I've written before about the potential need to address "muscle strains" with a neural perspective. Earlier this week one of my co-workers was doing a single-leg squat when he immediately felt intense and sharp upper inner thigh and upper posterior thigh pain. As a result, he displayed a significant antalgic gait pattern. I was busy that day, so I didn't get to look at him, but I, of course, suspected the potential spinal contribution.
The next day my co-worker came to me and told me when he tried doing a lunge the previous day his pain switched sides! If that doesn't tell you to look at the spine, I don't know what should. While he was feeling and walking a little better, my co-worker asked me to take a look at him at lunch.
Multisegmental Flexion: Slightly Dysfunctional Nonpainful
Multisegmental Extension: Significantly Dysfunctional Nonpainful
Multisegmental Rotation: Dysfunctional Nonpainful bilat
Deep Squat: Dysfunctional Painful
Sideglides in Standing: No significant asymmetry noted
HS Flexibility: WNL
Mild loss of hip flexion mobility bilaterally with reports of "tightness" in posterior hip
Hip IR/ER ROM: WNL
At this point, the most significant findings are the loss of lumbar extension and hip flexion. While I could have tried tensioning either the obturator or sciatic nerves, I was pretty certain the pain would respond to lumbar treatment. I had my co-worker perform a deep squat as his asterisk sign. My co-worker then performed 20 repetitions of prone press-ups with manual overpressure to the lumbar spine, followed by a reassessment of the deep squat. He reported a significant reduction in pain. Following an additional 20 repetitions, he had no pain with a deep squat and it became functional. I reassessed his lumbar extension and hip flexion mobility and some limitation remained. At that point, I did a lumbar manipulation bilaterally and hip distraction manipulation bilaterally to help normalize his lumbar and hip motion. His HEP was repeated press-ups and hip flexion.
There are a couple take-away points from this one. Always always always check spine. With "weird" symptoms, like switching sides, something neural is likely suspected, even if there is no lumbar pain. Also, in all our patients coming in with "muscle strains," perhaps we should be checking for neural components and trying to treat the spine as well. Both muscles strains and neural tension can present with a sharp and acute pain, so we must be sure to differentiate and treat appropriately.
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James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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