Continuing Education Bits for PTs & PTAs

Introduction by Marilyn Pink: from time to time EDUCATA has the privilege of hosting guest bloggers on this platform. This series is written and moderated by Susan Banberger, a PT since 1999. Susan is a Diplomate in Mechanical Diagnosis and Therapy and works at Advance Sports and Spine Therapy in Wilsonville, OR. She has contributed to several publications, including the International Journal for Mechanical Diagnosis and Therapy. 

The case study examines the experience of a runner who has recently dared long distances and comes to the PT with severe hip pain.Please feel free to participate and comment at the end of the article, as much is learned by all in the process of exchanging ideas.

A runner with hip pain – getting him back in the race

By guest blogger Susan Bamberger

When a runner comes to physical therapy with debilitating hip pain, there are a multitude of treatment options. The accessibility of information from the internet leaves patients confused as to which shoes they should wear, if they should wear shoes at all, if they should stretch, and if so, should they stretch before or after their run, or both? They come to us to help sort out this information and to determine what is best suited for them.

Physical Therapists have the responsibility to create an effective plan for each patient in a reasonable amount of time. Not every treatment works for every patient. Anyone can research stretches, strengthening and shoes on the internet. Our challenge is in proving that we hold unique knowledge and skills to deal with individual problems in this information age. This case study is an example of how skilled physical therapy provided excellent results and gave this runner the knowledge and treatment he needed to return to running, pain free.

physical therapy runner with hip pain

The patient is a 38 year old male plant manager and new long distance runner presenting with complaints of left anterolateral hip and thigh pain. He was referred to physical therapy from his orthopedist, who diagnosed him with greater trochanteric bursitis.

His onset of symptoms was 6 weeks prior to the initial evaluation, after running a marathon (26.2 miles). By the end of the race, he was in intense, constant pain, rated at a 5/10 that remained constant for 3 days after. His symptoms became intermittent, and have not changed much since that time. His plan was to run 4 marathons in the next year, but he has stopped running completely, as every time he runs the pain comes back to the same intensity it was immediately after the race.

Since becoming symptomatic he has tried many stretches and strengthening exercises he researched on the internet. He has also received advice from his massage therapist. However, the same pain comes back when he runs. He has good shoes, and changes them every 250-300 miles, per industry recommendations. Because of all of his research, he is concerned that this is an issue that is going to keep him from running altogether.

When asked if the patient had any imaging, he replied “only an xray”. Then he said, “Why, do you think I need an MRI?” Sensing fear of life-altering structural damage, the patient was assured that one of the goals of physical therapy is to determine the right place for them. With a careful assessment over 2-3 visits, we should know if further testing is necessary.

Given the history, which structures are you going to examine?

How can we establish functional baselines and how vigorous can we be in our examination?

What examination tests would you use, and why would you use them?

We look forward to your comments!

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Comments on: "How would you help this runner?" (62)

  1. Interesting discussion!
    I would go with an acetabular labral tear, personally. MR arthrogram needed to confirm this. Then arthroscopic surgery will be required. He may also have an underlying CAM or pincer impingement that has caused the labral tear (my money is on a CAM), so this will need reshaping by the surgeon at the same time the labrum is debrided to prevent future recurrences.

    • You are joking right???? So the pt is responding to repeated motions – hip extension – in half kneeling and function is improving and you want to have a MR arthrogram and refer to a surgeon for reshaping?

  2. neha Golwala said:

    I would assess lumbar spine and check for derangement first, then pelvic alignment, innominate assessment..Based on evaluation you can decide diagnosis and treatment

  3. Left anterolateral hip pain after a marathon. Not improving and altering activity.

    Cause: Overuse and most likely an imbalance in the spine or hip.
    Evidence: produced by running a marathon. At that distance a lot hurts. Pain is unilateral and has specific symptom planes.

    I’m an ultrarunner of 15 years. I’ve experienced almost every overuse injury and evaluated many runners. Almost always, with unilateral symptoms there is an obstruction to side glide in standing. 99% of the time the obstruction is to the right. This also comes with a rotation of the lumbopelvic region in the transverse plane. There is almost always a tight hip flexor component usually on the right side.

    How to treat with MDT?

    Assess side glide in standing very specifically. Monitor the ease of the motion pathway as it will also rotate.

    Extension will not always be clear. Treat the sideglide and rotation and check again to clear it.

    I find awesome results doing a right side glide static stretch on a roll (thanks Wayne Rath), adding rotation (5 mins each position so obstruction will clear). There is often a restriction in the thoracic spine and all the way up to the right upper cervical.

    Lastly, clear extension in lying, apply manual forces if necessary. I don’t always rely in symptoms centralization if the hip pain is due to soft tissue irritation. The lumbar extension will feel better and the hip pain will resolve due to the mechanical correction of the alignment.

    I’ve helped marathoners with severe symptoms 3 days before a race with similar symptoms and it works. It doesn’t take long either. Less than 4 visits usually.

    • but she already told you the lumbar spine was clear and the patient was responding to repeated hip extension in half kneeling.

    • The case is already evaluated and effectively treated in future installments, but I have a question about your answer.
      You would go lateral before sagittal- sideglide before extension without identifying a lateral shift first? And it sounds like you would sideglide away from the painful side rather than toward?

  4. The first thing I would check is lumbar sidegliding to the L and see if his symptoms are centralized or abolished using an asterisk sign. If so, then this patient would be easy to treat.

