Case study 1:
a golfer with a nagging left shoulder pain
Before I start, here's a pertinent quote from the Grand Old Man of Letter From America, Alistair Cooke: 'To get an elementary grasp of the game of golf, you must learn, by endless practice, a continuous and subtle series of highly unnatural movements, involving about sixty-four muscles, that result in a seemingly 'natural' swing, taking all of two seconds from beginning to end.'
A good friend who is an avid club golfer with a handicap of 4 and a right-handed stroke asked for help with his nagging L shoulder pain that had recently become markedly worse and finally was threatening to stop him playing. He said he knew he should have asked for help sooner, but he thought it would just go away (one of the
most commonly heard statements by treating practitioners!), and it had now been hanging around for about six months in total, despite regular coaching.
He said that originally it only used to hurt when he caught his chipper in the grass and disrupted his follow-through, but now whenever he used an iron he would feel a sharp pain unless he happened to stroke the ball perfectly. It would also ache when he slept on that side, and after playing a full round it ached for some days. He had tried a million different stretches and even seemed quite flexible with certain movements around the shoulder. In addition, for some years he had battled with R low back pain and anterior hip pain that, when really bad, would leave him limping for a couple of days after an 18-hole round.
Examination showed all the signs of rotator cuff tendinitis (inflammation and microscopic breakdown of tendon), with accompanying weakness of the muscle itself; leading, over time, to excessive anterior translation of the head of his humerus (extra shearing of the ball in his socket joint) on follow-through. This would likely cause an impingement of his already thickened tendon under the bony acromial arch of the shoulder, giving him the sharp stabs of pain he complained of more recently.
His standing posture gave us the most obvious clues as to why this had developed without ever needing to video his stroke biomechanics: rounded shoulders and a very noticeable low-back arch (lumbar lordosis) are classic signs of poor postural control leading to wrong movement patterns in his stroke. Gradually over time something had to give- often it is the non-dominant arm.
Had he been middle-aged we might have X-rayed his shoulder to look for any calcification of his tendon (he had just turned 30), and only if progress wasn't going well would we consider doing an ultrasound scan to determine the extent of scarring and tendon breakdown.
Rehabilitation would take a good month or two if all went according to plan - the main unknown factor would be how well he would take on the challenge of holding his shoulders and pelvis differently; this re-education process is often the most difficult (see also the following case study). The overall treatment process would first involve improving flexibility so that proper posture positions could be held - most of us get stiffness in some of our joints because of gravity wrecking our good posture.
Recent developments in sports physiotherapy have improved the speed of this process significantly. Apart from a systematic stretching regime by the patient, we 'release' muscle tightness by deep tissue massage and trigger point therapy, heat, a home programme of self-pressure massage with a tennis ball, and mobilising of the tight parts of the capsule of the shoulder with seat-belts. Tightness in the posterior rotator cuff muscles of this particular patient took a lot of work to free out, and lat dorsi and pec major/minor were also big players.
In addition, he had significant stiffness in his thoracic spine, especially with extension and L rotation, so that was worked loose, as were certain gluteal and hip flexor muscles.
The next two phases
Secondly, postural muscles needed to be 'turned on', i.e., recruited properly, and a programme of gradual strengthening their ability to control the joints for which they are responsible began. In this case the critical ones were the mid and lower trapezius and transversus abdominus muscles - we also taped them up occasionally to help him remember to keep using them, until it became more habitual.
Around this time, pain was becoming less and less of a problem and his postural control was developing well. He was able to return to his coach and start using the positional changes in his stroke, gradually increasing the stroke distance and frequency and all the while maintaining his flexibility with the tennis ball. This third phase, which involves incorporating the right posture into the stroke, is critically to do with the coach, and requires significant discipline on the part of the athlete to ensure he stays within the realms of what his new system can tolerate without being overloaded. He can still overdo it!
All went well, with the golfer achieving one his best ever scores in the Queensland Open Tournament three months later. However, two weeks after that he dived badly in a game of rugby and twisted the same L shoulder and ripped the same rotator cuff tendon he had worked so hard to mend... sometimes life just isn't fair!
