Category — Case Studies

Back in December (2011) a gentleman called me up and said he wanted to meet with me about doing some training because he wanted to ride in the Tour De France. We met at my facility to discuss what he had in mind and immediately I was intrigued as I knew it was going to be an interesting program.

Doug, a 52yr old masters cyclist, was looking to go to France in July and ride some of the Tour De France (not the actual race part that the pro guys are competing in, but an exhibition ride that takes place on the same stages the pro guys ride about one day before the pro guys role through – other pro’s and semi-pro’s ride this exhibition so there can be some heavy hitters here too). Doug has a left knee that will need to be totally replaced and was told by someone that strength training would be the best thing for him to help strengthen the muscles around the knee – so he figured having a strength coach work with him would be a good compliment to his riding program.

We began that day with some assessment and discussion of my ideas on training and preparation for the event and Doug informed me about who he was thinking about using for his cycling program. I told him this wouldn’t be a problem as long as the cycling coach could give him the program for me to look at so that I could make sure what we are doing at the gym does not conflict. We decided that this would work out just fine and we would begin in January as he was going to be traveling through Christmas and the New Year.

Two days after our initial meeting Doug called me up to say that he thought my ideas of preparation were interesting and was wondering if I could write the cycling program as well that way he didn’t have to bounce back and forth between two different coaches. I told him I wasn’t sure because I never wrote a cycling program but if he gave me a few days to do some reading I would let him know. Off to the library and Barnes and Noble I went for the next week! Reading. Thinking. Taking notes. Reading some more. Thinking Some more. Taking mote notes.

After a few days I let Doug know, “Yes, I can do it!”. After all, writing a program for cycling is not that much different than writing a program for other sports as long as you understand the physiological demands, you understand the energy systems you are attempting to focus on, and you understand how to sequence the training so that it makes sense in the big picture.

Tour De Roni

Before I get into talking about the training I would also like to bring awareness to the Tour De Roni fund that Doug was dedicating his Tour De France ride for. Doug is raising money for Roni, a young woman who is battling with appendiceal cancer. If you are able to donate anything or willing to spread the word about Doug’s fund and post this to your facebook or twitter pages we would greatly appreciate it. Here is the website for more information on donating – http://www.giveforward.com/teamroni – and here is Doug explaining the Tour De Roni cause (he did videos along the way through his entire Tour De France):

The Training

This was one of the most exciting experiences I have had as a strength coach because controlling all aspects of a program is really the best way to get what you want – this doesn’t always happen in the team environment where the sport coach can take the athletes and put them through grueling practices causing you to have to alter your program to balance things out a bit.

We began with some physiological testing to get an idea of where Doug’s max HR was as well as his anaerobic threshold. We also discussed all of his training over the past year to get an idea about where he was at and what he was doing. Like many endurance athletes I have worked with his training was a bit “scattered” – intervals one day, a hard spin class the next day, hills a following day, a long ride the next, a day of weights, maybe another long ride with lots of climbing – it was all over the map and lacked focus! Additionally, from our testing I could tell that Doug was leaving a lot of performance on the table because most of the training he did concentrated on extremely intense rides at high heart rates, basically trying to ride himself into the ground, not allowing for optimal recovery and a balance between quality hard work and quality restoration.

With all of this information I created a chart of training methods that we would draw from in our first two phases of preparatory training blocks. My initial goal was to back Doug off the high volume of intense rides through the week and build some volume using more cardiac output rides so that we could improve the function of his aerobic system and get him to rely less on his anaerobic system so that he could sustain higher power outputs with a lower percentage of his max HR. The program worked perfectly and within 5 weeks we rested his time trial ride and found that his power was through the roof in comparison to his first test and he was also riding at a faster pace at the same relative work rate. For lifting in this first phase we performed 2 workouts per week of just general strength training (3-4 exercises per session, 2-3 work sets x 8-10 repetitions).

