Ms. A is a 33 year old female, who presented to clinic on January 10, 2023, reporting pain in her right “sit bone” with workouts. She describes the pain as “nervy”. This pain has been present, on and off, for many years (~10 years), and has worsened recently. Her goal is to increase weightlifting, but she is discouraged because she feels this sensation with lower body exercises (ie: deadlifts, squats, running) and it feels like it could get worse if she increases her workouts, like she’s done in the past. She reports occasional tingling sensation in hamstring area after a workout, and tension in the hamstring with sitting. She has had success with IMS needling, and other physio treatments but never lasting.
- Multiple WAD injuries (3x)
- Separated right AC as a teen
- Lumbar disc injury in 2014 (when symptoms started)
- Crohn’s Disease – controlled with Humira, but flares with stress
- Multiple sphincterotomies
- Scar tissue around organs
Ms A’s meaningful complaint is pain and discomfort in the right ischium and into the posterior thigh with hip hinge motions. She is an avid exerciser and notices this sensation with lower body workouts and running. She also notices a numb sensation over her right hamstrings at times when the pain is worse. She is currently training for an endurance race this summer.
Ms. A feels like this problem is with her fascia around glutes and hamstrings because it seems to temporarily improve with foam rolling. After foam rolling, she finds she can contract her glut muscles appropriately. She also feels like her sciatic nerve is involved and that the disc injury from 2014 caused nerve tension.
Ms. A reported that her main motivation for coming for treatment is that she’d like to get stronger to support her running training and the issue arises when she tries to increase her weightlifting. I determined that her meaningful tasks are weightlifting and running.
Since weightlifting is her primary concern and her symptoms seem to have a dural component, I chose a hip hinge task as it lends itself to many weightlifting moves (deadlifts, squats, lunges). At a later date, I would also assess a single leg stance on the right for running as a meaningful task.
Functional Unit #1
Standing Postural Screen Including a Summary of Incongruencies
Because the position of the meaningful task begins in standing, standing was chosen as a start screen position. Most of the patient’s complaints involved an upright position (ie: weightlifting, running) and it is helpful to determine where the alignment of the body segments are relative to each other at the start of the task, so one can see when, and if, they change during the task, as the task is the most meaningful part of the assessment.
Start Screen Findings: Standing
Pelvis: left TPR, left SIJ unlocked in standing, right does not appear to unlock
Hips: Left femoral head is forward relative to pelvis
- Vertebrosternal region is translated right, rotated left
- Vertebrochondral region
- TR5, TR7 translated left, rotated right
- TR6 translated right, rotated left which is incongruent with the rings above and below. This is called, in ISM, a thoracic ring sandwich.
- TR5 and TR7 are incongruent with most of the thorax, where they are rotated right and translated left, while most of the thorax is rotated left.
Lumbar: L4 is rotated right, incongruent with the rotation of pelvis
Screening Task: Hip Hinge
FU#1 Biomechanics with No Corrections
Pelvis: The LTPR of the pelvis increased. Both SIJs unlock, the right side early in the task and the left side unlocks further at about 75% (since it was already unlocked)
Hips: The left femoral head stays forward relative to the right, but no additional shearing is present
Thorax: The priority rings in the thorax (TR5-6-7 – sandwich) get worse
The lower thorax follows the pelvis into further left rotation
Lumbar: L4 rotates right further
FU#1 Driver Analysis- Primary thorax, secondary pelvis
In this task, correcting the left hip did not correct the biomechanics of the pelvis or thorax in the task but gave the patient a slightly better experience. The pelvis, with a corrected TPR and some force closure, gave the client the best experience but did not correct the alignment of the sandwiched rings in the thorax, in fact, made the translation of the sandwiched ring (TR6) worse, though it did correct the hip alignment. The thorax correction of the sandwiched TR5-6-7 corrected the lower thorax, the TPR of the pelvis, and the alignment of the hip. It did not fully correct the pelvis, though, as the right SIJ still unlocked, though later in the task (~50%) and the left SIJ lost control at the very end range of the hip hinge.
The primary driver in FU#1 is the thorax, even though it doesn’t give the very best experience in the task, because it improves the biomechanics of the most things and doesn’t make any other regions worse. The pelvis is a secondary driver, though, as the force closure in the correction seemed to improve the sensation in the task.
