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“Micro Cases”: Random Patient Stories and Videos From The Clinic

Filed under: Case Studies,physical therapy,Random Thoughts — Shon @ 4:23 am March 5, 2012

As a physical therapist, the patients I see vary significantly in mobility, strength, and activity level.  This being the case, the challenges in treating them are all unique, based on their impairments (mobility, strength, and pain) as well as their functional level and activities they wish to return to.

Below are a few videos of recent patients (BTW, a sincere thank you to all of them for kindly allowing me to share their unique stories of their recovery here) in observation, assessment and treatment at the clinic:



Video One:  Functional Shoulder Weakness in a Swimmer

This young lady came to me after five months of physical therapy in another facility with a reputable physical therapist.  Her strength had significantly improved according to her mother, but she still was in pretty much constant pain in her left shoulder.  As we examined her, yes, traditional measures of mobility and strength were within normal limits and equal bilaterally, but there was nasty tenderness and trigger point activity in the teres major and infraspinatus.  Oh, and another slight problem:



This is a classic example of scapular winging on the left- which changes the working relationship of all the other muscles that attach to the scapula (teres major and infraspinatus-where she had significant tenderness), as well as a host of others  If the scapula is unstable, there isn't a good platform for the other muscles to work off of, and you have the "shooting a cannon from a canoe" situation, with the scapula being the canoe.  



 Scapular Instability:  Up the River Without a Paddle, Especially when the Canoe is the Scapula


Also, if you observe the right side, you also see decreased eccentric control of the middle and lower trapezius when the shoulder lowers from the elevated position, which happened to be a bonus pick up, as she is asymptomatic on the right. 

Hmm, I wonder what we are going to work on with her?  Stay tuned for the outcome, as she reported a pain free shoulder  for 24 hours after our first treatment- the first time in six months her shoulder hasn't hurt!


Video Two:  Joint Mobllization With Movement in an Anatomy Trains Context

I have recently treated a Division One lacrosse player with an acute onset of illiotibial band (ITB) "tendonitis".  He had not practiced for over a week due to pain at the patellofemoral slip of the illiotibial band rated 9/10 with (10/10 pain is akin to being hit in the shin by a Tim Lincecum fastball).  Pain was primarily present with the swing phase of full speed running, as well as with stair climbing.  A cortisone injection 5 days prior didn't help pain at all.  Ultrasound and electric stimulation anddistal  ITB "stick" work and massage were the treatments he was receiving, with no impact on his pain. 

When I assessed him:

1) There wasn't any significant ITB tightness or illiopsoas tightness, and strength in key areas was normal (glute med/ max, psoas).  There was however an audible and palpable "clunk") at the fibular head with passive deep knee flexion in prone-and it wasn't painful. 

2)  Ligamentous tests for laxity/instability were unremarkable and there wasn't joint line tenderness or swelling.  The patella (kneecap) was mobile enough and pain free, both passively and with active quadriceps contraction.  One legged squatting was with good control, again without pain/ symptoms being reproduced.  

3) There was pain with palpation/pressure to the distal ITB, the fibular head, the proximal anterior tibilalis as well as the ITB/ vastus lateralis interface, as well as the tensor fascia lata (see below).  There was also a mild anterior pelvic tilt, and decreased ability to brace his abdominals   


The Illiotibial Band- A Small Chapter… 


I felt the pain generator was primarily soft tissue in origin, with most of his tenderness following the spiral line outlined in  Anatomy Trains. 



The Spiral Line-The Rest of the Story


The elevator speech version of the spiral line is that it follows from the TFL through the ITB,  connecting the anterior tibialis and peroneals as well as the biceps femoris in "jump rope" fashion (Anatomy Trains, second edition, pp. 132, 140).  The spiral line correlated well to where he was tender on palpation, and with no other significant motion/ strength deficits present, involvement of this myofascial meridian made clinical sense to me.    As this athlete had driven 2 hours one way to see me between classes and practice, and given that his time and resources were limited, I wanted to achieve 3 goals during his visit:

1)  Decrease affected "spiral line"soft tissue tenderness by 80-95%

2)  Decrease/soften the fibular head "clunk" by 75-90%

3)  Allow stair climbing and running > 10 mph at  less than 2/10 pain.