Through the next phases of the program we hammered the aerobic system with a variety of rides and methods – hill repeats, cardiac power intervals, and high resistance spin bike rides – additionally lifting was increased to 3x/week with the intensity on two of the days being higher (3 exercises, 2-3 sets x 6-8 reps per set) and one of the days performing oxidative squats.

As we began to get closer to the event Doug’s fitness was really taking off. He was crushing hard rides, his power output was still increasing, and the speed he was riding at had improved nicely. He was hanging with some bigger riders on the road and was feeling very confident in his riding ability. Our last phase of training was the most intense and cycled through weeks of lactate power and lactate capacity using various climbs to prepare Doug for the climbs he would face in France. This phase was brutal but Doug hung in there, busted his butt, and reaped the benefits. One of the main benefits we saw in this phase was that during testing Doug’s max HR was now 10 beats higher then what it was at the start of training in January. The strength training program in this phase dropped to 1x/week with only moderate loads to maintain strength and we also used soft tissue therapy in this phase to help buffer stress resistance and allow him to be prepared for his harder rides.

This last phase of training was true overreaching. We trained Doug into a bit of a rut and saw a little bit of performance decrement before I backed off training with about 10 days until he needed to be in France. Doug was pretty beat up from this phase but we used some recovery modalities and easy rides to get him comfortable and back to normal and it worked extremely well. By the time he was ready to leave Doug was killing rides again – he even went up to Colorado to do some climbs.

The entire program was monitored using a recovery index profile that I use as well as the Bioforce HRV to help us understand how Doug was tolerating the stress of training.

The Result

Doug’s goal was to do well at the Tourmalet stage (one of the brutal climbs out in the Pyrenees). Doug did this event two years ago and felt that he wasn’t as fit, riding with the class C riders, and he even opted not to ride the Tourmalet that year. But this year would prove to be different for Doug. Doug, riding with the class A riders and being the oldest athlete out there, crushed the Tourmalet being the second rider in his group to cross the summit (the first rider was a pro cyclist who finished in the top 20 in the big race in Australia a few months prior). Doug did not miss a day of riding the entire time he was in France – over 300 miles of riding and over 28,000 ft of climbing. A successful Tour De France indeed!

Conclusion

I know it is common for strength coaches to just say “endurance athletes are weak and we need to just make the stronger”; however, I find this statement to be a bit limiting. Endurance athletes need specific physiological adaptations to excel at their sport and just training guys to be stronger and lift more weights, while important, should not be the main goal of training. The goal of training should be to improve them in their sport and this comes down to understanding their physiological and individual needs and then Tweaking Their Physiology to help get them there.

Once again, if you can spread the word about the Tour De Roni fund it would be greatly appreciated. As Doug says in the video above, “Cancer Sucks”.

Patrick
patrick@optimumsportsperformance.com

I am very pleased to announce that Dr. Ross Tourtchaninov was kind enough to include my soft tissue therapy case study on a collegiate football athlete with anterior knee pain in the latest issue of the Journal of Massage Science.

This is a free journal that Dr. Tourchaninov publishes himself and serves as a wonderful resource to the massage therapy community.

If you are interested in reading the case study you can do so HERE. Because the journal if focused specifically on massage therapy I did not include specific information on exercises that we used in the case study, however, you can read my assessment, thought process, and treatment approach that I used over the three consecutive days of treatment with this athlete.

Patrick
patrick@optimumsportsperformance.com

Below is the case study of a runner who was experiencing knee pain, not just when she tried to run but all day.  I was able to work with this woman eight times over a four month period (about two sessions per month) and the outcome was pretty exciting – especially considering the number of professionals this woman had seen for this issue over the past several years, with no improvements in her symptoms.

