Case Study - Developing a Movement Diagnosis

History: Hannah presents to physical therapy with complaints of low back pain that began two weeks ago. Hannah states that she was deadlifting with she felt a sharp pain in her lower back. Pain has decreased since her initial injury, but she still experiences pain with forward bending. No complaints of radiating symptoms.

Fundamental Patterns


Multi-Segmental Flexion

· What It Should Look Like: ability to touch toes with knees extended and uniform spinal curve while demonstrating adequate posterior weight shift

· What It Does Look Like: lacks uniform spinal curve; subjective complaint of pain

· Relevance: contributes to absorption, or flexion-rotation, pattern


Multi-Segmental Extension

· What It Should Look Like: ASIS clears toes and spine of scapula clears heels while demonstrating uniform spinal curve

· What It Does Look Like: spine of scapula does not clear heels; hinges at lumbar spine

· Relevance: contributes to propulsion, or extension-rotation, pattern


Multi-Segmental Rotation

· What It Should Look Like: pelvis and

spine each rotate 50 degrees with no spinal deviation

· What It Does Look Like: pelvis does not rotate 50 degrees; spinal flexion deviation;

right rotation more limited than left

· Relevance: contributes to flexion-rotation and extension-rotation patterns


Overhead Deep Squat

· What It Should Look Like: tibia and torso parallel; femur parallel with floor; no lateral deviation; hip, knee, and ankle aligned

· What It Does Look Like: positive torso angle; femur not parallel; right hip shift

· Relevance: contributes to flexion-rotation and extension-rotation patterns

Seated Tests

Hip Flexion Internal Rotation

· What It Should Look Like: 35 degrees actively and passively

· What It Does Look Like: right side limited actively and passively

· Why: tissue compliance

· Relevance: contributes to multi-segmental rotation pattern


Hip Flexion External Rotation

· What It Should Look Like: 45 degrees actively and passively

· What It Does Look Like: left side limited actively and passively

· Why: tissue compliance

· Relevance: contributes to multi-segmental rotation pattern


Modified Thomas Test

· What It Should Look Like: femur parallel with table with 90 degrees of knee flexion

· What It Does Look Like: femur not parallel; knee not at 90 degrees; left more limited than right

· Why: tissue compliance

· Relevance: contributes to multi-segmental extension pattern

Supine Tests

Double Knees to Chest

· What It Should Look Like: 120 degrees of hip flexion (proximal thigh touches abdomen)

· What It Does Look Like: no limitations

· Relevance: contributes to multi-segmental flexion and overhead deep squat patterns

Straight Leg Raise

· What It Should Look Like: 70 degree actively and 80 degrees passively

· What It Does Look Like: both sides limited actively and passively

· Why: tissue compliance

· Relevance: contributes to multi-segmental flexion pattern


FABER

· What It Should Look Like: knee within two fists of table

· What It Does Look Like: left side limited with and without core assist

· Why: tissue compliance

· Relevance: contributes to multi-segmental extension and overhead deep squat patterns

Quadruped Tests

Lumbar Lock Thoracic Extension-Rotation

· What It Should Look Like: 50 degrees actively and passively

· What It Does Look Like: right side limited actively

· Why: neuromuscular control

· Relevance: contributes to multi-segmental extension and multi-segmental rotation patterns

Prone Tests

Hip Extension Internal Rotation

· What It Should Look Like: 35 degrees actively and passively

· What It Does Look Like: right side limited actively and passively

· Why: tissue compliance

· Relevance: contributes to multi-segmental rotation pattern


Hip Extension External Rotation

· What It Should Look Like: 45 degrees actively and passively

· What It Does Look Like: left side limited actively and passively

· Why: tissue compliance

· Relevance: contributes to multi-segmental rotation pattern


Kneeling Tests

Closed Chain Dorsiflexion

· What It Should Look Like: 40 degrees actively and passively

· What It Does Look Like: right more limited than left; subjective complaint of pinching in front of ankle on both sides

· Why: joint dynamics

· Relevance: contributes to overhead deep squat pattern

Summary


In order to create a movement diagnosis, we must marry the patient’s subjective complaints with our own objective findings. While examining the fundamental patterns, we were able to identify that the multi-segmental flexion pattern was painful for Hannah. This is important because we want to avoid movements that may provoke the symptoms that Hannah is currently experiencing. In addition, we see a consistent pattern that Hannah presents with deficiencies that coincide with the extension-rotation right pattern, or propulsion up and across the midline to the right (highlighted in chart).

For these reasons, we would assign a movement diagnosis of extension-rotation right.


*Disclaimer: Evaluation was adopted from the Selective Functional Movement Assessment.