In this case study you’ll see how I blend take The Eclectic Approachand throw in a little yoga as to treat a youth athlete. 

History: Pt is a high-level gymnast with a h/o acute hamstring injury 8 months ago. She was treated in a traditional outpatient PT setting and is now pain free with ADLs. She still has pain during running, tumbling, and vaulting preventing her from competing at her highest level. Alleviating factors include rest, activity avoidance, over the counter pain medication.  

Objective:

• R SLR PROM lacking 20 degrees from opposite side 
• FADDIR decrease and painful pinch with overpressure
• Unable to maintain transverse abdominis (TA) contraction and breathing with hook lying knee lifts, significantly more ASIS movement on R
• Bridge with increased activation of hip flexors on R
• Palpable soreness of proximal R HS near ischial tuberosity 
• Test/retest of gymnastics skills complicated by concurrent UE injury (different mechanism of injury but could be another case study on its own) that limited UE weight bearing during the first 1-4 visits. 

1st Visit:

• Corkscrew hamstring/sciatica tensioner (see Dr. E's post here) 
• Hip inferior glide grade III
• Home program: self standing hamstring/sciatic nerve tensions (see Dr. E's post here)
• By end of treatment seeing 5-10 degree improvement in R SLR PROM

2nd Visit:

• SFMA Rolling - patient had the most difficulty going supine-prone
• IASTM proximal hamstring 
• Posterior chain activation exercise including single leg bridge, double leg bridge with single leg lift
• Yoga poses: Warrior I, II, III series for challenging hamstring response to stress and concentric/eccentric loads
• By the end of treatment session pt lacking only 5 degree PROM test by SLR compared to unaffected side. Also able to perform splits and cartwheel pain free. 

3rd and 4th visit: 

• Completing practice pain free (with the exception of vaulting - separate wrist issue) 
• Strength deficit on R - unable to perform single leg squat to the floor 
• Worked on retraining of landing mechanics with 2 footed and single leg jumping to improve force distribution during gymnastics. 
• Continuing posterior chain activation exercises from above with additional of single leg squat.
• Yoga poses to focus on pelvic control and neutral spine in quadruped with extension of arms and legs. Progressing difficulty of core rotational stability. 
• Added chair pose with emphasis on seating femoral head in acetabulum through tactile cueing of hip ERs prior to starting pose. Pt seeing immediate improvement in squat by being able to lower down farther and with decreased pain. 
• Instructed on how to use yoga strap to perform a self-inferior glide/hip corkscrew for R hip (will post a video of this soon!) 
• By 4th visit had equal HS PROM for the first time in 8 months. 

Final Thoughts:

• Sciatic neurodynamics was very important for regaining full hamstring motion needed for gymnastics 
• Activation of posterior chain and hip external rotators crucial to retraining squatting 
• This may be obvious…but your rehab needs to be SPORT specific. Too many times I see gymnasts who are “discharged” from PT, however still have deficits that either severely limit their gymnastics or put them at high risk for re-injury. 

Christine Walker owns her own PT practice inside in Charlotte, NC where she helps active adults and athletes get back to the activities and sports they love without painkillers, injections, or multiple trips to the doctor's office. To learn more visit her website or connect with her on Twitter.

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Welcome to the beginning of hockey season! Growing up loving, playing, and breathing hockey, this time of the year is like Christmas. So in honor of the kickoff of the NHL season, I’m going to talk about a really common injury in hockey — the dreaded groin strain. Studies have found the incidence of groin strains in professional hockey players to be 8-10% of all injuries and over 40% of all muscle strains, with possible recurrence rates over 30%. That ends up to be lot of NHL games missed. Not good if you’re in the hunt for Lord Stanley. A big contributor is the fundamental movement of the skating stride – where your glutes are prime movers and your adductors and hip flexors are prime stabilizers. This leads to a common profile of muscle imbalance and eventual muscle strain.

