Neuromuscular Physiotherapy: Megan’s Case Study

By studying Megan’s medical history and symptoms, key moments and events are highlighted on her pain and dysfunction timeline. Nine years ago, after the birth of her second child, it was the first time 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 your pregnancy a hormone called relaxin would have been released into your system to loosen the ligaments in your pelvis in anticipation of delivery. However, relaxin can also loosen the ligaments in other parts of the body and a longer and wider left foot would indicate the collapse of the major arches of the foot due to the laxity of the ligaments. This is one of the turning points in Megan’s story 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 a few years later she developed a feeling of tiredness and pain in her left medial arch, it was probably because of this. A dropped arch will lead to excessive pronation and this in turn will put the tibialis anterior and possibly tibialis posterior muscles under undue stress as they attempt to stabilize and counteract excessive pronation. Stressed or overwhelmed muscles will form trigger points (TP) within them and for the tibialis anterior this may refer the pain anteromedially as it passes through the retinaculum. TPs on the tibialis posterior will remit the pain to the sole / arch of the foot. Excessive pronation will lead to shortening of the peroneus longus, further inhibiting the tibial muscles, further exacerbating the problem in a continuous vicious cycle.

The whiplash injury she suffered last year would also add to Megan’s problems and since then she has experienced occasional headaches and a stiff neck. The whiplash injury almost certainly would have affected her suboccipital, sternocleidomastoid (SCM), scalene, and other neck and spinal stabilizers. This whiplash would lead to incorrect neck movement which in turn would lead to TP in the SCM and possibly longus colli on one side (left) possibly due to the leg length discrepancy. The TPs here would leave these muscles in a shortened state, causing the head to rotate to the right side. If the longus colli is involved, this leads to kinetic chain problems and affects the peroneals on the lateral aspect of the lower limb, further aggravating the fallen arch. With the peroneus longus muscles in such an unhealthy state, it is possible that it may have an effect on the sacrotuberous ligament of the pelvis and its ability to hold the sacrum in position. Megan claims that one day last year she felt a twinge in her right sacroiliac joint while helping an obese client to get up from a supine position. She experienced blockage / jamming and diffuse soft tissue pain in QL, multifidis, and stabbing pain in her hip. The fact that it was locked in flexion of the torso to the right suggests that the QLs went into spasm on the right side after the assault and, as we found out later, their sacral base is one inch up to the right and there is rotation posterior right ilium. with the resulting postural imbalance whereby 2/3 of Megan’s weight is pressing down on her right side. This additional load and postural imbalance has resulted in stabbing pain in the trochanteric region and referred pain in the lateral aspect of the thigh due to PT in the weakened gluteus medius and iliotibial band problems due to the overloaded tensor fascia lata.

With all this pain reaching excruciating levels, Megan turned to prescription drugs, codeine-based pain relievers, antidepressants, Zoloft, anti-inflammatory tablets, all of which would have exacerbated her problems over time by accumulating toxins in her system. She was also under the influence of painkillers, probably damaging tissues by performing activities that she would not have done if her natural pain alarm system stopped her. The elastic support belt and bandage would have made the situation worse by promoting atrophy of the supporting muscle tissue.

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

By considering Megan’s problems, symptoms, and medical history, we can see that she is suffering from abject pain and dysfunction along her functional kinetic chain. From pain in the plantar fascia, spastic peroneus longus, inhibited tibial, medially rotated tibia, medial knee pain, lateral thigh pain, trochanteric pain, pelvic lumbosacral pain and dysfunction, posteriorly rotated right ilium, left lower anterior superior iliac spine, 2 / 3 weight imbalance on the right side, low back pain with QL and multifidis in a shortened state, latissimus dorsi, neck extensors and flexors, all giving problems, we have to ask ourselves what functional kinetic chain we are dealing with. In my opinion, considering all the areas involved, it would be the spiral oblique chain.

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

  • Medical examinations.
  • Case history.
  • Postural evaluation.
  • ROM tests / neural tests.
  • All shortened and restricted muscles would have to be relaxed / lengthened with PT, MET, positional release / counter-effort therapy.
  • The inhibited muscles would have to be activated and strengthened with tapotement, MET and strengthening exercises.
  • Any joint area would need STR, friction between fibers, etc.
  • One consideration would be referral for PCI to initially address the pronated left foot with a plan to strengthen that area in the long term.
  • Megan’s nutrition was not mentioned, but I would refer her to a specialist in that field to ensure that she does not have nutritional deficiencies that hinder the healing process.

Written by Charlie J Molloy

September 14, 2020
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