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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.