Case Study: Soccer Player with Quad Strain

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