Case of the Week 9-19-11: The Female Marathoner

I saw this case several years back and was one of my "Aha!" moments that would be added to the "patterns" I use to assess and treat while forgoing special tests, which as you know, I HATE.  I love treating runners, they're typically very compliant, as long as they can back off the training when needed or cross train, they usually do fine. They are also great for repeat business! It never gets old when their history says "My knee/hip/SI etc... starts hurting around the 15th mile...."

History:

22 yo female marathoner/aerobics instructor and DPT student at the time, with pain in her right SIJ. It started after several miles and progressively worsened as the run went on. It resolved with rest, but came on each time she ran. It had been worsening in intensity and coming on earlier during her runs over the past 3 months. She trained on the treadmill most of the winter. No radiating Sx.

Objective:
Repeated motion exam negative in lumbar spine in all planes for Sx reproduction.

For brevity, here are some of my common "patterns" that I look for in the lower quarter. I test for these after observing function (walking, running, single leg stepdowns), to lead me to manual treatment.

Patterns

1) Prone hip extension - tested with simultaneous anterior glide and knee flexed to 90, one hand stabilizes just distal to the ischial tuberosity and the other lifts the distal femur into extension.
- Left was WNL/firm end feel
- Right was 0 degrees/hard end feel

2) Lack of Hip IR
- Left WNL/firm end feel
- Right was 12/hard end feel

3) Restricted Soft Tissues
- right iliopsoas, ITB, QL

4) Observation during gait/running
- lack of right hip extension causes excessive lumbar hyperextension during right mid-stance to push off

5) MMT
- weak gluteus medius, gluteus maximus on right
- weak hamstrings bilaterally
- true weakness: after manual treatment, or some corrective exercise prescription, the muscles don't magically test strong afterward, that would be inhibition.

Assessment: Signs and Sx consistent with lower quarter muscle imbalance causing excessive loading on the lumbar spine/SIJ during running

Treatment included TASTM to her ITB, and QL, followed by functional release to the psoas. Strengthening program included clams, progressing to sidelying hip abduction with neutral trunk against a wall, single leg stepdowns focusing on proper knee alignment over foot, progressing to on a rockerboard.

Hip anterior glides with prone knee bend mobilization with movement, as well as hip long axis distraction and MWM with belt for hip IR were also performed. All of this took 3-4 visits. At the fourth, she was pain free in running at any distance, her hip motion and gait during walking and running was normalized. She still tested weak in hip abduction and extension, but I don't keep someone around just for exercises they can do on there own, especially as she was a DPT student, and understood her HEP.

Discussion: Training off season on a treadmill inhibits the gluteals/hamstrings as the belt does the hip extension for you. She wasn't running on more than 2% incline. The lack of hip extension on the right (chicken or egg) caused restricted psoas, ITB, and also inhibited gluteus medius. This caused lumbar hyperextension and loading of her SIJ. Restoring the ST and joint mobility of the right hip normalized loading on the right, eliminating the painful movement pattern.

These patterns can be found in most people with lower quarter dysfunctions to some degree. Check them out and use them instead of special tests (unless for muscle length) to lead you to treatment and the patient's goals!