Case of the Week 6-16-14: Epic 3 Hour Eval and Treat | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Case of the Week 6-16-14: Epic 3 Hour Eval and Treat

This is what happens when you tell a power lifter stand with your feet together!
for SFMA it was knees/thighs together for consistency
I had my inaugural first cash based visit out of EDGE Rehab and Sport Science's new home at Crunch Fitness in Amherst and it was a doozy! It was an epic 3 hour visit (yes he paid the hourly rate for 3 hours).

A little background on the patient. He is a 49 yo competitive power lifter who also works as a MT in Pittsburgh, PA. He was interested in eval and treatment as well as some Eclectic Approach Soft Tissue education. Here are his goals...

  • 800 pound squat
  • 500 pound bench
  • 600 pound deadlift
  • Then work for a 2000 total.

best numbers are
  • 705 squat
  • 445 bench
  • 565 deadlift
Woah! Almost strong enough to deform fascia 2%! Luckily he was taught the lighter the better!
The 3 hours consisted of history, movement assessment, mentorship, manual therapy, movement re-education, and HEP review. It was capped off with some wings for lunch (Buffalo style of course, here we just call 'em wings).

Here is his eval in a nutshell.

Subjective: Pt reports 6-24-11 training for powerlifting meet. Was doing deadlifts, lifted bar to lower tibia, felt a pop in hamstring. Started work as a MT 11/13, within 8 weeks felt pain left lower lumbar spine. Currently c/o “tight” lower back, limited in flexion, left hip tight.  Sx worse: with squatting, deadlifting, after sitting > 15 minutes. Sx at worst 7/10.   

Objective: fair sitting posture
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



flexion FN
extension DN mod loss
rot Left DN sev Right sev

Shoulders LRF Left DP sev Right DN sev (both back of head)
    MRE Left DN min Right DN min

MSR Left DN sev Right DN sev
seated trunk Left FN Right DN mod

MSF DN mod
MSE DN, L hip DN mod
hip IR Left DN mod Right DN min
ER Left FN Right FN

ankle DF Left DN mod Right DN mod

SLS Left FN Right DN EO


Repeated motions
SGIS Left DN sev Right DN mod

deadlift with limited him motion, unable to prevent lumbar unloading

deadlift with max ability to load lumbar spine, eventually told to pack neck as well
Functional: Unable to hip hinge/DL with Olympic bar without dropping sternum and rounding lumbar spine. Unable to squat to 14" box (his target)

SGIS left (to involved side limited)

SGIS to right, not perfect, but greater ability to load uninvolved side
Repeated SGIS improved ability to sit and transition from squat/low sit to stand.

Myofascia: moderate restrictions L > R lateral thigh patterns, L QL, L > R psoas, L lateral upper arm

Treatment: with the bilateral severe limitation in trunk rotation and ankle dorsiflexion, I decided to tackle the major ssymmetry in the shoulders and the hips first with manual therapy, then restore the ability to load the left lumbar spine.

  • IASTM to above patterns
    • this improved hip IR to DN min loss on left, FN on right
    • it also improved left shoulder IR to FN
  • psoas and QL release (the updated, pain free versions)
    • this improved left hip flexion passively to FN, ASLR went from 40 to 70
  • functional mobilization with EDGE Mobility Band to left thigh, to improve ASLR and standing hip hinging
  • EDGE Mobility Band after IASTM with functional release to left upper arm
  • I was not about to try manual shift correction, but knew that he could get some leverage with SGIS against the wall
    • he was instructed to emphasize chest up to prevent unconscious unloading (trunk flexion)
    • he pushed on his left iliac crest to end range, held and did 3-4 diaphragmatic breaths
    • they were yellow lights, then rapidly became more comfortable
    • after 2-3 sets, he was able to squat down to a 14" box (his target), the first reps was slightly painful in his left buttock, then the next 10 reps were not - CNS being overly cautious at first?
limited SGIS (ability to load left lumbar spine)

improved SGIS after self Tx against the wall (not perfect, but better!)
  • we then examined his DL, which he very early unloaded (flexed his spine)
    • he was instructed to pack his neck, and lift his sternum, which made the motion much more comfortable
    • we only used the bar and practiced for about 10 minutes, no use on loading it up if the form is not there
  • after some practice, he had some reproduction of glut and left posterior chain "tightness" and immediately began "stretching his hamstring and calf" - via you guessed - flexion and unloading
    • I instructed him on simple end range REIS - think "limbo contest" is my verbal cue
    • this rapidly abolished the posterior chain tightness
  • to help him remain loaded in and upright position we did some prone press ups with me providing light overpressure to the lower lumbar area
  • next, was instruction on hip hinging with a dowel so he could maintain neutral spine with slight lordosis in his lumbar spine
    • emphasis was on practice with posterior weight shift and maintaining head, thoracic spine and sacral contact with the dowel during the hinge
before repeated shoulder extension reset

I see you! After 20 reps of repeated shoulder extension
  • the next instruction was repeated shoulder extension reset against the wall, both shoulders were limited in elevation, but were now symmetrically in IR (MRE a different story, but that's also thoracic spine limitations)
  • above two pics were the difference in elevation which was DN and much closer to FN after only a few sets of self treatment
  • last educational piece was 
    • use of a lumbar roll in all seated position
    • avoid sitting > 20 minutes
    • upon bending (unloading), either SGIS 2-3 times against a wall, or if symmetrical, perform REIL or REIS
That was 3 hours of eval, treatment, instruction, movement assessment, functional education, postural education, instruction on HEP, shooting pic and videos on his phone for his review. Then it was lunch at Duff's, the better wings place in Buffalo. After sitting across from him for several minutes, I noticed he often trunk shifted to the right (unloading the left). This is why use of a lumbar roll, when static sitting is so important when a loss of loading is contributing to the patient's presentation.

He ordered two McKenzie Lumbar rolls amazon prime before he left, 1 day shipping. By the time I followed up with him via email two days later, he said he was consistently able to squat down to the 14" box, hasn't been able to do that in years. He is also feeling encouraged, and wearing the lumbar roll around his back. Now that's motiviation!

The plan is to follow up via google hangouts sometime this week and next, and then follow up live again to work on the other limitations and see his progress. My first cash based visit was epic and the most liberating, fun, and rewarding visit in ages!

Keeping it Eclectic...

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