Manual soft tissue work (to the TFL, proximal ITB, anterior tibialis and biceps femoris tendon (where it inserted on the fibular head) achieved my first goal and was 50% effective in decreasing pain to 5/10 with stairs and running (traditional fibular head mobilization did nothing to soften the "clunk", which while pain free, was a barometer of sorts for his residual symptoms).  I devised the following mobilization  using a Mulligan belt, gliding the tibia and fibula anterior while moving into knee flexion, and ankle/toe plantar flexion/inversion in an attempt to decrease both the "clunk" as well as the pain: 



I really don't know why I utilized for this mobilization technique, but I was glad I did.  I just suspected that it would be useful.  After several repetitions over 10 minutes, his pain went to 0/10 with 10 mph running at  3 degrees incline (no Woodway treadmill in my place, sorry) as well as 0/ 10 up and down stairs repeatedly.  He returned to school and practice without incident, only needing to be seen for one visit.  Needless to say he was very pleased (in addition to his his coach and his team). 

Home exercise revolved around stretching the lower spiral line, both in prone and supine, with emphasis on the athlete "feeling" the affected areas under stretch tension.  Additionally, he was given some basic abdominal bracing strategies to decrease his anterior pelvic tilt and engage the superficial/global abdominal musculature (as the external/ internal obliques are  a big part of the spiral line).      

My rationale, as well as the mobilization certainly weren't "classic".  All I had was my gut feeling, based off of examination (with palpation playing a large part), previous patients with shades of this problem, as well as my increasing appreciation for myofascial meridians; my gut proved right in this case.  In the end, what I really did was assess, intervene and re-assess.  If you do this and if improvement is present, I believe you are on the right track, especially if what you are assessing is addressing  the patient's legitimate concerns.  In this case, the intervention (soft tissue work and the above mobilization) met his goal (run without pain) and mine (decrease the tissue tenderness as well as the annoying "clunk" at the fibular head).  Win-win for everyone. 


Video Three: An Example of Extreme Hypermobility



A long time patient voluntarily demonstrated this crazy level of upper extremity mobility to us the other day. We are treating her for a lower extremity issue (where she has just as much mobility). She is an advanced ballet practitioner and her mobility is obviously an advantage in her chosen endeavor. Our challenge is to help her understand that dynamic stability and functional strength are key in minimizing her symptoms; increasing these in the context of her high level of mobility will be our biggest clinical challenges.

 Wrapping Up

Mine is a fun job, especially whenso many different types of patients with unique problems present for treatment.  Having multiple treatment  approaches to draw upon and understanding how to implement them based on what you see, what you have seen, evidence, and (most importantly) what the patient is telling you usually leads you in the right direction.

Serratus Anterior Training Progressions

The serratus anterior is like that kid you knew in high school everyone knew: a bit mysterious and misunderstood, who was not necessarily in trouble, but was always around trouble when it happened.


Kato Kaelin may be the human equivalent of the serratus anterior


It isn't really a muscle that takes a regular beating like the long head of the biceps in a thrower, nor is it "married" to a joint complex like, say the supraspinatus.  However, more often I see it being a problem in people with traumatic neck pain (such as whiplash injuries) in addition to older patients with non-athletic shoulder pathology.

Obviously, overhead athletes (particularly tennis, baseball and swimming) with shoulder pain may have serratus activation/weakness issues, but the big trend I'm noticing is serratus under activation/ weakness in cases of neck pathology, particularly those of a traumatic nature.  This applies again to acceleration injuries such as whiplash, but also to athletes involved in collision sports (football, wrestling, MMA).  This recent study highlights the link between serratus dysfunction, poor muscular activation and cervical/thoracic dysfunction.

Anatomy of the Serratus Anterior

The serratus is definitely an oddly shaped muscle.  The best way to think of the serratus is to think of a hand. The origin(s) of the serratus are shaped like fingers and grasp the superior borders/ outer surfaces of the upper eight or nine ribs (o.k., we don't have nine fingers, but I get a pass on this one).  Your palm is the "body" of the muscle, while the wrist crease is the insertion of the serratus on the medial scapular border.


