trochanteric burisitis

[alophysio]

Hi fouche,

Thanks SigMik for your comments...very useful and insightful.

For me, it is all about the questions you ask - of the patient, the patient's body (thru your examination) and challenging beliefs and assumptions...

First question - how does the pain affect their functional activities - walking, stairs, slopes, sit-to stand, stand-to-sit, lying down, getting out of bed, sitting etc?
Next question - What is the significance of their pain? DO they have an altered perception of how large the area is or does it seem to be of a different magnitude of pain to the problem? If so, they might need pyschology as well...
Next question - what is their story and the meaning of that story in their lives - e.g. Have to get rid of hip pain to play in grand final this weekend...because if you fix their pain but can't them to play in the final, they won't think you are very good but if you can get them back in the final even with pain, they will love you...your approach will depend on their goals.

For example, a diagnosis of troch bursitis has been given to you - great! But how?
Because they had lateral hip pain and the doctor took a stab at the diagnosis?
Or they found swelling and degeneration in the lateral hip area somewhere on U/S or MRI?
Or because the pt looked it up on Google? Was it a specialist doctor who is on the top of their game and NOT "cut-happy"or a general practitioner who prefers to see nursing home patients?
All of these things make a difference.

The diagnosis of Troch bursitis is merely a description of where the possible source of pain is for the pt. Perhaps it describes a pathology that has been observed...BUT it doesn't tell you WHY they have an inflamed bursa, degenerated tendon or even why they have pain.

Ok - how did you find that the L4 has a component to the pain?
Was it by examination?
What component of the L3/4 or L4/5 complex was involved?
Was it the nerve, the muscles or the joints?

Is the L4 the primary problem that is leading to the hip pain or is it simply sore because the hip is causing altered biomechanics which has stress the L3/4 or L4/5 complex?

All of those questions need to be answered before you can formulate a treatment approach.

Asssumption: L4 is a secondary problem
* Find the primary problem - check the hip, the SIJ, the ankles/feet, the thorax etc. The primary problem will fail load transfer (FLT) first - it will give - the hip shifts in the acetabulum near the commencement of movement, the foot pronates before all other joints begin to take load, etc etc
* Treat the L4/5 or L3/4 segment as you see fit to relieve any pain but know that it is only symptomatic relief. You will be better off finding the primary problem and then clean up the secondaries later...they are often less sore and the pain doesn't come back as bad
* If you can't tell what is primary, then treat what you think is the primary - if you are right, the pain won't come back after a matter of hours, minutes or even a day or two. People who keep plugging away at problems without the patient getting better are not treating the right problem!!

Assumption: L4 (L3/4 or L4/5) is primary problem
* It will FLT first - hard to describe but it will often rotate or shift near the initiation of movement in that segment and all other joints will FLT after that
* If it is a joint problem, treat the joint - facet or disc using mobilisations, manipulations, etc etc - that is undergrad stuff. The stuff that SigMik said is great - that is beyond undergrad stuff because it is hard to teach someone how to repos if you don't have a patient to teach them on
* If it is a muscle problem - overactive, underactive, too short or too long - then treat it with what you know - soft tissue massage, acupuncture/dry needling, Muscle Energy Technique, stretching, exercising etc etc etc - there are lots out there for it.
* If it is a neural system problem - pinched/irritate nerve, neurodynamic problem, motor control problem, etc etc - then do that stuff

Once you have released what needs to be released in the (usually) joint, myofascial and neural system, then get proper alignment and posture going.

Then reassess their pain during functional tasks

If they need a cue to keep it all together, then give them one - keep you back flat, stick you bum out a bit, tuck you bum in a bit, think taller etc etc etc

Once they have all that together, then teach them how to do their functional tasks again with new patterns of movement and the FLT should disappear and thus the FLT won't cause excessive loading on the hip joint leading to "troch bursitis".

Hope that makes sense to you. It gets clearer for me each time i tell people what i do Mind you, i have spend 10's of thousands of dollars on courses etc over the years to learn this stuff...have fun with it

Cheers