Thoughts from the journey… Excerpts from a day in the life of Sherry McLaughlin

FAI and Hip Labral Tears

I frequent a running site where I get to hear about injuries that plague this group of athletes. There has been a recent increase in people complaining of hip pain, femoroacetabular impingement and labral tears. Some have had success with surgery, while many remain frustrated and have not been able to return to running.

The question that has to be asked is how did this happen to begin with? If the hip is sitting funny in the socket, then that is what ultimately causes a labral tear or wearing away of the femoral head.

For you people suffering with hip pain, know that there is a fix and it doesn't necessarily include a knife. We have had people contact us via email, receive a few exercises based on their answers to a few questions and they have become significantly pain-free in 1-2 weeks. It started out as my little pilot study and has yielded some really great results.

For you clinicians out there, there is a biomechanical fix.

Here are the things you want to check first:

1. Pelvic alignment - innominate inflares/outflares or anterior/posterior rotations will cause the hip to bind or pinch with IR/ER.

2. 90/90 hamstring test - if this is tight, check to see if they have a posteriorly displaced fibular head. You can fix that with a muscle energy technique or mobilization and it should improve hamstring length.

3. FABER's test - if this is (+) or limited on one side, the things to check are - latissimus dorsi flexibility (do the lat squeeze for those of you familiar with our techniques), correct inflare/outflares and mobilize the hip (this should be done last). If that doesn't work, check the opposite iliopsoas for a trigger point and if you find one, counterstrain it. Your goal is to normalize this motion as activating the glute is more difficult if this is restricted.

4. Piriformis test- If the patient gets a pinch in the groin with passive internal rotation, this also will impair the ability of the gluteal muscles to be activated during weight bearing activities. Common causes for this are inflares/outflares, a sacral torsion, trigger points in the iliopsoas or piriformis. Check these out on these patients and "fix what you find".

Remember, it's almost always about the butt... FAI and labral tears occur in hips where the gluteus medius and maximus were not functioning properly and more times than not it is due to a muscle imbalance or pelvic malalignment.

As for exercise intervention, once you determine why the glute muscles have taken a vacation, there are very specific ways to wake it back up. Stay tuned for more on this part.

Until next time...

The upper trapezius/opposite hip link…

I had a guy come in today with complaints of L upper trapezius pain that began insidiously over the past 5 months. He told me that his pain increases when he walks (he walks up to 4 miles a day) or when he is holding objects for a long period of time. He has a history of chronic lower back pain, L MCL tear (s/p 15 years) and broke his ribs on his R side 7-8 years ago in a motorcycle accident.

Visual observation revealed his R shoulder to be at least 1.5" higher than his L in sitting and standing. This position puts the L upper trapezius in a long/weak position and remember, it is usually the long/weak things that cry out in pain.

So, I set out trying to figure out why his R shoulder was sitting up so high. Checking the three key rotational spots, here is what I found:

Ankle - Decreased subtalar joint eversion on the R ankle; Decreased dorsiflexion on the L

Hips - Decreased L hip adduction (tight gluteus medius/ITB) and internal rotation (iliopsoas trigger point); Decreased R FABER (believe it or not, this normalized following counterstrain to the R quadratus lumborum trigger point)

Thoracic spine - limited L>R, primarily due to thoracic tightness (in other words, the range was normalized with thoracic NAGs)

After making the above corrections, his shoulder height was symmetrical. I told him to try walking his 4 miles tomorrow to see if his L shoulder pain was any better during that activity.

In the mean time, he is doing exercises to improve L hip adduction, R subtalar joint eversion and R gluteal loading and thoracic rotation.

The point is this: When the painful upper trapezius is on the lower shoulder, don't work to raise that shoulder up. Instead, hunt down the reason why the opposite shoulder is sitting higher. As you can see, the cause of a higher shoulder goes way beyond upper trapezius tightness. In this case, it came from a subtalar joint that wouldn't evert, a tight quadratus lumborum and a stiff thoracic spine and an opposite hip that wouldn't adduct. By the way, it isn't uncommon to see a quadratus lumborum trigger point on one side, and a gluteus medius trigger point on the other. They are, after all, functional synergists.

Until next time...

The dorsiflexion link to spondylolysis

I saw someone today who drove 7 hours to get an answer about her chronic back pain. That is some kind of pressure at the end of a long day.

She has had the pain for over 3 years. It all started when she was training for a triathlon. Left lower back pain with radiating symptoms into the L gluteal and thigh region. She felt it most when running. The pain persisted, causing her to undergo an L5/S1 fusion. That was in the summer of 2006. The pain has not gotten any better.

So, here is what I found...

She actually had severe tightness of the L gastrocnemius. This was picked up with the gravity drop testing with rotation to the R. So much so that the limitation in dorsiflexion has caused the beginnings of a hallux valgus deformity. She also had a trigger point on the L lateral gastrocnemius and L iliopsoas.

She performed a 1/2 squat prior to increased R knee valgus and L knee varus. Her sidelying thoracic rotation test revealed 50% rotation to the R, normal on the L. Her subtalar joint mobility was normal. She presented with a (+) FABER's test on the L, which was normalized following ITB soft tissue release and counterstrain to the iliopsoas tendon.

Now, if you are a bit confused, that is to be expected. This case leaves one a lot to think about. But see if you can picture this:

A lack of ankle dorsiflexion will result in a shortened opposite stride stance. In this case her tight L gastrocnemius was a major possible cause for this. This shortened opposite stride is linked to the trigger point in the L iliopsoas tendon. During gait, when the R foot is in front, the trunk is also rotated to the R.

In this case, lack of L gastrocnemius and iliopsoas flexibility has caused a functional rotational deficit to the R (notice her R sidelying thoracic rotation test). If you look at a model of a spine and cause the lumbar spine to rotate to the right, you can see how excessive R lumbar rotation actually causes facet joint compression on the L, a possible cause for spondylosis and spondylolysis.

The fix lies in restoring normal functional rotation to the R. I have prescribed stretching to the L iliopsoas, L gastrocnemius, L medial reach w/ contralateral arm at waist level to open up the ITB and restore normal L hip rotation (remember the positive FABER test?) and then work on strengthening the R gluteus maximus and medius (remember it is the overpronated side, potentially causing more supination on the L and perpetuating the already tight L iliopsoas)

If you have any questions, let me know. This is the third time I've seen a "spondylo" with radicular symptoms caused by improper rotation to the opposite side due to tightness in the ipsilateral gastrocsoleus and or hip flexor.

Worth noting...