The "classic" anatomy book rendition of the serratus anterior



Typically what we think of when we see a serratus in a lean individual



The serratus wholly dissected looks  kind of like this, that is if we had eight or nine fingers


Function of the Serratus Anterior

According to Kendal (Muscles Testing and Function, fourth edition), the functions of the serratus anterior are numerous, including letting the glenoid cavity of the scapula (the "socket" of the shoulder joint) rotate upward, as well as holding the medial border of the scapula against the rib cage. Also, the lower fibers may depress the scapula a bit.  I think both clinically and from a performance standpoint that the last two functions are very important. 

First, keeping the scapula held firmly to the rib cage by way of proper serratus function allows properly functioning "anchor points" for the rest of the scapular musculature,  the rotator cuff, as well as the middle and lower trapezius, as well as the levator scapula and upper trapezius.  Secondly, as an end range scapular depressor following the mild  concave contour of the rib cage, I believe we may ultimately help foster qualitatively improved glenohumeral elevation by lessening anterior scapular tilt

The Serratus/Rhomboid Fascial Connection

In "Anatomy Trains", Thomas Myers points out the fascial/septal connection between the serratus anterior and the rhomboids.  We know from Kendall that the rhomboids are antagonistic to the serratus (or as she puts it "direct opponents"). Myers coins the term "rhombo-serratus" muscle,pointing out the two muscles form a myofascial scapular sling, setting up scapular "ballast".  The two muscles appear as "kissing cousins" in these illustrations/ dissections.  So, as the serratus goes, the rhomboids will go (and vice versa), both from a length (short/stiff) issue as well as an activation/contractility issue.


Thomas Myers- The "Christopher Columbus" of the Anatomy World


These passive, active, and cozy connections provided me with an "a ha" moment when working two patients recently, both who had traumatic neck injuries related to whiplash, and my approach to their treatment.  

Both had multiple issues, including loss of neck and shoulder mobility due to soft tissue injury, and the loss of mobility was due to multiple factors, including segmental tightness at the cervical facet level and posterior shoulder capsule/element tightness.  Obviously these were treated in concert with soft tissue work to the rhomboids (at the point of insertion on the medial scapular border), activation work for the middle and lower trapezius, and postural restoration activities.


Weaving the Serratus/ Rhomboid Tapestry

When it came time to train the serratus, I utilized a three phase approach based on 1) supporting still sensitive, sub acute healing  cervical/ thoracic structures 2) gradually decreasing external support as our injured tissues allow 3) giving the rhomboids "equal time" to allow seamless integrated contractility/ activation in conjunction with the serratus.

Phase 1

I use a massage chair for trunk support to dial in what I want the patient to perceive as appropriate serratus function (scapular protraction with shoulder elevation).  The key is to maintian scapular protraction while elevating; retraction during elevation indicates poor serratus function and/ or too heavy a load.



Phase 2

As the patient gains an understanding of how to activate the serratus and control the scapula, we then move to a seated position to allow/ integrate trunk stability while the serratus does it's job:



Phase 3

After we have mastered the first two progressions, we then move to a standing position, which integrates further the trunk with the hip.  Again, Thomas Myers notes a fascial/septal connection between the serratus as well as the obliques and tensor fascia lata; standing allows potential stabilization/ integration between these elements:


Integrating Rhomboid Activation

The X factor that was missing in the equation for me in the past was addressing rhomboid function.  I had been so focused on not aggravating the upper trapezius/ levator scapula that I avoided rhomboid activation as I felt it encouraged too much "turn on" of the aforementioned groups.  However, with recent patients, careful integration of specific rhomboid work "greases the groove" for the rhombo-serratus anatomy train, and allows appropriate tri-phasic (concentric/isometric/eccentric) interplay in a scapula with great myofascial ballast (courtesy of early and appropriate soft tissue work, joint mobilization and postural restoration).  

Here, we perform a static rhomboid activation, careful to minimize upper trapezius and levator activity:



Beyond Basics:

After we've got our "new normal" scapular function, we can progress through our preferred  "pushing"upper body exercises.  I am biased toward push up progressions at first, as scapular mobility is encouraged vs. locking the scapula down with a bench press.

