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Runner with hip pain: progress & reassessment

By guest blogger, Susan Bamberger

The patient is better, but symptoms are not fully resolved. In determining the next step, considerations include the following:

  1. Analysis of the exercise:
    • Is he performing the exercises as prescribed?
    • Is he reaching end range?
    • Is the exercise correct?
  • He is performing the exercise correctly, and he is reaching end range. It is too premature to abandon the exercise. In one visit, he is demonstrating improvement, as he can run longer and with less pain.

2) Is he doing anything between the exercises that may aggravate his symptoms?

  • In his detailed journal, he had stopped all the other stretches as requested, and had not really changed his regular routine. He was not doing anything in his life that might aggravate the hip.

3) Was there anything about the posture of running that might aggravate his symptoms?

  • In this case it made sense to assess his running posture. This was not a running gait analysis, but rather an evaluation of the hip posture in relation to the understanding that his range of motion decreases and pain is produced when running. A derangement causes a mechanical obstruction, and therefore I wanted to see what it was about his running that was causing the mechanical obstruction.
    Example of the running posture he was assuming:

McKenzie runner b

With the forward flexed posture, it was reasonable to conclude this may contribute to his pain presentation. He was experiencing 2/10 pain when running during this demonstration, as he had just run over for the visit. So, I asked him to stand more upright by engaging his hip extensors. With this positional modification, his pain went away.

Visit three

Two days later, the patient returned, reporting he could run longer- 15 minutes, vs 10 minutes before, He reported he was learning to run upright, but was not able to maintain his upright posture, When he experienced pain, if he corrected his posture, the pain went away immediately.

Correcting posture with activities can be a process that takes a long time to correct. It is best to correct the pain before the pain comes on, but at first this may be challenging. With diligence, he should be able to permanently fix his running posture and avoid aggravation of his symptoms.

Since we were on visit three and he still could only run 15 minutes, it made sense to reassess the effects of the exercise. It was not completely clear that the stretch prescribed was enough to fully reduce his symptoms. At this point, it made sense to intentionally aggravate the symptoms through progressive mechanical loading to determine what it takes to fully reduce the symptoms.

Pt had 0/10 pain prior to the start of the start of this test. The patient performed unloaded hip flexion, or walking marches: there was no effect. I then had him perform walking marches into a full lunge, which reproduced his symptoms to a 3/10 and reduced his range of motion .I then had his perform his prescribed exercise, which reduced his pain to 2/10, but did not abolish it. I then encouraged him to hold his stretch 5-7 seconds longer, which abolished his symptoms altogether.

His instructions were to hold his stretch a little longer, and to gradually increase his running, integrating the prescribed exercise into his running, Some minor adjustments of the exercises gave him the results he wanted- a full resolution of symptoms.

He was given guidelines for getting back to running up to 30 minutes at a time. He was given the guidelines for pain production. He was instructed not to be afraid of the pain, but to respect it and be sure to move it when he feels it, so as to not aggravate it as he had during the marathon. He was instructed on what to do if his hip does truly worsen to the point that it causes constant pain; to perform the stretch regularly and take a few days off from running.

Visit 4: 2.5 weeks later

The patient was pleased that he was able to run up to 30 minutes without exacerbation of symptoms. He was so pleased with this progress that one day he tried running faster with some of his running buddies, which pushed his hip harder and further than he had been. During that run, he got the same 5/10 pain he had at the marathon. After the run, he immediately went back to the hip extension exercise. While they helped, they did not immediately abolish his pain as they had before.

An exacerbation of symptoms can be used as a learning tool for the patient; to see if they understand the principles of self management. McKenzie and May state in The Lumbar Spine: Mechanical Diagnosis and Therapy (2004) “At the first sign of recurrence, the patient should immediately commence the procedures that led to recovery”. Learning how to manage symptoms when they recur is a key to long term recovery and prevention of disability.

To determine if he understood these principles, I asked him what he did. He understood that he had run too fast and too far, and was not ready for it yet. He immediately went back to an increased frequency of hip extension in half kneeling, and stuck with them regularly for 2 days. He also stopped running altogether for a few days. Within a few days he felt much better, and was ready to start running again.

