"Your listening hand/finger and motion-creating hand/finger, together, reveal the dysfunction."
This case study will suit the practitioner with SFMA level 2 experience, now available as an online course as a pre-requisite to a live course. If you haven't heard of the SFMA, you can briefly watch an intro to it here.
A client returns with a recurrence of LBP. A history is taken. A previous neuro scan and respiratory scan has been done and there is nothing to indicate any change. It is appropriate to proceed with a review of her movement assessment, ie the SFMA top tier.
Cx F DN
Cx E FN
Cx R FN Bilaterally
MSR DP Bilaterally, with right being less painful.
My entry breakout is the deep squat, which reveals bilateral ankle dorsiflexion MD's, eversion MD's, hip ER MD's bilaterally (with hips flexed), left worse than right. I'm cautious with the DP of MSR, but I want to know a little more about hip rotation with hips extended to help me understand if ER is restricted in two positions - this refines whether I'm biased towards checking tissue texture abnormality via the active tissue palpation taught in level 2, or for joint play reviewed in level 2. Prone hip rotations reveal MDs in ER bilaterally, but worse on the left (29 degrees), with IR of 25 degrees.
While prone, I do a static palpation assessment of the lumbo-sacral region and observe her lower lumbar spine is subtly rotated towards the left.
My reasoning is to do LBE of hip and feet.
I find that despite the left hip displaying MDs of the physiological movements (ie limited osteokinematics), the right hip displays more restricted accessory movements (ie arthrokinematics or joint play). They are limited in multiple accessory planes so I perform a long-axis hip traction of the right hip with MET, 3 reps.
Reassessment reveals the left hip physiological rotation is now in the high 30's for ER and IR. Treating the most limited joint play on the right hip changed the most limited physiological movement on the left hip that was revealed in the breakouts. I had come to that breakout because I chose a DN of ADDS and cautiously added breakouts of the DP pattern of MSR. By the way, in prone, right hip ER reproduced left low back pain pre-treatment, confirming the cautious approach and consistency with what was found in left MSR.
I then went to the feet. Notable findings, left navicular was limited into pronation, medial-to-lateral glide and inferior-to-superior glide. There were restrictions also in midfoot joints at navicular-cuneiform and particularly at the medial cuneiform-to-1st-metatarsal which had very limited dorsiflexion but could plantarflex.
I did an indirect technique, as a positional release, then with MET. Specifically, I mobilised the navicular where it was capable of going comfortably, ie into supination, lateral-to-medial glide. The superior-to-inferior glide was a trickier element to add in, so I just "stacked" two planes, to R1 - it took a lot of quieting to create motion and listen/feel for it. Then I had her cycle a breath. I released. I repeated, then added isometric ankle dorsiflexion, then released. I repeated a few times.
Ankle dorsiflexion "let go" and increased, as did the 1st TMT joint into dorsiflexion, as did the subtalar joint. Both manipulated easily with a gentle direct oscillation technique. The left hip ER in extension went well past 40 degrees with R1 and beyond 50 degrees with R2. Hip IR was well beyond 30 degrees. The lumbar spine was neutral. MSR was DN bilaterally, as was MSE and MSF. No pain.
The Reinforcing and retraining drills were 1x1 figure 4 horizontal and vertical bridges, then 2x1 and 2x2 hip extension with ER and IR, then 3x1 tall kneeling rotations with KB and half kneeling chops and lifts (3x3).
Hit me up with questions.