Case Study on Hip Flexor Pain while walking (gait)

Posted on January 3, 2023

To watch the full video, click here: https://youtu.be/qotjgroWsGA

Coaches Welcome to the July 19, 2022 coaching call, for this one I wanted to do a case study Sunday that happened to be on Monday. So it’d be gosh, two days ago or a yesterday actually. And 1000 really kind of powerful way to kind of look at movement and movement dysfunction, as the mpmc course, certainly dives into movement dysfunction, but it doesn’t go at as an in depth view as you would do it for as we do it rather for one on one coaching. And that’s on purpose, right, we’re trying to get you to leverage your time leverage your skill set to a group of people and and will gain a better career is what the big focus is for them to see course. However, once you go through that, the next step will be is how to become a true kind of what we kind of coined a movement master. But someone who can really look at movement dysfunction software, very much like a physical therapist. Well, we don’t believe Rexy does a very good job of traditionally speaking. So, but basically a problem solver of movement dysfunction, so we call a movement therapist. So I had a one on one client, here’s a little backstory on it. She is an ER doctor female mom of two to natural births. Children are in the kind of still kids still kind of kindergarten first first grade realm. She is an avid runner, huge runner. And for several months leading up to the time where we started, she had the left anterior hip pain when she would run and actually stopped her from running, even hurts just walking down the long hallways in honor shifts on the hospitals. And so again, as we she’s walking, besides going through a full full movement assessment, it hurts in tz excuse me too. So when her left foot is behind her about on push off. So it’s a very much of a hip flexor type of area. And it bugs or bugs or, and the sensation is kind of more of a pulling sharpest, where you want to stretch it, but stretching hurts it. So she came to be through a referral of another client who we’ve helped through a movement dysfunction. And this client also of mine has incontinence, or when she does a jumping of any sorts, there’s a little bit of leaking, that happens pee, urine, excuse me a little more appropriate way to put it. So we know that there’s some pelvic floor dysfunction happening their pelvic floor would be any of those muscles that are directly attached to the base of the pelvis or the base of the pelvis. So you have your obturator internus. Next turn is those particular ones, which also have your abductors and your glutes, which definitely directly connect to the to the pelvic floor, then you have the base on the sides of the floor, which would be your obliques for different muscles. And then you have your top of your pelvic pelvic, or your pelvic neuromuscular system, which would be your diaphragm breathing. So it’s kind of a base baseline there. So as a as an ER doctor, she sits quite a lot actually waiting for patients to come in, but also doing a lot of documentation, a lot of documentation. So she actually sits quite often. And it’s very rarely in a sense in our total shift time, next to a table taking care and like doing surgery, right? In a sense, so that’s not what I expected. Actually, I kind of expected her to be kind of always be treating patients but that’s not always the case with an ER er doctor. So a quick little study, we started off with going after her her pelvic neuromuscular system, her pelvic floor, and we started to kind of bring in a lot more stability work through her adductors I actually chose not to go mobility first. I tried to go step stability first to add in more kind of support through her abductors and through her glutes and we have a pelvic neuromuscular ball. It’s basically a soft little ball, you can squeeze. And it’s also attached attached to like a rubber band, like a monster band walk, right. And so we started to go after that, and it was successful, but wasn’t long it wasn’t solving the problem. She would still say I have good and bad days. So good days is good, but that days are bad. So we started to kind of look into more, more what’s going on. And as we were going through her movement assessment, there’s a few things that really shined out in a negative way in a dysfunctional way. Obviously, an anterior lunge right at hurt so that was a big deal but also her on a single leg. So mobility and stability, testing her inside or her lateral lunges, right that kind of still pulled it’s still relative extension through the through The left inside thigh even though it’s a B duction. But it’s still a pulling apart of the hip, that bother. But the big thing that stood out, which we haven’t really addressed yet as when she went to an upside rotational lunge, that it’d be a huge amount of limited hip rotation. And especially when did she went into balance, you try to go to the left, boom, this really just lost it. And that also was the case when it went shoot to win and went to the right two, so both glutes had to have a limited amount of internal