Hip pain

Andrew is a half-marathoner for Stotan Racing.  He arrived at my office with a primary complaint of L hip pain, and secondary complaints of L hamstring and L Achilles pain.  All of which were combining to hinder his training and, of course, his racing.

I began my assessment by observing Andrew’s standing posture.  What was immediately obvious was his left foot progression, which I estimated to be approximately 25˚ away from the midline.  There was no progression of his right foot.  Next, I had him assume a single-leg stance with his right leg as the stance leg.  I asked him to stand on his right foot and raise his left foot off the floor until both his left hip and left knee were flexed to 90˚.  In this position, I observed his left femur adduct across the midline, while his left tibia rotated laterally and his right foot increased its progression to approximately 30˚.  I had him repeat the single-leg maneuver on his contralateral side, and did not observe any femoral adduction, tibial rotation or foot progression.  I was surprised he wasn’t also complaining of left knee pain.

For the next part of the assessment, I put Andrew on the table and assessed his hip joint single-plane movements.

Both L & R AROM hip flexion were limited to 65˚ and 75˚ (NL 90˚), respectively.  PROM testing indicated a soft end-feel on both sides.  RROM testing revealed some L proximal biceps femoris pain.  AROM assessment of hip extension was approximately 30˚ (NL 35-45˚) on both sides.  PROM assessment yielded a soft end-feel on both sides.  RROM assessment (prone with leg straight)  also indicated a painful spot toward the proximal end of the L lateral hamstring (long head of biceps femoris).

AROM of medial hip rotation was approximately 45˚ (NL 35-45˚) on both L and R sides.  PROM yielded soft end-feel on both sides.  RROM did not produce any painful spots.  AROM of lateral hip rotation was restricted on the left, testing out at approximately 40˚ (NL 60˚) with a PROM hard end-feel, and the right testing out WNL with a soft end-feel.

AROM for hip adduction was WNL (NL 30˚) on both sides, with a soft PROM end-feel in both.  RROM testing …no pain.  AROM for hip abduction was WNL on the right with a soft PROM end-feel, and RROM…no pain.  AROM for left hip abduction, however was limited to approximately 30˚ (NL 45˚) with a soft PROM end-feel.

Summary:  Short/tight hip flexors, but primarily L; Capsular restriction of L hip medial rotation; Short/tight hamstrings, primarily L biceps femoris with a proximal strain or scar tissue;   Short/tight L adductor complex.

I began Andrew’s treatment with a joint capsule release routine.  In the supine position, I proceeded with the neutral position femur-hip fascial and joint capsule mobilization and, internal and external joint capsule releases.  It required several sequences to bring Andrew’s L hip lateral rotation to a more normal range of 50˚.  I continued with the iliacus and psoas releases and stretching (during therapy) for this muscle group.

Next, I continued with Andrew in the supine position and tried to get some length back into the hip flexor complex (iliopsoas), utilizing the psoas major/iliacus sequences from the pelvic stabilization (hip) protocol.  This included stretching (during therapy) in the prone position.

I kept Andrew in the prone position and rechecked his PROM end-feel for L lateral hip rotation (remembering that I only achieved 50˚ in the supine neutral position).  It wasn’t as soft as I expected it to be, but it wasn’t hard either.  I checked the RROM for pain, and there wasn’t any, so I proceeded with the lateral hip rotator protocol.  I started with prone joint capsule work to free up Andrew’s L hip external rotation, and got the soft end-feel but not the 60˚degrees I was looking for.  I kept him in the prone position and proceeded with myofascial release and stretching (during therapy)…and finally got the last 10˚.

I then moved to the L adductor complex and reassessed PROM and RROM, which resulted in a soft end-feel and no pain.  I continued with myofascial release and stretching (during therapy) to obtain the last 15˚ of L hip abduction.

Hamstring work completed the therapeutic portion of this session.  I reassessed the active range and both sides were still short/tight, more so on the left.  Passive range was still soft for both sides.  I proceeded with myofascial release and cross-fiber gliding on both sides.  Stretching (during therapy)resulted in Andrew’s R hammy returning to a normal range of 90˚ with no pain, but resulted in some pain on the left, which verified the proximal issue I had identified earlier.  I utilized the multidirectional friction technique, pain-free movement, and eccentric scar tissue alignment.  After three sequences Andrew tested pain-free, so I continued with stretching (during therapy) and was able to achieve an AROM of 85˚ with Andrew’s L hammy.

Last, I reviewed the home stretching techniques for iliopsoas, hamstrings, and adductors, and explained the necessity for stretching in order to maintain the changes we had achieved.

Andrew recently achieved a personal best at the Chicago half-marathon.

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