Neuromuscular Physical Therapy – Megan’s Case Study

In studying Megan’s case history and symptoms, key moments and events stand out in her time line of pain and dysfunction. Nine years ago, after the birth of her second child, was the first time that Megan noticed that her left foot was slightly wider and longer than her right foot. The timing of this is relevant as during the course of her pregnancy a hormone called relaxin would have been released into her system to loosen the ligaments of her pelvis in anticipation of childbirth. However, relaxin can also loosen ligaments elsewhere in the body and a longer and wider left foot would indicate the collapse of the main arches of the foot due to ligament laxity. This is one of the turning points in Megan’s history that has had a detrimental effect on her health ever since. The relaxed ligaments may never have fully recovered their full stabilizing strength and when she developed a tired aching sensation in her left medial arch a few years later it was probably as a result of this. A fallen arch will lead to over pronation and this will in turn put the tibialis anterior and possibly tibialis posterior muscles under undue stress as they try to stabilize and counteract over pronation. Stressed or overwhelmed muscles will form trigger points (TPs) within them and for tibialis anterior this can refer pain anteromedially as it passes the retinaculum. TPs in the tibialis posterior will refer pain into the sole/arch of the foot. Over pronation will lead to shortened peroneus longus which will further inhibit the tibialis muscles which will further exacerbate the problem in a continuous vicious circle.

The whiplash injury experienced last year would also add to Megan’s problems and since then she has experienced occasional headaches and neck stiffness. The whiplash injury almost certainly would have affected her sub occipital muscles, sternocleidomastoids (SCM), scalene and other stabilizers of the neck and spine. This whiplash would lead to improper neck movement which in turn would lead to TPs in the SCM and possibly the longus colli on one side (left) possibly due to the leg length discrepancy. TPs here would leave these muscles in a shortened state resulting in rotation of the head to the right hand side. If the longus colli is involved it result in kinetic chain problems and affect the peroneals on the lateral aspect of the lower limb further exacerbating the fallen arch. With the peroneus longus muscles in such an unhealthy state it is possible that it could have an effect on the sacrotuberous ligament of the pelvis and its ability to hold the sacrum in position. Megan states that one day last year she felt a twinge in her right sacroiliac joint while assisting an obese client up from a supine position. She experienced locking/jamming and diffuse soft tissue pain in QLs, multifidis and shooting pain into her hip. The fact that she was locked into torso flexion to the right suggests that the QLs went into spasm on the right side after insult and as we find out later her sacral base is an inch high on the right and there is posterior rotation of the right ilium with resultant postural imbalance whereby 2/3rd of Megan’s weight is pressing down on her right side. This extra load and postural imbalance has led to shooting pain in the trochanteric region and referred pain on the lateral aspect of the thigh due to TPs in the weakened gluteus medius and iliotibial band issues due to the over worked tensor fasciae latae.

With all this pain getting to unbearable levels, Megan turned to prescription drugs, codeine based painkillers, antidepressants, Zoloft, anti inflammatory tablets all of which would have exacerbated her problems through time by building up toxins in her system. She was also whilst under the influence of painkillers probably injuring tissue by doing activities that she would not have done if she had her natural alarm system of pain stopping her. The elastic support belt and the taping would have made the situation worse by encouraging atrophy of supporting muscle tissue.

Megan’s right shoulder is lower than the left possibly due to shortened latissimus dorsi pulling on the humerus and inhibiting upper trapezius and hypertrophy of the pectoralis minor muscle pulling the scapula forward and down.

As we consider Megan’s problems, symptoms, and case history, we can appreciate that she is suffering abject pain and dysfunction up and down her functional kinetic chain. From the pain in the plantar fasciae, spastic peroneus longus, inhibited tibialis, medially rotated tibia, medial knee pain, lateral thigh pain, trochanteric pain, lumbo – sacral pelvic pain and dysfunction, posteriorally rotated right ilium, lower left anterior superior iliac spine, 2/3rd weight imbalance to right hand side, lower back pain with QLs and multifidis in a shortened state, latissimus dorsi, neck extensors and flexors all giving problems we have to ask the question as to which functional kinetic chain we are dealing with. In my opinion, considering all areas involved, it would be the spiral oblique chain.

Megan would have to be informed that her treatment will be extensive and prolonged because some issues have been there for a while and would involve neural retraining for the dysfunction and imbalances present.

  • Medical screening.
  • Case history.
  • Postural assessment.
  • ROM testing / neural testing.
  • All shortened and restricted muscles would have to be relaxed / lengthened with TP therapy, METs, positional release / strain- counterstrain.
  • Inhibited muscles would have to be fired and strengthened with tapotement, METs and strengthening exercises.
  • Any areas of bind would need STR, cross fiber friction etc.
  • A consideration would be referral for PCIs to address the pronating left foot initially with a plan to strengthen that area long term.
  • Megan’s nutrition was not mentioned but I would be referring her to a specialist in that field to ensure that she has no nutritional deficiencies that would hinder the healing process.
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