Background Information

• Chronic right knee pain for 5 years has kept this woman from running.
• She has had three kids, exercised through all of her pregnancies, including running, and had brief periods of back pain, but worked through them.
• Currently also has pain the right sacro-iliac region.
• She has seen various doctors, physical therapists, and chiropractors for this issue and the problem has not been solved.  Her husband is also a chiropractor who has been adjusting her frequently to try and help the situation.  He was present during the assessment to offer any other additional information about her condition.
• The knee pain is constant throughout the day.
• When the client was asked if she has found anything that has helped make it better she began to cry and stated that, “Nothing has ever made it better and I am afraid that I will never get to run or do normal exercise again.”
• The pain after her third pregnancy had gotten much worse and her whole body hurt, to the point that she felt she had fibromyalgia.  The pain all over her body has currently subsided and she only has chronic pain in her right knee and right sacro-iliac region.
• The last PT she went to told her to put some inserts into her shoe and then gave her open chain hip extension exercises which she claims did nothing except hurt her lower back.  So she stopped performing them and the inserts have not been successful in helping with her knee or back pain. 

Key Findings

• Extreme anterior pelvic tilt and very forward drawn.
• She barely had a toe touch (non-painful)
• Client has an upper chest breathing pattern just lying or sitting passively, which gets worse when she talks about her injury or is presented with movement challenges.
• Multisegmental extension was dysfunctional and painful
• Single leg multisegmental extension breakout showed the right side to be more restricted than the left.
• She was unable to perform rolling patterns in any of the four quadrants from either supine to prone or prone to supine.
• Thomas test was positive bilaterally (lower leg was almost in a straight line with the quadriceps!).
• Ober’s test was positive bilaterally (leg wouldn’t even drop down once I took my hand out from under it and emphasized that she needed to relax the leg, which she replied “was as relaxed as it gets”.). 
• Interestingly, the client had difficulty even just getting into side lying as lying on her side caused her to roll forward or backward.  Obviously if getting into the position is difficult, her side lying hip abduction was very poor.
• Active straight leg raise was asymmetrical, with the left leg raise being more limited than the right.  She was barely able to even lift the left leg off the table into flexion without the right knee flexing and the right hip rotating into external rotation.
• Prone hip extension showed the right leg to be more limited than the left and biased towards lumbar extension, anterior pelvic tilt, and hip rotation.
• Patella mobility is normal however she is very apprehensive when I move the right patella around.
• There is a leathery end feel with passive dorsiflexion and the client comments that her calves feel very “tight”.
• Right iliopsoas is very tender and produces a jump sign (I thought she was going to levitate off the table).
• Right TFL, Gluteus medius, and QL are more toned than the left.
• Trigger points present in the right rectus femoris refer knee pain which mimics the pain she feels daily.
• Trigger points in the right vastus lateralis refer knee pain that is familiar to her.
• There is tenderness at the quadriceps tendon and when the lateral and medial tissue around the patella are palpated or when the patella is passively moved from side to side it produces tenderness that is familiar to what she feels everyday.

My Thought Process

1. There is obviously a large psychological component to this clients knee problem, as she has been in pain for a long time and is visibly distraught about not being able to run, which is an activity that she loves and would like to some day do again.
2. The fact that the client was unable to even lie on her side tells me that she is incredibly weak.  The side lying posture and the side lying hip abduction are not only an appraisal of hip mobility and hip strength, but also the coordinated stability of the inner unit to fire appropriately to prevent any other unwanted movement.  Her husband, the chiropractor, even commented that he has a hard time adjusting her because she can’t lie on her side and stay there.
3. Treating the trigger points in the rectus femoris and vastis lateralis will be important because of their referral, which mimics her knee pain.
4. Addressing the anterior pelvic tilt and tone of the hip flexors along with glute strength will be important for creating stability in the sacroiliac region and taking the client out of the forward drawn posture.
5. Improving mobility prior to working on strength will be paramount in each session.
6. This client will need to start with the most basic, primitive patterns including straight leg lowering, toe touch, and multisegmental rolling from supine to prone.
7. Even though the client has a toe touch, she barely gets there and does not have a good posterior weight shift when doing so.  Because the multisegmental extension pattern was painful, I decided to begin by improving multisegemental flexion since it was dysfunctional but nonpainful.
8. Active straight leg lowering is an important pattern for her to re-learn, with a focus being on the left leg up in flexion and the right leg moving through the pattern, as this was the most dysfunctional in the assessment.  The fact that the right leg is unable to maintain hip extension when the left leg attempts to go through flexion is an asymmetry that I find to be very important for this individual to address.

