In an effort to be as transparent with patients and practitioners alike, I have decided to intermittently post case studies of the patients I work with. I have decided to begin doing so after reading a recent post from Dr. Doug Kechijian of Resilient Performance Systems. For consistency and ease of reproduction, I have elected to use the format by which Doug presents his cases as well. I have included Doug's introduction below.
"There are too many abstract discussions in the performance space these days about how to train and rehabilitate athletes. These circular arguments usually yield nothing substantive or actionable because providers spend too much time defending their ideology and trying to articulate why they are in the right instead of just being transparent and “showing their portfolio”. As an example, investors should demand that financial advisers share their own portfolios instead of pontificating about macroeconomic theory. Words matter but what people do when they have skin in the game reveals more about them than their explanatory justifications for said actions.
The point of these case studies is not to suggest that what we did in any of these situations is particularly good. If we’re being honest, we don’t always have robust outcome measures to suggest that what we do really “works”. More often than not, we default to the eye test. We coach and own our decisions. The intent here, therefore, is to be completely transparent about what we did when an athlete’s time, money, and readiness was at stake in hopes that other providers share their experiences and contribute to a more genuine collective conversation."
-Doug Kechijian PT, DPT
Background
Female recreational athlete with recent onset of right shoulder pain with tennis serve in addition to chronic right hip and right knee pain. All complaints have been exacerbated by increased Tennis activity. Patient was referred to me by a Personal Trainer in Dallas.
Constraints
Time: none, patient is open to plan of care without time constraints.
Logistics: No factor
Financial: Patient elected to forego out of network benefits and pay out of pocket.
Interpersonal Factors: Patient is active and working with a trainer ~2x/week. Patient has dealt with recurring injuries for several years and seen many practitioners with limited benefit.
Evaluation Findings
Shoulders:
Internal Rotation: L: 90 R: 70
External Rotation: L: 80 R: 80
Supine Flexion: L: 140 R: 140
Pain in the right anterior shoulder exacerbated by end range internal rotation. Upper trap, neck and pec minor pain not reproducible with passive movement.
Hips:
Internal Rotation: L: 50 R: 45
External Rotation: L: 32 R: 45
Adduction Drop Test: L: + (lim add) R: + (lim ext)
Straight Leg Raise: B: 90
Hip pain reproduced on right side with left hip adduction. Right hip adduction produced stretch but no pain in usual painful right hip location.
Plan of Care
Given the patient's age, training history, duration of injuries, evaluation findings and desired level of activity it was determined she would benefit best from a physical therapy program lasting 8 weeks. Over the course of 8 weeks the patient would be seen in the clinic 7 times and given weekly program progressions with detailed dosage and home exercise videos. The patient was also granted text/email access outside of sessions to ensure optimal program compliance and performance.
Session 1:
90-90 Hip Lift 3x5 breaths
Stand Bilateral Posterior Mediastinum Expansion 3x4 breaths
Left Sidelying Right Adductor Pullback 3x4 breaths
Right Sidelying Left Glute Medius 3x3 breaths
Trunk Lift 3x4 breaths each side
Patient given home exercise program of Standing Bilateral Posterior Mediastinum Expansion 4x5br, Right Sidelying Left Gluteus Medius 3x4br and Alternating Trunk Lift 3x3br.
Session 2: 8 days post initial visit
Patient reports ~60% improvement in right shoulder, has continued to play tennis.
External Rotation remains limited in bilateral shoulders and hips. Internal Rotation limitation has resolved.
Tx:
Supine Hooklying Bar Reach 3x5br
Standing Bilateral Posterior Mediastinum Expansion 3x4br
Right Sidelying Left Adductor Pullback 4x3br
Left Sidelying Right Hip Abduction 3x5br
Modified Elevated Sideplank 4x4br each side
Home Exercise program changes included removal of Left Glute Med (internal rotation) and addition of Right Glute Med (abduction) as well as alternating days of Trunk Lift and Modified Elevated Side Plank
Session 3: 5 days following last visit
Anterior shoulder pain has resolved, upper trap region right shoulder pain continues.
Shoulder and hip external rotation 100 and 45 bilaterally respectively. Shoulder flexion limited to 140 bilaterally
Tx:
Standing Bilateral Posterior Mediastinum Expansion 3x3br
Sidelying Right Hip Abduction 3x5br
Modified Long Seated Overhead Press 10# DB 3x8 (patient seated on bench with knees straight)
Alternating Respiratory Single Arm Pulldown 3x5br each side
Right Intercostal Expansion Over Physioball 3x4br
Patient's HEP progressed with reps of exercise and given Vacation Option of Standing Bil Post Med Exp and Trunk Lift for trip out of country.
Session 4: 8 days following last visit
Patient reports her knee pain has resolved. Now she has remaining cramping in the quad muscle but no pain. Patient feels her shoulder pain has resolved as well.
All upper and lower body tests suggest patient is neutral (not limited).
Patient reports wanting to feel more explosive during sport activity and wants to run with more efficient technique.
Tx:
Standing Bil Post Med Exp 1x5br
Modified Elevated Side Planks 4x4br each side
Explosive Stair Ascension 3x8 steps each side
Step over (riser+1) 3x5
Running Gait analysis (noticeable heel strike ~3 inches in front of anterior hip)
Running Gait Cadence Practice (Static and dynamic)
Patient's HEP progressed by reps and sets for Elevated Side Planks
Session 5: 6 days following last session
Patient reports she is feeling really good but her right upper trap tension has returned.
Lower body tests remain negative, upper body tests reveal decreased bilateral shoulder flexion and left shoulder HGER.
Tx:
Standing Bil Post Med Exp 1x5br (all tests negative following exercise)
Patient shown lacrosse ball STM technique for UT
Lateral Stairs 3x8 each side
Bil Ab Pulldown 3x5br
Modified All Four Belly Lift 3x4br each side
Running Gait Analysis (reduced heel strike, continued foot contact in front hip)
Pose Method Fall Practice
Sidelying Hip Lift
Patient's HEP updated to Modified All Four Belly Lift and Pose Fall Practice to encourage proper trunk rotation and efficient running technique.
Session 6: 11 days following last appointment
Patient reports after a long session of tennis she felt her pec but it was not painful, is not concerned with sensation.
Patient feels fatigued today
Upper and Lower Body tests indicate neutrality (not limited)
Tx:
Running Gait analysis (patient improved foot strike to underneath hip but is leaning back at torso)
Running Mechanics progression
Lateral Stairs
Elevated Side Planks
Patient's program remained same with additional cue to relax upper torse while running.
Session 7: 7 days following last appointment
Patient reports feeling great and satisfied with improvement/running pattern. Very mild cramping in right knee muscle after extended sitting but not bothersome enough to require treatment.
All tests negative (no range of motion limitation).
Tx:
Resisted Right Glute Max in sidelying 3x5br
Three Point Stance Sideplank 3x3br
Running Gait Analysis and Practice
Patient given final HEP included Resisted Glute Max, Three Point Stance Side Plank and Running through fatigue.
Patient discharged.