I have a client who had his right tibia and fibula crushed. He has a scar from his mid shin to the top of his knee cap. He only gets pain when lunging on the left leg (i.e., right hip extension). I’m using a Bosu to train him at the moment to improve knee stability. Is there any advice you could help me with?
Assuming your client has been cleared for exercise, there are several things you should be concerned with regarding this scenario. The obvious is the scar tissue’s collagen fibers adhering to the soft tissue underneath it. Any abrupt pulling on this tissue from the tibia along the myofascial chain up to the anterior hip can be exacerbated during hip extension/knee flexion. This range of motion may exceed the tissue tolerance at this time and produce pain. With a crushed tibia, it is likely your client spent a considerable amount of time on crutches. This usually requires hip flexion of the involved leg for toe clearance while using the crutches. Therefore, it is possible there is secondary shortening of the involved hip flexor that adds more tension to that anterior chain.
Progressive, integrated lengthening of the anterior chain including the ankle dorsi flexors, knee extensors and hip flexors may be helpful.
Also, you should find out from your client if there was any hardware used to help piece the fracture together. And if there was hardware, find out if the tibia and fibula were fastened together. If this were the case, the independent motions (albeit small) of these two bones will have been restricted or stopped. If they have been fastened together, the lunge may continue to be painful and have to be modified to avoid further pain and compensation.
There may also be an issue with the tibia not rotating over the talus in the sagittal and transverse planes with the back forefoot fixed to the ground as the ankle begins to relatively plantar flex. This is something that could be improved upon with mobilization techniques by a licensed medical practitioner.
Finally, the Bosu or any unstable apparatus should help improve proprioception to the previously immobilized leg. But standing on the Bosu for static stability is not a substitute for the lunging motion.
It may be necessary to segment the movement to find out what your client can and can not do through the process of elimination. You may also want to see if he has the ability to do anterior lunges at varying angles that are not pure sagittal plane motions. If so, you will have additional insight into the mechanism of his sagittal plane limitation.