Isla Scott, physiotherapist and sports massage practitioner (scenario author)

TREATMENT PLAN Aims and objectives To loosen the base of his lumbar spine, piriformis, ITB and rectus femoris.

ITB and also the piriformis. The athlete was then placed in a supine position and effleurage techniques were used to flush the quadriceps.

I wanted to provide

effective stretching advice to enable him to stretch his hip flexors to facilitate him regaining a full range of movement in his hips.

Treatment The athlete was treated in the prone position lying with his feet over a roll to offload his lumbar spine. Deep effleurage techniques and compressions were used to loosen the left base of the lumbar spine. The athlete was then placed in a side lying position and deep effleuarage, myofascial release, compressions and trigger pointing techniques were used concen- trating on the proximal and distal extremes of the

The following stretches were demonstrated - quadriceps, hip flexors, piriformis, ITB and lumbar spine. The athlete was then advised to train to a level that was pain free.

Treatment (Session 2) The athlete returned five days later having just completed 15km on the treadmill pain free. He stated that he had done a one hour hard road session two days previously with no knee trouble. The above treatment was repeated, adding in facilitated stretches for his hip flexors and his quadriceps which continued to be restricted.

OUTCOME The total treatment time was two hours and the athlete returned to full training and contacted the clinic a week later to say that he was pain free and training at his pre-injury level.

a. Single leg standing (Trendelenburg sign) b. Gluteus medius inner range hold capacity

TREATMENT If we assume that this assessment confirms an overuse ITB friction syndrome with no related injuries, then the following would be a suggested management approach:

■ PRICE: it is important to ensure that inflammation is reduced as this is the source of pain, particularly relative rest and ice

■ Training errors: it is highly likely that despite the obvious weakness and poor flexibility that the main cause here was overtraining, as such it would be important to look at and potentially modify this athlete’s training programme

■ Fascial release: mainly to the ITB although this may include trigger points into the tensor fascia lata

■ MET stretching: rectus femoris and lateral rotators of the hip using reciprocal inhibition/contract relax

■ Increased motor control and endurance of the pelvic stabilisers eg. inner range holds for gluteus medius, supine bridge on Swiss ball.

Once the symptoms have been treated and some of the causative factors removed a graduated return to activity may be started. Strength exercises that utilise single stance phase eg. single leg squat would be carried out to ensure optimal strength. Assuming the patient is still pain free at this stage mileage and intensity of mileage could be increased slowly towards full training.

THIS ISSUE’S CASE SCENARIO IS AS FOLLOWS: Case presentation: Symptoms ■ Footballer presents with non specific groin pain on the right side

■ No trauma ■ Has prescriptive orthotics ■ Trouble sleeping

Objective assessment ■ No pain on active, passive or resisted adduction ■ Pain on abduction ■ Pain on palpation ■ Tight hip flexors ■ Restricted internal rotation on the right side ■ Tight right adductor ■ Inhibited post fibres of gluteus medius and tensor fascia lata on right side

■ Hypertonic Ql right side

Despite a range of conservative measures this player didn’t get better.

Question: As a practitioner, what else would you consider?

The answer will be revealed in the October issue. You can discuss this case study at the new discussions area of our website at www.sportex.net

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