For the holiday, my gift to you is a little case study that we can all work on together.
Here is a 29 year old female massage therapist. Her goal is to be able to run 21K by next April. She currently runs 3 times per week of varying distances and had reached 11K earlier this week.
She complains of left lateral knee pain with running, but is able to continue and complete each session. Pain is vague and located just superior to the fibular head and slightly anterior to the LCL. Orthopaedic testing for all pertinent structures were found negative.
Her basic movement patterns are shown below:
- What do you see?
- What other questions would you ask this individual?
- What other testing procedures would you incorporate and why?
- What corrective exercise strategies, rehabilitative protocols, and therapeutic methods could you incorporate to manage this individual’s presentation? (this will obviously be based on additional info once the ball gets rolling)
- What, if any, are your recommendations?
I would like to get this discussion going so the more contributers the better! Tell your peers. Everyone is welcome to participate in this case study and you certainly do not need to be a doctor, therapist or exercise professional to do so. All I ask is that you try as best as you can to be clear with your comments so that we can be as productive as possible.
*NEW*
ADDITIONAL INFORMATION:
- Right Iliacus very tender to touch
- Right external hip rotators very tender to touch
- Decreased passive right hip internal rotation @ 90 deg of hip flexion
- Right Glute Med/Min complex tender to touch
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I’ll bite. I can’t see the images, but the first things that come to mind are IT band syndrome or a pes anserine bursitis.
The single leg squat shows significant loss of proximal stability, resulting in femoral adduction and internal rotation during closed chain knee flexion. It’s a little hard to tell what is going on at the knee during bilateral stance squat, and likewise difficulty to see what might be going on at the foot due to the patient wearing long pants. A thorough examination of the hip would be appropriate (case study did not specify if this has been done already). Treatment plan on first glance would lean towards proximal stability, specifically the glut med. Classic case of the knee being an innocent bystander to a problem somewhere else.
This answer is from @ManhattanPT (http://twitter.com/ManhattanPT):
“she has poor hip control and stabilization. Need to have specific training of the posterior gluts, and then higher level training”
Merry Christmas Dr. Cubos!
As Manhattan says.
The lady also says, “oops” quite a bit so, as SportSpinePT mentions, seeing the foot/ankle would be helpful too. The “oops” comments seem more possibly related to balance deficits – maybe? Can’t tell.
Running is basically repetitive movements. With runners, I also like to see stepping down from a step without upper extremity assistance; I like to see hopping; and then I like to see hopping basically in a 4-square kind of thing – forward/back, side-to-side, diagonals. Running on a treadmill can also be helpful for me to observe to get a feel of how she moves – frontal plane views and sagittal plane views. Videotaping them with camera phone can help too so patient can see the potential movement patterns that are problematic. (Also great way to capture change to help provide positive reinforcement to desired changes.)
Another piece missing, the description of her pain. Obviously, the pain isn’t stopping her. Sometimes, even when runners have obvious poor hip control and stabilization issues, they can have what might also be conceived as neural irritation – think (+) slump test or whatever peripheral nerve. Besides eliminating the poor movement patterns and improving balance, she may also need some type of neural mobilization activity.
~Snippets
Diagnosing something online is tough so I wouldn’t put a whole lot of stock in any answer you see here, but I figured I’d participate just for the fun of it.
- The first thing I would say is STOP FREAKING RUNNING. There was a debate on Mike Boyle’s blog about exercising in pain a little while ago so I won’t hash this out again, but suffice it to say that I think some people are built to run and others aren’t.
Mike basically said that when people come to us for advice they’re often looking for us to tell them what they want to hear instead of what they need. I’m of the same opinion. I’d tell her to take up another hobby.
- Assuming she won’t do this (they never do), I’d do some muscle testing for glute med on both sides. If they come up weak I’d check for various reasons it could be testing week and retest.
- I’d pay extra attention to the left side because that hip appears higher which might indicate weakness. Check that adductor too which may be tight.
- As Snipppets said above, check the slump test too. I don’t agree with treadmill running for assessment as I think this changes our gait.