Hip pain (2)

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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