A quick screen of the head and neck was performed in the hip hinge position with the FU#1 driver corrected to see if it was necessary to look for another driver in FU#2. With the thoracic rings (TR5-6-7) corrected, the sensation near the ischium was still present, though diminished, and right rotation of the head and neck felt stiffer. Therefore, more investigation was required, as the driver of FU#1 made FU#2 worse.
Functional Unit #2
Start Screen Findings: Standing
Cranial region: Left ICT, right rotated sphenoid, incongruent with the ICT, C1 translated right, rotated left, which is congruent with the ICT of the cranium.
C2 translated right, rotated left
C7 translated left, rotated right incongruent with upper neck and cranium
Shoulder girdle: Rotated left, congruent scapulae incongruent with most thoracic rings
Thorax: TR1 left rotated incongruent with C7
TR2 left translated, right rotated incongruent with C1, and to the shoulder girdle
In FU#2 the most significant findings in the starting screen position were:
- the incongruent sphenoid to the cranium,
- C7 being incongruent to the rest of the neck and cranium, especially C2, and
- the shoulder girdle being incongruent to most of the thoracic rings, including TR2, though it was congruent to TR1.
Screening Task: Hip Hinge
FU#2 Biomechanics with No Corrections
Cranial region: the cranium position corrects, along with C1
C2 translates further to the right and rotates left, while C7 translates further to the left and rotates right (ie: alignment gets worse), these two vertebra are incongruent to each other
The alignment of the shoulder girdle does not change
The upper thoracic rings (TR1, TR2) both correct
FU#2 Drivers for the Hip Hinge Task
In the task, the only components that do not self-correct in alignment are in the neck, specifically C2 and C7, and the shoulder girdle. The two vertebra were corrected separately, and C2 was found to correct C7 and all of the other elements of FU#2.
Prioritizing FU#1 and FU#2 Drivers
The next step was to prioritize the FU#1 and FU#2 drivers. In the task, correction of the thorax (TR5-6-7) and the neck (C2) each made the other better, and both improved the feeling of the task. The right SIJ was still unlocking at the very end of the task, therefore I hypothesized that the pelvis is still a secondary driver.
My hypotheses are:
- a slight motor control deficit at the pelvis, which makes the pelvis a Secondary Driver, or
- a dural vector in lower spine, with also neural tension in the right leg specifically, that is causing the pelvis to unlock at the end of the task, to avoid a pull on the sciatic nerve at the end range of the hip hinge, which makes the dural system a Secondary Driver. This was assessed at a second visit.
Functional Unit #3
A quick screen of the feet in both the standing start screen and the hip hinge task was performed. Even though there were some alignment issues at the feet, correcting the drivers in FU#1 and FU#2 (co-drivers) corrected the feet in the task and therefore, no further examination was required.
Overall Drivers for Task
In the hip hinge task, correcting both the thorax (TR5-6-7) and the neck (C2) together created the best patient experience for the task and almost completely restored pelvic control, so I determined that they were Co-Drivers. In this case, they correct each other, but do not completely correct the task, so there is still a secondary driver present.
In this case, the secondary driver could be the pelvis, specifically, the active control of the pelvis needs to be assessed. There is likely some dural tension present, but from the story, there could also be some scar tissue at the pelvis from past surgeries of the rectum, which could be causing neuromuscular, myofascial, or dural vectors.
The Cervical Region Driver (C2)
The first driver assessed was the neck (C2).
The active ROM of the neck was assessed to determine the mobility at C2. Notable findings were decreased upper cervical flexion on right compared to the left. With breathing, C2 also was pulled into further right translation.
For the hip hinge task, all the vertebrae in the neck should be in neutral. Since C2 started in left rotation/right translation, it had to be corrected manually for the task. The PROM of C2 in right rotation was slightly decreased compared to the left, but it was possible to correct C2 on C3 to neutral by derotating and translating the segment.
