SPORTS MASSAGE SCENARO

Last issue we published a sports massage scenario (sportEX dynamics issue 8 page 18) which we have subsequently put to a panel of practitioners. Below we reveal their consider- ations and treatment suggestions.

Paula Clayton, sports massage practitioner at English Institute of Sport High Performance Centre, Birmingham

CLINICAL IMPRESSION AND ASSESSMENT This scenario could be pointing to a number of different possibili- ties such as infrapatella fat pad impingement, patellofemoral pain syndrome (PFPS), or a tight iliotibial band to name but a few. Hyperextension of his left knee is likely to have led to long and weak hamstrings and calves therefore producing tight quadriceps muscles due to a muscle imbalance, which in turn could lead to an anterior pelvic tilt and therefore hip flexor, lumbar and sacroiliac joint involvement.

Implications are that he has really over done it, especially as he felt rough before the second race which could induce tightness.

Important issues to establish include: ■ Is there an increased Q angle ■ Leg length discrepancy ■ Neural implications

■ Muscle tesing (strength,

■ Range of Movement ■ SIJ involvement

inhibition, weakness, correct ■ Does the patient run on a firing patterns)

camber ■ Has he changed his footwear recently

Does the subject pronate? This leads to internal rotation of the leg which increases the Q angle and contributes to the lateral sublux- ation of the knee cap.

If there is impingement of the infrapatella fat pad, this may cause posterior displacement of the inferior pole of the patella when the knees are hyperextended which may have a series of implications including association with increased anterior pelvic tilt.

Limited internal rotation of the hip could be due to soft tissue struc- tures including a tight anterior joint capsule, short adductors, a tight tensor fascia lata muscle and/or hip flexors. These all restrict knee movement and may contribute to patellofemoral pain syndrome.

A tight iliotibial band (possibly caused by over pronation, and reduced internal (medial) rotation of tibia) could lead to an over- active tensor fascia lata muscle and subsequent weakness in the posterior fibres of gluteus medius, leading to excessive medial rota- tion of hip, a possible Trendelenberg gait on the right side, an increased Q angle and resultant PFPS.

Poor pelvic muscle control (abdominals, gluteus medius, minimus, hamstrings, lateral rotators of the hip) and tight hip flexors may lead to an increased anterior pelvic tilt, increased lumbar lordosis, increased length and tension of hamstrings and abdominals. The lateral rotators tighten to provide pelvic stability due to weak glu- teus muscles therefore limiting medial rotation of the hip.

Once the muscle imbalances have been identified, these need to be corrected by focusing on the tight structures first before trying to strengthen inhibited ones.

20

Michael Nicol MSc, BSc (Hons), GSR, SRP is BASRaT Membership Secretary and rehabilitation consultant to Harlequins Rugby League

CLINICAL IMPRESSION Indications suggest that this is a straightforward case of ITB friction syndrome due to decreased flexibility of the ITB as well as excessive training load. However there are some other factors that need to be considered before going on to treat such a case.

ASSESSMENT It is important here to do three things: ■ confirm the diagnosis ■ rule out other possible causes ■ locate potential aetiology of the injury.

In light of this the following could have been carried out: 1. Single leg knee bend – this will often elicit pain as the ITB tendon rubs over the lateral femoral condyle as the knee flexes

2. Lumbar spine assessment – this is important as not only could the pain be directly referring from the lumbar spine but any problems there may contribute to the stiffness in the hip and thigh. 3. Pelvic stability assessment – this is vital as poor pelvic stability may lead to a drop of the pelvis on the non weight bearing side may lead to increased stress to the ITB on the weight bearing side.

www.sportex.net