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Isolated Muscle Strains-Are There Always Underlying Causes?

Filed under: Uncategorized — Shon @ 6:43 am September 20, 2011

To that question, I would say many times yes.  The art is to find the movement impairments that exist around the strain.

To this point,I recently had a high school soccer player in the clinic who came to me with a diagnosis of hip/groin strain. He had noted increased anterior right thigh pain after winding up for a shot and striking the ball with his right foot early in the pre-season. He had continued to play through discomfort, but still had issues with running and kicking using the right leg.

When I evaluated him, it became apparent that the injured muscle (and pain generator) was the sartorius.  I came to this conclusion based on symptom reproduction with manual muscle testing as well as point tenderness along the course of the muscle from origin through insertion:

 The sartorius has the distinction of being the longest muscle in the body.  It acts as a hip flexor and external rotator; it is well developed in athletes such as hurdlers because of this action.  The mechanism of this  athlete's injury made sense, as preparation for the shot placed the right leg into a stretch position of the sartorius (extension, adduction and internal rotation), but  then I gained more insight when I observed him moving the right hip in prone lying:

 

Look closely at the right side; I attempted to have the player lengthen the sartorius with activation of the antagonistic musculature in prone lying to assess movement quality. This video shows a  laundry list of right lower quarter movement impairment:

1) Hip internal rotation mobility stiffness exceeds left sided trunk stability. When the right hip goes into internal rotation, the pelvis and lumbar spine take a ride into left rotation. Stated simply, left trunk rotation is more flexible (or less dynamically stable) then right hip internal rotation. Remember, the stiffest anatomical segment will dictate compensatory movement at a less stable segment.

In his case, Thomas test was positive for both illiopsoas and rectus femoris tightness (not shortness) . Since the illiopsoas is both a hip flexor and external rotator, internal rotation will place it under tension. With my soccer player, I believe illiopsoas caused the trunk to rotate, as its' passive tension could not be controlled by the trunk on the opposite side.

 

 

The solution:In the same prone position, teach him how to resist trunk rotation as he rotates his hip in with an aggressive abdominal brace in neutral spine. Progress to a point of increasing speed of hip IR to allow a quicker response of the abdominals in keeping trunk rotation neutral.  Also, I gave him a bilateral bridge with hip internal rotation (a standard bridge, except feet are wider than knees).

 

2) With active hip extension, there is compensatory anterior pelvic tilt.Again, this is because the athlete also has rectus femoris and illiopsoas tightness as well as decreased superficial abdominal control. There is significantly less anterior tilt when the left side is tested (rectus femoris and illiopsoas tested normal on the left).

Also, look at the amount and quality of hip extension: there is significantly less on the right side vs. the left.  Toward the end, the thigh drops , allowing more anterior tilt to occur, creating a bit of a vicious cycle. Gluteal contraction in a static position on the right was also notably poorer in quality, with the hamstrings contracting prior to the gluteals with the leg straight, indicating hamstring dominance and a bit of "gluteal amnesia", manifested in what was seen here.

The solution:Get the glutes in line with static contraction/ isometrics, as well as work on "pelvis/lumbar spine neutral" through superficial abdominal bracing statically.  These can be done either in prone or supine lying (I chose supine at first, as it was easier to get him to understand the concept in this position)

Once the  pelvis is stable, actively stretch the rectus femoris form prone:

Kinda, sorta.  No need to pull with the hand-just bend your knee actively abs braced

When he can get better isometric contraction/ activation of the gluteals and keep a neutral spine with and abdominal brace (as well as having decreased rectus femoris stiffness),  then we can add active hip extension:

Pretty solid…I will be happy if my guy does it like this in 2 or so weeks

 

But why is the sartorius strained?  My hypothesis is that the sartorius "got bullied" by the lack of gluteal contractility and abdominal stability, as well as rectus/illiopsoas tightness.  The sartorius, while the primary pain generator, was merely the conduit for more significant impairments as outlined above.  Without a stable pelvis and lumbar spine, the sartorius more than likely has to eccentrically load, concentrically contract and/or lengthen beyond it's normal means, leading to pain/ symptoms.