Using the last visit as a baseline, we tested the irritability of his symptoms through progressive mechanical loading. I ran him through the same litany of tests as before. Standing hip flexion had no effect. Walking marches into a full lunges had no effect. He then performed many squats, lunges, lunges with torso twists, and side lunges over the course of 25 minutes. None of these symptoms reproduced his symptoms or created any mechanical change, indicating a vast improvement from the testing we had performed during the last visit. My instructions were to continue with self treatment and gradually increase his running program.

The patient came in three more times over the course of four weeks. During these visits, we would mechanically test the hip as we had previously done. His hip remained stable, as there were no mechanical symptomatic changes with progressive loading. At this point in the program we started to work on hip strengthening exercises. He wanted to return to the exercises he was doing before, so we reviewed what he was doing and discussed how he could integrate the hip extension exercise into his exercises: If he overdid the strengthening and his left hip pain resumed, he could utilize the hip extension exercise to self manage his symptoms.

By the time he was discharged, he was running pain free up to 10 miles at a time, at his desired pace. He was contacted a few months later for permission to publish this case study He reported he was gradually increasing his running, was still painfree, and was on track for his next marathon..

In 8 visits over 6 weeks, this runner progressed from not running at all to training for a marathon again without pain. As health care changes, we have to be poised to prove our value in providing cost effective care. Ask yourself:

  1. How can we set ourselves apart as leaders in health care? What services can we provide that patients find valuable in this information age?
  2. How can we maximize health care dollars and prove to our payers that physical therapy is a valuable tool?
  3. What tools are you going to use to prove you are effective and necessary?

Thank you for your attention to this case study. I have enjoyed hearing from so many of you and hope you have received value through this exchange. Feel free to leave any parting comments below. Warmly, Susan.

 

A FINAL NOTE FROM EDUCATA:

If you found this case study interesting, you might really enjoy delving deeper into the McKenzie Method. During the month of June, EDUCATA is making this 2 CE-Hour course available at 20% off its regular price. Simply click here, proceed to checkout and enter coupon code MTD613 to avail yourself of this very special offer.

McKenzie 6-2013 promo 3

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ASSESSMENT: zeroing in on the problem with our runner

 By guest blogger Susan Bamberger

Thank you all for your detailed and well thought comments on the first installment of this case study! At the end of the history, we should have some idea of what might be going on. Performing a detailed interview will help to create hypotheses that we can test in the physical examination.

Giving some thought to pathoanatomical causes, it is possible the he may have a tendonosis of the psoas. It is also possible that he has a mechanical impingement of the hip joint. He may also have a structural defect such as a labral tear. The symptoms could be coming from the lumbar spine or the hip, SIJ, knee or foot. It is also possible that he has a stress fracture. Each of these pathoanatomical possibilities are managed in different ways. How do you discern which to treat?

While the pathoanatomical possibilities are there, we do not have the ability to look inside and determine the exact cause. The most accurate information we have in front of us in this visit is the patient’s pain presentation and its behavior of symptoms. We can look at the behavior of symptoms and assess for change in these symptoms through the course of testing. This will become the most effective guide in developing a plan of care.

My assessment utilizes Mechanical Diagnosis and Therapy (MDT) which is used to target the problem based on symptom presentation and behavior. More common in the spine, MDT has proven to be reliable, valid and prognostic in multiple studies conducted over the last 40 years. However, the principles of assessment can easily be utilized in any joint of the body, including the hip.

As I begin to plan the physical exam I must consider all of the factors contributing to his recovery:

  • The pain is a 5/10 on a 0-10 scale, 0 being no pain and 10 being the worst pain ever imagined.
  • It comes on as soon as he begins running and it ramps up immediately. However, it goes away within a few minutes after stopping his run.
  • He does not notice the pain otherwise- he sleeps well, and does not feel the pain when going up and down stairs.

He has been trying to run every few days, without any noticeable change. Any objective baselines I find must be related to the exact pain he experiences when running. However, he was not prepared to run on this visit, so another baseline will need to be used.

To get a solid baseline, I may need to be pretty aggressive in my examination on day one. However, in order for trust to be established, I decided not to try and provoke his symptoms, but rather to educate him in the assessment process and the need for him to participate in the analysis.

The location of symptoms indicates the pain could be coming from the hip or the lumbar spine. The behavior of symptoms does not exclude the hip or lumbar spine. So a screen of the lumbar spine was necessary before exploring the hip in detail.