rotation. We look at that from, from a physical standpoint, right? That the hip didn’t have the ability to turn in. And when the hip hip socket turns in, that that lengthens the glutes. So the glutes have a huge transverse plane attachment, right? They certainly have a lot of sagittal plane play, but they’re fit but their internal rotation play is probably one of the biggest hidden secrets, right? Hidden powerful movements of what the glutes do. They’re huge, rotators, massive rotators. So we want to be very, very aware of what they do, and how in her they were very inhibited. So in this session we had on Monday, we, we I looked into that because again, it was we were having some success, but not enough success. So the next thing that that we did is I as a tester, I had her do a toe and test. So x x i in her foot position. And I said go ahead, just rotate to the right and to the left. And when she rotated into the right motion was okay, it was decent, but she went to the left was kind of a much more of a stick. Or if she would push it her foot was her to spin out or foot or start to roll, right there’ll be there’ll be some sort of like movement leak, that would go somewhere else. So as we start to kind of understand and play with that, I said, you know, we gotta go after that, that glue. So as a massage practitioner, I got her on my table, and I started to do muscle palpation basically just push it on the muscle to see how it responded to to pressure to force. And when I push on her left glute, she but that’s like a 910 out of 10 like discomfort, like, oh, wow, that’s extremely uncomfortable for you to apply physical force to that muscle, which tells me that the tissue is bound down, it’s very adhere, it’s very dehydrated. So it’s prime movement is not happening. It can’t go through its own short stretching cycle, then it’s not effectively playing in the system of movement. So as I started NS and also did a gait analysis on her and just had her walk, I try to do these things before every session just to refresh and see where where she is. And as she’s walking, she walks in and watch my hands here. It’s very hip hiker ish, right? Very much hip hike. And it’s also interesting as she walks as a she’s a lot of hip height, and also is interested in her offside crossover hurts. Very much glute medius, glute medius, glute minimus, TfL, hurts very painful. Well,

that would be very painful if she’s very dominant in this type of pattern because it gets overused. And she doesn’t have a lot of rotation. When she walks out. Each person has kind of a way of walking that’s more unique to them. Much more hip hike, much more rotation, but the grand scheme of things we want a good access to both this access to it right. So immediately in that session, I had her do towing and lunging. Now again, when we tow when we’re going to force the glute to go into more loading. If it still can’t, then it’s going to hurt this hip even more. So I knew I had my spectrums to play with. Well, once you did a toe and lunch she actually as she went through and pushed off, right because it hurts and tz too. But if we can preload in tz one that’s going to transfer power into tz two or transformational zone two. And guess what? Lunging with Tobin felt better, not pain gone but felt better than what had her do Saturday do a same side by little hand rotation at chest height, which only takes the thoracic spine and spins into that glute more and guess what? Even less discomfort. So I had to do that down the 40 yards of our turf and all the way back. The pain was so minimal that I felt okay that some repetition some volume would be just just fine. And when she came back and she went for a run run was her litmus test. Running was a lot less painful, just by doing that one drill. So that told me something that that gave me feedback that with more glute transverse plane loading we’re getting a better Push off, because the glutes now engage more. And that took reduce stress off this hip flexor, front hip, let’s just call it that to keep it simple. So in the session, I said, Let’s go on the table and let me unlock that tissue more. So got my elbow in there, for him in there. Pull him in there and a toe, what if we did about 25 minutes of some relatively very good soft tissue work, unlocking that area. And just even coming off the table, there’s this sense of what we call naive range of motion. Because what we did is we unlocked connective tissue fascial tissue, but her proprioceptive system is off her nerves weren’t literally feeling what it’s like to have a glute with the more elasticity that came from 25 minutes of work. So when she gets off a table, those people who are doing long form foam rolling, or soft tissue work, there’s going to be a limp that happens. And we call it naive range of motion naive, meaning that the glute literally doesn’t have the sensation, the neurological pathways built to manage its newfound range of motion. And so it starts to go into a limp cycle and eventually the limp cycle it learn as it takes steps. It’s like a computer teaching itself, or software teaching itself. From the from