If you missed last week's post, several other clinicians posted their thoughts about my current patient. Most are assuming that he has right sided knee issues from his major crossover gait.
However, he is being treated for chronic left knee pain and right shoulder/scapular pain. The knee pain has been for years and he was convinced he needed knee surgery, and the right shoulder pain has been since last summer.
His shoulder complaints are brought on with swimming, abducting right arm, resistance training, pushups, bench press. Left knee any time he is running, but it is worse after 10-15 miles. He is able to "run through it" without stopping.
flexion DN, cervical flexion/rotation right DP
LRF left FN Right DP, mod loss
MRE left FN Right DP, sev loss
MSR, MSF FN
MSE, DN, limited by left hip extension actively and passively
Single leg squat left DP, mod valgus drop
Knee passive extension left DP, mod loss right FN - a pattern I check for proximal DP issues for the knee, passive knee extension is often lost, especially after surgery/poor rehab.
Cervical retraction and SB right had mod limitation compared to WNL on the left, repeated loading in this direction improved shoulder motion and decreased pain
Several points about this patient:
- surprising amount of thoracic mobility for such limited shoulder mobility
- he has been working with his swimming coach who notices his crawl is very inefficient due to the lack of his right shoulder mobility
- his right hand does not come out of the water enough and "glide" into it like his left
- he is also taking breaths much too often and thus losing time
I asked two of my colleagues/friends online to see what they thought of his video, not knowing his symptoms.
Zac Cupples had this to say:
Biggest things I see with this guy’s running thus far
- Greater ability to adduct on right compared to left. You can see that when he lands he almost crosses midline with his right leg and is not approaching that distance on his left.
- Minimal thoracic rotation R>L (evident by much more pronounced left arm swing than right). Though I would say he becomes more limited as he fatigues.
- Decreased active hip extension during stance (greater impairment left than right)
- Larger amount of pronation on his right side compared to his left.
Chris Johnson observed
- Obvious heelstrike pattern. This seems relatively consistent between the vids that Ive seen. It may be accentuated by the fact that he had already run that day though I'm confident that this is his striking pattern across most conditions unless perhaps he is running very fast
- Narrow stance width. Typically we should see that with increasing speeds that the stance width narrows though it seems to be excessive in this case...may be accentuated if he does not spend a good deal of time running on a treadmill.
- Overstriking a bit on the right if you pay close attention to the sound of his foot strike as its definitely more prominent on the right side.
- Left elbow flexes to a greater degree and there is much greater wrist movement which could be cleaned up
- He seems to underpronate or lack tibial IR on the left side as he remains in varus throughout most of the stance phase when compared to the right.
- He also seems to exhibits greater torso rotation to the left based on the anterior view.
- very asymmetrical arm movements with decreased trunk rotation to the right
- large crossover gait that occasionally crosses midline right over left!
- he told me in the snow, he leaves a line (wife joked like a one legged runner)
- much bigger elbow flexion moment with shoulder IR on the right
- lateral heel strike left greater than right with smaller knee valgus on left than I expected when compared to his single leg squat
- he runs in either Vibrams or other zero drop minimalist shoes... too much force going to his knees
- lack of hip extension on the left corresponds to lack of knee extension after his microfracture surgery and poor rehab
Part 3 will be my interventions for the first 3-4 visits (depending on when I get to writing it) and how he already has a new PR for half marathon!
Keeping it Eclectic....