Ischial Tuberosity Pain-Tough case

[Erica]

Hi everyone,
I have a interesting and challenging case that I need some assistance with. I will be brief, 30+ male, student, complains of right IT pain for one year. Patient is/was very active-ski, bike, yoga etc. Continues to bike and do yoga. Aggravating his sx's : driving in his Subaru, deep hamstring stretch in yoga, forward lunges with increased WB on the right. Easing sx's: really nothing, but movement helps like yoga -not pushing it. Presenting diagnosis from the MD was right upslip.

Findings (pertinent ones) Right PSIS, IT elevated. Right psoas-facilitated. Lumbar ROM-WNL's FB with overpressure-feels it in the hamstring. Resisted testing of the h/s-negative. Hip-anterior capsule-hypomobile. SLR: 80-85 degrees sensitized with dorsiflexion and neck flexion negative. with knee flexion: positive. Negative long sit slump and regular slump.

Single knee to chest with slight ER bias -somewhat positive. Mild tenderness lateral hamstring, no local pain at the IT or anywhere around it. PA mobility of the the right L5 S1 slightly hypomobile.

Treatment so far: manual therapy to correct upslip (which is now fine), neural glides-SLR's every which way, although slump was - , I gave it to him anyway b/c something just seemed "nervy" to me. Soft tissue/DNM to the hamstring, butt. MET to the hip to increase extension, stretches as well. HEP : neural glides and some somatics work.

All in all, he has improved. Driving better. But still gets it and this past weekend he played frisbee in a local park -alot of jumping etc and the next day his IT was killing him. He did yoga and felt better but not gone.

I thought this was a neural irritation of some sort but I think I am missing something here. Any ideas??
Thanks in advance,
Erica

[Diane]

Review inferior cluneal nerves - maybe one or more of these are entrapped. They branch out from sciatic as I recall, curl up over the IT into the lower buttock. Does he cycle a lot?

[Erica]

Diane,
Thanks for the reply. He does not cycle alot lately. But he is active. Hiking one weekend, frisbee another.
Erica

[Mary C]

If you have access to it, 860 nm LED 5 j / cm2 might help with local inflammation if there is tenderness on palpation. Beats sitting on a ice pack. Home gadgets (cheap) available at heelspurs.com

[EricM]

There might be some more ideas for you in here (http://www.somasimple.com/forums/showthread.php?t=2782) Erica.

[Erica]

Mary,
Not sure what LED is but if it is laser, I have done it already. There was no palpable tenderness at the IT but I tried it anyway. Not sure if it helped.
Eric-
Thanks for the link. I have done some of that work already. I was not as specific so I can try it again. The conundrum for me is that there is no real tenderness at the site at all. He keeps saying it is deep, tough to locate. Then I guess maybe the pudendal nerve is in play here.

The link to the psoas with the pudendal nerve is interesting-I have done various forms of psoas releases. Maybe it is the positioning here or something else?

I think maybe I am missing something up the kinetic chain.
Erica

[nari]

Erica,
Just a few thoughts:

This is a chronic sensitivity pattern, so it is unlikely to respond to things such as laser or LED. You are right in thinking it is a 'nervy' response.

You eliminated direct sciatic nerve involvement fairly conclusively, so I would suspect inf cluneal nerve as Diane suggested. Another possibility is Butler's idea of 'chasing' the nerve: take the positions you said reproduced pain, try them with different positions such as sitting and apply tiny amounts of overpressure for about 3 seconds each.

Also sitting, R leg over L knee, and bring R knee closer to the chest (it's already very internally rotated)and play it by ear with tiny amounts of overpressure, which is best applied by the patient himself to reduce anticipation of pain. I have found this useful in resolving some presentations of IT pain.

The other most interesting possibility is ideomotion. Do you want to give that a go? If I recall correctly, you have been to one of Barrett's classes?

Nari

[Erica]

Nari,
I like the idea of chasing the pain b/c I think that is what he needs. I am not as familiar with it as you. I assume from what you wrote it is putting the patient in the provocative position, so to speak, and literally chasing it I guess.
I did take one of Barrett's classes and thought of ideomotion but wasn't sure how to start with him, sitting, supine?

The consistent position that reproduces his pain is single knee to chest and knee extension. Not a true SLR I can get him to about 90 degrees and all he feels is the hamstring. But if I bend the knee, push the leg further into the chest and then extend the knee-that gets it. I think he is right when he says it is deep, b/c it is.

Thanks for your thoughts.
Erica

[Barrett Dorko]

Erica,

You start where he is and then go from there.

No need to thank me for such a specific piece of advice.

[Diane]

Hi Erica,
You could try treating the pudendal nerve and see what happens, especially if this is a "deep" pain he has.

Another way to tackle it might be to use a bolster, see if he can reproduce it with isolated knee extension (with thigh supported in flexion..).

