left, but those were mostly cleared up for over 1 year. He only scheduled for 1 30 min follow up so I didn't have time to look for other things and had to get right to it after a quick assessment. I probably wouldn't have looked at rolling patterns, but passive rotation and actively were both DP to the right in seated trunk rotation.

  3. Have you considered a waist leash?

  4. Yes, first thing I asked him. He said some dogs are too big and he'd be pulled over.

  5. I don't do rib manipulation, worried about possibly fracturing a rib. Thoracic manipulation seems to get everything moving and it's not possible to isolate a rib anyway.

  6. Evidence for inability to isolate rib?

    I've had success using a technique to "isolate a rib" when T/S manip doesn't reduce pain.

    I can understand the worry about fracturing a rib, but what is the actual occurrence? Anywhere near the incidence of MD events with medication prescription/injections/etc?

    Not trying to be aggressive. Just curious.

    Also, I'm jealous you came to Pitt a few years after i graduated. One of the faculty members I still talk to there said you were awesome.

  7. Not taken as aggressive because it's what we all learned. Very simply, the ability to isolate any region is impossible. Look at this editorial by the late Peter Huijbregts,

    It cites many of the references I adopted, as in P/A pressure in the lumbar spine moved the entire lumbar spine, there was no difference in unilateral P/A and central P/A, no difference in outcomes when doing a rotatory versus translatory... etc... I am not saying your patient did not respond to a "rib" manipulation, but that it could have been a combination of techniques, or a patient preference for one position over another. You also may be more skilled at rib based techniques versus spinal techniques. In the end, you cannot possibly be isolating one structure versus another, just using different techniques.

  8. Hi Dr. E,

    Interesting case. Obviously, you are familiar with the patient and his history. But, would you mind discussing the medical screening/differential diagnosis (both initially and within sessions) in this case given the difficulty breathing?

    I think that this is an important concept to discuss in this case specifically, and in practice, generally given that difficulty breathing generally and specifically with activity can result from a range of physiologic, medical problems (some of which are quite serious and some which are rare/unlikely). But, difficulty breathing can also result from "merely" mechanical, pain issues as well.

    This appears to be a nice case illustration, especially for students new to the medical screening process. How did you go about ruling out occult medical causes of shortness of breathing and ruling in a mechanical problem?

    Thanks in advance!

  9. Kyle,

    Since I know him very well (used to be a neighbor, treated him on and off for various injuries as a rock climber, and runner for over 10 years), I did not have to screen him medically for the breathing difficulties. Overall, he is a healthy young male, still running and exercising regularly with no significant medical history, other than his myriad of previous injuries. That was my first hunch at being mechanical. I also assume that an intermittent complaint, like pain and difficulty breathing with running only and not in general falls into the category of mechanical. This is because it's 1) intermittent 2) positional/movement related.

    Objectively, he demonstrated loss of thoracic rotation to the painful side, pain with deep breath/cough - not sure if I wrote that, normal rotation to the uninvolved side and a positive rib expansion test. PRI performs it by having the patient take a deep breath in, then after a full exhale, you hold one side of the ribcage down during the next inhale, testing the excursion of the opening phase of rib movement on the contralateral side. Holding his left side (testing rib expansion on the right) reproduced his pain and was very difficult for him.

    The provisional mechanical diagnosis would have been thoracic derangement or rapid responder, and this was confirmed by rapid improvement in thoracic rotation and ability to breathe with the manual intervention, breathing exercise with manual intervention, plus repeated thoracic rotation ballistic whip all having improvement on his complaints.

    He is having difficulty maintaining the improvements, despite being better because his business is running dogs, many of them large and a waist leash holder is out of the question apparently. Hopefully this makes sense in context, it's always easier to write up a case when you've known the patient for years.