I believe this is an example of how an "isolated" problem actually has root in more profound movement dysfunction.

As we address my patients' impairments as outlined above, I believe the sartorius will become less "edgy"and  become less symptomatic without significant direct intervention.  That is not to say I won't also include  direct static contraction/ activation work to this muscle (I still think it needs to be  "bullet proofed" a bit), it's just that by addressing the other key impairments, the sartorius should take care of it self. 

How will we know for sure?  As we always do, we assess (as we have done above), intervene (as we are doing currently in the clinic as well as with his home routine) and re-assess progress-then we know if we are on track.  We will also listen to the athlete and see how he feels he is doing with regard to his practice and game day abilities.  My plan is to video again in 1-2 weeks in the same position to see both qualitative and quantitative improvement  and post.   



Strength Training After Spinal Compression Fracture

Filed under: Uncategorized — Shon @ 9:54 am September 7, 2011

Many times I am caught off guard by the fantastic progress my patients an clients make at our clinic.  I had one of those moments last week with my former patient and current training client, Scott Alloway.  His gains have been outstanding in a brief period of time, and given  his injury and training history, I felt compelled to write about it .  Scott is the kind of guy who just brings it every time he walks in my door-never complaining, always smiling, and  steadily moving forward.   

First, a bit of background:  Scott suffered a burst fracture of his L1 vertebra after falling off a ladder on August 30 2010.  He spent an additional two weeks in the hospital with DVT's (blood clots) on his back. The next 3 months were in a clam shell orthosis with limited activity prior to beginning physical therapy. 

Scott's impairments were what you would expect for someone who spent this amount of time sedentary in a back brace:  decreased abdominal and hip strength, decreased thoracic mobility coupled with middle and lower trapezius weakness, significant paraspinal pain and point tenderness as well as very poor activity tolerance.  As if this wasn't enough, Scott is a self employed landscaper who not only has to managed his employees, but also has to perform significant manual labor tasks 20-30 hours weekly when in full season.

The only bright spot was that Scott arrived to us as a patient in late December, well ahead of his busy season in early March.  Physical therapy emphasized progressing active and passive hip mobility, thoracic mobility, abdominal/ middle/ lower trapezius  strengthening, and activity tolerance ahead of his busy season.  Manual therapy also played a role to address his lumbar paraspinal pain and point tenderness.    

Scott had a successful outcome 4 months later, gradually returning to more physical work in that time period, with full return in late April.  Happy with his overall progress and essentially seamless return to a very physical job, Scott had expressed interest in training with me twice weekly.  Scott had already had a good education in appropriate lumbar stabilization/thoracolumbar mobility coupled with great hip mobility and strength, as this was front and center in our physical therapy plan, so squatting and deadlifting  progressions were seamless. 

Teaching proper and progressive upper body exercise in the form of push ups and chin ups/pull ups was where most of our time was spent initially.  Low repetition sets with emphasis on technical performance (usually 3-5 reps/ set with 45-60 seconds of rest between sets) as well as a  larger volume of sets (8-10 per exercise) took precedent for the first three months.  Chin up/pull ups were initially performed with mini bands for assistance, progressing from two to one, followed by body weight reps.  Push up reps remained low, with weight added (by way of plates on the upper back) as quality reps increased beyond 6-8/set.  Lower quarter exercises (kettlebell front squats, trap bar deadlifts, and back squat patterning) followed the same loading and volume guidelines as the upper quarter.  Abdominal training is anti flexion/extension yielding isometrics, between exercise pairings.

Over the last month, we added interval training on the Concept 2 rower as well as Versaclimber, combining either short burst at high intensity (15-20 second sets) with longer rests (45-75 seconds) as well as longer intervals at a lower intensity (60-90 seconds/ set) with shorter rests.  Kettlebell squats and bodyweight push ups were also staged in interval fashion, usually 30 seconds on/off, alternating with a climbing/ rowing interval.

The two exercises which we limit in terms of load are the back squats and overhead press ( his L1 compression fracture is not real fond of axial loading).  I love the back squat with a bar (load limited appropriately) to engage the latissimus/thoracolumbar fascia/gluteal "tent" through a functional range of movement, as well as the overhead press (again, appropraite load to allow a  reasonable pressing pattern to take place) to gage scapulothoracic stability/ mobility in conjunction with appropriate glenohumeral mobility and coordination in my clients.