the environment that it’s now placed in. It’s really cool. Actually, it’s literally in an AI system, a neural net system. It’s pretty awesome. Anyways, getting into he was about to change topics. So as he goes into that, if there’s a lip pattern, but it’s not painful, limping is not a bad thing. As long as it’s what’s the limping going to produce? Well, fern is going to produce better movement, as she would limp her way out of her limp. Okay, so we went big back into it and started going into more of where her her hamstring attaches into her pelvis, and of backstory history, she tore that hamstring, literally off the bone in a in a skiing accident decades ago, or at least a decade plus ago. And you know, as I start to kind of think about past movements, right? Did that torn hamstring play into her fair for her fondness of running and start to start to kind of slowly put a dysfunction in that hip, where because the hamstrings are also powerful rotators as well, more so at the knee. Because one hamstring can pull in its pulls the knee and the other hamstring contracts and pulls me the opposite way. So that’s an that’s an open and closed chain or foot off the ground foot off the ground position. But since it affects the knee, it also attaches at the hips. So it also has rotation capacity at the hip. So could that been a play in this problem? And the answer is, of course it could was it? We don’t know. There’s no way for me to tell that. You know, I wasn’t on her runs. I know what’s going on. I don’t even actually know what hamstring muscles tore off the bone. Was it both? Or was it just one? Well, if it was just one, it would certainly tell us which which hamstring rotation bias she is. Well, dysfunctional. Right? Right, right, right left because the bicep for Morris has helped helps with external rotation that he were the forgetting the names of those two hamstring muscles semi tendinosis semimembranosus, medial hamstring muscles, pull into internal rotation of the femur or the knee. Long story short. It matters. So I’m digging into NASM SCART scar tissue now with scar tissue, you’re not going to loosen up the scar tissue. Right? That is it is a biological physiological connection of fibrous connective tissue that does not go under stretch anymore. However, that’s just the scar tissue. What about the surrounding tissue? Well, it’s scar tissues is like a black hole. If you know much about space, black holes, suck things in, look at my shirt. If I take my shirt and I spin my shirt. Right? What’s happening to the surrounding material? What’s happening to the surrounding material, right, you can see the lines of tension that are being drawn into this scar. And as I start to stretch away, right, you can start to see oh wait a minute lines of tension. Well, what if I start to move one way? What if I start to move the other way, right, these lines start to play into dysfunction it starts to spread or sucks things in spread. So though I cannot remove the tension in that one spot, I can certainly remove the tension of the surrounding areas. Right now though, that scar will continue wanting to pull in. Well if I have drills and movement patterns that start to always pull Look out, I can find a relative equilibrium that the person can have for the rest of their life. Will they always need to do drills will of course, all humans will always need to do some sort of training conditioning to give their body at a healthy level, always, because we always have movement patterns that are dysfunctional playing into our lifestyle, always it just the way it goes. So yes, there are some things you don’t have to fix this, they remain fixed. But long story short, we live in a dysfunctional life of movement, very asymmetrical, that, okay, so long story short, so I started going in around that soft tissue area, and working on those spots, also very bound down very, very tender. So we threw into a hamstring, such in the cage through her left foot up. And it wasn’t about going straight forward, it’s about getting into the rotational pieces, right, and left, or same side or opposite side, and playing into those stretches. So those are some great ways to do it. Now, as we got her off the table, I wanted put it into a glute stretch that was very appropriate for loading and unloading. Now we use the cage a lot, because it’s a massive helper in terms of putting our bodies into very complex, multi dimensional positioning, and have the stability and mobility available to us to master this spot. Now though, the cage is a very non functional piece of equipment, because we don’t have cages when we walk outside of the facility, but allows us to very narrow in on of structure, and focus in on it for the sole purpose of unlocking it and making it available to multi dimensional function. So that’s why we have so many cages, because it allows that, that that stretching and that and that detail that we want to go after. So we did an upside foot crossover, trying to go after this glute, which gets me into flexion gets me into abduction. And it gets me into not too much internal rotation, I’m actually relatively