Case study 2:
a teenage runner with a patella injury
This study is actually a personal one. I apologise for that but I hope you will think it was worth writing about.
As a teenage runner I suffered from chrondomalacia patella. Simply, this injury involves a maltracking of the patella femoral joint, which causes damage to the underside of the patella. At the time, the injury was attributed to over-pronation and weak vastus medialis. A quadriceps-strengthening programme and orthotics in the running shoes helped clear up the injury without further recurrence. As a consequence I have worn orthotics in my running shoes ever since.
The plot thickens
The initial assessment of my foot motion during running and suitability for orthotics was made by a qualified podiatrist experienced in sports medicine, using video-analysis equipment. I have no reason to doubt the assessment. Indeed, I also recall being quite 'flat-footed' at the time, with low arches in a standing position.
Recently, however, I visited a running shop which has a force-plate software system where you can assess your own running footstrike pattern. This helps the shop to recommend the most suitable shoes for you. The force-plate system is different from video analysis in analysing foot movement during running but is equally valid and provides the same information. You run over the pressure pad and the computer records the pattern of the pressure under the foot. Quite simply, the shape of the pattern tells you what kind of foot motion you run with. For example, if the initial pressure starts at the heel and the highest pressure focuses on the inside of the foot, then you are a heel striker who over-pronates.
I decided to try out the pressure-pad system merely out of interest before I chose my new pair of running shoes. At that point I assumed totally that I over-pronated and needed orthotics. After a couple of trials on the system, the assistant was looking puzzled. He told me that I didn't pronate at all and that my footstrike pattern was more towards the midfoot, with pressure distributed quite evenly, possibly tending towards the outside.
'How can this be?' I protested. 'I'm a pronater!'
I repeated the experiment, this time running faster, yet regardless of speed the results were consistent. After many attempts and much scrutinising of the computer screen, I accepted that somewhere along the line things must have changed. What finally persuaded me was the fact that when we looked at my feet in a standing position we could see that I was not flat-footed and had a normal arch position. As a result of this revelation, I discarded my orthotics and bought a neutral-cushioning running shoe, which I find very comfortable.
Why the change?
This story raises some interesting questions, assuming that both assessments of my running mechanics were correct, which I believe they were. First of all, when and how did I change from being a flat-footed teenage athlete who over-pronated to an adult runner with a normal foot motion and midfoot strike. In addition, have there been any negative effects from wearing orthotics when I didn't need them, thus having a very rigid shoe structure that was not suited to my running mechanics? While I can only speculate, I have come to the following conclusions.
I reckon there were three possible factors that could account for the change: 1. Age/increased strength and conditioning; 2. Some kind of adaptation to wearing the orthotics over time; and 3. Improved posture/running style.
It doesn't seem possible that simply due to becoming older and increasing my general levels of strength and condition from regular gym training over the years that my biomechanics have improved to the extent that I no longer over-pronate. I also considered the possibility that if one uses an orthotic long-term, and I used them for over 10 years, the foot may become more rigid - if you like; the orthotic remodelled the mechanics of the foot.
However, I decided that the most likely cause of the change was the fact that, over the past two years, I have made a conscious effort to re-educate my posture and running style. I had become aware that I had a lordotic low-back posture and slightly kyphotic upper-back posture. This means my pelvis was tilted forwards instead of being in a neutral position and my upper back was rounded instead of being tall and broad. Over the past 24 months, I have worked hard to improve this and I now consider myself to have good posture and better core stability. Over the same period, I have also paid a great deal of attention to how I run. This was inspired by reading Jack Daniels's 'Distance Running Formula' (published by Human Kinetics), in which he describes how elite athletes take around 180 steps per minute regardless of speed, and that this is the optimum stride frequency. In response, I have changed my style and now take quick, light and short steps when I run, which I believe is a more relaxed and easy style.