Treatments 1-2

We began initially with soft tissue work to treat the trigger points in her right quadriceps and treated the psoas, iliacus, rectus femoris, and TFL bilaterally.  Muscle energy techniques were used for the hip flexors following soft tissue work to help improve hip extension mobility.  During the soft tissue work I coached her through appropriate diaphragmatic breathing.

Following the soft tissue work we performed active straight leg lowering progressions performing more reps with the left leg up (right leg moving) and superset it with crocodile breath to work on breathing.  We then got off the table and performed toe touch re-patterning progressions.

After toe touches were finished, and we saw an improvement in range of motion for the active straight leg raise and toe touch, we worked on rolling patterns from supine to prone.  At first I used an airexpad to give the client assistance in getting over from supine to prone.  Additionally, while on the floor, I would perform soft tissue work and muscle energy techniques on areas to help drive the rolling pattern.  Most notably, I was working on the neck to try and better drive the rolling pattern.

By the end of the second session the client was able to roll from supine to prone in all four quadrants and could perform a healthy toe touch.  We began to work on rolling patterns from prone to supine in session two, and again soft tissue work and muscle energy techniques were used during parts of the rolling pattern to help facilitate the movement. 

Treatment 3-4

The client was excited to report that her knee was starting to feel better and she had periods of the day that were pain free.  She does not  feel confident enough to run on her knee yet, but has started walking more outside.  Client has maintained her toe touch.

We again performed soft tissue work to the structures listed above and followed it by working on breathing, straight leg lowering and rolling patterns.

During the fourth session the client was now able to roll proficiently in all four quadrants from supine to prone and prone to supine.  Once she could perform these movements, we moved to performing bird dogs, tall kneeling chops, and stick RDLs (double legs first).  All exercises were superseted with breathing activities.

Treatments 5-7

Client is starting to do more walking outside, has started hiking, does not have pain in her SI-joint region, and has decreased knee pain that is only “minimal” after walking/hiking.

Soft tissue work on the structures above was repeated.  Client has maintained a toe touch and her rolling patterns.  The active straight leg pattern has improved substantially and is now symmetrical 2′s.

Warm ups include breathing, hip flexor active isolated stretching, straight leg lowering, 1-leg glute bridges, and bird dogs.

Exercise includes single leg RDL, half kneeling chops, and half kneeling 1-arm cable rows.  We also started performing box squats with body weight and an RNT knee pull into valgus using a pink cook band and emphasizing a more vertical tibia.

Treatment 8

Client was 20min. late to the session.  She came rushing in and was crying a little bit.  She apologized for being late and told me that she was out hiking before the session and felt so good that without even thinking about it she began to run and ran pain free for 20min. for the first time in five years.  We skipped the soft tissue work, did our warm ups, and worked on a few exercises and called it a day.

Patrick
patrick@optimumsportsperformance.com

Below is a case study of a soccer player who came to me following a quad strain during a soccer match and some of the things we did in the four sessions that I treated him.

Background Information

• Right quad strain on 9/12/10 during practice, while taking a shot.  Client reports immediately discontinuing play and resting and icing the quad for the next week, which was painful and had some swelling.
• 9/19/10 client reports going back to play soccer and re-injuring the right quad, which felt worse than the previous injury on 9/12/10.
• Client reports the leg aching with walking and said that he had been icing the right quad following the second injury.
•  Client has been performing a stretching routine given to him by a physical therapist after the initial injury (9/12/10), which consists of static stretching to the piriformis, quadriceps, and hip flexors.  The client states that he stopped performing the stretches after performing them for two days following the second quad injury because they were painful for his quad.

