Case of the Week Aug 8: The Triathlete is Back! This Time He Can't Swing a Bat

History:
A month ago or so I posted about using the fascialator on a posterior tibial tendinitis patient who is a triathlete. He's well known to me and comes in intermittently with various exacerbations or new conditions which is most likely befitting of his lifestyle. Most of the time his problems are ITB related with a loss of hip IR and gluteus medius weakness. He developed pain while swinging a bat from mid-swing to follow through. His pain occurred in his right inguinal area and proximal hip flexors and only with this motion. It was limiting his hardball performance. It was acute in nature and this was the only thing that reproduced it.

Objective:
limitation of bent knee fallout (FABERs) but strangely enough had full hip IR.
lumbar screen was negative for Sx reproduction, but he had limited L5-S1 rot left in springing and with a lower trunk rotation test (hooklying and dropping legs to left and right to see if one side has limited rotation). The right side was more limited (scapula rose earlier) but with no pain
Palpation revealed: severe restrictions in right QL, and psoas, proximal ITB was also limited in proximal to distal direction and transverse muscle play.

Treatment:
QL Release

performed in sidelying with contact point behind midline and between 12th rib and superior iliac crest, starting with oscillations and then progressing to functional release of patient repeatedly moving right UE into elevation.

Psoas Release

Performed in supine with hips/knees flexed. 2-3" lateral to umbilicus and pushing slightly medial and posteriorly until you come to a stop, but not so medial you feel a pulse. AROM hip flexion should make the psoas palpably contract. Started with oscillations and progress to heel slides as a functional release.

Lumbar spine was rechecked, but still limited. A lumbar thrust manipulation in rotation was performed bilaterally.

Finally, some TASTM to the proximal ITB where palpably restricted was performed.

After these treatments, the patient was able to perform the swinging motion completely pain free. He was instructed on QL and psoas stretching for HEP.

Discussion:
You could make the argument that I should have retested the batter's swing after each treatment, but time is limited and I wanted to get everything in one treatment. His hip ER was limited by restricted psoas, thus causing his lumbar spine to over-rotate and further straining his hip. The lack of ER was also causing excessive hip hiking, closing down right lumbar spine and shortening his R QL. Restoration of hip ER with psoas release, and release of QL and ITB, plus a lumbar thrust manipulation for good measure restored his mechanics and prevented hip/lumbar strain. He was to follow up by text or email and would only schedule if another visit was needed. Thus far he is still doing well.