The physical exam reveals an athletic man in no apparent distress. Left hip passive range of motion into flexion, abduction internal and extension rotation were tested in supine. IR and ER were tested supine in 90 degrees flexion. Extension was tested in side lying. Flexion ROM is approx 100 degrees and painful. Abduction is approx 25 degrees and painful. There is a minimal loss of internal and external rotation, with pain greater into external than internal rotation. Extension lacks approximately 5 degrees to end range.

Resisted motions are strong and painless in all directions except flexion and adduction, which are weak and painful. These tests were performed in supine. Resisted flexion in supine, in particular, produced his primary pain. This was the baseline to refer back to when I perform my mechanical testing later.

While special tests ( Hip scour, compression) could be performed, none were performed on visit one. The patient had been referred from his orthopedist, who was confident there was not an operable structural issue, and there was nothing yet in the history that indicated surgical referral. At this time, special tests did not have a practical use. If there was not a consistent response to the repeated motions, at that time special tests may be indicated for further clarification.

Screening for the lumbar spine did not reveal any significant lumbar component. This was done by first checking for lumbar range of motion in standing, flexion, extension and side gliding were  within normal limits. To determine if the lumbar spine was involved, 15 progressively loaded lumbar extension mobilizations were performed in prone, and then his primary baseline ( resisted hip flexion in supine) was retested for change. There was no change, indicating it was necessary to move to the hip for further testing.

The next step is the repeated movement examination, a key component of the MDT assessment process. Responses to symptomatic, mechanical and functional baselines give us the information needed to classify his condition and devise a directed and effective treatment plan. Repeated movements can be performed dynamically, with sustained positions or with resistance. If the baselines demonstrate an immediate and lasting change, the classification is derangement and the prognosis is excellent.

Repeated hip extension in half kneeling was the first movement chosen. Given the irritability of the symptoms, half kneeling would provide a great deal of force, and is a good start to providing movement that will provide immediate and lasting results. The direction of extension was chosen as this is often the direction most frequently seen for patients with hip derangements. The position of half kneeling was chosen as a relatively aggressive position, knowing that since an aggressive force was needed to produce the symptoms, that an aggressive force would be needed to reduce the symptoms.

The patient had 0/10 pain at the start of the repeated motions exam. There was some pain at the end of the range of the first repetition, in the same location as his primary pain. This pain progressively improved with subsequent movement, as did his ability to move further.

In retesting his primary baseline (5/10 pain with resisted hip flexion in supine), 10 repetitions of dynamic hip extension in half kneeling reduced his pain to 4/10, and 10 more reduced it further to a 2/10. His ROM in all planes were restored to symmetrical and within functional limits.

runner flexing

With an immediate and lasting change in range of motion and pain, the repeated motions exam confirmed a classification of derangement, indicating an excellent prognosis. As his pain decreased, his strength also improved, indicating the weakness with resisted hip flexion was more likely related to pain inhibition than true strength loss.

Since we have not actually tested running, we cannot conclude that this movement alone will resolve his primary pain. However, since we were able to find a baseline that reproduced his primary pain, and it changed with the repeated motions exam we have something to start his treatment plan.

The patient was sent home with instructions to assess the effects of this test over the next few days. He was instructed to discontinue any other stretches he was performing, and to perform just this one exercise until he came into the clinic again. This would help to determine the effect of this one stretch alone. Specifically, he was instructed to do hip extension in half kneeling, 10-15 times, 4-5 times throughout the day. In a few days, he was instructed to test running, to see if a few days of the repeated hip extension in half kneeling produced any positive results for running. Pt understood the mechanical issue, and experienced the immediate results during our assessment. He was eager to take a role in the analysis of his symptoms.

Visit two

Four days later, the patient presented to the clinic with a journal describing his pain behavior and exercises. There was a consistent effect with the exercise: immediate discomfort, then a loosening of the range of motion and a lessening of pain with each subsequent repetition.

He had tried running two days, and was encouraged as he could now run 10 minutes before experiencing pain. In addition, the pain was not as intense- it was a 2/10 instead of a 5/10 as before. He ran to the clinic for this visit, and was experiencing a 2/10 pain towards the end of his run to the clinic. He demonstrated the exercises, and was performing them correctly.

The patient is better, but is it enough to continue with the current plan of care?

What would you like to add to his home program at this time?

What would you do on this visit?

What other treatments would you want to apply, and why?

