Friday, August 17, 2012

No Longer Hamstrung

Last fall a local triathlon coach referred one of her clients to me. He'd been in physical therapy for some hamstring issues that were hampering his running. Things weren't getting better and she thought he'd be up for an evaluation with me.

D had been running marathons and half-marathons for quite a while. In his early 50s, he was in great shape and potentially looking to try a triathlon or two, in between marathons. But for the last 4 months, he'd not been able to really run at all. The guy who used to be able to walk out the door and hit 6-10 miles without a problem couldn't finish a mile without both hamstrings "locking up" and forcing him to shut it down. It was killing him. He thought he was washed up.

A few things caught my attention in the evaluation. First, D had been working with a local personal trainer, but the leg work consisted of leg presses and a few walking lunges, with some scary heavy barbell deadlifts thrown in on occasion. Second, there was a history of a slight lumbar disc herniation several years ago that he'd basically forgotten about. No real dysfunction after he'd had the MRI at that time. This little tidbit became more intriguing after he told me he could ride his bike or an upright stationary bike for hours on end without issues, along with run hills relatively pain free. Hmmm. Was the hamstring pain disc-related and relieved by a bit of lumbar flexion in these instances? Finally, D never did any structured warm up other than a bit of jogging prior to really running.

D had religiously gone to physical therapy 3 times per week for 4 weeks the month before and basically saw no change in his function. The visits were sometimes up to 90 min so I was curious to find out what type of work he'd been doing. As much as I hate to say this, once again I was utterly disappointed to find out that he'd been doing traditional physical therapy fare: stationary bike, calf raises, wall slides, supine hamstring stretches, seated leg curls. He did everything that was asked of him and was basically independent while he was in the clinic. At no time was he given a structured warm up to do prior to attempting to run. He also had a mysterious groin pain (that also came up when he started running) that had been extensively worked up without any definitive diagnosis.

My evaluation quickly revealed a few key things, at least in my mind: 1) super tight hip flexors, 2) super tight IT bands L > R --left hammy always locked up first, 3) hamstring length within normal limits. SLR test for disc issues negative. Movement skills were ok; he'd just not really done any multi-plane lunging or bodyweight squatting. Functional strength was lacking. Nor had he ever been shown how limited his anterior hip mobility was. I could provoke the hammy pain and groin pain with certain hip movements and positions in standing and half-kneeling. I could also lessen them with specific movements and postures.

My theory was that this guy needed to learn how to warm up; his hamstrings were likely battling some of the tightest anterior hip musculature I'd ever seen and they needed relief. This body needed global movement and specific mobility. I contacted his triathlon coach and we coordinated a return to running plan, emphasizing warm ups and gradual increases in speed/volume. D chafed at the whole dynamic warm up thing at first, but began to understand the necessity of a good warm up after he was able to finally run close to marathon race pace on the treadmill only after swimming and biking in a local indoor triathlon.

We did 8 formal physical therapy visits and then transitioned into post-rehab work about once every 2 weeks for 2 months. D also continued with his personal trainer, but promised me he was doing our extra warm up work and doing "approved" leg work: Gambetta leg circuits, lunge & reach, lunges with rotations, 1/2 kneel and sidelying hip mobility work, Hexlite bar deadlifts, jump rope, multi-plane jumping jacks, step ups. The groin pain disappeared fairly quickly. The hamstrings were a bit more challenging.

Long story short: D is back in action and doing well. Now this took about 9 months to do and there was lots of trial and error with the re-introduction of running into his life. There were many emails back and forth that included me and his coach. We needed his feedback after specific workouts to determine what was working and what wasn't. We needed him to buy into consistently warming up the legs and improving his hip mobility. We needed him to back off on intensity and volume and gradually work back into things. We had to educate him on what it means to train like an athlete.

It has also helped that D has transitioned into triathlon full-time vs. just running. He says his running volume is now half of what it used to be and that he is enjoying the swimming and biking; he feels fitter and fresher. He also has a new personal trainer who has a track background and supports D's newfound approach to workouts. No more heavy leg presses or barbell deadlifts with suspect form. He is religious with his mobility work.

I am thrilled. D has his groove back and having a grand time training for his first Half-Ironman. There is nothing better than helping someone become pain-free and giving him or her back the joy of movement.

I wanted to share this story because I think it illustrates some of the challenges faced by active people who have chronic musculoskeletal issues. For many, the traditional physical therapy model does not work. First, the therapist is way too busy seeing too many patients to spend time communicating with coaches or patients outside of face-to-face appointments. There are always important variables outside the therapy session that need to be addressed.

Second, there are way too many therapists who are stuck in therapeutic exercise purgatory. Their toolbox is out-of-date and does not evaluate for or work to develop basic movement literacy and physical competencies. Their approach is driven by an anatomically-based diagnosis, not a movement-system based diagnosis. And it is limited by referral or insurance-based time constraints. Sometimes 4-6 weeks just doesn't get it; many of these issue develop over months or years of poor movement patterns.

Finally, the typical therapist is not able to really spend quality time giving movement feedback and direction to patients. I spent every minute with D watching him like a hawk, peppering him for feedback. How in the world can you expect anyone to make movement therapeutic if it isn't done with precision, with purpose and under educated supervision?

Movement, properly dosed over time, is my modality. If I allow a patient to just go through the motions, I am failing my patient, myself and my profession.

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