externally rotate, rotate, excuse me, but what I do is I put weight on the inside of the foot. And I’m going to put weight on the inside of the foot that draws me into more internal rotation more reason, though relativity because the slant of this thing, I’m actually an external rotation, but I really can’t get into too much internal rotation anyways. So by drawing weight on the inside of the foot, that pulls me into enough internal rotation to the femur, which means I have triplane loading of that glute, and all three planes of motion. I place my hands in the in place. That’s, that’s, that’s comfortable. And I started to say I can now head over foot, which loads the glutenous at sagittal plane puts me into more hip flexion. I said now slide the hips Oh student and I said hey, does that do you feel that glute stretch? Or do you feel a hip flexor pinch, because whenever she would drive her knee up, walking upstairs, intact out

running the hip Pike, she felt a massive pinch. And that pinching sensation not to go too far off topic is essentially the hip flexor saying I’m trying to flex the hip. I’m trying to and she actually Tate’s going upstairs, because she knows every time she drives her knee up, it’s going to be the binding grab. And then as she takes the next foot up and drives up, she’s gonna get that stretching, achy feel. So it’s kind of a dual play. She hates going upstairs. So when we’re trying to stretch her, which essentially we’re having to put put a foot up up on a stair. Now what I want to do is I want to give her a stretch of the glute, which is kind of the reciprocal inhibitor. Long story short, it’s the opposing muscle of the hip flexor for me to get more hip flexion means I need more glute flexibility, right? It’s just the, that’s the way it goes. If I want knee up, I need the glute to say I’m going to stretch, I’m gonna going to open up and hip flexion I’m going to contract or shorten. So even in this position, she was feeling that pinching. And I believe that’s because her body has again a software built into it already. That saying knee. When you go up hip flexor you must do it. Even though the glute is not under much tension because it’s kind of resting my attention is in this standing leg. It’s in the standing leg. But again, her body is preconditioned to flex to over tense this hip flexor, even though her knee is not under much tension. So if I put her into a more glute extension, her hip flexors arguments a fight, go into work. Fair enough. And it did. So like bummer. Okay, so sagittal plane. We can’t go there. I said okay, so keep your head head back. Hips slide to the left. So more ad duction fired up. Again. I’m like, Ah, dang it for a funnel plane. body’s not ready for that yet. Let’s go transverse plane. I said just rotate your head and I went through a thoracic spine. Mind spin versus a hip spin. And it’s fair enough, boom, fired up again. I’m like, dang it, there’s my three options. How am I going to try to override her nervous system to not play into this hip, and to stretch to this glute? Because she felt no glute stretch? So I played into it more. So the answer is still out there. So intuitively, I said, Well, let’s load that hip flexor to that load that glute more not by body positioning, but by direct force. So I said push your foot hard, which I don’t think she was at all, but push your foot hard into the second platform. That direct force is already in isometric muscle contraction. Then I said, head over foot. And I said, Do you feel hip pinch or glute stretch, he said, I feel a glute stretch and no hip pinch. Now it’s kind of a reminder to me like, Oh, I’m awkward. Come on, like think about the principles, right? I could have probably bypass that that step. But I didn’t. But I eventually got got to it. pre load the tissue, then go into a stretch versus just position it and then try to go in and have the stretch. Either way, we problem solve it by putting pressure into the foot, head over foot more sagittal plane flexion, sliding or hip out or more femur, more relative adduction. And then looking and rotating the body out more internal rotation, guess what all of them were glute stretches. And none of them. Were hip flexors. So we were able to bypass her pre conditioning, which was great. That’s what we want. And we drove it and we stretched it, and we dialed it in. And guess what, when she came out of it, again, her limp was back like, right, because again, we massively took more connective tissue lengthening more than her body was able to do, again, in a very artificial environment, put it into direct function of loading of gravity, and pump the hip with the lip was there again, naive range of motion, not a bad thing. But we want to immediately train it to manage artists manage real gravity, real ground reaction forces, real Massimo menten. But I don’t want to over challenge her, because I over challenged that glute, and it can’t manage it. Right, it’s going to go into a tense state, once again, just like we are mentally, if I give you too big of a challenge, you’re not going to accept it, you’re gonna be like, No, that’s too