trochanteric burisitis

[katiemac70]

i have a patient who's been treated for awhile for hip bursitis...he has made significant improvements with ultrasound, acupuncture, ex's and stat bike. He can now walk on even ground with no pain but as soon as he is on rough terrain his pain returns. Any ideas??

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[SigMik]

Hi, Ed.

I'm a bit short of time these days, so my comments are a bit stumped, BUT:

- I've been going through these issues several times, observational findings, i.e. is it really a dysfunctional movement or not? Is it related? In which way? Is it dysfunctional due to compensation because there is pain inhibiting movement another place? Neuroscience research points out (what we all knew), that let's say you hurt your finger, the shoulder muscles will actually get inhibited. So if the shoulder is observed to move not optimally, will a correction of the shoulder make the hurt in your finger go away?
- Alophysio, you say that to be good in detecting FLT, one need to know what "normal" is... Normal? I know you can give me a better explanation than that!
- I'm thinking that findings like FLT positives will be heavily influenced by observer bias, when I think I have observed something of importance, I'm probably going to project this belief to the patient as well and even give a more convincing treatment
- I'm doing my dissertation on reliability of PAIVMs, but it didn't take me long to see that studies on observations or palpation of movement ARE NOT RELIABLE and will never be.

These comments does not serve justice to Alophysio's and Damien's last well-tought of posts, but I just had to let it out. I'll try to contribute more next time I post when I got a bit more time...

[alophysio]

Hi Ed C and SigMik...

1. CM protocol - i think Ginger likes to refer to a post he put on RehabEdge...PM him if you have to...it is something he does,not something that i have learned.

2. Normal - what is normal? hehehe
Well, ideally there should be axis of motion. The easiest is the shoulder - it should spin in the glenoid fossa. Tighten the posterior capsule and it causes excessive translation - what is excessive translation? What is the ideal starting pos? etc etc - this is subjective and based on informed opinion. Ideally though, when you load the GH joint, it accepts the load and doesn't shear thru the joint. In the end, physiotherapy will never be fully scientific because it is an art.

I actually have a Pilates Instructor who is more talented than I at seeing dysfunction. She can't describe it properly scientifically or what she is seeing because she tends to feel what is wrong (she sees it thru her eyes but it transmutes into a feeling in her body that makes her feel "icky"!!) - it sounds all new-agey etc but it is simply how it works for her. I act as a "translator" and listen to what she says and her descriptions and then combine that with what i see and fix the patient...quite often she is right and i have missed something or it is so subtle that it is not easily seen (but she feels it).

A good book to read is "Blink" by Malcolm Gladwell - some people just have good neuronal connections for certain things. LV (my pilates instructor) is good at seeing dysfunction.

I also have a massage therapist (JW) who can feel tension wrapping through the body - things that i don't feel nearly as clearly but when she tells me these things and i examine the patient, sure enough the areas she feels are tensioning are dysfunctional in the way she describes.

All that was just to reinforce what evidence-based practice is...as defined by Sackett himself...paraphrasing here [sorry] Patient experiences, clinical experience and scientific studies all are important in practicing EBP

3. With your finger and shoulder muscle example, careful assessment will show that the finger is more the problem. Also, lets say we know the shoulder is secondary to the finger - do you then leave the shoulder to be dysfunctional? At what point does the secondarily affected shoulder become a problem - does it have to hurt first?

4. Lastly, bias is in everything so just go by how the patient feels. No matter how much i believe the pt's leg is NOT broken, a broken leg will be a broken leg and hopping will not be possible. Proper treatment will result in rapid progression relevant for the condition

Out of time - gotta go

Cheers and thanks for the good questions!

[Fouche]

Hi

me again...

I have got some extra info on the patient that I am seeing with this bursitis. He has had it for 1 year now.

Most importantly is that the pain presents mainly at night(wakes up due to the pain), but says once he's got up and walked a bit he will be pain free for a few hours again. The pain is described as a dull feeling and can be pin-pointed to the greater trochanter.
The pain is also felt going down the side of the leg(ITB) and then down the outside of the lower leg, but does not go into the foot. This is described as n numbing sensation and does not seem to be originating from the back.
He cycles everyday(spinning) and plans to climb Kilimanjaro in Dec. During activities he doesnt have pain, only at night which tells me theres def a inflammatory aspect to it.

Please help!

[Laura Jayne Physiotherapy]

Hi,
I went on a tendonopathy course recently and found the Clam exercise very helpful for this condition. I also had a patient who struggled with uneven ground. She improved well with the Clam loaded plus some posture rehab.

Laura Jayne Physiotherapy

Laura Jayne Physiotherapy

[Fouche]

Hi Laura

Thanxs for the reply!

Clam exc? You talking about glut med strength exc?

Cherz

[Laura Jayne Physiotherapy]

Hi Laura

Thanxs for the reply!

Clam exc? You talking about glut med strength exc?

Cherz

Hi Cherz,

Yes glut med. Doing as many rep until fatigue and increasing the load. Then moving onto straight leg abduction work. Seems to work well. I've only had one patient who it flared up the symptoms so we had to settle pain down first as it was to acute.

Regards

Laura
www.laurajaynephysiotherapy.com

[alophysio]

Hi Fouche and Laura,

The strengthening of the deep hip external rotators are excellent...however i think there is some doubt as to whether the clamshell exercises target the glut med...Alison Grimaldi has done some studies and i know she has used realtime ultrasound on the clams exercises and shown that clams preference the TFL, not Glut med.

But really that is a moot point...the most important thing is to make sure that the hip muscles are working together as a team because any overactive or underactive elements will cause the axis of rotation to change and thus cause dysfunction and poor load transfer.

Cheers!