If not, then get his foot up on the bolster - i.e., more hip flexion. The point is to see if you both together can reproduce his pain symptom while he is relatively relaxed and supported. If he can sense it, then you can play with foot placement a bit, see if one degree more internal rotation tweaks it more than one degree more external rotation.. anyway, when you find it, keep him there, then add some compression straight in through the trochanter while skin stretching the back of the thigh up toward the knee. If it helps he will immediately indicate relief somehow, usually verbally, definitely kinesthetically.

If you can get a force in there sufficient to help his brain turn it off, then just stay there for as long as your arms hold out, 3, 4, 5 minutes or even longer. It will feel like hard work, probably, so load in slowly. The slower you load in the less shaky and quivery your own arms will get. You will be pressing probably with upwards of 30 or 40 pounds of pressure. This sounds like a lot but is nothing compared to the kinds of forces the pelvis is capable of taking with normal self-generated movement. You will note his body/system accommodating itself if it likes the input. You can alter your angles/vectors a bit in response. When you let go, let go slowly. The slower you move the more his nervous system will be able to "learn", then "retain", about not letting that particular pain pathway reassert itself.

[nari]

Erica, when I say 'chasing' it's rather like hunting something (which I have never done with a gun of any sort).
Move slowly, be alert to any changes, and don't scare the 'prey'. In this case, the patient's CNS. A position could be called 'communicative' rather than 'provocative', and I'm actually more cautious than David B's chasing techniques that I have experienced myself.

So start with the position that might be called provocative and 'touch base' with the pain for one to two seconds. Back off. Touch again - the actual movement further into knee extension might be less than 2 degrees. Or 1 degree. Remember you are talking with a nerve or two which get very cranky. Whatever happens, never stay longer than a second or two. Stop when you know nothing is changing.

Diane's method follows the same principle: you are trying to turn off the barrage of don't-do-that!! output coming from the nervous system. It has to be informed that it's OK and stop fussing.

With ideomotion, it's just how Barrett says: start from where he is and let him go where he wants. You might touch his leg or hip for a few seconds. The starting position does not matter at all. If you feel supine is better, because that is the 'ususal' position anyway, that's OK.

Nari

[Erica]

Barrett, Diane and Nari,
Thanks for the replies and the detail. I actually read the pudendal nerve section of the Tunnel Syndromes book this morning and after reading this and looking at the anatomy, I really do think this is the case with him. I will try the various positions suggested.

It is interesting because one of the yoga poses he does that actually helps him is one where he is seated in a "twisty" position, so to speak, ( I never remember the names of these postitions!), with knee in full flexion and rotating the torso left and then right with different foot positions. Probably turning the nerve on and off I would imagine. Interesting...
Erica

[Erica]

I saw my patient yesterday and did some of the things mentioned in the thread. A combo of full single knee to chest with some hip adduction (like the inner hip flexion quadrant) was positive at the IT and then with some added knee extension -worse. Nari-we did some "chasing the pain" -gave him a HEP to do as well.
Diane- I tried the technique you suggested. I had to get his thigh over a small lumbar traction bench for support-got my fingers on the IT went medial and he told me that was where it usually is located but I could not elicit any tenderness. I applied the compression through the trochanter -I assume you meant medial because I could not think of any other way -I did feel something where my fingers where-I did it for like 3 minutes until my arms/hands got tired.
We'll see if it helped until I see him again.
Thanks
Erica

[Erica]

Just wanted to update on this patient. I have seen him 2x since I posted this. He is improving. In fact, he said these were the best few weeks he has had. He has also had 3 sessions of acupuncture.
Diane, the technique you described is a real arm burner for me! I am working HARD. But I have to say it is worth it as I get used to the hand positions. I really think this is helping in some way. We are also doing some of the things Nari described as well. He only comes in once a week so we'll see. He has not cycled and has curtailed his hamstring work in the gym as well. thanks for the help on this. I will keep you posted.
Erica

[Diane]

Hi Erica,
Diane, the technique you described is a real arm burner for me! I am working HARD.
:)
If you start soft and load in really slow, by stages, you can recruit more of your own motor units and be there for the long haul. Also the patient's system will have more time to accommodate you and make way for you, so there'll be less resistance over all. Plus, after awhile, you'll just beef up. Sort of..

I'm neither strong or fit, but I get by fine.

[Erica]

Thanks Diane. I am already stronger for it all! :thumbs_up I'll keep you posted.
Erica

[BB]

Erica,

I was working really hard at first too. There is a bit of motor learning on our part with this. Think about providing the force using all of you instead of just with your hands, try distributing the contact area evenly across the hands, stay in a bit of constant movement so you are not doing an isometric. This is what helped me.

