Kelly is an age-group triathlete who has been training for Lake Placid Ironman for the past 12-months. She came to my office complaining of a ‘tightness’ or what felt like a ‘restriction’ on her whole right side. Her health history indicated no specific injuries that could be contributing to these symptoms.
I started the session with a standing postural assessment. I could see right away that her R shoulder was low, and her upper traps were facilitated on the L side. Kelly’s R iliac crest and R ASIS appeared high, in comparison to her left. Further observation of her shoulder and hand positions indicated symmetry of her shoulders in the transverse plane. At this point I started to think about R lateral line compression (coronal plane).
Next, I performed the standing/forward bending test to determine if there was a possible iliosacral fixation on either the left or right side. There was neither. So, I put her in the supine position on the table, and utilized the sitting/lying test to check for any anterior/posterior (sagittal plane) rotation of the ilia. There was none. So, I rolled her over into the prone position and checked her iliac crests and PSISs. Her R PSIS appeared high in comparison to her left. To double check for R upslip of the ilium, I kept her in the prone position and rechecked her iliac crests for symmetry. The R side still appeared high, so I tractioned both hips at the ankles. Upon releasing the traction, her R hip rebounded into a superior position, in comparison to her left. This confirmed the R upslip (coronal plane) within the R lateral line compression (coronal plane).
Finally, I rolled her back into the supine position and observed her ASISs in relation to her belly button. An asymmetry here could indicate an inflare/outflare relationship of the ilia (rotation of the hips in the transverse plane). I was relieved to see there was no inflare or outflare. It’s less complicated to work in one plane of motion, especially if it’s associated with a ‘cardinal’ line.
From the supine position, I moved Kelly into the side-lying position, with her right side up. Since I already knew her R QL was short and her L QL was overstretched, I wanted to test RROM to see if her R QL was harboring any strain or scar tissue. Kelly tested positive for a strain near the midline, just inferior to the 12th rib. I decided to work on this last.
I had a pretty good idea about where I was heading with this session, but I also wanted to check some hip range of motion. So I did.
Results: arom L R prom end-feel L R rrom pain L R
Extension 45˚ 30˚ S H NO NO
Flexion 90˚ 90˚ S S NO NO
Int. Rotation 40˚ 30˚ S H NO NO
Ext. Rotation 60˚ 60˚ S S NO NO
Abduction 45˚ 35˚ S S NO YES
Adduction 30˚ 30˚ S S NO NO
I began the Tx portion of the session with Kelly in the prone position so that I could work on the R anterior joint capsule release. Then, I flipped her over (supine), and proceeded with the R iliopsoas release. Between the two protocols, Kelly’s R hip extension returned to an AROM of 45˚ and a PROM soft end-feel.
Next, I concentrated on Kelly’s abduction issue. Her AROM was a bit restricted, but it didn’t seem to be coming from a tight adductor, so I decided to focus on her R quadratus lumborum. I proceeded with the QL/erector spinae protocol. I was wondering if, or how much of the abduction restriction was being caused by the strain/scar tissue. I went through the protocol as described in Clinical Massage Therapy (Waslaski, 2012). The multi-directional friction and eccentric scar tissue alignment worked well, and the strain/scar tissue cleared after a few sequences. The hip-hiking portion of the QL PNF stretch must have gotten the QL firing, because after the stretching (during therapy) Kelly’s R hip abduction was into the 40-45˚ range.
I then moved on and addressed Kelly’s internal rotation restriction. I kept her in the prone position and started with internal rotation joint capsule work on her R hip. As usual, this proved to be exceptionally effective in yielding a soft end-feel and increased ROM. I also utilized the lateral hip rotator protocol, especially on the piriformis and quadratus femoris. I finished this portion of the Tx with the deep six stretch.
Because I thought the whole R lateral line could be involved, I wanted to include some work on her R ITB and R lower leg (tibialis anterior and peroneals). I utilized the ITB Syndrome protocol to release the TFL and gluteus maximus, hoping to reduce the tension on the ITB. Then I worked to release the ITB from the vastus lateralis.
Finally, I addressed Kelly’s lower leg. She described a sensation of feeling tight on the lateral portion of her lower leg. In the neutral position, I could see that her R foot was significantly more everted than what would be considered neutral. This observation suggested the possibility that the peroneals were short and tight, leaving the tibialis anterior overstretched and weak. I did a quick AROM test and found her eversion was WNL, but her R inversion was restricted at about 25˚. Both end-feels seemed about right, with eversion feeling a bit more ligamentous. RROM did not yield any painful points so I just released the peroneals ( origin to insertion) and worked the tibialis anterior (distal to proximal), trying to put everything back where it belonged.
To end the session, I reviewed home stretching techniques for the iliopsoas, quadratus lumborum, lateral hip rotators, gluteus maximus andTFL.
Kelly completed her first iron man triathlon in 13:16.
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