My personal favorite test of good serratus function is a handstand hold, as I feel  a real satisfying scapular position on the ribcage with this exercise: 





At The End of the Day…

1) The serratus anterior is a tough muscle to wrap your head around from a three dimensional standpoint; however it's function really is a keystone for proper scapular function (and the scapula is a keystone for trunk/ extremity integration, if you really think about it). 

2) Serratus function is an interplay between both the serratus and the rhomboids, both from a passive (shortness/ stiffness) perspective, as well as an active one; both need to be addressed.

3) Strengthening the serratus is more about proper, integrated activation in conjunction with the rhomboids after appropriate positioning/ballast of the scapula has been established through appropriate manual therapy/postural intervention.

4) Advanced upper body push activities should allow free scapular movement, such as push up, dip and pressing pattern progressions as tolerated (remember to pick your candidates carefully for pressing and dipping) 


Teaching the Squat

Filed under: Case Studies,Exercise Instruction,Exercise Progression,Exercise Technique,Squatting — Shon @ 2:16 pm December 6, 2011

An easy way to get a training client or patient to understand the concept of thesquat/  hip hinge is to use a couple of mini hurdles in front of the shins to provide an "environmental constraint" (motor learning speak) to movement.  Maintaining the "vertical shin" position allows more hinge action at the hips, and also lets us cue in good trunk stabilization.  Below are two examples; one unloaded as well as one with a little bit of load:



Note that I use a dowel to maintain a neutral and stable torso  while hinging at the hips.  Also note the increased box height with and Airex and Nautilus pad to decrease forward lean.  I also use the classic Westside "spread the floor-push out your knees" cueing to maximize gluteal firing posterior chain activation.  This video was taken within the first two or three minutes that the client learned the exercise. 

Below, we add some load with a more experienced (but still new) trainee.  Again, the hurdle placement proves invaluable to keep the shins vertical and knees apart:


In this case, this young athlete had been training with me for about three months.  The first progression was with the dowel and hurdles, progressing to bilateral kettlebells/ hurdles, and then the straight bar (with hurdles).  I have loaded her with a front squat as well; this particular day we happened to use a straight bar.

I do eventually abandon the hurdles, but if mechanics "go south" as load increases, I quickly break them out again to get form in line. 

Key Points:

1) The top of the hurdle should be to the level of the tibial tuberosity.  The tibial tuberosity is more sensitive to touch than other parts of the shin, and provides a great tactile cue for the patient/ client.

The tibial tuberosity-a great tactile cue -also hurts pretty bad when you bang it into a coffee table

2) A spotter is needed to place the hurdles when using a bar.  Note in the second video, I have someone take the hurdles away before re-racking.  Walking out a loaded bar while stepping over hurdles is a recipe for disaster along the lines of squatting on a Bosu Ball. 

3) Hurdles are generally parallel to the ASIS of the pelvis, the bar, or both.  I am a fan of symmetry, and straight line hurdles subliminally get the trainee to think "straight/ tight" with technique.

4) A box isn't always needed.  Early in the progression, the box obviously helps teach the hinge, gluteal/ hamstring activation, and proprioception/ depth.  However, like training wheels on a bike, you eventually remove this prop, as the trainee becomes more confident/ capable and comfortable with the technique and load.  







Positive Posture Changes-Chronic and Acute

Filed under: Case Studies,Posture,Uncategorized — Shon @ 7:16 pm December 1, 2011


Appropriate posture is the foundation for both upper and lower quarter functional mobility.  If you are reading this, chances are you already know this, either as a professional or as a patient.  The question is how quickly can we affect changes with our people, both in chronic, long standing cases as well as acute changes from traumatic injuries.   

Recently, I had the chance to take a few "before  and after" pictures of a few pateints.  Below is a District level high school cross country athlete who I saw for 10 visits this fall for a diagnosis of neck strain.  What we were really dealing with was a combination of  Janda's  upper and lower crossed syndrome (a quick review: upper crossed syndrome-weak deep neck flexors, overactive upper trapezius/ levator scapula, weakened sccapular depressors; lower crossed syndrome-.weak, underactive gluteals and abdominals, tight illiopsoas and erector spinae).   