I remember when Diane first showed this to me and Eric. Eric was the subject, Diane and I each working on a leg. I asked Eric if what we were doing felt similar and he said that Diane was providing more force and moving more. I looked up at her and she looked completely at ease, whereas I looked like I was working hard.

[Diane]

If you saw the difference between Cory's physique, and mine, you'd have to laugh at what he wrote. (:D)

There really is something to be said for remaining relaxed while you treat. You won't hurt your own body or hands, and you'll be able to feel the other person through your own hands/body a lot better.

All you have to do basically, is put your hands into position, then wait for your opening. It will be provided to you courtesy of the "third" party in the room, the combined nervous systems, yours and theirs. Then you take advantage of the opening by leaning into it. That's all. These openings just crop up in their own time. What's important is that you're there for when they happen, and provide some environmental containment/pressure.

I don't know if this makes it any clearer or not.. but the main thing is, look after yourself first; then their nervous system will trust yours better and tend to relax better. If you're struggling, the patient's system tends to wait for yours to stop struggling first (maybe it senses a threat somehow) before it can relax, which just makes things harder for you.

[Erica]

Cory and Diane,
Good advice, for sure. I definitely do not look at ease with this technique, yet. With all my hard work, it is helping him. I can only imagine if I relaxed and got my nervous system under control, how much better the patient would feel! Less is more....
Erica

[Diane]

Yup. Less is way more...

[Baecker]

Erica,

I was working really hard at first too. There is a bit of motor learning on our part with this. Think about providing the force using all of you instead of just with your hands, try distributing the contact area evenly across the hands, stay in a bit of constant movement so you are not doing an isometric. This is what helped me.

I remember when Diane first showed this to me and Eric. Eric was the subject, Diane and I each working on a leg. I asked Eric if what we were doing felt similar and he said that Diane was providing more force and moving more. I looked up at her and she looked completely at ease, whereas I looked like I was working hard.

This is quite interesting I always imagined it to be a very subtle way of skin stretching. I am a bit confused now about how much force is really being used. Any more advice on it?

[Diane]

Skin stretching is involved, but often there's a free hand that can be used another way simultaneously. The point is to get the cutaneous nerves to move, one way or another, but sometimes
a) some nerves you might like to move are deeper, and/or
b) some cutaneous zones are off limits.

Also, about the "constant movement" idea, there's already constant movement, provided for free by the patient's system. If you just get on that, you can ride along with it effortlessly and save yourself a bunch of sweat plus, as Cory alluded to, not have to be so isometric.

[nari]

I've tried to think of an analogy for DNM, and considered the art of riding a horse.
When one first starts, it's hard work, almost all isometric, until one feels and thinks the rhythm of the horse. Until that happens, we feel we work very hard to 'stay' with the horse.

The horse knows that and probably wishes we would hurry up and go with the flow. I think it is called riding fitness; of course it has nothing to do with strength but is about paying attention to the horse and not our choreographed posturing ideas, which are universally taught in order to ride 'proper'.

Nari

[Diane]

That is a brilliant analogy Nari. In a treatment situation the patient's nervous system is indeed the "horse"; one "rides" it with one's hands, but lets the movement go through one's own body.

I was thinking of something like surfing, but actually riding a horse is a better analogy.

[BB]

Hi Baecker,

The technique is for sure very gently applied. The gradual and subtle accumulation of force can sometimes become substantial, but often is not. It depends on where you are lead. Often times as we come out of treating an area the patient will say something like, "I didn't realize how much was really being done. It felt so light. But, the skin recoil was a lot."

The hard work, for me, was coming from the isometric and using just my hands. Hold any position isometrically for 2-5 minutes, regardless of how light it is, and you'll feel the discomfort most likely. Now, I usually feel like I could go on all day long if need be because I'm in constant movement and distribute the force very widely.

[Baecker]

very interesting. I guess I was doing too much isometric before. What Diane always described a being easy etc, is actually an art which needs to be mastered first.
I can tell you its not that easy. My arms were quite exhausted stretching skin for 2-3 minutes. i will try to go on the ride. :)

[EricM]

I'm in constant movement and distribute the force very widely.
If anyone could see me while I'm working with DNM they'd probably liken it to Stevie Wonder. I constantly ideomote to maintain my own comfort, more so when the patient is prone and can't see me.
Since moving into my own practice where I can give myself as much time as I want, I have been able to progress to a lighter application of force. I think its easy to get stuck into a cycle of feeling like you need get so much done when time is limited and using increased force just seems to follow despite the irrationality of doing so.

