Recent Case Updates | Modern Manual Therapy Blog

Recent Case Updates

First up, the lateral foot pain case from last week. You had two choices in terms of what I chose for treatment.



1) SGIS to the right, neurodynamic sliders to peroneal nerve, followed by RockTape to peroneal pattern
  • to restore lumbar loading on involved side
  • to modulate peroneal nerve pain on right side
  • taping to continue Sx modulation of peripheral nerve container
  • instruction on SGIS and neurodynamic tensioners for HEP
2) QL Release on right, hold relax to left hip adductors with hold relax to right hip flexors, IASTM to peroneal patterns, followed by neurodynamic peroneal sliders
  • Hold relax - to restore neutrality and ability to stance phase on left, helping to inhibit L AIC Pattern
  • IASTM to peroneal patterns to modulate pain during neurodynamic tensioner
  • instructions on 90-90 hip shift with left hamstring and adductor activation and neurodynamic tensioner for peroneal nerve for HEP
Most who read my blog regularly would have chosen choice #1, and that is most likely what I would have done to change her gait/pain levels under normal circumstances. However, it was a trick question to most of you except the PRI devotees.

Since the patient was a previous coccyx pain patient, and despite being a manual therapist, I haven't "gone there" yet, as in gloved up for a coccyx manip. My wife, a former women's health PT assures me you can't miss it, but I do not want to find out. PRI advocates a homeostasis of movement in reciprocation of the LQ and UQ, thus restoring proper tone in the pelvic floor among other things. Since she tested positive previously as a left AIC Pattern, and responded to those treatments I went with this again.

It also helps that I am taking Pelvic Restoration home study and this is fresh in my mind again, so I also wanted to see if I could use PRI's tests and exercises sped up a bit with some IASTM and QL release. The first treatments changed her gait pattern from WB on the lateral right border of her foot with lack of push off, to more pronation with push off, and even improved her lack of arm swing on the side that was not swinging. Gait immediately felt different to her, but her foot was still painful. That's when I tested neurodynamics and found peroneal bias to reproduce her pain.

Instead of using tensioners as a treatment, I treat the neural container lightly for IASTM (lateral upper and lower LE) for a few minutes and then retest. Peroneal bias was almost pain free and pain rating during gait was barely a 1/10 according to the patient. She was reinstructed on the 90-90 hip shift for the Left AIC pattern, which she performed every once in a while since last year if her coccyx pain returned. Tests for Left AIC were now negative. We are following up in a few weeks, but via email she said she was pain free until she played kickball. She continued her HEP, and was pain free again the next day. She was told to double down on her HEP of 90-90 and peroneal tensioners prior to any exercise activities.

Part 3 of The Triathlete running analysis case. Part 1 is here, 2 is here. Thanks to everyone who chimed in with their thoughts!

He is doing well, with a recent PR in a half marathon, and then this weekend coming in first place in the 2014 ECC Kats Triathlon for the 35-39 age group. He missed our last appointment (the one we were going to address all those foot striking and hip asymmetries the video showed). However, after treatment to his right UQ including
  • functional release to right pec minor
  • IASTM to cervical, upper trap, scapula, and lateral upper arm patterns
  • subscapularis release
  • light GH joint mobs
  • HEP of cervical retraction with SB right
  • repeated shoulder whip
    • funny story about his "whip" as I was demonstrating the reset, I told him I hit some guy at the 50 Yard Dash Fun Run last year behind me, so I told him to be careful when he's doing it in public. He said, "Yeah, I know, that was me." - Seriously it was, I asked if I apologized, and he said I was very polite!
  • the repeated shoulder whip was eventually progressed to the modified corner stretch with either the squat or leaning into the anterior shoulder stretch repeatedly
    • this enabled him to attain end range much better and after visit 2 was really responsible for him attaining FN ROM after 3 visits
His right shoulder motion continued to improve. At his last treatment, follow up 3, his right shoulder was FN for LRF and close to FN for MRE, much improved since the initial visit. After his PR for a half marathon, the only thing that hurt 2 weeks ago was his anterior right shoulder. This was completely abolished by his swimming coach, who noticed he was crossing over midline, possibly due to his now dramatically increased ROM. I was disappointed he missed his last visit a few days prior to his recent triathlon. This is the one he placed first in his age group! He told me afterward he felt great, had no right UQ pain, and even more surprising to both of us, had completely no left knee pain. I have not seen his gait, but I am curious if normalizing his right shoulder motion as a driver changed his overstride on the left. His increased speed may have also increased his cadence, thus decreasing the GRF, but I'm just speculating. It is still significant, and not a fluke as he had c/o knee pain in every single run for the past several years.

Either way, he was very pleased. I told him he still needs some coaching that I will provide next time I see him and I need to check his SLS, ODS, and hop tests.

I will update with another gait video prior and after treatment.

This was posted via his facebook page... "I do have to give a HUGE thank you to a couple folks who helped me even get to the starting line...Brandi Bashor for correcting the flaws in my swim stroke and Erson Religioso III for the manual therapy on hip/quad/shoulder/back...getting old isn't easy!"

Keeping it Eclectic...



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