Key Findings

• Client was noticeably limping when he walked into the facility and commented that putting pressure on the right leg was painful and difficult.
• Because of the acute nature of the injury (client was seeing me three days following the injury) and because the client was noticeably in pain trying to stand on the right leg, I did not conduct an SFMA or standing movement assessments and went with more table assessment and some of the Janda assessments.
• Clients arches are very high and rigid, with little mobility (locked in supination).  The client commented that he has had many ankle sprains over the years.
• Active straight leg raise was less than 70 degrees bilaterally.
• Passive straight leg raise displayed limited hip mobility as well.
• Passive mobility of the hips were bilaterally stiff with hard end feel.
• Client exhibited a forward drawn posture with a bias towards flexion, which may have been even further exacerbated by his limping.
• Side lying hip abduction showed a bias towards hip flexion and increased rotation in the lumbar spine.
• Right prone hip extension led to lumbar extension, increased anterior pelvic tilt, and knee flexion (which can all be interpreted as potentially weak gluteus maximus).
• Left prone hip extension led to lumbar extension, increased anterior pelvic tilt, but no knee flexion (he was able to keep his leg straight during this movement).
• Obers tested was positive bilaterally and painful on right.
• Thomas test showed limited hip extension bilaterally, hip external rotation, and abduction (Right was more limited than Left).
• Hamstring strength was normal bilaterally.
• Left quadriceps strength was normal.
• Right quadriceps strength was weaker than left with discomfort.
• Quadriceps length (in prone) was significantly limited bilaterally (< 90 degrees).
• The right achilles tendon was tender to touch, and the client mentioned that last season he suffered significant achilles tendinitis problems.
• Right quad was tender to light touch.
• The musculature of the right lateral hip was hypertonic and tender.

My thought process

1. Because of the acute nature of the right quad strain, I was not going to be aggressive on the quadriceps and only treat them with some gentle skin stretching and light general effleurage.
2. My main focus will be directed at the lateral hip musculature, especially the TFL*, which are very hypertonic (probably from limping for the past few days).
3. To address the anterior pelvic tilt the goal will be to work on the iliacus and psoas, bilaterally, as well as treat the clients calves (especially the right calf which had suffered achilles tendinitis the season prior) and feet, which are very rigid and immobile.  Additionally, because of the clients over supination, I’ll work on the posterior and anterior tibialis.
4. Movement and strength wise, I will work with the client on improving the active straight leg raise pattern, which is problematic for him, and work to develop glute strength.

*TFL* – My thought process with treating the TFL when there is swelling and injury in the lower extremity has to do with its fascial connection with the fascia lata.  The fascia lata is the fascial sleeve which surrounds the entire thigh – meaning that even muscles which are antagonists to each other are connected together by this fascial sleeve (IE, quadriceps and hamstrings).  The thickest portion of this fascial sleeve happens to be the IT-band.  The tensor fascia lata’s (TFL) job is to tense this fascial sleeve and help move blood back up towards the heart.  My thought process is centered around trying to influence the TFL (which in a hypertonic and shortened position would be weak) to help improve blood, lymph, and fluid movement to help facilitate a healing environment.

Treatment #1 – 9/22/10

• Treated the right lateral hip, focusing on the TFL.
• Treated the right quadriceps with skin stretching and light effleurage.
• Treated the bilateral psoas and iliacus, and left quadriceps, to help decrease the anterior tilt.
• Treated the bilateral calves, posterior tibialis and plantar fascia.
• Treated the right hamstring.

Treatment #1 outcome

• Client felt better after the massage.  Right quad still felt sore and tender to the touch however client could stand on one leg and had improved ambulation.
• The client performed straight leg lowering corrections and glute bridges.
• The client was asked to foam roll the glutes, lateral hip musculature, and calves, as well as perform straight leg lowering corrections at home.

Treatment #2 – 9/24/10

• Client reported less pain and tenderness in the right quadriceps and no problems with walking.
• Repeated the same soft tissue treatment as in treatment #1.
• I was able to go deeper into the quadriceps on the right leg.
• I also focused a little bit more on working down the lateral leg, through the IT-band, to effect its connection and slide over vastus lateralis and biceps femoris.
• Again straight leg lowering corrections and glute bridges were performed.
• The client felt greater relief after this session and much less tenderness and pain.