In Passive Listening #1, where the segment is corrected and quality of the movement is felt (ie: how difficult is the segment to correct), it was noted that traction of C1-2 to allow space for the translation part of the correction was more difficult than the lateral translation of C2 on C3. This could mean than there is likely a myofascial or capsular vector on the left and a neuromuscular vector on the right. In Passive Listening #2, where the corrected segment is let go and the direction, quantity, and quality of movement back to the resting position is felt, the vectors noted were the right longus colli, middle scalenes, left upper fibres of trapezius, and left splenius capitis and semispinalis capitis.
No ligamentous laxity was present in the neck, and there was little in the story to recommend that this would be a factor
In the task, there was increased activation of anterior neck muscles (SCM, scalenes) as soon as head crossed the shoulders in sagittal plane, especially on the right. This would cause C2 to translate right, and rotate left, as was noted in the task.
After release, control of C2 came back until the very end of the task. Therefore, a control cue for the neck was given as part of the home care program to improve motor control of the driver.
The Thorax Driver (TR5-6-7)
The second driver assessed was the thorax, specifically the “thoracic ring sandwich” created by rings TR5, 6, 7 where thoracic rings 5 and 7 were translated left and rotated right and the ring 6 was translated right and rotated left. Prior to assessing the active mobility of each individual ring, the Ring Stack and Breathe technique was applied to decrease the neuromuscular vectors in the muscles of respiration (intercostals, diaphragm). This corrected the TR6-7 part of the sandwich, leaving TR5 and TR6 parts to assess.
There was decreased flexion of the right T5-6, and decreased excursion of the right ribs with breath. Notably, there was decreased superior glide of right rib on exhalation. Once the ring stack and breathe technique was performed, these findings were eliminated. They are also not important to the hip hinge task. After TR5 returned to neutral, TR6 was the priority ring in the sandwich, and the only one that didn’t correct with ring stack and breathe, so I should have assessed right rotation, as the thoracic rings, like the neck, should be neutral in the hip hinge task.
TR5-6 were the harder segments to correct in the sandwich, so the Ring Stack and Breathe technique was performed, as described above to remove some of the neuromuscular vectors so that passive mobility testing could be assessed. At that point, TR6 was able to rotate right back to neutral, though there were still some vectors present.
In Passive Listening #1, it was noted that the rings were fairly easy to correct. It didn’t feel like there were any capsular vectors that were difficult to correct. Neuromuscular vectors feel easy to correct and one only needs light correction, and visceral vectors are need slightly more pressure to correct.
In Passive Listening #2, the vectors felt at TR6 on release of the correction were neuromuscular and visceral. The neuromuscular vectors pulled TR6 on the right, and were likely right serratus anterior and external oblique where they interdigitate at ribs 5-7.
The visceral vector at TR6 was quite strong to the right, so a general and local listening for visceral vectors was performed. The general listening technique (Barral), performed by applying gentle pressure to the top of the head in standing, produced an anterior sway in the body. The local listening (Barral), performed in supine, showed a vector in the small intestine, specifically the region of the duodenum.
When Ms. A was in standing, the strongest neuromuscular TR6 vectors, seemed to be the right serratus anterior and external oblique where they interdigitate at ribs 5-7, but interestingly, in supine, the rib angle showed that the left external oblique and right internal oblique had the most resting activation. This is inconsistent with TR6, which was the priority ring in this assessment. This showed that the visceral vector was very strong, since it changed the position of the thorax in standing versus supine. After the visceral vector was released, the standing and supine vectors for TR6 were the same (i.e.: left EO/SA, right longissimus)
The other notable vector of TR6 was the left longissimus. It was determined that it was the left longissimus over the other erector spinae muscles because the right SI joint was the side with poorer motor control. Since the origin of the longissimus through the erector spinae aponeurosis is more medial than iliocostalis, it nutates the sacrum to assist in force closure of the pelvis.
With the neuromuscular and visceral vectors of TR6 released, there was no ligament laxity present in the thoracic region assessed.
Active Control was assessed in standing, after vector release, using isometric flexion and extension of the arms, starting at 90 degrees of flexion. This position was chosen because even though there were no weights in the screening task, holding weights in that position is a normal part of the task. TR6 translated to the right/rotated left, when the flexed arms were loaded into extension, isometrically. The client was able to maintain control with cueing with moderate resistance, so motor control exercises will be important to build capacity and endurance of the thoracic stabilizers. Active Control was also assessed in standing versus in the hip hinge task because of the dural vectors that weren’t released yet, and it was more appropriate to work on some motor control in neutral than with a dural pull.
