Four Case Histories
Case History #3
Harry is a 47-year-old male employed as an Adaptive Physical Education Teacher. During class, while sitting on a bench in the school gym, Harry observed an autistic child, with tendencies toward uncontrollable physical behavior, running across the room. When he realized this child was out of control, he held out his right arm to catch the child as he ran by him. As he caught him, Harry's torso twisted to the right and he immediately felt a sharp pain across his low back, left worse than right.
During my initial history intake, I learned he was an avid body builder and, for a few years, had been a “power lifter.” Harry had terrible difficulty rising from or sitting down in a chair and was barely able to get on the treatment table without assistance. He stated that his typical pain level was 7/10 and he experienced this pain no matter what activity he was doing or not doing. He had been diagnosed with a herniated disc at L4-5 several years before and he feared he had re-injured himself. He had not had surgery for this problem and feared he may need that now.
After performing several ROM tests for the lower half of the body, I was surprised to find most of those tests within normal limits. For someone in as much pain as Harry, his ROM for most tests was either well within limits or better. At this point, although his pain complaint was his low back, I asked him to perform a simple test for the mouth opening. A normal interincisal opening should accommodate 3 knuckles of the non-dominant hand. His was nearly 3-1/2. I, also, observed his ability to hyperextend his elbows.
These two tests showed that hypermobility was part of the problem. In the presence of hypermobility, ROM testing can often be misleading. When the joints are considerably “lax”, muscles must work harder to control them. This extra effort is a considerable factor in the perpetuation of pain following muscle trauma.
Of all the tests I had Harry perform that day, only one proved to be clearly positive. The hip extension test for the iliopsoas is performed with the patient supine and one knee held to the chest. The opposite thigh and leg are extended and a measurement taken between the horizontal surface and the popliteal fold. Harry was positive by a width of approximately 16 centimeters on the left and 12 centimeters on the right. Negative result would be 0, bilaterally.
The psoas muscle attaches to the anterior lumbar spine, attaching not only to the vertebral bodies but also to the discs. It then travels caudally through the “well” of the pelvis, joining the tendon of the iliacus as it inserts at the lesser trochanter. It is the primary hip flexor.
In almost every case treated by this therapist, when there is low back pain and a history of disc bulge or herniation, the psoas is found to be not only hypertonic, but frequently found to be disproportionately more shortened on one side than the other. We find that as the shorter psoas muscle pulls the lumbar spine into increased lordosis, it also rotates it to the ipsilateral side.
This in turn narrows the intervertebral space on the side of the shorter psoas, while allowing the psoas on the opposite side to pull on the discs where the space between the vertebral bodies is greater. This can contribute to a disc bulge and/or herniation. I believe this was the case with Harry.
I used Myofascial Trigger Point Therapy and soft tissue mobilization in conjunction with other techniques to release the psoas muscle. As a result, Harry experienced a dramatic decrease in his pain by the second treatment. After releasing the psoas, quadratus lumborum, lateral aspect of the obliques, lumbar paraspinals and the latissimus dorsi, I was able to mobilize his lumbar spine. Harry was able to get off the treatment table with almost no pain, as well as sit and rise from a chair without hesitation. He reported his pain level as a 1–2/10. Needless to say, we were both delighted with the outcome.
As Harry began to increasingly engage in normal activities, there were minor exacerbations of his pain to a level of approximately 3–4/10. He was usually able to control the pain with his home exercise program, which included a specific stretch for the psoas muscle. After considerable modification of Harry’s workout routine at the gym, he is now pain-free and does not require the surgery that he so dreaded.