  5. Mark Masse PT,MHS, DPT said:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565630/
    Patellar Pubic percussion test quick easy test to do

    I am starting MDT lumbar and hip exam on day 1 looking for reproduction of symptoms…

  6. Beth Rubenstein M. said:

    I so appreciate everyone’s very thorough evaluation here. I have been dealing with this for many years. . For a few years I have been looking at balance, functional relationships of the pelvis/feet/jaw/c/s. My techniques are not elaborate- single leg stance, do some manual work, check again, give HEP noticing pressure on different parts of foot with running and walking. My evaluation encompasses much of what is mention here, SI, Hip, knee, L/S. I am not in a position to do an evidence based study on my own, but would be happy to be part of one concerning balance and assessing weight on feet, with pelvis and C/S.

  7. Leon Richard said:

    Given the current findings and response to the intervention, I think it’s fairly safe to suggest we are treating a sacroiliac dysfunction here.

    Now… How come? It’s not because a bird pooped a SI joint dysfunction as he flew by and it happened to land on his hat. Maybe he just runs in the same direction on the same route daily, and the road has a “crown” on it that is excessive?

    Is there a “true” laxity in the supporting ligaments predisposing this individual to this? Does he have a leg length discrepancy? Is there a predisposing problem in the foot/ankle leading to excessive strain across the kinetic chain?

    I’d think at this point, I might take a look at leg length. Perform a cursory exam of his ankle/foot mechanics. And provide him further instruction at stretching of the hip and low back musculature to assist in maintaining positional integrity of the SI joint.

    Some general body mechanics and behavioral intervention/education is likely indicated here as well. Insure proper technique with stretching, lifting, sitting, adjustment of computer/desk chairs.

    • whatever happened to evidenced based? why is everyone so hung up on zebras ie – leg length, SI joint, CT vs MRI??? really?? patellar-pubic oscultation? is that even a word? SEEK AND DESTROY ALL DERANGEMENTS! Keep it simple.

    • Philip Paul Tygiel PT, MTC said:

      While I would not yet rule out Sacroilliac dysfunction I do not see that it is “safe to suggest that we are treating a sacroilliac dysfunction here.” All of the tests described, and all of the others I can think of for that matter, that test the hip also test/stress the sacroilliacs at least to some extent. Also all of the tests that are described to test the sacroilliac are also imperfect. They might suggest a sacroilliac problem but by no means are they definitive. For that reason’ in this case I might address both the hip and the SI in treatment and see how the patient responds. My primary suspician though is that we are deling with a hip problem. I do n ot like using the term “derangement ” as it really is an MDT vernacular term that is not universally interpretted or understood No problem with the binitial treatment approach though as long as it is working.

      • michael k PT, OCS PA-C said:

        So, even after she told you that it is a hip problem, classified as derangement, and is responding to extension, you still want to look at the SI joint (that really does not move and last time I checked the patient is not a young pregnant female)? Good luck on that.

      • Leon Richard said:

        Personally and professionally I’d challenge anyone to sort out and treat “the hip”, “the sacroiliac joint”, or “the lumbar spine” in isolation from all the others. They’re invested in one another to such a degree that doing things in isolation is not really practical. The muscles and ligaments often cross one or more of the joints affected and what happens with one has a directed effect on what happens to the others.

        So far as mobility in the sacroiliac joint goes…

        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565116/

        I think Richard Dontigny and a host of co-authors who did studies on live specimens under real world functional conditions would disagree with the studies using cadavers in a lab. But a person is welcome to hold opinions on things based on whatever evidence they choose to accept.

      • Leon Richard said:

        You intent to treat, and energy, may well be directed at a specific structure in that region. But whatever you do that imparts any change in that region in muscle tension, strength, range of motion of any of the joints, has a direct mechanical effect on the rest of the structures. Some issues defy the specificity we would all like to have in “Evidence Based Practice” and the lab.

  8. Tobi Daniel said:

    I believe this is a forum for scrutinizing professional skills and analyzing phantom-like cases and not a forum for professional debates on PT branding. Ipso facto, PTs are expected to carry out all necessary investigaton, perform required examinations, come out with concrete analysis of findings, clear and accurate clinical impression/mechanical diagnosis. This will give way for proper PT intervention which can be monitored to validate its effectiveness

    • Bruce Linder, PT said:

      Interesting Tobi. Assuming you are confident of the diagnoses and of the cause, do you first address the problem(s) (and which first) or the cause? How do you deal with a varied patient population? The athlete vs the factory rat vs grandma, vs the middle aged weekend warrior.

      I would hazard that there are multiple successful treatment approaches that not only address a diagnosis (diagnoses) and/or a cause for that diagnosis, but also take into account the patient’s personal biases/needs.

      I am certain this site will help me understand better how to evaluate and treat my patients, but it will likely not provide the one and only one solution. (Unless, of course, I was right with my WAG stress fractured femoral neck (from too much running, too fast) / early avascular necrosis, in which case the only answer is refer them to an orthopedic surgeon.)

  9. Matt Himsey, PT, DPT, SCS said:

    Given the history, I’m going to start by examining the hip. To me, start local until proven otherwise. Its a lot easer to get your patient to buy in to what you are saying if you look where their pain is first. That said, I have a lot more questions before I can start an adequate examination. I want to talk to him about his training mostly. When did you start running? How quickly did you increase your mileage? How often do you run? Questions along those lines.

