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Hey guys,
I am treating a pt. right now that is a runner and has quite a few gait abnormalities. I would love to get everyone’s input on treatment planning and where to start with her. The video of her running gait analysis is included (gracias Miguel).
Some background on the patient…primary c/o R anterior hip/groin pain and posterior gluteal pain, with occasional R calf pain, that began insidiously with running 3 years ago.
-occasional numbness in R calf and foot
-Aggs: running > 5 min., hiking, wide straddle pose in yoga, low lunges (with L foot leading), ascending stairs, sitting > 30 min.
-Eases: temporary relief from chiropractic manipulation of R SIJ every 6-8 weeks, dry needling to piriformisObjective Findings:
-Functional Biomechanical Screen:
-Bilateral Squat: anteromedial hip pain at end range
-SLS: decreased stability on R with R ipsilateral trunk lean
-Swing Test: pain in R glute during R terminal swing
-SL Squat: bilateral valgus; pain with R
-MMT: pain and weakness with R hip flexion (4/5), R ER (4/5); weakness with B hip ABD (R: 4/5, L: 4+/5)
-TTP at R rectus femoris, TFL, piriformis, glutes
-moderate flexibility restrictions in B iliopsoas
-hypertonic L QL
+McCarthy/Fitzgerald, FAI special tests
-Lumbar & neuro screen (-)
-SIJ provocation tests (-)The results of the article, “The relationship between hip strength and trunk motion in college cross-country runners” were that decreased hip extension and abduction torque was correlated with increased trunk axial rotation and pelvic obliquity in the frontal plane. These results can be applied to my patient’s gait. As you can see in the video, her trunk is upright throughout the gait cycle and she gets almost no hip extension at terminal swing. Unlike most runners that we see in the clinic, she has what I would consider decreased stride length and an appropriate cadence. She’s not necessarily a pt. that would benefit from cadence cues. She presents with significant trunk compensations, displaying increased L thoracic rotation at R toe-off. The increased trunk rotation may be due to decreased hip extension/glute activation which is leading decreased propulsion (thus she is trying to generate propulsive forces from increased trunk rotation and arm swing). She also has hip abductor and extensor weakness (contralateral hip drop, valgus and pronation at midstance), which the article alluded to is correlated with increased trunk rotation. In addition, she has excessive L lateral trunk lean during L stance phase, which is also present in static standing (not as excessive). I thought that this could be due to LLD, however, upon examination, she did not present with an apparent LLD. She does have mild scoliosis, but I would not expect such an excessive lateral trunk lean with the degree of scoliosis that she has. Other gait abnormalities that are present are increased vertical excursion, excessive knee flexion and decreased rotation during R swing and decreased knee flexion and increased ER during L swing, crosses midline on L.
There are definitely quite a few impairments to address with her and I’m sure I missed things during my initial examination. Eric suggested that I take a closer look at her pelvis and and reassess the mobility there since it appears that she may have a hypomobile pelvis; in addition I need to further assess the mobility of the thoracic spine. Anyone else have any other suggestions on objective measurements that I should assess/reassess that I may have missed?
I have only seen her for two treatment sessions. Manually, I’ve been doing STM to iliopsoas and QL. For TherEx: thoracic SB mobility to open up L side, clamshells, side stepping with T-band around arches, quadruped alt LE, kickers, posterior step downs, trunk lean with alternating hip flexion/extension for glute activation.
Any suggestions for further evaluation and treatment ideas would be very helpful! Thanks!
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great case and article was great too.
Big thing i took from the article. Stronger hip abduction correlated to less pelvic motion.
She does not appear to have much pelvic motion or hip strength based on the video and what you talked about above
She looks like she gets all the motion up the chain at her TLJ and thoracic spineI see that her shoulders are very elevated
Almost looks like a compensation pattern for scapular and thoracic/TLJ weakness.
Maybe combining some of the hip strengthening with TrA and multifidus (side plank clamshells, bird dogs on half foam, SLS with hip abd) could helpI am wondering if working on her UE mechanics (penny pinchers) and scapular stability with strengthening and motor planning (mirror for cues) will help with this pattern.
I know that hip is #1 but i bet working more on the external feed back may help. Just an idea -
Great suggestions Kyle! I definitely agree with you that taking a more global approach to address her impairments and not focusing solely on the hip is the way to go. Since I have only seen her for two session we have not begun gait retraining on the treadmill, however, I like the idea of using the mirror for visual feedback. Question for the group: when would you start gait retraining with this patient? Would you begin immediately or would you take the initial visits to focus on treating impairments with manual therapy and TherEx/NM Re-ed in preparation for running? If she doesn’t have the strength and NM control, would it be counterproductive to start gait retraining right away?
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that is a great question
I have tried to do the whole task and break down task training from the beginning
Trying do put it all together and break it down each visitI think I got this strategy when working with children on my last rotation. The combination worked well
What has worked well for everyone else? -
Hey great case and I appreciate the video. Just curious as to what lumbar/neurodynamic screen you went through? When I see this asymmetry I think spine (whether it is lumbar spine versus thoracic spine) especially with N//T involved. Were her peripheral nerve bias tests also negative or a slump with thoracic SB or rotation? Seems like she may be increasing tension on that side or wanting to avoid compression? I would think that prior to gait re-training working on NM control and strength and breaking movement patterns down for her may seem more beneficial since this has been going on for ~ 3 years. What was her single leg calf raise MMT like?
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Thanks for your comments and questions, Cameron! I did a lumbar screening during the initial eval which included lumbosacral AROM w/ OP, quadrants, slump and SLR. All of these were negative. I did not test the peripheral nerves or add in thoracic SB with rotation during slump. These are great suggestions and I will perform these tests when I reassess her next visit. Her single leg calf raise was equal bialterally in terms of excursion with no symptom reproduction.
I agree with everyone’e suggestions that working on strength and NM control prior to gait retraining is the best way to approach this case.
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Great case! You all make an excellent case on focusing on impairments first, then addressing gait. I could justify in my head also starting gait training earlier than later if her irritability allowed. It sounds like anything more than 5 mins is aggravating (and I wouldn’t want to flare her symptoms if she truly can’t make any form adjustments due to lack of flexibility/strength initially) but maybe just a few mins per session early on to work motor control in the task that she struggles with would be beneficial. I’d have to see her be able to make some modifications to feel it was accomplishing anything (mirror might come in handy here) and if she truly could not adapt form due to other impairments, I’d work there before doing motor control training on the treadmill. My brain tends to go back to the article where they looked at retraining gait mechanics in running vs training step downs and found only training running led to improvements in running (and improvements in step downs) while training step downs did not improve neuromuscular control with running. Just a thought :)
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Great thoughts, Casey! I agree with you that sports-specific training is best for NM control. We have been working on some running-specific exercises (which I hope will have NM carry-over to running). We’ve been doing single leg squats to bias glute activation and mimic running as well as alternating hip flexion/extension against wall to work on lumbopelvic stability and glute activation. If anyone has any other good running-specific exercises I’d welcome any suggestions!Thanks!
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Casey I love the defense of both points of view. Makes both strategies sound effective depending on what irritability looks like
I am with you on the article about the only way to truly effect the pattern is to perform it. But like you said staying under the threshold
Could also see breaking it down with the one leg kickbacks keeping neutral spine or other partial tasks like thoseHow did the patient do the next few visits?
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