Analysing the changes
It is these changes that I believe are the most important in the alterations to my foot mechanics. The link between posture and foot position is quite obvious and can be simply demonstrated: see how your lower leg and foot position can change in a standing position by tilting your pelvis forwards and backwards. In the lordotic, tilted forwards position, feet are flatter and knees are aligned inwards. With the pelvis tilted backwards, your feet are pulled off the floor with the pressure more on the outside, and the knees are aligned away from the body. Thus, by improving my posture in a standing position and my core stability so I can maintain my posture while I run, I have re-aligned my lower leg and foot into a better position. This, together with my change in running style, has meant that I now strike the ground with my mid-foot and push off evenly in a more efficient manner, as opposed to my earlier over-pronating action which involves a heavy heel strike which rolls inwards, thus requiring more effort to achieve push off.
As for any negative repercussions from using orthotics needlessly, I wondered if one of them was the fact that my IT bands have been very tight over the past few years and get worse the more running I do. If I was effectively over-supinating by using the orthotics, this could possibly have placed extra stress on the outside of the knee and hip, stressing the ITB. Subjectively, I feel that my ITBs have relaxed somewhat since changing my shoes.
I realise that this is a subjective account and one can only speculate as to why my foot mechanics have changed. However, there are two key issues arising from this story. First, this case does suggest that change is indeed possible. It may be that improved conditioning and, particularly, greater focus on posture, core stability and running style can improve one's biomechanics in a specific manner. Second, it also suggests that those who use orthotics should have regular assessments to see if they are still appropriate.
Case study 3:
an international-level amateur triathlete with ankle pain
Many foot and ankle problems, especially when chronic in nature, present medical professionals with a complex challenge in problem solving and clinical reasoning. Here is an interesting case study for both athletes and medical practitioners that highlights the importance of thorough history taking when assessing musculoskeletal injuries. We will see how by initially missing an important component of this athlete's problem we may have caused a drastic change of events in its management.
This 25-year-old international amateur Olympic-distance triathlete presented to the clinic complaining of pain on the outside (lateral border) of the ankle/foot brought on by running during track sessions and shorter road runs (at under 4 min/km pace - his race pace for 10km). This pain had been present for roughly two months and was worsening. The pain would start approximately 10-15 minutes following onset of activity and progressively worsen with continued running. The pain was never significant enough for him to cease running (either because the pathology was not significant enough, or through sheer determination); however, it would be present for at least 24 hours post training. It was also interesting to note that the pain was not present on longer road runs (at over 4.5 min/km) or during cycling. No neurological symptoms were described. At the time of the initial consultation, the patient did not recall any traumatic incidents to the ankle.
Examination began with assessing this patient's gait mechanics during walking. Nothing untoward was discovered here regarding rearfoot (heel) to forefoot motion. The only significant finding upon assessing the foot was a mildly plantar-flexed first ray (big toe pushed down) on the right. It was found that the pain was localised to the tendons of the peroneus longus and brevis muscles as they pass below the outside heel bone (malleolus) and along the outside of the foot. The movements of dorsiflexion (foot up) and also inversion (foot in) were significantly reduced, due to muscle tightness/tone in the calf muscles, and also in the peroneal muscles. Full passive inversion actually reproduced some of the lateral ankle/foot pain. Palpation of the peroneal muscles elicited some local muscle pain and trigger points.
It was hypothesized that this patient was suffering from peroneus longus/brevis tendinopathy. The attributing factors would have been two-fold. First, the patient highlighted an increase in mileage three months earlier, which may have contributed to the tendon pathology as an overuse injury. He was at the time completing two 15 km runs per week (no faster than 4.5min/km pace), two 7-8 km runs per week (at faster than 4min/km pace), and one track interval session with a squad that covered approximately 4 km per session. This was a total of around 50 km per week, up from a preceding total of around 30 km per week. He was also cycling approximately 150 km per week, and participating in two squad swim sessions per week.
A biomechanical fault
Second, it was thought that the increase in speed with track sessions and the faster road runs were contributing to a biomechanical fault in his running style. With an increase in speed, stride length will increase causing the swing leg to externally rotate more as the foot is about to heel strike. This would cause the foot to strike at more of an angle (varus position). This would affect the speed at which the first ray or big toe hit the ground. This is controlled by the peroneus longus. Furthermore, with an increase in speed the foot will tend to strike more on the midfoot and not purely on the rearfoot and give insufficient time for the peroneals to perform their role, and thus the muscle will 'stress out'. Finally, the athlete's track sessions were done in an anti-clockwise direction with the right foot on the outside and this would have accentuated the biomechanical fault.
