Today’s case study is an interesting example of a hidden transverse-plane (rotational) dysfunction in a Division 1 athlete that went undiagnosed by a certified athletic trainer and the team chiropractic doctor. This is an excellent example of the pain focus and causative problem not being in the same place.
Knowledge of the treatment principles for rotary activities (tennis, golf, baseball, vacuuming, raking, bending with twisting, etc.) is essential in your multimodal chiropractic treatment toolbox. It starts with assessment and continues with treatment for both mobility and stability dysfunctions.
Since we move in synergy within all three planes, a dysfunction in one plane may manifest as pain in an apparently unrelated movement pattern. Obviously, all planes of motion need to be assessed; this case focuses on rotational (transverse) plane assessment and treatment.
Presentation / History
Mary, an elite Division 1 high jumper, presented to the office with a primary complaint of mid-thoracic pain that began insidiously approximately one year previously. Low back pain of a lesser degree was also noted. No specific injury or causative event was noted. A secondary complaint of “chronic tendinitis” in her knees, with the left being worse, for several years was also mentioned.
Previous treatment for her back pain included “mobility drills,” foam rolling, and CMT by the school’s DC. For her left knee pain, she received a PRP injection (it is significant that her left foot is her takeoff foot). Her only allergy is to peanuts, she was not on any prescription medications, and denied any other significant illnesses or injuries.
Although she felt tightness and soreness, it did not prevent her from training or competing. The pain was “just there” and she felt it was “normal from all my training.” However, she did find back squats and compressive loading of the spine exacerbated her lower back pain, so she discontinued those exercises. Pull-ups, rows and hex-bar squats did not aggravate her mid- or low back pain.
Clinical Tip: The thoracolumbar stability mechanism creates stability for rotational activities and is maintained by increasing tension in the thoracolumbar fascia. However, the canister mechanism for stability (the diaphragm and pelvic floor) protects the lumbar spine from compressive loads. Therefore, at this point we know Mary needs diaphragm and pelvic-floor strengthening for certain.
Examination / Findings
Examination revealed no nerve root compression or traction signs, as DTRs, sensation and motor strength of the major muscles were all WNL. Chiropractic evaluation revealed joint dysfunction at the right SI joint, L5-S1, T12-L1, and T5-T8. The thoracic kyphosis was reduced, lumbar lordosis was increased and pronation was noted bilaterally.
Ankle dorsiflexion was limited to 10 degrees bilaterally and pain free, with a stiff end feel in the ankle mortise joints bilaterally. Dynamic Trendelenburg test revealed weakness in the gluteus medius bilaterally. Prone leg lift demonstrated poor contraction of the gluteus maximus bilaterally and the gluteus medius firing pattern side-lying was dysfunctional bilaterally – it demonstrated hip flexion. Modified Thomas test revealed hip flexor tightness bilaterally.
Clinical Tip: The gluteus medius maintains the hips level in the frontal plane and controls the femur from adducting (rotating medially) with weight bearing. Therefore, Mary’s “jumper’s knee” and gluteal weakness are related. This is reinforced by her hip flexor tightness, which indicates quadriceps dominance – another provocative factor in patellofemoral pain. Finally, her lack of ankle dorsiflexion impacts the knee due to inadequate shock absorption as she plants her takeoff foot.
Bodyweight squat assessment revealed limited descent as well as an increased forward lean of the torso. It also produced an increase in the lumbar lordosis. Elevation of the heels allowed for an increased descent, underscoring the significance of the lack of ankle dorsiflexion found on chiropractic testing.
Functional assessment demonstrated full-body rotation to be limited bilaterally, slightly greater to the left, and was consistent in tall kneeling. However, in the lumbar locked position, thoracic rotation was nearly full, and with slight overpressure it was normal.
Therefore, Mary’s rotation deficit was in the lumbopelvic region, which explains why the prior treatment of thoracic CMT and mobility exercises was not effective.
Clinical Tip: Let’s put it together: In the sagittal plane, Mary has quadriceps dominance; in the frontal plane, the gluteus medius and lateral subsystem are relatively weak; and the transverse plane has a lack of mobility in the lumbopelvic complex.
Treatment / Outcome
Treatment consisted of myofascial release of the iliopsoas (pin and stretch, post-isometric relaxation), and CMT based on joint restrictions in the sacroiliac joints, costovertebral joints and bilateral ankle mortise joints. Post-treatment rotation was bilaterally symmetrical and in full standing, kneeling and lumbar locked positions. (Visual learners can watch the assessment at YouTube/DrDeFabio: “One-Visit-Wonder: Back Pain Fix.”)
Corrective exercises outside the office included gluteal isometrics with bridging and prone hip extensions, and diaphragmatic breathing. Instructions were also provided to the trainer at Mary’s school to strengthen the entire gluteal and hamstring complex, especially the gluteus medius.
Clinical Tip: Optimal full-body rotation exposes the opposite shoulder when viewed from the rear and is performed with uncompensated movement. Standing, the feet are together; in tall kneeling, the knees are together; and in lumbar locked position (similar to child’s pose), the legs and knees are kept together. Deficits in the lumbar locked position indicate thoracic mobility dysfunction; tall kneeling deficit indicates lumbar or thoracic dysfunction; and standing is an overall screen.
Take-Home Points
Assessment of movement in all three planes can be performed on all your patients in just a few minutes. However, if pain is preventing movement, the pain driver must be addressed first. The areas of joint dysfunction will need CMT; tight, shortened soft tissues will need to be lengthened (use your technique or modality of choice); and stability concerns need to be addressed with isolated strengthening and movement repatterning.
In the stability / mobility continuum as described by Boyle, the thoracic spine is stable, the lumbar spine is mobile and the pelvis is stable. In this case, the thoracic spine was fully mobile, yet the lumbopelvic hip complex required mobility and possessed unusual presentation.
Regardless, a thoughtful approach to treating your patients requires an inquisitive mind and expansive therapeutic toolbox.
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