The Primary Driver of this task is a Co-Driver including the neck and thorax, with a secondary pelvis driver. Most of the vectors are neuromuscular, which indicates motor control issues, more than articular faults. Because the pain comes on in a dural tension position, it could be classified as neuropathic pain, considering the original injury at the lumbar spine. However, due to its chronicity, it could also be classified as nociplastic pain. A slump test and a straight-leg raise test were performed at a later assessment, when the pelvis was reviewed as a secondary driver.
Initial Treatment Session
The vectors of the C2 and TR6 were released through multiple techniques. The first technique was Ring Stack and Breathe. In this technique, the driver in question is manually corrected and the patient is instructed to breathe deeply, in and out, three times. Then the patient is instructed to rotate to the side of the translation. In this case, both the neck (C2) and thorax (TR6) were translated to the right/rotated left.
Ring Stack and Breathe was performed separately at each the neck (C2) and thorax (TR6). Following this, the visceral vector of the thorax was released in supine, using a visceral release technique that involves holding the vector organ, in this case, the duodenum, then holding light pressure at the neurovascular bundle (superior mesenteric ganglion), sympathetic innervation (T6-8 intervertebral foramen), and parasympathetic innervation (vagus nerve) of that organ. The holds are applied until a shift is felt at the organ and it gains back some of its regular motility (this is a Barral technique). Finally, the rest of the neuromuscular vectors of the neck and thorax were released using Release with Awareness (RWA) – an ISM technique. This technique involves shortening the affected vector muscle and applying light to medium pressure and asking the client to relax or release the tension at the muscle. After a change is felt in the tissue, a stretch is applied. This technique was used on the right longus colli, middle scalenes, left upper fibres of trapezius, and left splenius capitis and semispinalis capitis in the neck, and the right serratus anterior and external oblique, and left longissimus muscle. These techniques were taught to the client using a RAD roller release tool, to perform as part of their home care program.
The Align Cue that worked best for Ms. A was to create space in the mid-thorax, especially around TR5 and TR6 and imagine a paper fan opening. This helped to hold the alignment of the priority rings of the thorax.
The Connect Cue needed to maintain control of the neck was to imagine a guy wire between the sternal notch and the spinous process of C2, and then imagine something is gently pulling the end of the wire up. She was able to use this cue to maintain control of C2 until the very end range of the hip hinge task.
Since the pelvic control doesn’t fully come back at the end range of the task, the pelvis needs to be assessed further at a different session. In order to work on building motor control and coordination of the task, the hip hinge task was given in four-point kneeling, rather than standing, where pelvic control can be maintained through the task.
Home Exercise Program Summary
- RWA left side neck, upper fibres of trapezius, right serratus anterior, external obliques, left iliocostalis thoracis
- Postural cue: create space in rib cage, throughout the day in various positions
- Motor control cueing of neck 3×10, 3x/day in standing
- Four-point hip hinge 3×10, with neck cue
In a subsequent session, Ms. A reported that she was still having a pulling sensation in the right ischium with full hip hinge, but has been working on motor control in sitting and 4-point, but also continuing to perform her regular workouts. The slump test and straight leg raise tests for dural tension in the right side were assessed and both were positive on the right, reproducing the original symptoms. When the primary co-drivers, C2 and TR6, were corrected, the sensation only came on at the very end of the range in the dural tension test. After releasing the vectors, which were the same as the previous session, in the neck and thorax, and performing a slump slider exercise with the drivers manually corrected, the sensation of pulling into the ischium was completely eliminated and the right SIJ had complete control through the whole hip hinge task. The slump tensioner exercise to gently lengthen the dural system was added to the HEP, with instructions to complete it after the release, align, and connect exercises.
Future sessions will focus on increasing the level of difficulty for the motor control tasks to continue to build capacity and endurance of the local stabilizers of the neck and thorax. Additionally, weights could be added to the hip hinge task to assess the effect of the shoulder girdle further.
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