trochanteric burisitis

[SigMik]

Excellent post, Alophysio, great that you took it into the broader picture! Starting to get an impression of how you work, and it's stimulating to see different approaches to a problem. I've looked a bit, unsuccessfully, on the forum and googled for information about the FLT you talk about. Would you mind directing me towards any sources or explain a bit more about this observational tool? From what I can read, any joint moving first - fails the load transfer test? And where do you go from here? How do you perform these tests? Again, I enjoyed that post, thanks!

Ziggy

[Dr Damien]

Dear Alophysio

This approach of managing a patient is not new. I believe its something that Bobath therapists have used for many years, I believe Kinesiologists have described in many texts and I also believe even podiatrists use this approach.

Having read your comments, I believe its purely common sense for anyone who is addressing any mechanical issue to consider the body as a whole because every part is linked. It takes years of training and practice to acquire the skill that you clearly have...

However, this is nothing new to be honest, on a very basic level...its the same concept that is put into practice when a shoe raise is prescribed for a limb length discrepancy... its all about understanding the body biomechanics and seeing the whole body as one not individual parts...

Bobath therapists start by understanding what "normal movement " is, deviations from the norm is what we try to correct. I think we are all saying the same thing but speaking different languages...

Why I was impressed with SigMik's comment was because I thought only bobath therapists assess that way, but clearly it is a holistic problem solving approach.
It is the same reason why we treat someone with an impingement syndrome, we no longer treat symptomatically, we aim to address the faulty biomechanics that are resulting in the impingement...

Some author will wake up tomorrow and give this old concept another name...he could decide to call it...reverse pathomechanics and start a whole doctrine on something that isnt new but make it appear new...

why do scoliotic clients sometimes have backpain, or why would having a forward neck give you back pain, or why would having pronated feet cause back pain, or varus knee give you neck pain, or an LLD cause back and hip pain?
In My own experience, I have found that this approach cannot work for every single patient because the question still remains who are we to define normal movement or appropriate biomechanics? what is normal for you may be abnormal for me?...where there has been structural changes, this aapproach will not work...this is where you begin to start thinking of adaptations.

It is theoretical to explain but the reality is that people come in all shapes and sizes. Perhaps in an acute case in a young client you might be able to apply his approach, however the body has a way of adjusting to the forces it experiences (sometimes for good sometimes for bad)...attempting to align one part to address one issue can easily also cause a malalignment some where else making things complicated... this is why sometimes symptomatic management is fine for as long as a patient gets relief and is left with good advise and being well infomed of what the problem is and how to self manage...

I think I say this because right now I am basically seeing elderly clients wherein they do not follow the norm of what our trainings or courses have to offer...

A typical example...
saw a man with chronic back pain (greater than 15 years) with a clear small kyphose lumbar spine, extreme caps limitation in the spine, pelvic obliquity, with a forward neck...this man was roughly 6ft three had a protruding stomach, he was 83 years old...osteoporotic generally...history of a heart problem etc... can hardly stand up straight,
howver way I understand the pathomechanics going on...it is unlikely that any of my myofascial release, realignment and postural correction would make a difference to this mans symptoms...Things have become structural...im likely to cause more damage by applying any phsical intervention...

Another example, 19 year old cerebral palsy with tight adductors, plantarflexors, lordotic spine and retracted neck...where do you want to begin to address any pathomechanics, some surgeon was suggesting surgery to elongate the tight muscles...only problem was this was likely going to cause major balance issues as this boy had adapted to the postural control he had learnt since a baby...

I agree with you that a better description would be to call it an awareness of the neuromusculoskeletal system as a whole...there is an author sharmann I think his/her name is and they popularized some aspects of understanding movement disorders like the one you describe but the reality is it is not a new concept...

Based on what you've said, I agree with you that it should be an eye opener for all physiotherapists in general to understand the science of movement better...I have always felt it is easier for a neuro physio to have this skill than most other physios because they tend to see patients with a global movement disorder as opposed to MSk physios who are more likely to see patients with apparent localized problems...

cheers

[alophysio]

Thanks SigMik and DrDamien,

about what i wrote DrDamien, i don't believe i have ever said that this is new or not done before. In fact i reference the fact that i have spent lots of money learning these things...which implies it is not new...

As for your 83y.o. man, you simply agreed with me It has become structural - that is joint pathlogies have caused structural changes which physically limit this man's ROM...however what is functional for this man? Does his joints work properly in the positions that he is in. It may well be true that we cannot help him and i agree that "myofascial release, realignment and postural correction" would not make any difference but that is the point of the assessment procedure i outlined above.

I guess my point is that there are physios who would try to do those things which wouldn't likely help...

...but i have a better example for you...

90+y.o. woman who came in unable to look parallel to the ground. Severe kyphoscoliosis and had pain for about 2 weeks. I asked her when her pain started the first time...she said 2 weeks ago. Thinking i was unclear, i asked, "no, i meant when was the first time ever you had back pain?" and she said again"2 weeks ago"!! I would have sworn that she had pain before but she didn't.

I assessed her, found FLT in her ribs, released the myofascial structures causing a problem and in 2 sessions she was painfree and back to normal ADLs. She didn't look 1 degree straighter but she was back to her "normal"...

The author you refer to is Shirley Sahrmann - she has an interesting point of view - one that i think is coloured by the fact that US physios often only get a handful of funded sessions from private insurance companies so she does very well with chornic pain in limited time but there could be so much more elegant things done with her work...

Lastly, again, the concepts i talk about are not new, just not common. That is why i talk about them. Hopefully people get interested and try to broaden their experience...

SigMik, The Pelvic Girdle 4th edition by Diane Lee and LJ Lee (no relation to each other) will be out very soon. Stuff will be in that but it is the overall concepts proposed by Panjabi, Vleeming, Lee etc thru various models which ask therapists to think of different systems throughout the body.

To be good at detecting FLT, you have to know what "normal" is so Shirley Sahrmann's book, kendalls Muscles Testing and function book etc outline normal muscle and joint motion so you will then see poor movement patterns and FLT.

Examples of FLT you are already aware of (no doubt):
- loss of ER control of hip during squats, STS, lunges, step up/down etc.
- overpronation at the feet during WB
- anterior shoulder translation during GH movement
- Scapula winging during loaded shoulder girdle movement

Examples of FLT you may not be aware of... but play with them and see!
- uncontrolled lateral glide of C/S during arm movement - cervical column should not move if your head is stationary.
- Hip anterior translation during increased WB or in NWB
- SIJ FLT and what that looks like
- excessive L/S rot during sagittal plane motion

Have fun. Happy to help out more but have to run.

Drdamien, i hope it clears a few things up. I am sorry if you got the wrong idea. Cheers!

[Ed C]

Hi guys,

Really interesting responses which have definitely made me think about and reflect on my assessment, clinical reasoning and practice.

Can I just ask what is the Cm protocol to rule out a spinal cause which was mentioned earlier and in the thread and where could I find some info/references about it (a googe search wasn't too successful)?

And alophysio, I take it spotting the primary problem comes with time, practice and experience? Have you got any tips for best way to observe the different areas that could fail all in one go? I guess what with my limited experience it is obviously easier to identify the more noticable of the FLT areas but that could not be the first to fail.

Thanks for sharing your expertise and experiences,

Ed

[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!