The picture on the left is his first visit, while the picture on the right is at the time of his last visit:

 As you can see, there are pretty significant changes.  Lower cervical extension is better, as is thoracic extension, both passively and actively.  The thoracic spine being more upright allows a better "table" for the head and cervical spine to sit on.  His rounded shoulder position is improved by virtue of improved scapular retracion; scapular retraction is better just as a result of thoracic extension being improved. 

Just as impressive are the changes in lumbopelvic posture:

On the left (obviously, the first visit) you can see the ASIS/PSIS relationship as marked by the tape.  Arms overhead didn't help this (but were necessicary to capture the picture), as this further accentuated his lordosis secondary to his tight thoracic spine dragging his lumbar spine and pelvis into further extension.  On the right side, not only is lumbopelvic positioning more ideal, with a beautiful neutral spine posture, but the "arms overhead" position isn't a problem anymore because thoracic extension is also much better, leading indirectly to improved scapular and glenohumeral mobility. 

How did we achieve these changes?  Primarily with low load prolonged postural stretching of the thoracic spine into extension, improving mobility of lower cervical extension with concurrent upper cervical flexion,, as well as a bunch of time spent showing him "pelvis neutral" along with low load stretching of the psoas and rectus femoris.  Many of these activities can be performed concurrently, once the patient understands what is expected. 

This athlete has a bit more work to do independantly, namely get stronger.  He has done limited weight training activities with his cross country team, but hasn't performed what I would consider "proper" strength work yet.


Another patient presented recently after suffering a whiplash injury.  Below are "before"  pictures from his first visit:  

Following are pictures taken immediately afer his first  visit.  We did only low load thoracic/ cervical  passive positioning this visit to achieve these changes. You can see significantly less activity in the upper trapezius and levator scapula, as well as decreased sternocleidomastoid activity.  Needless to say, he felt a whole bunch better, at least for the first few hours post treatment.

In subsequent visits, we did hone in on more specific soft tissue work to the left upper quarter, as the left levator and rhomboid was significantly flared up.  You can also see winging of the left scapula, which we addressed aggressively with high set (10/ session) serratus activation work (30 seconds per repetition).  His levator/upper trapezius pain impairments are more than likely tied to his serratus dysfunction, as the scapula acts as a "roundhouse" for shoulder function with many significant competing vectors of pull (reference Anatomy Trains, specifically page 164 to see the relationship between serratus anterior and the rhomboids).  As his serratus improves, I believe his rhomboids and levator will improve as well.

The long term key with him is to make sure that chronic adaptations never take hold, or he may develop an upper crossed pattern.  Continued targeted soft tissue therapy, appropriate low load postural stretching, activation and strengthening of  underactive and weak musculature should be the ticket to achieving a long term improvement in his upper quarter posture. 




“Thin Slicing” Expertise and a New Case Study

Filed under: Case Studies — Tags: , , — Shon @ 10:27 am May 31, 2011

In my last post,I mentioned my friend Shane Pratt, a multi year veteran of Penn Relays competition.  As we were watching the races at this year's Penn Relays from our vantage point in the stands, we also had a clear view of the paddock, where competitors were setting up for the third leg of the 4 x 100 meter relay.  As the men's heats were progressing, Shane would casually note which team he thought would win the heat just by observing the competitors in the paddock area.  I started to take notice after he had been correct five times in a row. When I pressed him on his prediction, he couldn't really answer how or why, only that he had an instinct while watching each athlete in the paddock (BTW it turns out by the end of the day he was spot on 80% of the time).

How could he have been correct so much of the time just observing an athlete stand in a confined space prior to a race?  Shane is not an active coach currently.  He doesn't have a degree in movement science, and hasn't competed or coached in over 15 years.  I was dumbfounded  until I recalled an anecdote from Malcolm Gladwell's excellent book, Blink.