    We can establish functional baselines and establish intensity of physical exam by asking him about tolerance. Does the pain come on with activities other than running? Stairs? Squatting? Walking long distances? He’s been running with pain – how much? How long can he run before onset of symptoms? How long before he feels he needs to stop if pain is still constant? How long after he finishes the run until the symptoms cease or come back to baseline? Getting irritability of symptoms will help us to determine intensity of examination.

    All that to say – I have no idea what tests I’d use yet! Hip ROM and MMT? Most likely. Thomas, prone knee flexion, FABER, and FAIR? Probably. We’ll see as we get more information!

    Thanks for a lively discussion everyone!

    • Leon Richard said:

      Right on, actually. The subjective side of the evaluation is skinny, and I’d like it filled out a bit more myself. My low back screen doesn’t take five minutes and isn’t “distinct” from the rest of my exam. If I can’t find much during the hip exam, I can go back and do all the “repeated movements” and such.

      Enjoy!

  10. As previously, mentioned I would like to rule out lumbar spine and look at pelvic alignment, leg length discrepancies. Further looking into AROM and PROM and palpation to see if any symptoms and pain can be reproduced. I think it is important to ask the patient about his training and his mileage increase as well as the stretching and warm up he has or not has done. I would also like to know if he did any cross training, strength training, ect during his training. As previously stated just because he has looked up stretches to do on the internet does not mean that he is doing the right stretches or performing them correctly. I would like to further look at weight bearing and non weight bearing activities as well as muscle strength. I would like to see his walking and running gait to look into any biomechanical issues. Is there a certain phase in running gait that he experiences pain and does the pain immediately start when running? I would perform FABER test, ober test, gillet, sit to supine test, SLR, thomas test to begin. I look forward to hearing further details in this case study.

  11. michael k PT, OCS PA-C said:

    Bruce, I know that there is limited data right now. However, I guess my point goes beyound this case and more about the profession. Since the profession wants to be called ‘Doctors’, I would think there should some standard of care (not cookbook), where the patient is evaulated and managed with an evidence based approach. I do not believe our profession is currently doing that considering all you hear is evidenced based evidenced based evidenced based. This case points that out. You have people wanting to look at footwear, core strengthening and even wanting an MRI right from the start. I bet you will see treatment approaches from US, Stim, Kineisotaping and perhaps voodoo.

    • Leon Richard said:

      Couldn’t care less about being called “doctor”, honestly. I completed the DPT through the university I earned my Masters of science degree at because I thought the coursework would round out my clinical performance. It’s been beneficial in some ways and hasn’t harmed anything to the best of my knowledge. If someone introduces me as “Dr. Richard” I am always the one to interject, “Physical Therapist”.

      Some in the profession are performing at a higher level than others… opinions can vary as to the level of practice. These case studies are certainly entertaining, if not illuminating, with regard to the thought patterns of other clinicians for me anyway.

      What would you do with this patient, based on the information we have at hand?

      Personally, I don’t have information enough yet to decide. I am still performing my evaluation, and may incorporate some measures and interventions that may prove to be diagnostic as well as therapeutic. It will help me in my assessment. Likely having to do with mobilization, manipulation, resisted movement and contract-relax stretching to see if it’s possible to isolate a tissue or anatomical structure that is the origin of this pain.

      Once I find that, if I can find that, then I might be able to examine and investigate “contributing factors” as I implement the plan of care and monitor the response.

      Tape and modalities, heel lifts, all interesting and sometimes may be beneficial. But the main intervention I use is therapeutic exercises and home program, manual therapy, then behavior modification and risk mitigation. But you have to know “what” your mitigating the risk of before you can do anything.

      Evidence Based Practice is something I aspire toward and take some pains with it. However there are things that there will be no level of evidence to ever support.

      BMJ. 2003 December 20; 327(7429): 1459–1461.
      doi: 10.1136/bmj.327.7429.1459
      PMCID: PMC300808
      Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials
      Gordon C S Smith, professor1 and Jill P Pell, consultant2

      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/

      “What is already known about this topic

      Parachutes are widely used to prevent death and major injury after gravitational challenge

      Parachute use is associated with adverse effects due to failure of the intervention and iatrogenic injury

      Studies of free fall do not show 100% mortality

      What this study adds

      No randomised controlled trials of parachute use have been undertaken

      The basis for parachute use is purely observational, and its apparent efficacy could potentially be explained by a “healthy cohort” effect

      Individuals who insist that all interventions need to be validated by a randomised controlled trial need to come down to earth with a bump”

      Enjoy! It’s what this is for, and learning, teaching, sharing.

      • Bruce Linder said:

        I graduated in 1980. I’m a PT, meaning a BS in PT.

      • Bruce Linder said:

        I just finished your post. My son is a 1st LT in Army Airborne unit. (Lots of parachuting.) The end of your post gave me the giggles.

    • Bruce Linder said:

      (To your post I can only say, ‘Yep’.) I see a wide variety of patients, but I would say my best talent is with athletes. My particular vantage point for this patient is to look for a running issue. A PT who specializes in back manipulations will likely see a disc or an alignment problem. Of course, we cannot exclude the referring doctor who thinks it is a hip bursitis. Interestingly, we might all be correct. (Just because you have an HNP, it does not mean you do not also have a hip bursitis.) How we address the problem will relate to how we have successfully addressed a similar problem in the past.

      Patients often have multiple problems, and different patients respond well to different approaches. My best successes are with patients who are exercise junkies. I used to trade patients with a manual therapist. Her patients liked to be manipulated (however, she was not very good at developing a thorough HEP). I am not a fan of manipulation, preferring mobilization exercises instead. Oddly enough, just as there are multiple approaches to helping a patient, there are multiple approaches that will help. (Which is best? Depends on the particular skills of the PT and the particular desires of the patient.)

