Remedial Massage Treatment of Sports Injury
Pubic Symphasis Injury/Strain
I began treating a Track and Field sprinter (3x National Champ) last week suffering Osteitis-Pubis. She has been assessed and treated by a Physio and Sport Doctor, and has not trained for three months on their advice to take total rest. She continues to experience discomfort in the groin and her coach has referred her to me for supplementary treatment.
She advised prior assessment determined her injuries were Osteosis-Pubis and Psoas Bursitis.
Assessment included general postural and hip alignment examination, testing Quadratus Femoris strength and Hip Flexor condition. All proved good except the right Quadratus Femoris which was slightly weak. Palpation of Lowerback, Glutes, Hami’s and Quads revealed pain and tightness at the right Quadratus Femoris and the right Adductors. Treatment also included use of Orthobionomy to release hips and a procedure to treat the origin of the Adductors at the Pubic Ramus, also known as the Obturator Nerve Release.
The Obturator Nerve exits the pelvis through the Obturator Foramen. The foramen is covered by a membrane through which the nerve passes. The foramen and membrane are surrounded by Adductor muscle origins and where they are tight, it impinges the Obturator Nerve.
The Obturator Nerve Release is an invasive procedure, so it is necessary to brief the patient beforehand and gain consent. It is not advisable to attempt this procedure without first practising on a volunteer and gaining proficiency before doing so in clinical practise…one slip of the hand can be cause for considerable embarrassment and leave the practitioner open to charges of impropriety.
With patient supine and leg bent at knee, the therapist at the side of the table and facing the head, reaches over the bent leg and holds the patient’s knee, stabilising it between their elbow and torso. With palm of hand holding the hamstrings, thumb on the medial aspect of the leg, move the hand toward the groin seeking the origin of the hamstrings at the Ischial Tuberosity. On encountering the Tuberosity, move thumb laterally and superiorly approximately 1.5cm in each direction. This should place the thumb in the Obturator Foramen. Pressing in a medial direction will engage the origins of the Adductors along the Pubic Ramus. Move the thumb around the medial half of the Obturator Foramen applying pressure...static and/or deep tissue crossfibre work. More commonly the tissue is tight, hard and painful. In this instance due to tendonitis, I encountered considerable tight gristle/bubble like tissue. Carry out deep tissue treatment until softness is achieved. Often one session is sufficient, however this case likely to need at least one more treatment.
Confirmation a good result was been achieved in this case as the patient felt intense relaxation and softness through the entire limb as impingement of the Obturator Nerve was relieved.
She will miss selection trials for the 2016 Olympics which are imminent but has ambition for the 2020 Olympics. I expect more massage treatment will need to be incorporated into her regime, altered training practises and dietary considerations to avoid a relapse.
It was noted the patient does have wide hips and a large Q angle…consideration for reducing lateral lunge exercise loads in future. She advises there has been much exercise of that type in the past.
Instruction for Theraband exercise of Quadratus Femoris was given.
Back line engagement of core, glutes and hami firing order to be checked next session. I expect other practitioners/coach to be on top of this but will do so anyway.
I have brought the concept of Collagen Supplementation to her coach's attention. It is new to me and I am trialing it for general health benefits but, more particularly, for an old knee injury (several dislocations at head of fibula...amongst other things) that has been deteriorating recently. It may prove beneficial in fortifying this athlete's Pubic Symphasis.
Note: Since treating this client, I have learned about the little known Short Right Leg Syndrome (SRLS) that affects so many seeking treatment. Tight right adductors and rigidity at the right hip owing to the pendulum effect on gait are one of the cardinal signs of SRLS. At the time I did not do a close examination for leg length difference with this client. It is highly likely SRLS is the primary underlying cause for her condition.
Quadratus Femoris - Lower Back & Pubic Symphasis Injury
Aussie Rules players were once plagued by pubic symphasis injuries until the importance a small credit card sized muscle, low in the butt, became known. It originates at the Ishium and inserts at the top of the Femur, and is a lateral rotator, adductor and a stabilizer. It holds the head of the femur securely in the hip's acetablum. Should it weaken, other musculature will attempt to do the job but the resulting imbalance strains the lower back and pubic symphasis leading to injury.
My recent back injury may be attributed to this condition. Testing proved the right Quadratus Femoris, my dominant side, is weak. Theraband exercises have been prescribed.
Interestingly, it took an experienced Remedial Massage Therapist to work this one out for me (Lance Dixon 30yrs RMT & Shiatsu)...the Osteo, GP and TCM doctors were not aware of the condition.