And… The Results Are In! Part IV, Severe Central Cervical Pain Case Study

Chris Chase PTBy guest blogger Chris Chase

I’d like to start this fourth & final post by answering questions that came up. The provisional classification of derangement syndrome as defined by Robin McKenzie was confirmed. The initial treatment goal of a cervical derangement is to reduce the condition, and, as shown in Part III, we obtained rapid reduction of pain level and an increase in ROM. Part of full reduction means obtaining full ROM and removing obstruction to movement. For an acute derangement with a lower cervical kyphotic deformity, that means obtaining full lower cervical extension which we were able to reach during our first session.

Maintaining full extension will be challenging. So, exactly what home exercises will he do to maintain his reduction? Many great ideas were offered, and I’d like to focus on two important themes:

  1. It is generally easier to perform self-treatment in sitting position, so whenever possible I tend to use seated exercises for my cervical patients. However…
  2. …deformities usually need to be treated supine due to the severe obstruction to movement.

I gave him two exercises and gave him specific advice about his sitting posture, sleeping posture, and avoiding prolonged flexion activities, especially computer work and while driving. I also instructed him to do his exercises hourly or as soon as he felt his ROM beginning to obstruct.  This may seem unreasonable but since the exercises only take a couple of minutes and will hopefully only need to be done for a few days at this frequency, it is practical.

Shawn was returned to the seated position and retraction and retraction/extension were attempted in an upright chair. Unfortunately even though his pain was only a 1/10 and he could rotate and sidebend better, loaded cervical retraction was quite difficult and still partially obstructed. He could perform both supine retraction and extension off the table but, since he desired to return to work by the following day, I wanted him to have an exercise available where he would not have to lie down. I had him stand against the wall to try retraction and his head bumped the wall, so I folded over a pillow and placed it across his shoulder blade area.

With his thorax away from the wall he could perform retraction quite well and considerably better than when attempted in sitting. I instructed him to perform both retraction standing as well as supine retraction and supine extension for his self-treatment.

With this condition, if he can maintain the extension, I generally expect quite a rapid recovery, although not all deformities can be treated quickly. Left untreated, this condition could deteriorate and potentially turn into a deformity of torticollis which is much more difficult to treat, and often takes longer.

Shawn and I exchanged emails in the ensuing hours. He reported 85% improvement, could move his head even better as the day progressed, and returned to work. I emphasized that, even though he felt better, he needed to maintain his self-treatment exercises and return for treatment the next day.

When he came in the following day (a bit over 48 hours from first assessment), he reported feeling 95% better even confessing that his exercises were not done as frequently as instructed given his rapidly improving condition. He never filled his prescription for muscle relaxers and was not taking any medications. I emphasized the importance of maintaining full pain-free ROM for at least one week before attempting flexion movements but told him he could decrease the frequency to 5-6 times a day –more if he felt increased pain or stiffness returning. Here are some images of his ROM gains 48 hours after initial assessment:

REASSESSMENT: RETRACTION

REASSESSMENT: EXTENSION

REASSESSMENT: FLEXION

REASSESSMENT: RIGHT ROTATION

REASSESSMENT: LEFT ROTATION

REASSESSMENT: RIGHT SIDE-BEND

REASSESSMENT: LEFT SIDE-BEND

At this point I instructed Shawn to return in one week for further care, unless he became obstructed again, in which case he should call to get in immediately. At one week, he felt 100% back to normal and was only doing the exercises a few times a day. Flexion, rotation, and all movements were now pain-free and back to his pre-existing level of  function.

According to treating the derangement model, the first order of business is to reduce the derangement, then maintain the reduction before performing recovery of function activities, and finally, to perform a preventative home program focused on maintaining full ROM, especially in the reductive direction (in this case, lower cervical extension) and continue to practice proper posture. Shawn was instructed what to do if his pain returned: avoid sleeping in extreme positions of flexion, break up static flexion activities (slouching ) with intermittent lower cervical extension, and to always end cervical stretching exercises his reductive exercise (retraction/extension). With ongoing practice of this advice, I anticipate a low chance of recurrence. However, Shawn has now been educated in how to self-manage and knows to get into PT right away if the problem returns and he cannot self-manage.