It was reasoned clinically that the peroneus muscles were working far too hard and for too short a time period to dissipate forces, and this was causing the muscle/tendon problem. Furthermore, the tightness and trigger points would reduce the compliance or 'give' of the peroneus muscles. Therefore, the athlete was initially treated with peroneus muscle trigger point therapy and flushing deep tissue massage. He was shown how to stretch the peroneus muscles, and given some free standing eversion (foot out) exercises to strengthen the peroneals. Local electrotherapy was also used to settle symptoms. His foot and ankle were taped to control the amount of inversion occurring with his running. He was advised to reduce his volume back to 30 km per week at 4.5min/km, and to avoid track running for a two-week period.
It was also decided that we would videotape his running at some stage to identify any stride length faults or foot strike faults in order to correct these. He progressed well over the two-week period, where he was pain-free running only with the easier 4.5min/km pace. However, we still had not tried him at track pace. It was decided during the third week to allow him to participate in a track session to assess the progress the ankle had made.
Unfortunately the pain returned at about the same time of the session as before, but not with the same severity. I was happy at that stage that we were on the right track, and with tendon problems being notoriously hard to heal, I reasoned we needed a bit longer with the same treatment to assess the progress properly.
The past strikes back
It was around the fourth week of treatment that an interesting discovery was made. Through the course of conversation this patient suddenly recalled a traumatic ankle sprain suffered eight years earlier while playing rugby at school. I found this interesting so I pressed him a bit further. After some prompting and encouragement, he remembered that the injury had required about a week on crutches, and about five weeks of further rest before he could play again. No physio treatment was sought for this incident. This patient had forgotten this particular incident when questioned during the first consultation. I was thinking to myself about the possibility of a severe ankle ligament disruption at the time of the injury which would have healed poorly (weaker and longer) without treatment.
With a few warning bells sounding, I took this new-found knowledge and assessed the stability of the right ankle. It was discovered that this patient had a gross laxity of the right ankle with an anterior draw (orthopaedic test for assessing stability of the lateral ankle ligaments), that resulted in an excessive amount of ankle movement (to an extent I had never seen before) and actually reproduced a clunk of the talus against the tibia. Blimey! I said (actually I said a bit more than that). This new finding changed my clinical reasoning somewhat. A big attributing factor to this patient's problem will have been the excessive use of the peroneal muscles to compensate for the chronic instability of the ankle. This patient was still suffering from peroneus tendonitis, however the cause was now more significant. From a prognostic point of view, such a gross instability could potentially influence the long term outcome of this patients ankle. The worst case scenario in this situation is that the instability of the ankle due to the disruption of the supporting ligament complex would require surgery to 'stabilise' it. After explaining to the patient the pathomechanics of the ankle, he was advised that we would best continue with the approach we had been taking to determine the outcome of conservative rehabilitation. If after a time period of 6-8 weeks the ankle had not improved, a surgical consultation would be sought to assess suitability for orthopaedic reconstruction to stabilise the ankle.
Moral: study the history
I continued with three weeks of aggressive rehabilitation to specifically strengthen the peroneal and calf muscles (using a comprehensive range of ankle stability exercises), and continued maintenance of soft tissue length through deep-tissue massage and trigger-point therapy. The patient was gradually progressed over the next five weeks back into full training including track sessions (while taped). He was reviewed two months after discharge and was doing quite well with his track running and had improved his 10 km time by 25 seconds. He was continuing with a home programme of peroneal exercises, self-massage/triggering and stretching. He was no longer taping his ankle.
The point of this case study is to highlight the importance of history taking during musculoskeletal assessments, because the information derived will significantly determine treatment planning. It is first and foremost the responsibility of the medical practitioner to seek out this information in a thorough and concise manner. It is also the responsibility of the patient to be honest and offer all relevant information, irrespective of how trivial it seems