In Blink, Gladwelltalks about the ability to make quick decisions with "thin slices" of information; the few important details that come when previous experiences meet rapid cognition, leading to a correct conclusion.  One  example was how the world class tennis coach, Vic Braden, could call a player's second "double fault" almost instantly, while 1) watching the match on TV and 2) having never met, coached or seen the player prior to the serve.  When asked how he knew the faulty serve was coming, he couldn't answer-he only knew it was inevitable (it turns out > 90% of the time). 

I believe this is how Shane was able to predict heat winners based on quick observations in the paddock.  His own high level of innate skill (10.32 FAT will not be seen in Pennsylvania high schools for a long time!), his years of waiting, watching and competing at the Penn Relays, as well as countless other championship events (youth, high school and collegiate), and his continued passion for the sport as a fan have given him the ability to "thin slice"- that is take a little bit of information at hand and arrive at an appropriate conclusion. 

Extrapolating forward, I also believe this is how excellent physical therapists, athletic trainers and strength& conditioning coaches are able to make decisions for their patients, clients and athletes quickly and seamlessly-the culmination of multiple years of experience, the quest for continuous improvement and refinement of skill, as well as just "paying attention" (in a Patrick Jayne/"Mentalist" kind of way).

I can't believe I actually referrenced this guy in my blog-but he really is a great example of "thin slicing"!


Case Study 3- Hamstring Strain in a High School Speed/Power Athlete

In the spirit of  the state high school track and field championships here in Pennsylvania this weekend, I'll review another interesting case that again wasn't what it initially seemed.  Part 1 will detail our treatment, while part 2 will outline a training program we implemented during the athletes indoor track season after additional information was gathered regarding the athlete's true impairment.


My patient was a high school junior who played running back as well as defensive back on an elite 4A team in  Southeastern Pennsylvania.  In conversation withhis father, he had strained his right hamstring at the origin in spring practice, approximately 5 months earlier.  His pain resolved with rest, but through summer conditioning, the pain never fully abated.  In pre-season "2-a-days", he re-injured his hamstring; 10 days later, we saw him in the clinic.  At this time, he was not actively practicing/ participating.

The athlete's main complaint was proximal hamstring pain near the origin at the ischial tuberosity.

Key Findings

Functionally, the athlete had pain only withascending 2-3 stairs at a time, with symptom reproduction in the region of the ischial tuberosity.  Level surface walking was pain free and non-antalgic (sidebar: for non-PT's, antalgicsimply means"avoiding pain"; if he had antalgia, he would have had an altered gait pattern to avoid aggrivating his hamstring.)


Straight leg raising was measured at 60 degrees on the injured side vs.  75 degrees on the non-injured side.

No, not me, and definately not my athlete, but motion was this poor!

Additionally, hip flexion was limited to 125 degrees on the right (130 degrees left).  Anterior hip tightness was not significant when observed in "figure 4" prone lying.  Thomas' test/ Ober's test were negative for IT band, rectus femoris and/or illiopsoas tightness.


Hamstring strength (measured via hand held dynamometry) was noted to be 35 lb. right withpain on resistance, as compared to 69 lb. left.  Hip extension withknee extension (to elicit hamstring contraction) was 38 lb. right vs. 57.6 lb. left.  Hip extension with knee flexion ( testing gluteus maximus with significantly less hamstring involvement) was pain free on the right side.  Adductor strengthwas pain free on the right, withstrengthgrossly equal as compared bilaterally.  Remaining right lower  extremity strength was grossly equal and did not cause pain/symptom reproduction.


Point tenderness was significant near the hamstring insertion near the ischial tuberosity.  The belly of the hamstring muscles (medially-semimembranosus and semitendinosus, and laterally biceps femoris) were not significantly tender.   

My Thought Process in Treatment

1) The "strain" was high, and was therefore more likely a hamstring insertional tendonitis/tendonopathy.  Straight leg raising, while not great was not significantly limited on the right side vs. the left, and pain was not in the muscle belly of the hamstring at end range.  Additionally, tenderness was at the insertion point on the ischial tuberosity, with no significant muscular point tenderness. 