Treatment #3 – 9/27/10

• The client reported feeling so well this weekend that he actually played in his game on Sunday.  He felt a little soreness in the right quadriceps late into the game after playing on it.  He did not feel 100% and was tentative to take any big kicks with the right leg, but felt good enough to run, dribble, and pass the ball.
• Repeated the same soft tissue treatment as before.
• Client then warmed up with active isolated hip flexor stretches, straight leg lowering, and glute bridges.
• Client then performed a dynamic warm up of some general movements and then we moved into some moderate paced skipping variations and short sprints at about 70% intensity.

Treatment #4 – 10/1/10

• Client felt near 100%, no longer had a limp while walking, and was back to playing and practicing.
• We repeated the soft tissue work in treatment #3 as well as the exercises and warm ups, and we were able to be more aggressive in all areas.
• Client left feeling good and confident that he was ready to play more aggressively

Final Outcome

Following the fourth treatment the client reported being back to playing and practicing normally.  He reports that he is back to taking normal shots/kicks with the right leg at full speed and intensity.  The client states that he has been actively working on his straight leg lowering pattern and has revised his pre-game warm up, from just jogging a few laps around the field, to including the movements and warm up techniques that we worked on during his treatment.

This client is by no means “out of the woods” with regard to his movement inadequacies.  Unfortunately, four sessions was all the time I had with him.  It would be advised that the client seeks out a professional to properly screen him and develop an exercise program that properly addresses his movement needs.  As evident from my short time with him, active straight leg raise is a big limitation.  This movement is the starting point for the FMS in the corrective exercise hierarchy, so addressing this pattern for the client is critical to ensure that the asymmetrical lower extremity mobility pattern is healthy prior to adding stability to the pattern and then soccer specific fitness (running, cutting, etc.).  Hopefully this client will take my recommendations seriously and work towards fixing his weak links.

Patrick
patrick@optimumsportsperformance.com

This case study is on a competitive powerlifter who was complaining of a “hamstring strain” that he suffered a little over five months prior to him coming to see me.  I’ll discuss a little bit of the background he gave me, some of my key findings on the table and with movement assessment, my thought process on what I wanted to do, and some of the main things we focused on in the two sessions I saw him.

Background Info:

• One year ago the client suffered a lower back strain after a squat/deadlift training session which is still bothersome for him to this day when he performs those lifts.
• His lower back feels chronically tight, even without activity; however, warming up and training makes it feel a little better unless he goes heavier on his lifts and then it can stiffen up.
• He reports straining his left hamstring a little over five months ago while performing some dynamic stretching activities.
• The hamstring is still very bothersome during activities and especially hurts when stretching and squatting to parallel.
• He currently trains six days a week and just lives with the chronic pain in the hamstring and lower back.
• He says that when squatting or deadlifting heavy he feels his weight shift further forward onto the right side and this usually causes the hamstring and low-back to act up and become more painful.

Key findings:

Table Assessment

• Client presents with  lower-crossed posture
• Passive ankle mobility has a hard end feel (left feels more restricted than right)
• Patellar mobility is tight in all directions (bilaterally)
• Right straight leg raise is poor (< 70 degrees) and provides discomfort
• Right passive straight leg raise has greater range of motion but still provides discomfort
• Right iliac crest and ASIS are lower than left iliac crest and ASIS
• Active side lying hip abduction is accompanied with hip flexion and external rotation
• Iliacus and Psoas are tender and feel hypertonic (bilaterally)
• Glute medius and TFL feel thickened and fibrotic
• Right hamstring strength is normal (with some discomfort)
• Right hamstring skin tone feels very tight with limited mobility
• Right adductor magnus was more tender than anything else during the assessment
• Right adductor flexibility is very limited with pain – Client says he feels the pain high up and points to the medial portion of his ischial tuberosity
• Obers test and Thomas test are positive bilaterally

Movement Assessment (key findings)

• Toe touch is dysfunctional non-painful – client reports that he has never been able to touch his toes in his entire life and has “always been very tight”.
• Right single leg toe touch is dysfunctional and painful – again there is pain on the medial portion of the back of the leg, and up towards the medial ischial tuberosity.
• Overhead squat was dysfunctional nonpainful.
• Left ankle mobility was much worse than the right when we tested active range of motion.