      Just for giggles for this particular patient I am going with an ultimate diagnosis of ‘stress fracture of the femoral neck and/or early vascular necrosis of the head of the femur’ – only because it reminds me of a patient I treated long ago. I hope it is not because from a PT stand point, there is not much we can do.

  12. michael k PT, OCS PA-C said:

    WOW! It never ceases to amaze me how one case causes responses all over the place. And all you hear is ‘Evidence based practice’ right? Well, how are we doing as a profession then when we have responses ranging from core strengthening, putting a heel lift in, wanting a MRI before proceeding? If the profession was truly asessing and treating on evidence based, wouldn’t there be more consistencey in the responses? At least it seems the majority would clear the lumbar spine first.

    • Bruce Linder said:

      Michael, I believe this is an evolutionary discussion where not all of the info is given at the outset. We are responding to the limited data being presented, so of course our responses are all over the place. That said, once all the data is presented, I suspect we will still be all over the place in our treatment approaches. Hence, the ‘art’ of medicine.

      As to what area would I ‘clear’ first’? Too soon to tell from the limited info provided. Right now I know we have a male, who has ‘recently’ started running and running full marathons at that, who has anterior lateral hip pain that has not responded well to treatment (though what that was is unclear). He has been diagnosed by a physician as having a hip bursitis. (We do not know how thoroughly his physician was in examining him to provide this diagnosis, and may be making assumptions on that as well.)

      This is a delightful mental exercise, and I am waiting for more data. More please.

  13. Walking appears to be ok, pain only when patient runs
    During walking hip abducts with internal rotation.
    During running hip abducts with external rotation

  14. Inflammatory response from the repetitive loading initially (constant) & then more mechanical (intermittent):
    Ideally we need more info regarding aggravating and easing factors but my gut feel on lower back pain in runners is that this is unlikely a back problem (almost all runners with running induced lower back pain complained of lumbar-sacral pain).
    I would look at his hip, especially the labral structures given the onset being running related – repetitive strain and being a relatively new runner, likely overload and fatigued. After 6 weeks he still has the SAME pain which is aggravated by loading (running) in a seemingly reproducible way. Running is regarded as one of the classic predisposing activities for hip labral tears.
    Also what does a plant manager do all day – walking?? / stairs++? Or sitting ++
    Given his poor response to basic exercises and the unchanged nature of his condition after 6 weeks, there is likely a mechanical lesion because this is behaving much like a knee meniscus injury.
    I wouldn’t be concerned about his shoes, rather his dynamic control.
    So clear Lx (particularly facet given the potential closing down of the posterior joint from the jarring of running and possible exaggerated back extension which accompanies weak gluts) but I think this is unlikely.
    Full examination of hip ++ check hip ROM, for any FAI and labral tears.
    Dynamic control tests of the lower limb.
    Another differential diagnosis is ITB – 90% happens at the knee but 10% over the greater trochanter of the hip – same features – area of pain, pain with loaded activity, poor lower limb dynamic control yet there should have been at least some relief of his symptoms from his “exercises” then
    Left Lx structures eg facet joint (area – can refer there; new runner may hinge into Lx ext with his running style loading the facet joints & has not built up sufficient global strength (cross training) to cope with the running
    Hip joint (if hypermobile or with poor control may have increased sliding of the femur head in the joint irritating the labrum, hip joint can give pain to the area above
    Could be trochanteric bursitis –area, repetitive loading, poor motor control eg in single leg standing
    What about micro tears of the glut muscles
    How can we establish functional baselines and how vigorous can we be in our examination?
    How vigorous – I think one can be quite vigorous, but how quickly does the pain come when he runs For a 70 kg man (not heavy!), 1 km of running puts 30 tons of load through each hip – the forces are HUGE so I would agree – assessment may well need to be vigorous because at this stage we only know of the running which is the aggravating factor.
    Functional baseline – not sure what this means? Is this how far he runs before the pain comes on? How many sit to stand exercises before the pain comes on?? I also am unsure of what this means, I think you are on the right track Marcelle.
    I would say that this may take the form of some functional reproducible exercises such as squats / wall runner / step downs

    What examination tests would you use, and why would you use them?
    Lumbar spine – extension – left lateral flexion to load the facet joint I think you would need more so after checking these, I would think I would progress to a quadrant test
    Hip joint – passive physiological tests, Fitzgerald tests to assess for the labrum pain FAI (a “predisposer” to labral pathology)
    Bursitis & micro tears glut muscles – palpation, concentric muscle activation to ‘squeeze’ the bursa, can he lie on the left hip – motor control tests to see WHY this happened eg may be clam, may be single leg tests for balance, control, foot pronation, etc

    Loads of single leg tests especially dynamic ones involving hoping and jumps because this more simulates the impact of running and forces which need to be controlled

    • Susan Bamberger, PT, DIpMDT said:

      Hi Ina and all,

      Many of the questions you ask will be cleared up in the next entry- so stay tuned! Here are a couple of things to think about:

      Even though he has been doing many exercises for this problem, who knows if those are the right ones? It is our job to figure this out. Therefore, taking a shotgun approach, ie thinking of everything it could possibly be and treating all of them before we know what we have, may lead us astray in the reasoning process. While any of these may be a possibility, by assessing for all of these possibilities on day one, any clinician, regardless of experience and expertise, can get confused. Remember that many of our tests and assessment procedures have unreliable and questionably valid outcomes when put to the test in research. All we really have in front of us is the symptom presentation and behavior. If we can make an effect on this quickly and are able to make a cause and effect response, then we know we are getting somewhere.

