Quick Case: Perfect Symmetry in Runners Needed?

image from rehab4runners.co.uk

Do you really need perfect symmetry in runners?
We have all heard about asymmetry and motor control being a predictor of injury. Just how much symmetry is needed? Does both sides of each and every joint in the body need perfect symmetry?

The short answer is, you need as much symmetry as possible for the corresponding movement, loading information, and peripheral tissue stresses as inputs not to be interpreted as threats.

A colleague (PT) had been diagnosed with an adductor tear by a local physiatrist. This physiatrist is known to love TrP injections, and make suggestions such as you need to stop running and you may need hip surgery in the future. Ugh.... As a result, he had stopped running and working out for about 1 year prior to deciding to come see me. Here is a quick rundown of my friend's evaluation...

Subjective: Pt reports tearing adductor longus playing softball July 2013. No change in 3 months, had diagnostic US. Complaints of stiffness in groin, with IR, pivoting in WB. No issues spinning, elliptical. Sx rated 2/10.

Objective: fair sitting posture

key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension

ROM

Cervical all FN

shoulders LRF Left FN Right FN

MRE Left DN Right FN

MSR Left DN Right FN

MSF DN

MSE DN

Left LE DN Right FN

ankle df Left DN Right FN

SLS both FN EO and EC

ODS DP

Hip

Flexion Left DN sev Right FN

Extension Left DN sev Right FN

Int Rot Left DN sev Right FN

Ext Rot Left DN sev Right FN

Ankle

Dorsiflexion Left DN min Right FN

Plantarflexion Left FN Right FN

SGIS Left DN sev Right DN mod

As you can see, on the symptomatic side, more than just the hip had asymmetrical movement. Most of the areas other than the hip had active limited, but passive was either close to FN, or at least DN but improved. The hip both actively and passively was DN, severely limited in multiple planes, and had very bony like end feels.

Treatment:

a healthy dose of Pain Science Education regarding the future prognosis of his left hip, how his imaging was not relevant for his pain levels and perceptions of tightness
Pain free psoas and QL release on left side
Shift correction with overpressure to restore SGIS left
IASTM and progressed to TDN around left thigh to reduce tone
IASTM to anterior ankle patterns and lateral lower leg patterns
tibial IR functional mobilization

HEP

SGIS against wall
EDGE Mobility Band wrapping around left thigh for squats and self hip IR mobilizations
EDGE Mobility Band around calf for self tibial IR mobilizations
repeated ankle plantarflexion reset to improve dorsiflexion
self tests of SGIS, half knee ankle dorsiflexion, single limb squat for stability, and self tibial IR check in sitting

Granted this took 5 visits, with the first two being weekly, then progressed to every 2 weeks. By the end of the 5 visits, he was back to working out and started a graded exposure back to running pain free. All perceptions of tightness and pain in his hip were abolished. Objectively

Tibial IR, ankle df, SGIS were all FN compared to the other side
hip ROM in flexion was DN, min loss, but IR was still DN sev loss, and ER was DN, mod loss

In other words, the main area of complaint was the only one with most likely a true physical limitation, that could not be addressed, at least as rapidly as the others. However, in restoring symmetry in motion, and ability to load, plus addressing any thought viruses he had about returning to working out and running, he was able to resume function. A few months later, he emailed me and stated he was back to running several miles a day, 3-4 times/week and back to fully weight training.

Take homes:

restore as much symmetry and ability to load in LQ for runners as possible
some areas you cannot change physically, but the perception regarding pain/tightness or threat level may change

Keeping it Eclectic....