History:
1) had surgery about 10-12 months ago – left adductors. He told me he got 2 procedures done at once.
2) Currently gets cramping sensations in TFL. Glut med is also extremely tender, all on the left side. TFL is extremely painful when palpating. His hip flexion pattern on left leg is poor. My thinking is that iliopsoas is not doing its main function of hip flexion and that the short adductors and TFL and try to compensate the movement of hip flexion? Going on Sahrmanns weak synergist idea.
3) Has good days (no pain), and bad days (slight pain). But he would always be aware of his hip.
4) He cannot perfrom any knee dominant exercises, particularly split squats. Pain in adductors of left leg. Gets some cramping in TFL with some hip dominant stuff but no pain at all in adductors.
5) FMS – squat pattern is v poor, his in-lunge is also v poor. Shoulder mobility v poor.
He is currently finishing his football season here in Ireland, and then hoping to get a good off-season of strength and re-hab work in.
To me it seems he does not respond well to doing strength work one day and football training the day after. His hip seems to have a limited time frame of work capacity before it bothers him.
His tissue quality in adductors is not terrible. In and around pubis bone he has some scarring though.
1. Let’s get a surgical report or communication through the surgeon to find out what kind(s) of approaches and techniques were used. Surgery by name of X can mean a dozen totally different things sometimes. Considering the direction of invasion, what muscles had to be resected, etc. are all factors that can explain why you are seeing what you are seeing.
Did everything go well? I don’t expect the surgeon to say he F’d this and that up, but when you see things that don’t make sense, sometimes there is an easy answer.
This may explain a lot of the lateral symptoms despite the suggestion that the surgery was for medial structures.
2. Keep in mind that TFL will often be a reactor. When there is poor spinal stability, the ASIS hip flexors will take over. They were likely facilitated for some time as a component to the original symptoms and injury. Perhaps now they are not talking back, but screaming back at your athlete. Gentle release choices should be employed.
3. I would agree that the psoas is involved, but I would not start there. And yes, the TFL and Sartorius can become dominant in the presence of an inhibited psoas. If that’s where you’re coming from, then yes, I agree.
But before you look for the psoas efficiency, I would look to segmentally stabilizing the spine in the sagittal plane. Supine should be with legs propped into hooklying, and progressing the hip flexion over maybe a 2 week period until he can hold his legs up with mild hip ER and knee flexion and hips as flexed as he can. This is the precursor to restoring Active Straight Leg Raise and Toe Touch.
Prone should begin in crocodile position progressing to low propped on forearms to elbow to cobra pressup. Using extension oral-facial drivers and cervical extension here can be useful to facilitate the multi-segmental extension pattern.
The breathing in these positions should not only reflect a “belly,” but lateral expansion as well. The ribs should depress, and the umbilucs should descend. This is always what a concerted training breath should reflect.
When you believe you have sagittal stability, retest the psoas. This may sound like a slow go, and if it is, let’s look at it from the complicated surgery and pain you are seeing with him.
4. Don’t expect a proficient split squat if he can not extend in the hip. Look at the Janda Hip Extension Test. Look at Thomas and Faber. Look at standing hip extension with a trunk plum line. How far does the hip alone extend.
Can you be old school and just split squat high in a pain-free range and see what that gets you? But also remember that working things like ASLR and TSPU could free up the limitations if you can put split squat on the side for now.
5. In terms of the FMS, if he is in pain, those patterns probably aren’t the best indicator movements. We’ve already discussed MSF and MSE of the SFMA.
Ignore the Deep Squat and Inline Lunge for now. Shoulder mobility is a priority. Huge priority. Work that for the rest of the season hard since he is still playing, and the lower quarter volume is likely going to outrun what you can do from a manual therapy or corrective exercise approach. Sometimes the car just needs to be put up on the lift. If that can’t happen now, do what you can do, but the shoulders are a huge impact to what is happening on the hip. I believe there is literature that the SM screen is the best predictor of Star Excursion Balance Test proficiency. Stick to the recipe and use your skills.