      We are clinicians that use our skills, experience and intuition to figure out this sort of issue. When we rely too much on one more than the other, we become biased in our perspective. We use stories created in school, with our colleagues and with our own personal experience to determine what we’ve got before we even have a chance to see them move and assess response to movements, which at the end of the day will tell us more than any special tests or measurements for leg length discrepancy. All we have in front of us is what we have. Our next task is figure out what happens when this pain comes on. Just my .02. Stay tuned!!!

      • Leon Richard said:

        Reminds me of my anatomy professor… “Sometimes, blokes (English you see), patients get better despite what you’re doing and not because of it.”

  15. Melanie Di Martino, SPT said:

    First, I would position the patient in hip flexion, adduction, and external/internal rotation to determine if the patient truly does have trochanteric bursitis. In the position of flexion/adduction/ER I would resist IR to assess for pain and the possibility of tendinopathy. I would also do a fulcrum test to assess the possibility of a stress fracture as well as ask the patient how the hip feels when walking. My CI also mentioned auscultation of the pubic bone to rule out a stress fracture. If the fulcrum test were positive then I would recommend an MRI to confirm. I would also check hip abductor strength as the pain may be a result of weakness, the mechanics of the foot, and levels of ASIS/PSIS (looking for anterior innominate rotation) and leg length. Additionally, I would palpate over the lateral gluteal muscles for tenderness/pain provocation. I would want to be quite vigorous in my examination to see if I could provoke the pain through testing. I would establish functional baselines based on the results of my examination.

  16. John Salituri PT, Cert. MDT said:

    Susan, I look forward to your MDT exam. Until then cannot think about rx. Every pain has it’s source. Rx must reach the source. Rx must be beneficial to the source. These are sage words from Cyriax who was thinking like a MDTer. In summary, we cannot successfully treat what we cannot accurately diagnose/classify.

  17. Bruce Linder, PT said:

    New to running? Our bodies need a lot of time to adapt to prolonged or heavy exercise. I would hazard to guess that a 38 year old runner would need 2 years minimum (and preferably 5 years) to comfortably tolerate running a marathon. While I would encourage patient to continue running, I would advise on changing competition from full marathons to 5 K’s, 10 K’s and Halfs.

    (I am also a fan of interval training as opposed to distance running, as a way to develop running skills – but that is a whole different discussion.)

    Hydration is often an issue with runners. Are they hydrating properly?

    Optimal running style is with a midfoot or a forefoot strike. Look at the runners shoes. If the heels are significantly worn, they are heel striking.

    Pain about the anterior lateral hip has two typical causes, weak core or tight ITB. Stretch or strengthen accordingly.

    Anti-inflammatories. I am strongly opposed to using pain meds to practice or compete in an exercise program. If a runner is using pain meds during exercise, they are likely masking their symptoms and simply exacerbating their problem. I would advise to only use anti-inflammatories after a workout session has been completed.

    I could go on, but those are the top five things I would consider with the information provided.

    • Philip Paul Tygiel PT, MTC said:

      Great points Bruce. While the immediate goal has to be getting this guy pain free once that is done you really have to address why he got this way in the first place. Was it poor/unwise training? Way too much, way too soon? Is there a stuctural problem that can be addressed? A biomechanical problem? Is this a guy who just shouldn’t be running marathons? Not all of us were born to run.

      • Bruce Linder, PT said:

        Not all of us were born to run??? Bruce Springstein would be rolling in his grave, if he were in his grave. Is there an age when we should stop running? Before you answer, read, ‘Born to Run’ by Christopher McDougal.

        You mention a biomechanical problem. There are probably several. Many of my middle aged runners mimic car wrecks. They have everything wrong. (Rotated pelvis, tight hams/ITB, weak abs and gluts, a spasm in their glut med or piriformis, a hip bursitis, poor distance running technique, and poor hydration leading to irritable muscles. They may also have a lumbar HNP with a radiculopathy.)

        Part of the joy of being a PT is figuring out which to treat first. (Poor running technique is usually at the top of my list, as I figure if this isn’t fixed, the runner will keep getting irritated.)Runners, in particular, are interesting, because a runner will do anything you tell them to do – except stop running.

      • Philip Paul Tygiel PT, MTC said:

        :-). Here’s to Bruce.

  18. Janice M, PT, OCS, Cert. MDT, CSCS said:

    can’t look at anything til low back cleared – active, passive range; really look for deviations and pelvic motion as it relates to spinal motion (check T spine mobility also)
    then I’d get into hip motion isolated, then in relation to low back and pelvis (active and passive; and passive posterior glide-ability of femur in acetabulum)
    general strength testing in an isolated open chain format needs to be done to make sure each muscle activating (plus I’d go into sahrmann’s activation techniques for back, hip – look into her ‘anterior glide syndrome” that I see often in runners).
    I always do a quick “level-ness” check for possible leg length (structural vs functional): I especially like pube levels – easy to feel; and if sensitive that’s usually a tip off to look further for leg length and/or pelvic obliquities. then I’ll do a quick NWB vs WB foot check ; first ray mobility and 1st MTP mobility (esp into extension); check dorsiflex mobility at ankle..
    can’t do functional testing til all this is looked at first; then:
    single leg stance speaks volumes for athletes! too many functional tests on 2 feet not applicable to runners….
    then go into single leg dead lift motion (pelvis facing forward? kneecap facing floor? hip hinging or low back extending?)
    run shoe check is a must (make sure they bring in a pair with some miles on them -at least 100): look at the insole NOT the outersole for wear pattern! very very valuable info to be had from insoles: great insight to their run form.

