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THE REHABILITATION of a RUNNER with ILIOPSOAS TENDINOPATHY USING an ECCENTRIC- BIASED EXERCISE-A CASE REPORT Carla Rauseo, DPT, CSCS1 IJSPT

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THE REHABILITATION of a RUNNER with ILIOPSOAS TENDINOPATHY USING an ECCENTRIC- BIASED EXERCISE-A CASE REPORT Carla Rauseo, DPT, CSCS1 IJSPT CASE REPORT THE REHABILITATION OF A RUNNER WITH ILIOPSOAS TENDINOPATHY USING AN ECCENTRIC- BIASED EXERCISE-A CASE REPORT Carla Rauseo, DPT, CSCS1 IJSPT ABSTRACT Background and Purpose: While there is much discussion about tendinopathy in the literature, there is little reference to the less common condition of iliopsoas tendinopathy, and no documentation of the con- dition in runners. The iliopsoas is a major decelerator of the hip and eccentric loading of the iliopsoas is an important component of energy transfer during running. Eccentric training is a thoroughly researched method of treating tendinopathy but has shown mixed results. The purpose of this case report is to describe the rehabilitation of a runner with iliopsoas tendinopathy, and demonstrate in a creative eccentric-biased technique to assist with treatment. A secondary objective is to illustrate how evidence on intervention for other tendinopathies was used to guide rehabilitation of this seldom described condition. Case Description: The subject was a 39-year-old female middle distance runner diagnosed with iliopsoas tendinopathy via ultrasound, after sudden onset of left anterior groin pain. Symptoms began after a signifi- cant increase in running load, and persisted, despite rest, for three months. The intervention consisted of an eccentric-biased hip flexor exercise, with supportive kinetic chain exercises and progressive loading in a return to running program. Outcomes: The Copenhagen Hip and Groin Outcome Score, the Visual Analogue Scale, the Global Rating of Change Scale and manual muscle testing scores all improved after 12 weeks of intervention with further improvement at the five-year follow up. After 12 weeks of intervention, the subject was running without restriction and had returned to her pre-injury running mileage at the five-year follow up. Discussion: The eccentric-biased exercise in conjunction with exercises addressing the kinetic chain and a progressive tendon loading program, were successful in the rehabilitation of this subject with iliopsoas tendinopathy. This case report is the first to provide a description on the rehabilitation of iliopsoas tendi- nopathy, and offers clinicians suggestions and guidance for treatment and exercise choice in the clinical environment. Level of Evidence: 5 Keywords: running, tendon, tendon pathology, tendon loading CORRESPONDING AUTHOR Carla Rauseo, DPT,CSCS Total Rehabilitation Centre 60A Boundary Road Extension San Juan, Trinidad and Tobago E-mail: [email protected] 1 Total Rehabilitation Centre, San Juan, Trinidad and Tobago Phone: (868)-389-5768 The International Journal of Sports Physical Therapy | Volume 12, Number 7 | December 2017 | Page 1150 DOI: 10.16603/ijspt20171150 INTRODUCTION are already upregulated. Rather, they suggest that Tendinopathy is the term used to describe the clini- eccentric exercise can have a positive effect in the cal condition of tendon pain, swelling, impaired ten- degenerative stage when tendons are less irritable. don performance and dysfunction, independent of It has also been recommended that during this pathology within the tendon that has developed as stage, the athlete avoid the offending activity,14 or a result of acute or chronic overload.1–3 While ten- can perform walking/jogging once there is minimal dinopathy is a common condition in the athletic pain.15,16 Exercise to address the kinetic chain and population,4 its pathophysiology is still not fully contralateral deficits may be performed through- understood.5 Tendinopathy is generally considered out the continuum of tendon pathology as this will to encompass both inflammatory and degenera- help to unload the tendon, improving success of tive processes.6,7,8 However, although inflammatory rehabilitation.9,11 markers may be present, tendinopathy does not have a typical inflammation response, and expres- Eccentric exercise as a method of rehabilitation for sion of these markers occurs in response to cyclic tendinopathy has been heavily investigated in the 15–33 load.5 In addition, the relationship between tendon literature, but has yielded conflicting results. 