But what if I told you that this could be avoided? It all starts at the hips.

A study by Tyler et al in 2001 looked at the hip strength profiles of 81 NHL players and followed them over 2 seasons. The authors measured abduction strength (muscles that bring the leg out to the side) and adduction strength (“groin” muscles that pull the leg in). What they found was that hip adduction strength was 18% lower in the players who ended up sustaining a groin strain. In addition, players whose adductor strength was less than 80% of their abductor strength were actually 17 times more likely to have a groin strain!

Now what? Let’s say you find out you or your hockey playing client has a low adductor to abductor ratio. Can we change this? Tyler et al sought to answer this question in a study published in 2002 where they took “at risk” NHL players (<80% ratio) and put them through an intervention program consisting of adductor strengthening and sport specific exercises. The authors found a significant reduction in risk by implementing this intervention program.

Although there is more research to be done, those in elite hockey are definitely interested in what looks to be a way to prevent a very common injury. In fact, over the past couple months I have been involved with testing at the university level for a colleague’s study as well as at the professional level for injury prevention program prescription as part of my Sports Physical Therapy Residency.

ADDUCTOR STRENGTHENING

What are adductors? They are a group of muscles commonly referred to as your “groin muscles,” located on the inside of your leg. Your adductors pull the leg towards the body, but they are also very important stabilizers. That means they help you to stay balanced when you are doing challenging dynamic exercises such as jumping or skating. 

To strengthen these muscles you can start with something easy to activate them and then slowly add weights or resistance bands. The general motions will be bringing the leg in and squeezing together.

I’m demonstrating an example of each in the first 2 photos above:

1. Bottom leg lifts: In this exercise your are bringing your leg toward midline. This can be done off the floor like this, or it can be done in standing. When you do it in standing, you can experiment with therabands or even a slide board when it starts to get easy. Try to vary the speed as well, making sure to do some reps where you are lowering your leg slowly to fire the adductors eccentrically.

2. Bridge with ball squeeze: In this exercise you are doing a normal bridge but squeezing your knees into a ball at the same time to fire your adductors. You can do the same movement with single leg bridges too by holding the other leg straight with your knees in line. I like this exercise because it works the adductors along with the hip extensors and your core, which is a really powerful combination. Just remember that this shouldn’t be your only exercise since it is also working the hip abductors.

Squeezes can also be done with the legs straight. It’s good to consider exercises where your legs are straight as well as exercises where your legs are bent in order to hit the different fibers of the adductor muscles 

The same can be said about stretching position. The last 2 photos above demonstrate a stretch with the leg straight (3) and one with the leg bent (4). You can also use a form roller for mobility drills, but keep it short. Remember that the main goal is to strengthen the adductor muscles. If you overstretch, it’s possible to do the opposite of what you’re going for here.

Finally, it’s important to incorporate dynamic and sport specific drills as well. Athletes can start with generic stability exercises that challenge all of your hip and core musculature such as lateral hops, zig zag hops, jump landings, and agility ladder drills.

At the same time, you need to be doing exercises that are sport specific. For a hockey player this can be advanced exercises on the slide board as well as exercises on the ice. For other athletes this will look a little different. The most important this is that your body starts to learn how to use the strength you’re building in a functional manner that can help you improve performance and decrease injury risk in your sport. 

Good luck — and for you hockey players, make sure you give yourself a hip check!

Go Islanders! Read more from Laurey at combatphysio.com

edit: Go Pens! - Dr. E

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RESOURCES 

Tyler TF, Nicholas SJ, Campbell RJ, Donellan S, McHugh MP. The Effectiveness of a Preseason Exercise Program to Prevent Adductor Muscle Strains in Professional Ice Hockey Players. The American Journal of Sports Medicine 30:5, 2002.

Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The Association of Hip Strength and Flexibility with the Incidence of Adductor Muscle Strains in Professional Hockey Players. The American Journal of Sports Medicine 29:2, 2001.

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

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