  19. Hersh Shukla said:

    With the limited information that has been provided, and based on the symptom location alone, the lumbar spine is likely the culprit. That’s where I would start. I’ve seen this presentation many times, and I’ve treated the vast majority of them with a lumbar spine approach.

  20. Peter glatthaar said:

    Examination: Thor. Spine from T8 to lumbar spine , SIG, hip, muscles, nerves, fem. , obt.,
    Intestines Bladder…
    Test: up to end of Range
    MRI: exclusion of bursitis

  21. Linda Talbott, MS, PT, CSCS, certMDT said:

    I would start with a lumbar spine evaluation using the McKenzie method and see if the pain can be reproduced with repeated movements and/or sustained lumbar positioning. MMT/ DTR’s of the lower extremities; seated slump test, SLR and posterior to anterior articulations of L1 through L5 would be included in this part of the exam. From there I would examine the hip with ROM and strength testing , scour and repeated movements . Then I would look at pelvic alignment and from there would do a LE biomechanical exam from iliac crests to the ankles and include assessment of leg length; ITB, hip, knee flexor , quad and calf flexibility would be included. Functional tests could include single and double leg hopping. I would look at the type of running shoe he is using and compare that to what ever foot type he has to see if he is in the correct type of shoe. Also knowing how he trained to prepare for the first marathon would be important to know; i.e…say he always ran the same way on the same road may have been a factor and how long he took to prepare for the marathon, whether he had been doing 5K or 10K races prior, etc.
    Additional history needs to be obtained such as any pattern to when he gets the intermittent pain: walking, sitting, standing, sleeping, etc. At some point watching him run on a treadmill to reproduce the pain would be important to look at his running mechanics.
    Agree that stress fracture in the hip or pelvic area might need to be kept in mind, but depending on if the exam can reproduce the pain and what tissue seems to be at fault, I would trial a course of therapy first and if no relief, would send him back to ortho for further workup of CT/MRI.

    • Susan Bamberger, Dip MDT said:

      Linda,

      This is all great information, and will all lead to a very thorough picture. Be sure to ask yourself why you are doing each of these tests, and if all of these tests are necessary at the onset. If you find a leg length discrepancy and lumbar involvement, ITB tightness and issues with functional stability, where would you choose to start, and how would you determine which one is most effective?

      Red flags are always something we need to keep in mind, but we have the clinical skill set to assess safely over a period of 4 visits and refer when necessary. Just don’t treat until you know what you have.

      • Linda Talbott, MS, PT, CSCS, certMDT said:

        My first thought is to clear the lumbar spine…if that is the culprit after eval , then that is where I would treat. I listed sort of the order of how I would examine him: lumbar spine first, then hip, pelvic alignment and LLD would be the top 4 things. The rest would follow.

  22. Philip Paul Tygiel PT, MTC said:

    As always, an interesting case. Thank you for introducing it.

    Given the history, which structures are you going to examine?

    I would like a bit more history before deciding anything. Any previous history of back or lower extremity problems? How much training and what kind of training routine did this guy have before running his first marathon as a “new long distance runner?” What kind of athletic endeavors did he pursue prior to deciding he wanted to run long distances? Had he been running shorter distances with no problems for several years? Did he change shoe brands or type recently?

    As far as what to examine you have to start with a postural assessment. Look for functiomal or anatomical leg length discrepency. Gait and running analysis probably will not tell you much right now if he is in pain. That can wait until after the pain is under control but should be done before full return to running. The foot, ankle, knee SI and lumbar spine have to be cleared. Then full assessment of the hip joint and related structures can be done.

    How can we establish functional baselines and how vigorous can we be in our examination?

    Not sure about setting functional baselines just yet. Still need more
    of the information above. I would be pretty vigorous with my exam. I would want to see what provokes the pain. I’m not too worried about breaking his hip with any exam trechniques. Heck, the guys been walking and running on it without it falling apart. Not much I can do to create a worse fracture or dislocation with any exam techniques I can think of.

    What examination tests would you use, and why would you use them?

    I would not be in a rush to get an MRI until after I came to some conclusion about suspected pathology and saw how he was responding to whatever treatment I decided to start with.

    One thing I would try no natter what I found is an old trick from Florence Kendall. She would always try a heel lift in the opposite shoe of anyone with lateral hip pain even if she could not find an apparent leg length discrepency. She often found that by doing that and essentially placing the involved hip in slight abduction she could reduce the lateral stresses on the hip and eliminate the pain. Always worth a try. Sometimes simple solutions are the best. Thank you Florence.

    • Susan Bamberger, Dip MDT said:

      Phillip:

      Thank you for your comments, and to everyone for their comments. It is fascinating to see the diversity of replies to my case study, First of all, I think most of us are in agreement that the lumbar spine has to be cleared before moving on to the hip. The question is how? Many tests in the lumbar spine combine hip movements, and vice versa. In the end the answer lies in finding a lasting effect with the presenting symptoms, whether they are in the lumbar spine or in the hip. So keep that in mind as we move through the case study.

      Agreed, if this comes on with running, we can be pretty agressive. I agree, I don’t think moving him around to test this thing is going ot exacerbate a potential stress fracture. However, he has tried many things over the weeks and is concerned he is running out of options. If we are too provocative, we may discourage him from the get go.

