A Difficult Case of Posterior Thigh Pain in an Olympic Hockey Player

I saw a really interesting case today and thought that other physicians and therapists would enjoy hearing about it. A female athlete who plays for her National/Olympic Hockey Team presented to our office (Sports Performance Centres – Mississauga) with a chief complaint of posterior thigh pain after reaching for a loose puck (her symptomatic leg was extended with the knee flexed). At the time of the injury she felt pain in her anterior thigh and was diagnosed with a quadriceps muscle strain, however within two days she began feeling pain in her posterior thigh and low back. All resisted muscle testing, stretching and palpation of the external hip rotators, quadriceps and hamstring muscle groups was within normal limits (muscle testing was 5/5 on the Oxford scale), however she did have a positive Thomas test, indicating psoas muscle tightness. Testing for lumbar spine segmental dynamic instability was negative, however orthopedic testing for the sacroiliac joint was positive (using the Laslett et al. battery of tests, although discrete testing for SI joint instability as described by Liebenson was negative, with the exception of dorsal sacroiliac ligament palpation). Palpation of the sciatic and femoral nerves reproduced her chief complaints, as did stretching of said nerves (palpation of the femoral nerve as it emerged through the psoas muscle, done through the abdomen, was exquisitely tender). Also, creating and relieving systemic neural tension/dural tension (a technique learned from Dr. Stuart McGill, arguably the world’s leading researcher in spinal biomechanics at the University of Waterloo and an absolute genius in the fields of research and clinical medicine) increased and decreased her peripheral nerve symptoms respectively. Her pain was not typical of stretching an inflamed peripheral nerve (neuritis) but instead was consistent with neuropathic pain (pain originating from a nerve). I found allodynia (painful stimulation of the skin from a non-noxious stimulus) on the anterior and posterior thigh as well, again indicating neural involvement. I also examined her for biomechanical issues relating to hip extension using the Janda hip extension pattern, the hip/pelvic examination described by Geraci et al, and the Functional Movement Screen by Cook. All the aforementioned procedures found excessive lumbar spine extension compensating for poor hip mobility (known as “false hip extension”) and excessive use of the hamstring muscles with decreased contribution from the gluteus maximus. For treatment, I did manual neural flossing/mobilization and soft-tissue therapy using Integrated Therapeutics techniques and Active Release Techniques(R); spinal, peripheral and local input (in the femoral and sciatic nerves) acupuncture with low-frequency stimulation (2 hz); microcurrent calibrated to the edema setting (300/300, negative) along the course of the sciatic and femoral nerves; soft-tissue therapy to the dorsal SI ligament using the Integrated Therapeutics instrument called the “Integr8r”; mobilization of the sacroiliac joint; kinesiotaping applied along the course of the femoral and sciatic nerves in the thigh; neutraceutical therapy that included Wobenzyme, quercetin, resveratol, vitamin A and C, boswellia and curcumin; and home rehabilitation exercises emphasizing abdominal bracing and low spinal penalty exercises as per McGill, in addition to those promoting proper gluteus maximus endurance and activity/timing to aid in hip extension (such as balance sandals and single leg stance rocker board exercises with perturbations). She left the office in significantly less pain and without the allodynia.

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