much, you can get scared, like jump off this cliff into the lake, too big not going to do it. But if you have a small enough jump, oh, I go cool. I’ll do it. So that cycle social behavioral is is hardwired into our muscles as well. So I had to grab on to the to the cage, actually, what I did is I had to grab onto a moped stick first. And I said, go ahead and do give me a single leg balance, and just start to literally translate through the hip sagittal plane, translate to the hip frontal plane, translate it to the hip and rotational plane. And all that was it was good. It was good. It wasn’t great, great, though, because her range of motion was still really limited because she had her preconditioning movement patterns that just didn’t want to give up. So what I did, I said not that’s not good enough. Grab on onto the cage. And on these platforms, we have two slapped slanted platforms, where if I have a platform with my left foot on the left side, I’m pushing more into pronation or more into heel II version. And if I put my left foot on the right side, I’m going to be more supination or more heel inversion, which allows my foot to pre position itself for better biomechanical sequencing. So I wanted more glute loading, which I want more relative foot pronation or heel e-version. So I put the left foot on the left side, I had two handholds, which are totally stable. And I said, I want you to get into flexion. And I want you to head over foot, and I want you to foot pushing into platform taking all that we’ve already learned from a previous stretch. And that was all hip loading and no hip flexion binding or pinching. And then I said, I want you to literally drop your hip into your right hip into your left, which gives me a lot of internal rotation. But more so gives me a lot of that AB reduction, or abduction, excuse me, a D D duction, which was very painful in her movement. But because it’s in a very supportive environment, she doesn’t have to manage all the physics. It’s very supportive. She says, that’s an amazing stretch. And I said, Now I want you to unload out of it. Load into it, load out of it. And now you get a lot of glute motion. And she says on the first few slides, I don’t feel much at all. I just feel motion. I’m like, that’s fine. Because your glute does it. It’s crazy how muscles work. They don’t just fire up right there. Just start working. They kind of have to kind of feel the flow of it all just like us as human beings. Right. So eventually I said just keep going until that glute starts to get tired, not fatigued, not dead, not burning, just you start to feel the tiredness, the working of it. Sure enough talking about 20, fiber ORS or so reps for movement to kind of fully get grasped into it says good, tired, good. I say Good. Now let’s switch sides, get into it come out of it and her rights as well, my rights that I feel almost immediately, like, oh, they get playing into the dysfunction. But now it’s now it’s coming into her own her own ownership. But that’s the key piece, right? Me telling someone something is really not even good enough, right? They have to own it. And if they can feel it, that’s why through that through, you can learn a several ways where you can hear it, you can see it, you can taste it, in a sense, right, but you can feel it, and it starts to become ownership. So that was a real cool, cool, cool time went back and forth on a few reps to get that glute fired up. And then we immediately went into a walking pattern. And we started to go into a walking pattern and immediately pain was gone. Now will it stay gone? We have to figure out more to make sure that that’s that’s an issue or not right, because again, we just trained her for a few moments, is her body going to stay there not in a few reps, right? Not in one session is going to have to be more drills to kind of really fine tune her body to have the tone 10 and a new movement pattern for her to access. But again, even as I saw her her walk, her gait pattern didn’t just swept by she was still kind of just here, you know, kind of in this kind of spot versus getting this full, repetitive, rotational, multi, multi dimensional pattern and she’s still in this spot. But we took her glute into the story enough to relieve hip flexion discomfort. Even though the hip flexor is still pissed off, right? The glute worked enough to not make it scream. Okay, cool. So I had to do a step up onto like a tire I had like a tire flipping just said, Just go and step up onto that tire, drive your knee, no pain, cool, step up onto the tire and drive up and get to an extension. No pain. Cool, great. Problem solved. No, just we had a good session. Now we have to continue to feed and train and condition, that new movement pattern to access this rotation at the hip. Which means when I see her walk into the facility to next time, I want to see her walk through more hip rotation versus hip hiking. Now, will that happen or not? Well, that’s where the transmission will go to the next step. How do we continue to train her body to move in a particular way. And that is that is more functional and more healthy.