25 pathology, pain and function is unclear.5 These Norregaard et al found no differences in improve- mixed characteristics of tendinopathy present a ment between eccentric and stretching exercises challenge to clinicians, as understanding the time- over a one year period. In a recent review Coupee 34 line and sequence of pathology is important in et al concluded that eccentric exercises were not determining the proper treatment. For example, it superior to other forms of exercise loading applied to has been suggested that the most important aspect patellar and Achilles tendons, and suggested that the of a tendinopathy rehabilitation program is appropri- direction of movement may not be as important as ate loading and progression to prepare the tendon to the load applied to the tendon. Other reviews, while meet the demands of sport.9 According to the donut reporting positive outcomes using eccentric exer- theory,5 an area of cell degeneration within a tendon cise, were unable to establish its superiority over 14,28,33 is usually surrounded by healthy tissue, and reha- other forms of exercise. bilitation should focus on increasing the tolerance of In contrast, Roos et al35 reported superior pain reduc- 5,9,10 this healthy tissue to loading. However, concern tion in mid-portion Achilles tendinopathy and return has been raised as to when and how that load should to sport after 12 weeks of eccentric work when com- 4,5,9,11 be applied to the tendon given the risk of exac- pared to splinting. A number of other studies have erbating the pathological state of the tendon. also shown positive results from eccentric exercise A few models of tendon pathology have been pro- when compared to other forms of treatment.15,18,24,26,32 posed.11–13 The most recent model by Cook and Two systematic reviews have reported eccentric exer- Purdam,5,11 relates the stage of pathology to the cor- cise to demonstrate superior outcomes compared to responding clinical presentation. Although the rela- other interventions in patients suffering from patella tionship between pain, structure and function is tendinopathy36 and Achilles tendinopathy.37 unclear, this model is still useful as it provides the Although there is considerable literature investi- clinician with a framework within which to deter- gating the effects of eccentric exercise on Achilles, mine timing and type of interventions. It is interest- wrist extensor, posterior tibialis, and patellar ten- ing to note that clinical tendon staging in this model dinopathies, there seems to be no studies that have is based heavily on loading history, clinical presen- investigated its effect on iliopsoas tendinopathy. tation and age of the individual, which can easily be This condition is rarely described in the literature. determined in the clinical setting. Blankenbaker et al38 found one case of iliopsoas ten- Cook and Purdam 5,11 caution against eccentric load- dinopathy in a cohort of 40 patients with snapping ing in the early stages of tendinopathy when the hips. Other reports of iliopsoas tendinopathy have tendon is already being significantly loaded from been documented in patients with total hip replace- acute bouts of athletic activity, and tendon cells ments39,40 with an incidence of 4.3%.40 The author The International Journal of Sports Physical Therapy | Volume 12, Number 7 | December 2017 | Page 1151 of this study found no cases of reports in runners, run, but had no pain once warmed up. She therefore whose prevalence of groin pain is as high as 18 per- continued to train and run. The pain would present cent.41 Whether it is a rare condition, or under- or mis- after running and she occasionally could not lift her diagnosed under different names such as tendinitis, leg to get out of her car upon returning home after a bursitis, or snapping hip syndrome, seems unknown. run. The subject reported that pain was worse after faster runs and after runs on hills. Eccentric exercise may be an appropriate method to use in the rehabilitation of iliopsoas tendinopathy Initially, she had no pain at rest, but as she contin- in runners, given the role of the iliopsoas tendon in ued running she began experiencing pain during the energy transfer during running. During stance phase day after prolonged periods of sitting, the onset of in running, the hip is rapidly extending. The ilio- snapping in the groin at night while turning in bed, psoas contracts eccentrically to decelerate the hip, and sharp pain when rising in the morning. The pain and in doing so, gathers potential energy as it elon- eventually affected her ability to walk after being gates. This energy is then released during swing as stationary for prolonged periods, but would decrease the leg slingshots forward.42 Because of this action, as she continued to walk. Beserol®, a muscle relaxer it makes sense to train the muscle with an eccentric with an analgesic component, would decrease her component in order to prepare the muscle for the pain when present, but would not prevent further demands it faces in running. episodes. Three months after the initial injury, she sought the services of a physician, received a diagno- The rehabilitation program for a runner with ilio- sis of iliopsoas tendinopathy confirmed by diagnos- psoas tendinopathy should consider the pathophysi- tic ultrasound, and was referred to physical therapy. ology of the tendon, the biomechanics of the kinetic The subject’s primary goal was to return to running chain during running, and the characteristics of the without pain. load placed upon the iliopsoas tendon. The purpose of this case report is to describe the rehabilitation Detailed hip and functional assessments were per- of a runner with the rarely described condition of formed. A clinical running analysis on the treadmill iliopsoas tendinopathy, and demonstrate a creative was also done to observe technique. Asymmetries in eccentric-biased technique to assist with treatment.
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