Case of the Week: 7-29-13: Movement Normalized, Now What? | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Case of the Week: 7-29-13: Movement Normalized, Now What?

I am fortunate enough to have regular referrals from one of Buffalo's top Running Shops, they recently referred me a half marathoner in her mid 50s.

Her last half marathon was sometime in 2012 which she ran with no issues. She started boot camp sometime after that year and has complaints of bilateral plantarfasciitis ever since. Her eval is as follows as done by myself and my current intern.

Physical Therapy Evaluation 7-9-13

Pt reports to PT with ℅ bilateral foot pain, right greater than left, that is 2/10 at rest on the VAS and 5/10 after activities. In July 2012, pt began to experience symptoms after a bootcamp session in R sole of foot. Symptoms lingered until November 2012 when they were exacerbated after a run resulting in 8/10 pain. Pt has attempted frozen waterbottle and rolling tennis ball with some relief. Pt reports that walking aggravates symptoms, and recently has started to experience similar symptoms in the L sole of the foot and around the achillies tendon insertion. Significant PMH includes: HTN. Medications: Lisinopril 20mg, L-Thyroxine (synthroid) 50 mcg.

key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension

Cervical FN all planes

Rotation Left FN Right DN
lumbar lock   Left FN Right FN
tibial IR Left DN mod Right DN min
tibial ER Left FN Right FN

Shoulder all FN

Flexion Left DN Right FN
Hip IR Left FN Right FN
hip ER Left FN Right FN

Ankle df Left DN mod Right DN mod

-Arms crossed DN
-Single Leg DN B
-Hip Ext
Deep Squat DN (L tibial ER, B knee valgus)

Myofascia: moderate restrictions along lateral  lower LE patterns B
Special tests: lower limb neurodynamic test limited and painful on L>R

There were definitely issues in her movement screen and we went right to addressing them. Normally with runners, I start from the bottom up so we addressed her lack of ankle dorsiflexion and tibial internal rotation. She was instructed on the use of the Strassburg sock, and it turns out she was already using it, but not as instructed. I instruct my patients to wear it the recommended 6 hours and to have a moderate pull on the great toe to activate the windlass effect for a continuous passive stretch at night. She was told to wake up around 1-2 am and put it on then as opposed to going to sleep with it on and ripping it off in disgust around 3-4 am. Patients who do this often do not experience benefits as they then sleep in plantarflexion, shortening the plantarfascia and getting the morning WB complaints.

However, she only had 1 sock, and thought she could get along with alternating.

Day 1: For manual treatment we performed IASTM to her bilateral posterior lower leg patterns upper and lower, along with lateral tibial bony contours, anterior talus and calcaneus. We gave her repeated plantarflexion for ankle reset plus tibial internal rotation to improve both that and ankle dorsiflexion.

Day 2: She came back with improved motion, almost FN in tibial IR and ankle dorsiflexion, however, she stated she was feeling no better. My intern was really disheartened! I guess he is getting used to rapid responders! I told him, it's just the second visit, work on her motor control. Hurdle step was 2 on each side with less motor control on SLS on the right than left. He instructed her on march steps with hands on head for HEP. IASTM was performed as before and the plantarfascia was added. Joint mobilizations to the calcaneus and talus were also added to further improve ankle dorsiflexion.

Day 3: Still no improvement in her complaints, however now her ankle and tibial ROM were FN. My intern asked me to step in, and since her motion was better in the lower quarter, I asked her exactly what part of boot camp bothered her. It turns out it was quite a lopsided program, with tons of mountain climbers, full burpees, just the floor part of the burpee, and lots of steps! Essentially, very tough on eccentric loading for her calves and functional lengthening of her plantarfascia. It really is an unbalanced program and obvious after that explanation why her plantarfascia has been bothering her for over a year now.

Changes to Tx: We had her lie prone with hips in neutral, knees extended, ankles plantarflexed, and great toes extended to activate the windlass effect. In that lengthened position, we used IASTM on her hamstring and calf patterns as well as her plantarfascia. She was taped in the posterior calf and hamstring patterns. She was instructed on eccentric heel drops off of a step and getting a second Strassburg sock. Hurdle Step was praticed, still 2's on each side, and was instructed to continue for HEP.

Day 4: Noticeable improvement in pain, especially after adding eccentric heel drops and a second Strassburg sock. She has no pain in the morning and much less during the day. Treatment was the same as previous.

Day 5: Even more improvement, barely any pain during the day now, any discomfort is easily alleviated with eccentric heel drops. Hurdle step is more controlled, but not quite a 3 on the right, now a 3 on the left. Ankle df and tibial IR still FN. Lower limb neurodynamic testing also WNL now. This was the latest visit, we are going to start focusing more on motor control, and her MSE, which is still DN, due to motor control/stability issues with hip extension (passive FN and active is DN bilaterally). I'll keep you updated on her progress!

On a side note...

Happy Blogiversary to The Manual Therapist! Thanks to all of your hits, comments, shares, forum posts, OMPT Channel views, and OMPT Daily reads, I hit my goal of 1 million hits before the end of July 2013, 2 years from when I started! At the end of July 2011, I was psyched to have 1000 hits! Thanks to your support, The Eclectic Approach is going international and EDGE Mobility Products are being used in every major sport and by practitioners, athletes, and patients world wide! I could not have done it without you!

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