      I am also not in any rush for an MRI; I want more conclusive evidence to the symptom response to my examination in the clinic before I send him back for a very expensive test. As I told him, we will know if we need to send him back within 4 visits of therapy.

      I love The Florence Kendall reference, but wouldn’t putting a heel lift on the opposite shoe cause an adduction force on the involved LE? In any case, I am nowhere near ready to start working on changing the structure- I want to see if we can make a mechanical change first.

      • Philip Paul Tygiel PT, MTC said:

        Hi Susan,

        You raise some interesting philosophical points and questions about patient care management that are not necessarily directly related to this case but are certainly worth discussing. That is one of the beauties about this forum. It often raises more questions and tangents to be discussed.

        Regarding tests that stress both the spine/SI and the hip, you are quite right in that more often than not these tests provoke both making differentiation difficult. When I was a younger PT and was quite sure that I knew everything and that my diagnostic and treatment skills were infallable, I could state with certainty that the problem was coming from the hip, or the SI or somewhere else and I could hone right in and treat the offending structure. As I’ve gotten older and hopefully wiser I am no longer so sure. For that reason, for the past few years when I treat what I think is a hip problem I also mobilize the SI and vice versa. It doesn’t take very long to mobilizew those structures and I seem to get much better, more consistant results. I don’t really care if it was one or the other or both as long as the patient gets better.

        Regarding being afraid to provoke too much pain for fear of discouraging the patient, I find that what more patients find discouraging is when I cannot provoke the pain during my initial evaluation. If I cannot provoke the pain the patient has no confidence that I am even close to being on the right trsck. Without that confidence it is difficult to establish a good clinician/patient relationship. Now I’m not sayimg that we have to provoke the pain to an excruciating level or a level that will leave the patient feeling much worse than when he came in. That is overkill. We should be able to reproduce the symptoms though.

        Lastly, regarding Florence Kendall’s heel lift approach – If you put a lift in the opposite shoe you will raise the pelvis on that side which will result in the involved hip being placed in slightly more abduction(Look in the mirror if you doubt that). This reduces the lateral stresses of soft tissues that cross the greater trochanter.

        I think that all too often when a patient has what we consider to be an ITB syndroome, we make the assumption that it is because the ITB is too tight and therefore we must treat it by stretching out the ITB. Please consider that it is quite possible that the ITB is not tight but rather being pulled taut because of any number of postural or biomechanicl issues ranging from true leg length discrepency to weakness of the abductors on that side. In that case stretching the ITB will not be helpful at all. Correcting the discrepency and strengthening the abductors may do the trick. (Note: I am not at this point diagnosing this patient as having an ITB syndrome. Much too early in the discussion for that.) As an aside this issue of tautness vs. tightness might also apply in discussing other problems we treat like plantar fasciitis, piriformis syndrome and scaleni/thoracic outlet syndrome.

        As far as not “changing the structure” before correcting the biomechanicl problem goes, If I can correct the problem and reduce the pain with $0.25 worth of 1/4 inch orthopedic felt I’ll do it first every time and worry about trying to correct the biomechanics afterwards.

  23. Erik Salley said:

    Because there are multiple musculoskeletal pathologies that can produce this pain pattern, all the tissues that can refer pain to this region must be examined. I would start with the lumbar spine, then pelvis, then hip using repetitive end-range loading strategies. Only moving to the next structure as the previous region is cleared. Functional limitations can first be established according to what he is able to do during the examination or according to his responses with further inquiry; squat, jump, hop, sole, etc. His running history suggests a moderate to significant amount of loading to provoke symptoms so I imagine we can be fairly aggressive. Of course this can be confirmed, refuted and / or modified as a result of prudent observation during clinical loading strategies ,e.g. lumbar eil/ fil / ril etc, pelvic then femoral-acetabular provocation.

  24. Gary Diny said:

    I have seen several of these and the symptoms can vary.

    A progressive activity/loading process should be done and noting how/if symptoms react. walking, squatting, stairs, single leg squatting, low amplitude jumping, higher amplitude jumping, low amplitude hopping, higher amplitude hopping would be a progressive loading process.

    ROM and strength sometimes do not load the bone enough to ilicit the true sharp bony stress fracture symptoms, may be low grade dull symptoms that might lead one to muscle/tendon related issues. If someone is highly reactive with strength and ROM testing, then more red flag thinking is warranted as to a femoral neck/pelvic stress fracture being high on the differential diagnosis. As I noted above, these cannot/should not be missed as they can lead to very detrimental outcome and surgical requirement for fixation.

  25. Larry D. Physical Therapist said:

    I would want to know if the x-rays were negative.

    I would begin my examination by looking at his global posture and assess the integrity of the sacroiliac joints. I would also look at the foot posture and assess for pronation or supination postures which may be a contributing factor. Of course I would also look at the hip range of motion and strength to determine if there are is a muscular imbalance contributing to the symptoms.

    I would examine the individual for a functional leg length difference which may indicate SI joint dysfunction. I would perform the weight bearing test which would determine whether or not orthotics would be indicated to correct foot and ankle posture. I would perform the Thomas test to check for hip flexor tightness, the FABER test and the hip quadrant test to determine whether or not hip pathology is present.

  26. Sandy C said:

    My initial target areas of interest would be the hip abductors and the foot.

    I would screen the entire LE chain. We already know the hip is irritated, biomechanically I would want to know why. In addition to lumber, hip, knee, and ankle ROM and strength testing – particularly hip abductors; I would also evaluate foot arch in both weight bearing and nonweight bearing.

