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Dressage Tips - From the Experts
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Case Study: The Effect of Riding Boot Fit on Low Back Pain in a Dressage Rider
by Stacey Brown, PT
[Stacey Brown is a contributing writer to the Sho Clothes Sho News monthly newsletter]
The rider is a 48 year old female, amateur dressage rider who presented with a complaint of left low back and sacro-iliac joint (SIJ) pain, which was longstanding, and that had recently become severe enough to limit her riding time. Riding exacerbated her left “sciatica” pain (left hip to lateral calf) from 3/10 at rest, to 8/10 with certain leg aids and positions. Especially painful, were lateral movements to the right, and downward transitions from canter to trot, on the right lead more than the left. It had become so consistently painful to perform these movements that she questioned how much longer she could ride at all. Her two horses, one an upper level dressage performance Dutch Warm Blood, and the other, a rescue Thoroughbred , trained with dressage principles as a rehab method, needed regular exercise and conditioning. Not riding, was not an option for the rider. We set about identifying the cause of her recent increase in pain and dysfunction, with a thorough functional evaluation.
The rider’s history was a complicated one, but not unusual for committed horse enthusiasts. She had been riding since childhood and had competed successfully as a hunter jumper. She also enjoyed downhill skiing. In recent years, she performed the hard physical work of running an equine boarding and dressage training facility. She had a variety of physical injuries, and strain patterns as a result. Her major injuries included a left medial meniscus injury, a fractured right fibula, a fractured right “pinky finger”, and a right rotator cuff tear (subscapularis muscle 3/4 insertion tear) with subsequent scar tissue adhearing to the insertion of the biceps tendon, resulting in right bicep long head tendon atrophy. She complained of chronic left elbow pain which was aggravated with repetitive motion associated with stall mucking. Twenty years ago she had her left SIJ treated with prolotherapy, twice, in an attempt to reduce her “chronic pain and hypermobility”.
She had recently started using her show boots for daily training, in order to “break them in”.
On physical examination, lumbar disk symptomology was ruled out and her neurological examination was normal. She had exaggerated spinal curvature in the cervical, thoracic and lumbar segments. She tested positive for pelvic obliquity with the left ilium in a posteriorly rotated position relative to the right, with an associated sacral rotation. This asymmetrical pelvic posture, resulted in asymmetry of the rest of her lower extremity joint orientation, left leg compared to right. The right femur was held in internal rotation with the right tibia externally rotated, and the opposite was true for the left leg. The feet and ankles were also affected, with loss of arches, and an everted, or upturned lateral aspect of the left foot, compared to a “lifted” medial aspect of the right foot. In other words, she was “crooked”. There were similar asymmetries in position and use of the upper extremity joints, due to the continuous nature of the myofascial connections with the lower extremities, through the trunk, both same side, and diagonal pairs.
This sequence of compensatory myofascial patterns and resultant joint changes, demonstrates the resiliency of the functional kinetic chain of the lower extremity. The functional kinetic chain of the lower extremity, refers to a continuous fabric of muscle and fascia, along with the boney struts that comprise the foot, ankle, lower leg, knee, thigh and pelvis. (Upper extremity kinetic chain is similar involving the joints from the hand to the shoulder girdle) It provides for the storage and transmission of energy that allows us to move. Picture the body in a deep squat with the joints of the lower extremities fully bent (flexed). This positions the kinetic chain to store energy. Now picture the body jumping from the squat position into the air, releasing all of the stored energy and resulting in a elevation of the entire body off the ground, as the joints of the lower extremities straighten (extend). Through injury and improper use, our muscles get out of balance. The body finds a way to substitute or compensate with other muscles. Some of the muscles will be in an unusually shortened resting position, and some may be in a comparatively lengthened resting position, but they will still work. They aren’t optimally efficient in their adapted positions, so will lose energy, to the adjacent tissues, and often result in injury.
The rider is an individual with quite elastic connective tissue (joint and muscle support structures), compared to others, on the more fibrous (stiff) end of the normal tissue characteristics range. So, even though she tested “normal” for nearly all joint ROM passively, when it came time for dynamic posture and function, her asymmetries were readily apparent. In addition to the differing patterns in her lower extremities, the myofascial patterns were also asymmetrical right to left, in her trunk and upper extremities. In short, with her history of injuries, she learned new ways of moving when her pain prevented her from moving normally. A blessing and a curse, is the truism “the body will sacrifice structure for function”.
The rider’s riding was impacted by these asymmetries of movement. The efficient progression of energy throughout the myofascial system, requires that there be no blockages or restrictions which would disrupt the flow. Picture the force generated by the inner left leg at the girth, as you prepare for half pass to the right. If the foot, lower leg and thigh are in good anatomical alignment, the rider is using the core muscles properly to stabilize the trunk, the horse’s barrel and the saddle accommodate the angle of the rider’s tibia and femur, etc. there is no loss of energy. Instead, the leg aid is applied, and the horse is directed. The energy is returned back to the system, from the pressure against the barrel of the horse, is accepted, and absorbed up the kinetic chain of the human foot, lower leg and thigh.
