Case Study #2

DEBBIE LENSING, DPTInstitute for Athletic Medicine

Eden PrairieEdina

Patient Presentation

• 30 y/o male

• Ran 1st Marathon June 19th 2010 – July 2010 pain onset L lateral knee

• Presented in clinic in August 2010

• Running history

– 20-30 miles/week average

• No other previous running injuries

• Presently training for Dec 2010 Marathon

Chief Complaints

• L lateral knee pain• Aggravating factors

– Running beyond 6 miles and post run

– Prolonged standing– Prolonged walking

• Relieving factors– ITB strap – minor relief– Did not rest much

• MD Orders: L ITB syndrome – running eval

Activity

Previous Activity Level

• Ran Marathon – Grandma’s Marathon June 2010

• Marathon time = 4:37:52

Current Activity Level

• Running – but pain at 6 miles

• Running 20 miles/wk-would like to be at 40 miles/wk

• Biking painfree

• No strength program

• Prior to marathon was doing Cross Fit program

Goals

• Pain free running

• Would like to complete Dec marathon ‘BAREFOOT’/5 finger shoes

• Goal is Marathon Dec 2010 sub 4:30 marathon – Team in Training - Hawaii

• Would like to be up to 40 miles/week

• Continues to wear 5 finger shoes with training

Objective Exam• Structural Analysis

– Genu varus L>R with standing alignment

• Feet / Footwear

– L>R pes planus

– Normal Forefoot mobility

– Normal Ankle DF ROM and TCJ mobility with step forward from 8 inch step

Lun et al. Br J Sports Med 2004; 38:576-580Wen DY et al. Med Sci Sports Exerc 1997; 29(10):1291-8

• Strength (with MMT)– Strong: B quads and

hamstrings, hip abductors, hip flexors and hip extensors.

– Weak: L gluts noted with single leg bridge and delayed glut firing with prone leg extension

Objective Exam

• Palpation

– Just proximal to L lateral femoral condyle

• Functional Testing

– Lateral step down

– SLS balance

– B squat

– Hop Test

Hopping

McClay Davis et al. Clin. Biomech. 18:350-357, 2003. Noehren , B, Davis, I, Hamill, J. Clin. Biomech. 22: 951-956 (2007)

Initial Visit Summary

• L ITB Syndrome

– MMT B Hip Ext and Abd = 5/5 – but delayed glut max firing L>R

– Weakness also noted with single leg bridge L>R, lateral step down and hop test

– L>R pes planus

– Good TCJ / ankle DF ROM B

Treatment

Patient Education

• Discussed Footwear

– Patient wants to stay with Vibram Five Finger shoes – so arch support or increase stability with a shoe not an option

– Increasing cadence –since rest is not an option

Brigit De Wit et al. Journal of Biomechanics. 2000; 33:269-278Morley et al. Journal of Applied Biomechanics; 2010; 2:205-214.

Treatment

Beware of the runner with the FLAT BUTT!

Niemuth PE, Johnson, RJ, et al. Clin J Sports Med. 2005; 15:14-21 Leetun et al. Med Sci Sports Ex. 2004; 36:926-934Fredericson et al. Clin J sports Med. 2000; 10:169-175

TreatmentProne Hip Extension with knee at 90 degrees flexion

Single Leg Bridging

Treatment

Runners are GREAT COMPENSATORS!

Step Backs

Treatment

• Walking Lunges

Tight low abs with flexed trunk to minimize lumbar extensors and maximize GLUTS.

Initial Video Anaylsis

Post Video Analysis

Initial Video Analysis

Post Treatment Video Analysis

Video Analysis Summary

• Initial Video– 0% grade– Barefoot / 5 fingers– Pace 10 min / mile

• Findings:– R>L hip drop – curvature of

spine/hip drop R when WB on the L leg

– B high arm guard– Min trunk rotation– Not too much vertical

displacement – good– L>R pronation and toe out

• Final Video – 11 weeks later– 0% grade– Barefoot / 5 fingers– Pace 10 min / mile

• Findings:– While WB L leg = min R hip

drop– While WB L leg = min trunk

curvature laterally– Less high arm guard– Still in 5 finger shoes!– Still pronates!

5th Visit Follow Up

• 5 PT visits

• Over an 11 week period

• Progressing toward goals

– Running 30-35 Miles/week

– Continuing to wear Five Finger shoes

– Walking and standing painfree