As mentioned above, Scott trains with me twice weekly.  This past Tuesday (August 30), he casually mentioned that it had been one year since he had fallen and broken his back (as well as his heel, which I forgot to mention).  I shot some footage of Scott during his session that followed.  Check out Scott during one of his chin up sets exactly one year after his injury:

http://www.youtube.com/watch?v=Ip32TZPzSdY

Here is Scott pressing within 2 weeks after learning the exercise:

http://www.youtube.com/watch?v=gQtraviXGuA

Go into most commercial gyms, and chances are you will not see many trainees performing exercises like these with form like this.  What I think is amazing is that Scott has been training for only four months and had never lifted weights prior.  I think his progress is testament to a few factors:

1)  Good physical therapy teaches movement patterns that transfer seamlessly to activities of daily living, both easy and hard.

Scott learned how to hip hinge, brace his abdominals, and move his shoulders overhead with good thoracic mobility as a patient.  These were all goals of ours in physical therapy, as his job demands required these abilities.  When Scott decided to train, there wasn't a need to re-teach basic patterns he had already learned as a patient.  All we did was progress and manage load for the lower extremity movement patterns.

Teaching upper quarter exercise progressions were no problem, as Scott already had great ability to set his abdominal and hip musculature, resulting in a stable base for a  proper push up.  Having appropriate thoracic mobility and abdominal contractility made it easy to tolerate chin ups and pull ups (as well as the press pattern).

2)  Mastering "need to have"exercises gives you currency to purchase "nice to have" exercises. 

Scott's program doesn't include much fluff.  As outlined above, we concentrate on hip hinging, pushing and pulling in a whole body manner.  Interval training utilizes the Concept 2 rower and Versaclimber-not real fun, but very effective.

At Scott's request, I have included some direct biceps and triceps work.  However, this is always done at the end of the session, so as not to interfere with our "money" exercises.  Obviously, if we emphasized triceps pushdowns, dumbell curls and leg pressing at the expense of our current program , progress wouldn't be where it is.  Again, I have no problem with inclusion of these things, but they should be looked at like you look at desert at the end of dinner-not something to start with, and not to be consumed in excess.

3)  Slow, steady progress-boiling the frog or melting the snow pile,-ensures long term success.

Steady progress in a strength and conditioning program is similar to the analogy of boiling a frog-turn up the temperature with a frog in a pot of water, and you can boil the frog without it even being aware of the process (I am not reccomending you try this BTW). When a huge snow pile melts too fast it results in flooding, or at least an undesirable mess. When left to gradually warming temperatures and sun exposure, the snow subliminally retreats without you really noticing it until it is gone.

Prior to chin ups, we utilized cable lat pulls in a tall kneeling position, again in a low rep/ high set fashion.  This allowed abdominal engagement and good latissimus force production.  When pulley column weight was at a level I deemed appropriate, we switched to chin up and pull up progressions. Scott started off with chin ups using a mini band for assistance, struggling with 3 reps per set initially. This was in mid June-just shy of two months ago.  Progress remained steady on a weekly basis, and external load was added as tolerated, progressing to the point where we are performing solid reps with 25-30 lb. of external resistance.

The same progression was utilized for trap bar deadlifting and push ups.  Typically we perform 10 sets, at 3-5 reps/ set, adding weight, decreasing reps, adding reps, adding weight.  The end result is Scott can now push up with solid form and 45 lb. external resistance for 10 sets of 5.  Deadlift progressions have been slower recently as Scott's job demands take a toll on his lumbar spine at the end of a 12 hour day, but his form remains rock solid.

All the above factors played into Scott's successful physical therapy outcome as well as his current progress in training.  Moving forward, what he has developed is a great foundation for future program progress, the ability to tolerate demanding job activities as a self employed landscaper, and an appreciation for what it is like to be mobile, strong and functional following a solid training program.

Guys like Scott are why it's easy  for me to get up everyday and do what I do.