    Functional measures would include single leg stance stability, squat, and step ups at a minimum. I want to see how the LE chain elements work together in functional activities. Ideally, get the patient on a treadmill and evaluate walking and running pattern. From the patient’s history, I would be suspicious of excessive pronation that was creating a hip internal rotation moment with the impact of running. If that was confirmed; a trial of pronation correction to determine any change in symptoms would be appropriate.

    Assuming the detection and correction of a biomechanical dysfunction, then localized treatment for the inflammation of the bursitis can be implemented.

  27. This is not a history its an overview – there are so many other quesions to ask the list is huge. There is only an indication for an MRI if you think like a physician – please can we have better care studies?????

    • Hi M Jubb! This is the first installment. More information will be provided but at this point the idea is to invite others to participate: given THIS information, what is the next course of action? The case will develop over the next weeks, so: keep tuned in!

  28. Leon Richard said:

    I’d begin with a thorough screening of the lumbar spine and pelvis myself. Then look at whatever remains of a hip exam. It’s anterolateral hip pain which reduces the level of suspicion of hip pathology. But the possibility can not be ignored. The presentation and history is indicative of an inflammatory process involving either the bursa or tendons of the hip region.

    Full range of motion, active and passive, of the hip and knee, ankle. And strength test, aggressively at the hip. I want to reproduce these symptoms and if I can not during my exam I may discuss with him running until he feels his pain and returning to the clinic immediately.

    Some want to argue “without MRI we are feeling around in the dark”. I would beg to differ. Without symptom reproduction we don’t know what we’re dealing with. MRI will rarely show you something that will affect his course of treatment without correlating symptoms.

    I’d reproduce his symptoms, perform my assessment. Discuss with him the risks and benefits of going ahead without imaging. We would decide on the best course of action for him, and head there. If he’s not better in 3-4 weeks, or he declines, I’d call the orthopedist and discuss that. Otherwise, send the orthopedist a copy of my evaluation and get this guy back to running.

    Frankly, it sounds like he’s been over-training and really forced the issue when running the marathon. We should be able to reproduce his pain, cautiously, without injuring him or causing further damage. Once we do that, treat with anti-inflammatory protocols and develop his home and therapeutic exercise programs.

    My initial thoughts are to look far away, and work my way toward the tensor fascia lata area… stopping only when I reproduce his pain reliably.

    • Gary Diny said:

      I think this patient needs an MRI to rule out an femoral neck stress fracture. In a long distance runner, that is the diagnosis until proven negative with MRI/CT scan, bone scan type imaging. This is something that if missed leads to big issues with occult fracture and possible surgery (fracture fixation or if unrepairable, a joint replacement) that can be avoided with proper diagnosis.

      Pain with ROM of IR, ER, pain with hopping on symtomatic leg are all flags for femoral neck stress fracture. Some other options are patellar-pubic oscultation noting side to side differences (stethescope at pubic symphysis, tapping on patella with reflex hammer, differences in sound are indications of + test).

      • Patrick Hansen said:

        While we are always concerned about red flags, I’m not sure an MRI until further evaluation of the symptoms is needed. I think you can safely reproduce his symptoms in the clinic. He sounds active enough to where anything you do in the clinic is most likely not going to do more stress to the bone than he already does on his own. I have not treated a patient with an active stress fracture in the femur, what are their pain symptoms usually like? His pain is now intermittent (though no information on what makes the pain worse at this time since he is not running). Would just walking or stairs make this type of injury hurt? Just curious, thanks!

      • Kory Zimney said:

        I would agree with Gary that a MRI may be useful to rule out potential pathology. If negative then it also provides reassurance to the patient that there isn’t any significant pathology stopping his recovery and that possibly the “hurt does not mean the harm” to tissues. Of course a good thorough eval as suggested by others would be important. If no significant findings on those were found then definitely the MRI might be warranted. Of course we would have to ask for this referral carefully as patient was sent from an orthopedist, so a call to the physician to see why they did not think it was needed. Maybe after they found out your findings along with theirs they may think it is needed.

        If something does show up in evaluation progressing carefully understanding that stress fracture is still possible.

      • That a very good idea, at least in ruling in your hypothesis. CT may be to much radiation for his age.
        But I would use a tuning fork it is done for other fracture.
        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681212/

      • Leon Richard said:

        Thank you Gary. Certainly, nobody can ever be faulted for caution in a case where someone’s future function is concerned. I’d certainly have a higher index of suspicion with groin pain, than with anterolateral hip and thigh pain for a femoral neck stress fracture. But it’s entirely possible.

        I think, as the case develops I’ll have clearer information regarding reproduction of symptoms. That will allow me to see more the way to go here. If it comes right down to I really suspect a femoral neck stress fracture, I’ll have to call the orthopedist and discuss the case with him. I wouldn’t recommend saying much to the patient about it until afterward. I’d give the surgeon the courtesy of a phone call, rather than questioning him to a patient.

        For my own purposes, reproduction of symptoms, and can I palpate what is hurting the patient or is to deep inside and referring outward?

        For my own purposes… I’d like to know where in his stride the pain occurs? Is the pain constant? When it began, was it intensely sharp and does the pain change once it begins or does it remain constant?

        A pain that is a 5/10 is not quite enough to slam the brakes on most athletes. They may limp a little, but most will play through 5/10, up to 6-7/10.

      • Gary, any literature available on patellar-pubic oscultation?

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