BOX 2: THE THOMAS TEST Used to test the flexibility of the iliopsoas muscle group.

Standard version (see online extras video) n Patient is supine with one knee flexed and held to the chest at the point when the lumbar spine begins to flex. n Assess the thigh of the opposite leg to determine if it maintains full contact with the treatment surface. n This test is positive if the thigh is raised off the table.

Modified version n Patient is supine at the very edge of the treatment table. n Patient brings both knees to his or her chest. n In this position, the patient performs a posterior pelvic tilt. n While the contralateral hip is held in maximum flexion, the tested limb is lowered back towards the floor.

This test is positive for iliopsoas muscle tightness if the thigh is raised off the table. If the knee extends when an extension force is applied to the hip, then the rectus femoris is considered tight.

BOX 3: THE OBER TEST Used to assess tightness of the iliotibial band and the tensor fascia lata.

n Place the patient in the side-lying position with the test limb uppermost. n Extend and abduct the hip joint. n Attempt to lower (adduct) the leg down toward the table and release it. A positive test is found if the leg remains in the abducted position.

Ober test (Box 3) was also restricted tensionally compared to the right side by 5o

. His hip movements were positive for restriction on the

left passive range of movement on internal rotation of about 10 degrees with tensor fascia latae and iliacus as the main culprits. Other testing included ligament stability tests for the

knee, squats double and hopping, Trendelenberg gait analysis and muscle resistive tests for the thigh and hip, but they showed no signs.

The only functional test that reproduced minor signs was single leg squats at parallel. It was also noted that his left foot was slightly over-

pronated compared to his right. He already had orthotics for this and they had recently been reviewed.

DIFFERENTIAL DIAGNOSIS The differential diagnosis consisted of: n Meniscal irritation (suggesting inflammation of the meniscus from a trauma, overuse, or tear, etc.) n Myofascial pain n Referred pain from the hip or lumbar spine n Patellofemoral joint syndrome (PFJ) which includes poorly localised patella pain.

Contributing factors to PFJ include: n Increased femoral internal rotation n Increased knee valgus n Increased tibial rotation n Increase subtalar pronation n Inadequate flexibility, patella position, soft tissue restrictions and neuromuscular control of the vasti. There was also the possibility of a combination of the

above pathologies. 8 sportEX dynamics 2009;21(Jul):7-9

TREATMENT

Initial treatment began with soft tissue massage and trigger- point therapy to bilateral quadratus lumborum muscles. This was followed by: n Muscle energy technique – to correct ilium and sacrum. n Myofascial tension technique (MTT) – to the left gluteal fascia (to improve the Ober test) and to the thoracolumbar fascia bilaterally (shear/tensional load was applied to the area of greatest myofascial restriction). n Soft tissue massage and myofascial tension technique – to the left tensor fasciae latae and cross-fibre mobilisations to iliacus (to improve internal rotation of the left hip). n Myofascial tension technique – to the left rectus femoris to improve prone knee bend and Thomas test range of movement. n Trigger-point therapy and soft tissue therapy – to the left vastus lateralis to reduce functional signs for the one-legged squat (trigger-point therapy treatment consists of specific longitidinal gliding and stroking to the site of the trigger point; treatment to trigger points on the muscle belly reduces tensile load to the attachment sites). n Trigger-point therapy – to the left popliteus for tibial extension. n Soft tissue massage and trigger-point therapy to the tibialis posterior (for over-pronation of the left subtalar joint).

OUTCOME Following the first treatment, a marked improvement was noted for 4 or 5 days at a drop of symptom score to 1 out of 10. The second treatment gave the same result, but unfortunately there was a full return of symptoms when the patient went running. At this point it became clear that the treated muscles had a significant relationship to the condition, given the change in symptoms. However the return of symptoms indicated that there was some underlying problem so the patient was referred on to a Gonstead chiropractor for assessment and treatment of any spinal or lumbopelvic structural restriction. They adjusted the S2 which indicated the posteriorly rotated sacrum (Box 4). Then the patient was referred to an exercise physiologist for functional testing of the lumbopelvic area. This testing was undertaken using real-time ultrasound to assess endurance strength. The results were interesting as there was a fatigue pattern on the left gluteus medius on endurance load. Further investigation revealed that he had recently competed in a half iron-man endurance race where he had modified his road bike to a time-trial configuration with no professional setup.

This adaptation resulted in an extended forward position

of his body. The time between the modification and racing in this new position was only 1 week. Such a short period

BOX 4: GONSTEAD CHIROPRACTICS

Developed in the USA by Dr Clarence S. Gonstead (1898–78), this form of chiropractics deals with the spine – anatomically and physiologically – as one highly integrated neuromusculoskeletal complex. It is based on the concept that changes in one area of the spine, whether functional or organic, can and do produce biomechanical and neurophysiological changes in other areas of the spine.