[Erica]

Just wanted to update you on this patient. He had been away because of some eye surgery he had. Since he has not been active b/c of the surgery, his IT pain has not been bad at all. When I saw him yesterday I reproduced the symptoms once again with single knee to chest, and full hip flexion with knee extension. (same as before) Taking big steps also reproduces his sx's. He feels that if he starts becoming active again, his sx's will return.
The treatment for the pudendal nerve has been helpful and both he and I believe it is the single most tx that has helped him. The sx's are more manageable. But it is not gone and I am wondering if there is anything else that I can do in addition to what I have done already.
Any ideas?
Erica

[Diane]

Hi Erica,
Have you checked out the other cluneal nerves?
Take a look at the superiors and medials. The superiors dangle all the way from lumbar zone, over the back of the pelvis (through fibrous tunnels, then suddenly superficial) all the way down on some people to their trochanters. These are definitely worth getting on and skin stretching.
The easiest position to treat these in is side-lying.
The medial cluneals can be treated by simply stretching the skin along the "SI joint." I've put quote marks around this because the SI joint is so deep that you'll be nowhere near it (unless your patient is emaciated), just lined up over it, and a few inches away from it probably.

While in this position it's easy to stretch skin around the trochanter, often very helpful (clinically) for freeing up external rotation. Probably helps the feed the neural bits in the bursa somehow.

[Erica]

Thanks Diane I will check these as well. He is actually restricted in ER-maybe this will help. I feel like we made some good headway and see the light at the end of the tunnel but we are stuck b/c we ran out of gas, so to speak! :)
Erica

[ginger]

Erica, ischial pain is commonly referred from L1 and L2, along with the coccyx and sacrum. Protective responses at these levels are easy to test for ( ie hypomobility with passive mobs with localised tenderness at L1/2 facet joints) . Five minutes of mobs at both these levels ( unilateral , CM ) will reveal in short order , changes to his pain at or near the ischium. Presuming you are successfull in turning off protective behaviour at these facet joints , the results will be permanent.
All the best

[Erica]

Hi Ginger-
Thanks for the response. I believe I tried some sort of joint mobs at one point or another on him but could check again. I did not know that the L1/2 facet joints referred directly to the ischium. Do you see this pattern alot?
Erica

[ginger]

Erica , the method I use is known as Continuous Mobilisation ( CM), the details of which can be found on the RE site under manual therapies. Briefly though , it is a manual method for restoring normal , pain and irritation free mobility to facet joints. It is by the removal of spinal protective responses leading to joint /nerve irritation that referred events and pain are revealed to have been present. Such as is likely with your patient with ischial pain. Yes these relationships are routinely seen in my own clinic. T12 to L2 may refer into the sacral, ischial /coccygeal areas when inflammatory (joint related )neural irritants are present. Five minutes of CM to each of these joints will produce results both to the joints themselves and the possible referred events as well.

[Diane]

Ginger, you conveniently ignore the fact that superficial nerves come out in that zone, i.e. the superior cluneals, and drape down over the buttocks ( through which you must push your thumbs to get anywhere near any actual facet joints). Then you reason (backwards) that only if the facet joints are contacted (somehow) with thumbs, will the pain that is magically referred to the buttock supposedly by these joints (associated with the spinal segment out of which these nerves surface), somehow resolve.

I think we could easily do away with facet joint superstitions.. head straight for the nerves themselves.

[ginger]

Erica, just a few notes on method. best results are to be had with unilateral mobs . If your thumb pressures stray too lateral , away from direct prerssures on the lateral mass, resolution is slowed . further distance away from the facet will produce little or no reductions in tone. I refer here to the tone of paravertebral muscles taking part in a spinal protective response. Cm is a very safe method which , with skill , will allow the therapist to deal effectively and permanently ( in most cases ) with referred pain from spinal facet joints/nerves. Definitely worth a good try with your case as above.
All the best.

[Baecker]

Hi,

today I had a Ginger case. Pain was in the rt thight, quadriceps to the knee. PA pressure on L3 reproduced the symptoms. I just tried skin stretch over it and the pain dissappread.
Like Ginger said paravertebral muscles where tight and protective around L3. But skin stretch did it as well. I tried PA pressure again and protectiveness was much less. Patient was happy.

[Diane]

today I had a Ginger case. Pain was in the rt thight, quadriceps to the knee. PA pressure on L3 reproduced the symptoms. I just tried skin stretch over it and the pain dissappread.
Like Ginger said paravertebral muscles where tight and protective around L3. But skin stretch did it as well. I tried PA pressure again and protectiveness was much less. Patient was happy.

Yup, that's my whole point.
Why wreck your thumbs? Why bother trying to dig down to facets when closer to the surface there is already a "structure", i.e., a superficial branch of the dorsal ramus, that can convey your wishes to the brain via a certain segment if you wish, and through appropriate handling?

[Erica]

Ginger,
I am pretty well versed in joint mobs-do them all the time. Centrals, unilaterals whatever. I just don't think that continuous passive mobs of the L1.2 area will make a difference here as I know I have tried some form or the other at some point with him.
Erica