Both parties move on, and there is no damage done.
But what happens if the energy is unable to proceed along the intended line? What if there is poor alignment of the tibia and femur? What if the barrel of the horse is narrow and the rider cannot squeeze the lower leg adequately, without also rotating at the lumbar spine, hip or knee? Or perhaps the rider has tight hip flexors and adductors on one side, and overstretched, weak hip flexors and adductors on the opposite side. What if the saddle twist is not optimal and forces the thigh into inefficient position? What if the boot is too tall and prevents the needed excursion of movement between the joints and tissues of the knee? That energy has to go somewhere, and will either be absorbed in the myofascial system , further damaging the structures of the kinetic chain, or be lost in uncontrolled movement, both of which will diminish performance and ultimately cause injury.
In this rider’s case, her show riding boot was too tall and too stiff. It stopped her lower extremity kinetic chain from compensating for her dynamic postural asymmetries. It stopped her from allowing the foot to rotate outward and evert (turn upward), which it needed to do in order to give her the strength to put pressure on the horse’s barrel. Each time she tried to put her left leg on, particularly with the knee in a flexed position, she felt lack of strength and power in the left leg, and excessive movement of the hip and lower back, creating pain and tension on the structures of the spine and pelvis. The source of her sciatica.
Going back to riding in her half chaps and paddock boots reduced her sciatica. She was able to ride both of her horses on a regular schedule, and enjoy it again. She also gained an awareness of the areas of her body that needed to be addressed in order to ride more efficiently, reduce injury, and improve performance. Understanding the improper movement strategies that she had adopted, gave her insight and direction in her pursuit of centered and correct dressage performance.
The rider received physical therapy interventions to correct her posture and improve the use of her core, in order to stabilize her spine in a more neutral posture. Myofascial release and muscle balancing manual therapy techniques, helped ease myofascial restrictions, and allow energy to be better transmitted through improved circulation in blood, lymph fluid, and generally improved cellular energy of impaired tissues. The use of low level cold laser made the process easier and less painful, by quickly reinforcing correct movement and assisting the body to speed up the healing process. She performed specific exercises to strengthen weak muscle groups, and stretch shortened, tight ones. She began making changes in her body mechanics while performing her daily activities, and delegated some of the more routine and physical tasks, in order to let injured tissues heal. She was quick to analyze her saddle fit, and began to cross train and reinforce her posture and movement strategies with yoga. The rider’s trainer was kept informed of the problems, treatment and progress toward goals, and was involved in providing feedback and coaching of new movement patterns while riding. Through hard work and strong motivation, The rider has progressed over the past year from riding first level to fourth level , and is pain free. She continues to receive physical therapy intervention and is more supple now than she has been in years.
Conclusions: Humans are asymmetrical for the most part. Most of the time, this is at least partially correctable. Whether due to hand dominance, injuries, chronic postural requirements, habit etc, addressing these imbalances, and correcting them as far as possible, will improve the riders contribution to the correct performance of dressage. It is a process, much like the sport of dressage itself. If we expect the horse to perform symmetrically, the rider should be able to as well. During this process, it is important to consider factors that may make the situation worse, by limiting the compensation strategies needed for the current level of fitness. Restrictive boots, worn down or improperly fitted saddles, etc. may cause pain and contribute to injured tissues. There are a variety of equipment adaptations available to reduce the strain that accompanies myofascial and joint restrictions, that may or may not improve with time and treatment. An example is the choice of half chaps over boots, and the use of angled stirrups. Sport specific physical therapy, dedication and hard work on the part of the rider, and good communication within the riding “team”, can help determine what can be corrected and what must be compensated. At least for the moment.
If you would like to schedule treatment, have questions, or suggestions for future informational columns, please contact Stacey at: info@animalrehabinstitute.com or (971) 226-0010 mobile. You will find directions to her clinic on the web site www.AnimalRehabInstitute.com.
Stacey Brown PT CERT received her degree in physical therapy from Pacific University and is a native of Portland Oregon, where she practiced human physical therapy for 30 years, and equine rehabilitation for 7 years. She has a strong background in both neurologic and orthopedic treatment, and combines her experience in a unique and effective approach. Stacey now practices in the Wellington, FL area, and specializes in the assessment and treatment of equestrian athletes. She is an athlete, rides herself, and has a life long interest in nutrition and wellness. Through movement analysis and physical evaluation, Stacey designs individual treatment programs to enhance performance, as well as treat injuries. She is skilled in muscle balancing techniques, myofascial release, soft tissue mobilization, joint mobilization, and uses a cold laser to speed healing and enhance nuero-motor retraining. She is also certified in equine rehabilitation, and uses her skills to improve the performance of horse and rider pairs.
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