My Thought Process

1. I was leaning more towards an adductor strain based on his main complaints during the assessment.
2. The left ankle mobility restriction is a big time issue for this guy, as he complains of shifting weight towards the right foot and getting “more forward” on the right side during his squat or deadlift.  This is probably because he can’t get the dorsiflexion he needs on the left side.  He has to make the lift happen somehow, and going towards the right side is one way to do it.  He is a strong guy, so he can get away with it when the weight is lighter, but as things start to get heavy, the lack of left ankle mobility becomes a problem and sets off the chain of events that makes him shift forward on the right and irritate his right adductor and lower back.
3. His poor hip mobility and the lower-crossed posture are not doing is lower back any favors.

Treatment #1

• Soft tissue work was performed on the both lateral hips (TFL, glute med, attachments around the greater trochanter).  The musculature there was very thick and fibrotic but loosened up quickly and the tissue layers began to slide more freely over one another.
• I treated the Iliacus, Psoas, and rectus femoris on the right side to help decrease amount of anterior tilt and because the right side pelvis appeared to be lower than the left.
• I treated the left lower leg (calves) and performed some ankle mobility work with the client on that side because of its greater restriction compared to the right.
• Multi-directional friction was used on the belly of the right adductor magnus and along the right ischial tuberosity, paying special attention on treating the adductor magnus attachments there.  I also treated the other adductor attachments on the pubic bone (which were very tender) and performed some general massage on the adductor and hamstring muscle bellies.
• I finished by treating the lumbar erectors and QL, bilaterally.

Outcome of Treatment #1

The client felt less discomfort immediately.  The clients toe touch went from dysfunctional non-painful to being functional non-painful (right side unilateral toe touch was no longer painful either and was functional) and he was amazed as this was the “first time he ever touched his toes in his life”.  We finished with some more ankle mobility drills and I discussed these drills, straight leg lowering drills, and some hip flexor mobility drills with him to be used as his warm up prior to lifting.

Treatment #2

• Client reported feeling much better after the first treatment and only has a little bit of soreness after he stretches, but no where near as bad as it has been the previous five months.
• Client has maintained his toe touch pattern and it was still functional non-painful a week after the first session.
• I performed a similar treatment as I did in session one, to get a sense of how things felt.  His lateral hip musculature was much more pliable, less thick, and he had decreased tenderness.  The adductor magnus and the attachments for all of the adductor muscles were sill a little tender and the adductor magnus was again treated with multi-directional friction.  I worked some more on helping to improve his left ankle mobility.
• Prior to performing the straight leg lowering drills, we did some muscle energy technique for the hamstrings, which led to an immediate improvement in mobility.
• Active straight leg raise was now pain free and bilaterally symmetrical (2′s bordering on 3′s if we are using the FMS scoring system).
• Again the client performed his ankle mobility drills, keying in on the left ankle (performing double the reps on the left than on the right).
• We performed some active straight leg raise drills and because we had a gain in mobility (and it was pain free) in this session, I decided to move him towards some stability exercises to try and “own” his new range of motion.  We performed single leg glute bridges, 1/2 kneeling chops (greater number of reps on right than left), and 1-leg/1-arm RDLs to try and re-pattern the active straight leg raise.
• Client felt good and pain free following the session.  He had improved mobility and his toe touch was still functional and non-painful

Outcome after 2 treatments

The client informed me that everything is feeling great and was surprised that things felt so good after only two sessions.  He does not have any of the previous issues and has been diligent about performing the movements I showed him in his warm up and between warm up sets during his workout.  He is back to pushing heavy weight and is preparing for his next competition.

Patrick
patrick@optimumsportsperformance.com