Subjective: The Patient complained of chronic right hip pain and hamstring tightness during the season. He reported a dull ache during batting practice and games. He experienced limited stride length during running and inability to swing a bat without a sharp pain within the right low back area. The patient had been experiencing low back, right hip pain and patella femoral discomfort, intermittently for the past 5 years.

Objective: I started treating the patient at the beginning of the off-season last year. The evaluation demonstrated the following:

Range of Motion and Palpation

• -Structural evaluation of the pelvis demonstrated asymmetry of the iliac crest; the right iliac crest was elevated.
• -Over pronation of the meditarsal and subtalar joint was noted bilaterally. Collapse of the medial arch was observed during running and walking gait. Non-weight bearing demonstrated a forefoot varus bilaterally, excessive inversion of the forefoot and eversion of the calcaneus.
• -Range of motion of the lumbar spine was limited in side bending right and rotation left. Backward bending and forward bending was also limited at the end of ranges.
  
• -Trigger points were palpation within the belly of the quadrates lumborum and sciatic notch area on the right.
  
• -Range of motion of the right hip was limited into internal rotation
  

Muscle Strength Testing

• -Muscle strength was tested using Isokinetics. The right hip internal rotators were 50% weaker than the left hip internal rotators. No deficit was noted of the external rotators.
  
• -Manual muscle testing indicated weakness of the right hip abductors and extensors

Special Tests for Muscle Flexibility and Balance

• -Positive Thomas test on the right (specific for rectus femoris tightness)
• -Straight leg raise was to 70 degrees with tightness of the hamstrings
• -Hop test indicated a deficit of muscle strength of the right lower extremity
• -Single leg knee 1/2 knee bends demonstrated instability Patient was unable to maintain balance

Assessment: The patient demonstrated muscle imbalances within the pelvis resulting in instability during one leg standing and functional activities of baseball.

• + Over pronation of the meditarsal and subtalar joints contributed to the patella-femoral pain and general instability within the pelvis.
  
• +Tightness of the rectus femoris and hip flexors along with weakness of the hip abductors, extensors and internal rotators contributed to the patella femoral pain and pelvic instability.
  
• +Pain and weakness of the quadratus lumborum and the lumbar spine restrictions resulted from years of overuse and compensations.
  

Plan: The patient was placed on a strength-training program for the hip muscles. The emphasis was placed on the rotators, abductors, and hip extensors. Abdominal and back extensor strengthening was also accentuated. A periodization program was developed using a hypertrophy phase, strength phase, and power phase. Manual therapy was also incorporated to improve lumbar segment mobility, which was stabilized by the appropriate strengthening exercises.

The strength training was performed in the open kinetic chain and the closed kinetic chain for the pelvic and lower limb. Traditional exercises were used for strengthening the lower leg such as free weights, pulleys, stack weights, and Isokinetics..

An important aspect of the closed chain rehabilitation for pelvic stability was the Dynamic Edge. The Dynamic Edge was used for balance, coordination, power, agility and strengthening. Resistance was applied to the femur to increase the strength of the femoral rotators. Resistance bands attached to the foot plates also opposed the side-to-side movement on the Dynamic Edge.

The initial phase of strength training involved the highest setting for the resistance bands on the foot plates and resistance cords to the upper leg. As the patient progressed to the power and agility phase the resistance bands were eliminated and the patient was capable of performing quick side-to-side movements, without holding on the support frame. The patient was asked to perform 30-second bouts as fast as possible. (3-4 bouts were performed each training session with appropriate rest between bouts) This explosive resistance training provided by the Dynamic Edge was the final phase of the sports specific training and simulated the powerful foot and leg movements needed during the sports specific activities on the baseball field.

Results: The final testing demonstrated 100% improvement in muscle strength of the hip rotators, abductors and extensors. The patient reported no right hip or low back pain with any sport specific activities and demonstrated increased bat speed and sprint time. The patient was instructed in a maintenance strength and power program during the course of the baseball season.

Robert Donatelli, PhD, PT, OCS, is national director of sports rehabilitation for Physiotherapy Associates in Atlanta.