So what I wanted to take away from this one is that you know, the hip flexor can have a lot of dysfunction. And you know, my previous thought processes, add Dr. Add doctors to bound down so you go into extension, it doesn’t give it this has to overstretch for this abductor because it’s under stretching to produce enough power. Well, in this case, that’s wasn’t what I saw her adductors are actually doing relatively fine. It was a glute, her SameSite glute wasn’t getting enough loading. So as she powers through, this didn’t get enough loading. So as it drives up, it has to overdrive and overcompensate for posterior hip. The crazy thing is, I can make four more videos on a different scenario of why the hip flexor hurt, but I wanted to give you an example of why something can happen. So as you start to do movement assessments, you start to realize like wow, they have hip flexor pain, their glutes really bound down again, that’s a possibility. So you start to kind of glean and learn from past experiences. To me, this is what we call empirical data. Right? Is this out of some Journal of Science and medicine, you know, that’s been published and studied know? How am I going to replicate this pain in someone else? It’s very challenging to do that, if not impossible, but empirical data will tell us like here are here are situations biomechanically that have come to a result. And though every person is relatively unique and different, there are still biomechanical patterns that people plant play into. So I want to share this one with you as in terms of the hips, the glutes, not giving enough hip extent or basically they’re not going through enough stretching, I would call it to make a simple I don’t really like like that word, but lengthening. So therefore the hip flexor had over contract and got pissed by doing that, but also through walking, she wasn’t getting enough hip rotation. Again, limited because the glutes also demand a lot of rotate, rotate For function, and she just had to kind of find another way to walk, which is much more hip hiking. So when you see someone walking in a gait, gait analysis, you really want to see how much hip spin are they offering, they really stand behind them and kind of see how much how much the butts waggling back, back and forth, right. And as it getting much more up and down, which begets more lot more up and down, we’re gonna get a lot more tension through the lateral hip, and they’re gonna get pissed and tired and that hence why her upside. Lunge was so achy, especially on her left side. So again, food for thought food for you to consider. If these were concepts that were like way over your head yet, like I had no idea what you’re talking about. I want you to discord message me privately if you want to, and just say and let me know where you came to. And then drop dropped off, just for my own knowledge. So as we build more and more material for you all we know where you’re at, and we can build to it, if you understand exactly exactly what I was talking about, but didn’t really know my thought process of how I got there. Message me. Because I want to know, again, how we can understand deeper into your, into where your lack of or where your gap is, in your knowledge and how we can fill that it’s not lack of knowledge is that there’s a chasm there that we need to fill. So you can jump to that next understanding. Again, not everything was perfect in my session, not everything I have fully understood. I’m always in practice. But again, this is where this communal learning comes from this sort of this open sourcing comes in for us to apply more and more of our movement, understanding what our truths are principles of movement of physics, of biomechanics, of biology, of behavioral science, and then into our intuition of placing these things together by connecting more and more dots. So thanks for your time. Appreciate you all. Have a great one. And we’ll be talking soon.