“It hurts right here,” said K., pointing to a spot just above her left posterior superior iliac spine (PSIS). “It has been uncomfortable but not debilitating for many weeks, but it does affect me when I play.”
K. is an elite-level collegiate tennis player, one of the best in the nation. Her movement patterns and body awareness are superb, which makes working with her a joy.
“Is there any simple movement that you can do now that re-creates the pain?” I asked.
“Actually, I feel it as a slight pull or nagging sensation when I simply bend forward at the waist. I only feel it on the left side when I bend straight forward.”
I observed her flexing forward and we established an exact angle of flexion that initiated the discomfort. This helps track progress; the goal is either greater motion or, at the very least, minimal to no discomfort at the same initial angle of flexion.
In my mind, I ran through possible suspects that included muscles such as the multifidi, erector spinae, and quadratus lumborum. The long dorsal ligament and the iliolumbar ligament were also possible suspects, as was the sacroiliac joint. I had K. lie on her side and began by treating the multifidi. Starting on the surface of the sacrum, I treated the multifidi thoroughly all through the lumbar spine, finding only a few tender areas. After I finished, I had her stand up to audit the original movement again.
“No real change,” she admitted.
“OK, I know what it isn’t!” I pronounced. “Let’s explore another muscle, called the quadratus lumborum. Please have a seat on this stool.” Sitting behind her, I carefully examined all three sections of the quadratus. Unfortunately, no spot re-created her pain, even though some points were sensitive. Asking her to stand up, we reassessed forward flexion again. I could tell by her facial expression that it had not improved.
“Sorry,” she said. “No change.”
“No need to be sorry,” I replied. “Let’s examine another possible cause. Please lie on your right side again.” At this point, I decided to palpate her iliolumbar ligament, which was located near the epicenter of her pain. Challenging the ligament did not elicit the presenting symptom, however. I moved my finger slightly inferior to be just medial to the PSIS and found a sensitive point. Pressing medial on the anterior superior iliac spine (ASIS), I was hoping that the sensitivity on the point near the PSIS would decrease. (Pressing medial on the ASIS decompresses the sacroiliac joint.) No such luck.
I asked her to stand up and again flex forward. Doing so, she looked up at me with an apologetic face. “No need to say anything,” I said. “I can see that didn’t work either. Just so you know, this isn’t over until you flex forward without discomfort. No excuses.”
“You’re relentless!” she said teasing, then added, “Just like me.”
“I’m sure that is true,” I said. “What makes both of us excel is an unyielding commitment to results. No matter how difficult the journey or how long it takes, we embrace the struggle, because that’s where learning takes place.” As our eyes met, I saw in her someone who had known great success, and also learned from countless failures along the way; impressive wisdom for someone so young.
“Wait, let’s try this,” I suggested, breaking the moment. “What happens if you flex forward from a seated position?”
“There isn’t any pain at all,” she stated, sounding surprised.
“OK, what would account for that?” I asked myself, thinking out loud. “Stand up again and let me try something.”
This time, I cupped my hand around her sacrum, guiding it forward as she flexed her spine. Unfortunately, there was no change in the pain. Positioning both my hands on her pelvis, I guided it anteriorly as she flexed.
“Wow,” she exclaimed. “That totally eliminates the pain. Amazing!”
“Here is what I think is happening,” I explained. “There are muscles that create a posterior pull on your hips as you flex your spine forward. If the hips don’t have enough motion, the spine is forced to do too much. Let’s treat those muscles and see what happens.”
Placing her in a side-lying position, I did fascial work over the posterior thigh and specifically treated the adductor magnus and bicep femoris.
K. rose from the table to check our progress. I knew immediately from her smile that the results were positive. There was still a slight pull, but at a much greater range.
Her trainer called me the following day, thrilled with K.’s progress. For me, I kept thinking about how a personal commitment to excellence allows us to recognize and celebrate that same commitment in others, no matter what their discipline. Luckily, as therapists, giving our best enables those we treat to perform at their best. What an honor!
Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com or email him at doug@nmtmidwest.com.
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