Two more case studies of individuals in pain and how they were treated
Case study 1
Arnica and rehabilitation exercises were sufficient for a minor knee strain
A 45-year-old female client of mine who normally follows a running fitness programme suffered a knee injury while on a skiing holiday in Switzerland. The injury occurred when her downhill ski got stuck in the snow at a slow speed as she attempted to turn and as a result her knee twisted and some damage was caused. This is quite a common way for an inexperienced skier to become injured.
The injury was not very serious, as she was able to ski back down to the resort, but it ended her holiday and there was swelling and pain the following day. When she returned to England we spoke and decided that as she could walk on the leg we would meet first
to discuss the injury before booking an appointment with a physiotherapist.
I met her five days after the injury at which time the knee was still swollen, which meant there was a limited amount of knee flexion but she could place her weight on the leg. We decided to go with a gentle exercise programme using the 'no pain then its OK policy', which meant that if an exercise did not hurt or cause a reaction she would continue it to regain the strength and mobility of the knee.
Her programme for the first week involved the following (she completed this routine three times in week one):
1. 10 minutes of gentle rowing.
2. Leg press (with one leg). (2 x 12)
Using a light weight (initially less than body weight) and a limited range (0-600).
3. Static stretch for the quadriceps.
In week two, most of the swelling had disappeared and nearly all the flexion range had returned to the joint. The programme progressed by adding a limited-range single-leg squat exercise off a 6' step to promote proprioception in the knee joint. She performed this particular exercise every day in week two and the earlier ones three times.
By the end of week three she had increased the strength on the single- leg press exercise to significantly greater than body weight, the flexion range of motion was complete and the control of the one-leg squat movement was smooth and balanced on both sides. At this stage she attempted a 10-minute jog from which there was no reaction and after this she resumed her normal running programme of 2-3 jogs per week.
During the three weeks, the rehab exercises were supplemented by doses of Arnica, which is a homeopathic remedy known to be very beneficial for promoting healing from injury.
This simple exercise programme combined with the homeopathic remedy was able to solve this minor knee strain and keep the client active during the rehab period. This is encouraging for trainers simply to understand that it is possible to solve certain injuries with exercise alone. However, had the programme not worked or caused a negative reaction, I would have referred my client to a physiotherapist immediately.
Case study 2
A swimmer with left-sided thoracic pain
This 27-year-old swimmer came to our clinic complaining of left-sided thoracic pain and occasional lower back problems, both of a mechanical and postural nature. He mentioned 'by the way' that he had a left-shoulder problem that had prevented him doing any freestyle for a number of years as part of his general fitness regime, owing to sharp pain and a clunk which his GP said 'could not be helped'.
It was decided to investigate his shoulder as the major issue and as a secondary issue to deal with the spinal pain.
His shoulder pain was reproduced at 90 degrees abduction with internal rotation, coinciding with the out-of-water phase (recovery phase) of freestyle. There was no pain on 'catching' the water with the arm or during the pull-through
phase. On observation, active movements of flexion and abduction were painfree; however, quadrant position and the inclusion of internal rotation to elevation brought on pain and a clunk. Poor scapular control on descent from elevation at 90 degrees and segmental stiffness at thoracic spine levels were evident.
Closer examination revealed an anteriorly displaced head of humerus (HOD) by 0.5 cm in resting position, mild posterior capsule tightness (clear from stiffness on a post-glide of HOH and marked decrease in internal rotation through range of elevation) tightness with
trigger points in infraspinatus, teres minor, pec minor and subscapularis muscles.
In prone, internal rotation
with the therapist retracting the scapula and holding the
HOH centrally, confirmed the noticeable external rotator tightness and inner-range weakness of subscapularis. These factors were central to understanding why the swimmer had gradually lost scapular control and why the axis of rotation of his HOH had been shifted anteriorly. (Trigger points in infraspinatus and teres minor will weaken the ability of these muscles to eccentrically hold the HOH centrally in the glenoid fossa.) Finally, the pec minor became shortened and overactive and pulled his scapula
into downward rotation and protraction; consequently his thoracic spine lost its extension mobility.
This is what then had resulted in sub-acromial impingement, with thickening of the rotator-cuff tendon, possibly explaining the audible clunk on the recovery phase. However, it is commonly very difficult to ascertain which factor is the chicken and which the egg in multifactorial chronic injuries such as this.
Treatment progressed on three levels
Deep-tissue massage, trigger-point releasing and stretching were employed with gradual progression towards the impingement directions, e.g., firm massage of infraspinatus with the arm abducted to 90 degrees, and in 45 degrees of internal rotation (scapula held in place by a seatbelt) or pec minor massage in 90 degree abduction or the quadrant position (as tolerated). Home stretching with due attention to scapular position is crucial.
2. Control and re-education
As flexibility returned in the rotator cuff and pecs, lower trapezius-setting exercises with infraspinatus activation (through a co-contraction in the shoulder) were progressed gradually towards the prone recovery movement of freestyle. Subscapularis had to be taught how to work in inner range and thereby stabilise the HOH with infraspinatus.
This needed to be evaluated in the pool, and two factors needed to be changed: (a) he was encouraged to drop his elbow to a sufficient degree and to lead with his hand (still keeping the elbow above the hand, however) early on in his return to freestyle; (b) there needed to be increased body roll when his right arm pulled through the water, and he was encouraged to learn how to breathe bilaterally, not just to the right side.
All these factors have been critical in his full return to freestyle as part of his routine, but they will require constant monitoring and maintenance of flexibility to prevent recurrence.