Case of the Week 8-28-13: Crown of the Road | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Case of the Week 8-28-13: Crown of the Road

I wanted to blog about how I recently integrated PRI and the FMS. The case is about a runner who was out of town and ran for 15 miles on a road without switching sides and felt "hiked" on her right side the entire time.

Terminology post is here!

The re-eval is as follows (just saw her 3 months prior)

S: Pt reports running out of town for 14 miles on the L side of the road, and feeling as if her R hip were hiked superiorly. This was 2.5 weeks ago and since then has been unchanging. Sx rated 6-7/10 and felt in R piriformis, QL, and “entire tailbone.”

Adductor drop positive on L DN sev
trunk rot R, DN mod
L SLR DN min, all positive for L AIC Pattern

R QL mod DN tone compared to L

Treatment 1: I wanted to see how quickly the PRI tests would change. I have been using my own rule if 3 or more are positive for assymetry, then I will try some PRI corrective exercises. In her case, she had an extremely limited left adductor drop, lower trunk rotation right, and left SLR was more limited than the right.

We showed her the 90-90 correction for left AIC pattern. She performed 4 sets of 4 breaths, taking about 4-5 minutes. To our suprise (intern and myself) and to hers, her left adductor drop test (similar to a modified Ober's) now completely matched her right side, which was basically medial knee to the table... the difference was significant with definite change in tone as her thigh previously was parallel to the table. Her left SLR was now equal to her right, and her trunk rotation was normal.

I thought, what the hey... I'll just leave it at this and instruct her on nothing else.

Treatment 2: Follow up was 1 week later. Her pain with running and WB ADLs was significantly reduced from about an 8/10 to less than a 2/10 when it happened. The frequency and duration was also much less, at least 90% improved according to her history. All of her PRI tests were normal for symmetry. I tested her Hruska Adductor Lift test (a functional test invented by Ron Hruska, founder of the institute), and while she only scored a 2/5, it was symmetrical.

I do not have enough experience yet on where to take her with PRI, but technically she was neutral at least for the lower quarter tests I leanred in Myokinematic Restoration. She felt like she could be discharged, but has seen us in the past year and did not follow through after her pain went away. This time she wanted to also prevent future injury. We explained the FMS to her and tested her for functional asymmetries.

She scored a 14, which is 1 point shy of the "injury risk" cutoff score of 15 according to some studies done on more active individuals like firefighters and professional athletes. However, I am not as concerned with her total score, and more that she had a 3/2 shoulder patterns, a 1 on her trunk stability pushup, and a 3/2 on her hurdle step.

Someone could easily score above a fifteen, but still have asymmetries and if you're cool with letting someone go because they think they should be done or are pain free, don't be too surprised if they injure themselves again in the future. Can we totally prevent injury? No... these are just risk predictors, just like how every morbidly obese patient will not have a CVA or MI.

We addressed trunk stability by shower her prone anti rotation UE and LE based exercises with hands  on a chair, as she could not perform them in a plank position. Since her deep squat indicating ankle mobility issues scoring a 2, we worked on her left > right ankle dorsiflexion with manual therapy and instructed her on tibial IR self treatment with the half kneeling ankle df stretch.

Treatment 3: Ran 18 miles completely pain free in her hip, but had minor thoracic pain. DS is still a 2. MSR was left DN right FN, lumbar locked rotation left upper and lower with both FN (NW vs WB MSR), indicating motor control/stability issue. She was instructed on thoracic whips which made seated trunk rotation and MSR to the left FN. Ankle df was still limited DN mod compared to right DN min. We worked on loaded DS (goblet squats) which were much easier with her holding a 15# kettlebell, she was able to perform them without falling on her buttocks, which she did each time she was tested prior. This was also added for HEP, as the loading increased her stability.

That's it for now, she is following up tomorrow, and even though she is pain free, the thought is to address any of the motion and motor control asymmetries so she won't be back, unlike what other closed minded practitioners think, I'm not just doing this for the $$, we're only 3 visits in, not 30!

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