2) Lack of active hip flexion mobility was a significant issue.  This was my hypothesis before even evaluating the athlete.  His father had described the history of injury to me at least 1 week before I had evaluated him; my initial thoughts centered around what I thought he would present with when he came to the clinic. My intuition served me well in this case.  Without "reserve" hip mobility passively and actively into hip flexion, the athlete was not allowing his hamstring to lengthen at the ischialtuberosity appropriately as his distal leg moved through swing phase during his various activities at football practice.  Microtrauma developed over time at the hamstring attachment in the ischial tuberosity, leading to the tipping point of dysfunction that brought him  to see me.

3) So as the Hip Goes, the Hamstring Goes.  My focus was on restoring hip flexion mobility through joint mobilization as well as increasing dynamic hip mobility in multiple planes using  progressive hurdle circle drills I devised.  The net result is a "flossing"  action of the hamstrings; the adductors and hip rotators get to "go along for the ride" as well. 

4)  Hamstring Yielding Isometrics/ Static Contraction  in Open Chain Rather than Eccentrics in Open Chain.  My bias is static contraction/ yielding isometrics for strengthexercise in the clinic for most pathologies.  I feel time under tension is a variable I can control along with load and position, so I chose this vs. eccentric OKC training for the athlete.  We also utilized Romanian deadlifts (RDL's) as part of treatment, so eccentric strengthening wasperformed,  just in a closed kinetic chain.  I also feel with an RDL, motion is dictated by the athletes' unique mobility/ biomechanical profile using free weights vs. using eccentrics in OKC on a leg flexion machine where whole system mobility options are limited.

Treatment/ Outcomes    

The athlete was seen for 10 visits over a 1 monthperiod.  Treatment emphasized hip joint mobilization with an emphasis on techniques to increase hip flexion passively and actively.  Ultrasound was used prior to mobilization for the first five visits to increase tissue temperature at the injury site and allowing my manual techniques to be more comfortable initially.  Manual therapy was followed by my hurdle circle/ hip mobility progression, progressing from a 12 inch height to ultimately a 24 inch height without pain.  Static knee flexionwas initated on the second visit, with a 30 second contraction/time under tension  Hip hinging/ box squatting  were initiated after 3 visits, RDL's on the fourth visit.  Weights, repetitions and time under tension was progressed every visit.  Full practice was resumed after 5 visits.  At  the 6thvisit, the athlete noted pain only with activities that involved decelleration at practice.  After 10 visits, he self discharged, just prior to a formal re-assessment, as he was symptom free in both practice and scrimmage activity.  He finished the season without re-exacerbation/ re-injury, fully returning to starting positions on offense and defense.

What I Would Do Differently Today

Le me preface this section by saying that I was pleased with the outcome above.  All long term goals were met in a timely manner, with a great long term result.  The athlete is now in a Division 1 program and projected to start in the defensive secondary next year, and has not had a single instance  of pain/ symptoms since he was seen in 2007.  That said, there is always room for improvement.  Some things I would have considered:

1)  Assessment of single leg function sooner.  You noticed I said sooner?  That's because after the football season, I trained this athlete  10 weeks during the winter, while he was running indoor track.  I had assessed his right  single leg  squat ( the involved side) after I noted a valguscollapse on the right with relatively light training weights in the box  squat and trap bar deadlift.  At a height of 23 inches, technique was poor, with the athlete barely able to complete 1 repetition without losing balance, compared to 19 inches for 5 excellent quality repetitions on the left side.  Over the course of the next 10 weeks, we were able to get to a point where he could single leg squat a a pair of 20 lb. kettlebells from 17 inches for sets of 5.  Not so coincidently, his best indoor 200 meter time dropped by 0.8 second  in the same time period.




2)  More agressive soft tissue work at the injury site.  At the time, my treatment bias was on re-establishing hip mobility and static hamstring strength.  Again the outcome was favorable, but I believe I could have expedited this even more sowith the use of soft tissue manual therapy, especially tool assisted soft tissue massage  , as tendonopathy responds well to this manual therapy intervention. 

3)  Assessing trunk strength and stability.  A stable torso is  important for a strength/power athlete in allowing force transmission through the lower quarter; if anterior/ posterior and lateral muscular forces aren't held accountable, then lower quarter muscular forces aren't fully transferred  through the trunk.  Making sure that trunk stability was in check would have been prudent as well.