IN SUMMARY

There is much to be learned from the treatment  of Shawn. Be patient and attempt to restore extension slowly with this presentation. Manual therapy can assist in treatment with gentle manual traction, but there is no need for manipulation or aggressive techniques. Once Shawn’s deformity was reduced, self treatment and good posture were very effective interventions emphasizing that there may not be a need for expensive modalities, numerous treatments, or outside referral. Shawn has continued to do well. Within two weeks, he was climbing again, exercising regularly, and even occasionally doing his exercises.

* * * * * *

Thank you to everyone who contributed to this case, as it was unveiled. I hope it was useful and informative and I look forward to any additional comments or questions. I have enjoyed my first blogging experience.

Chris

The “Three-step treadmill test and McKenzie mechanical diagnosis” paper is available for free to EDUCATA members. Not a member? No problem! Registration is easy and free — and has benefits!

The McKenzie Method course is approved for CE credits in most states and provides a great overview to this practice.

Part III: TREATMENT (central cervical pain case study)

Chris Chase PTBy guest blogger Chris Chase

TREATMENT

It is now time to begin treatment to see if we can assist Shawn with his painful condition.

Based on his sudden onset, his obstruction to movement, and constant pain presentation, I provisionally classified him as having a lower cervical derangement with kyphotic deformity and chose as the course of action the treatment  outlined by Robin McKenzie. For this condition, it requires unloading the patient and attempting to reverse the forward flexed position of his lower cervical spine by moving into lower cervical extension gradually. It is recommended to start with the patient’s head accommodated into flexion, and I chose to use folded towels to control the degree of protrusion.

I had Shawn gently retract into the towels and as his pain slowly decreased, I then removed one towel at a time. He had slightly less pain in this position, so we started to move out of the forward flexed position, and his pain began to lessen significantly. The following pictures were taken over approximately 30 minutes of treatment with Shawn performing intermittent retraction into the towels, and eventually into the treatment table.

Once Shawn achieved maximum retraction into the table, I began to push further extension off the table while cradling his head. At this point, gentle traction was applied while assisting his pain since gaining retraction was still quite slow and difficult.  It took a considerable amount of time and repetitions before he could get to end-range retraction off the end of the treatment table, and the degree of traction was slowly increased to promote increased lower cervical extension.

This took an additional 10-15 minutes.

Shawn was returned to the upright seated position and his baselines were rechecked. His ROM was mildly better, but his pain was considerably less. Because it was still improving, overall, we agreed to continue treatment and  attempt further improvements.

The next progression recommended by the McKenzie Method is to apply extension to the lower cervical spine. I returned him to supine since seated movements were still obstructed. While attempting extension, I still applied traction as we worked into lower cervical retraction/extension because it was it was giving us a very good response. Slowly, his ROM improved to the point where I could fully extend him to end-range. Pain levels continued to decrease and became centralized to a very small area at the base of his neck.

Attaining full extension took at least another 15  minutes of repeating the movements in sets of approximately 8-10 repetitions with frequent breaks between sets. At this time, all efforts were made to prevent any protrusion or lower cervical flexion between sets of extensions.

After repeating end range mobilization of his lower cervical spine into extension and before attempting sitting, Shawn was placed into sustained end-range extension three times for 1-2 minutes to ensure he had attained end-range extension. Throughout Shawn’s entire treatment, we were monitoring his pain intensity and location. At no point did things intensify or worsen. In addition, special attention was given to screening for any unusual findings including dizziness, nystagmus, visual disturbances, feelings of nausea, etc. None were reported, in fact, he could not believe how much better he was feeling as our treatment progressed.

At this point, Shawn returned to the upright position with only slight central pain and approximately 50% better ROM. He was given a very specific home exercise program, ensuring he understood the precautions, and was instructed to return in 24 -48 hours for reassessment. He was also told to call the next morning if his pain worsened in any way.

So, at this time I’d like to throw it back to you:

  1. Is the provisional classification of derangement correct and, if so, what is our primary goal?
  2. What is Shawn’s home exercise program and is there any other special advice that needs to be given?
  3. What is Shawn’s prognosis and do we expect a slow or fast recovery?

I look forward to the ongoing discussion! In our fourth and final post I will share the results of Shawn’s treatment with photos of his ROM after 48 hours. I will also discuss the overall management of Shawn’s case and long term treatment plan.

………………………………………………………………………………………….

This paper is available for free to EDUCATA members. Not a member? No problem! Registration is easy and free — and has benefits!

The McKenzie Method course is approved for CE credits in most states and provides a great overview to this practice.

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