structural variation

[BB]

Does anyone assess for structural variation as part of your examinations?

For example: hip ante/retroversion, tibial torsions, forefoot/rearfoot varus/valgus and so on.

Just curious.

Cory

[Diane]

Hi Cory,
Do you mean 'structural variations' i.e.: skeletal, or just asymmetries that "look like" structural variations? I look for asymmetries, then I try to mop them up.. all the things you mentioned can be just holding patterns in the body due to pain; I think it's good to try to right them by dealing with the pain factor..

Just a couple comments:
1. how would we know it's true 'structural variation' unless we x-rayed both sides?
2. even if it were, what real difference would it make to our efforts... don't most people come to see us for pain?
3. lots of asymmetric looking people don't have any pain..

I'm sure there will be more comments,
:)
Diane

[nari]

Hi Cory

I would agree with Diane - some people have all sorts of symmetrical and asymmetrical anomalies, but it often does not mean anything.

I might observe a severe pes planus and see if it was affecting a particular painful area: spine, knee etc - otherwise I would ignore it or recommend a podiatrist if the owner of the foot wished to.

In a standard assessment, for someone who has come with pain somewhere between vertex and great toe - no I would not bother much at all with structural changes, except maybe a quick note in the file.


Nari

[Diane]

Cory, Bernard, Nari,
I guess I am still trying to find out exactly what Cory meant in his original post, by "structural variation."

To me it means that (in an individual) the two sides of the body are built in an asymmetric manner, by the embryo. That not only do the two sides "look" different, they actually "are" different in size or in orientation. Two different kinds of hips (on x-ray) would be an example.

There could be "structural variation" that is not asymmetric, is more midline, as in someone who was born with spina bifida. Or someone with a spondy. Or missing a vertebra altogether. Or has an extra one. Or one that is fused on one side with the sacrum.

The examples that Cory mentioned, hip ante/retroversion, tibial torsions, forefoot/rearfoot varus/valgus might appear structural at first glance, but upon careful manual examination turn out to be mirages that vanish with treatment, especially pelvic distortions.

Tibial "torsions" go away too, most of the time, as do foot asymmetries. Treating the back of the knee will help the neurovascular bundle back there be less hung up in the calf fascia. Treating the muscular bits that form the top parts of the long foot tendons can make a huge difference in flat feet supinated feet that don't match the "norm."

In a manual mood today, (most days actually..)
Diane

[bernard]

Hi All,

My previous point of view is more functional and you noted it in your post, Diane. I believe that we are seeing more structural (but functional) variation/changes than a decade before!

Every week, I drive my daughter to the train station and I perceive these little variations in gait, postures which are consequences of a variation of habits and fashions. I think that is a reversible state?

[BB]

Hello,

By structural variation I did mean skeletal structural variation.

I think that this is important to differentiate between structural and functional type asymetries, as functional variation can be changed in the way that Diane speaks of, and skeletal can not.

One example that always jumps out at me, is the hip torsions. X-rays are the gold standard, but there are also some very easy and reliable (I'll look for the references) clinical measures. Those being Craig test in which you feel for the greater trochanter at its lateral most point and see what position the hip is in. Also, looking for asymetry between ROM of rotation ER/IR in supine and again in prone.

If an asymetry is present that seems to be related to the pain, finding out why it is present will only help ability to help. For example, a male golfer with a retroverted hip in the lead leg. During his swing he will be putting excessive torque at end range hip IR. A simple thing to help is to point the toe out slightly to clear up more room for the hip to rotate.

I do like your thoughts on the foot Diane. Definately many things can affect over or under pronation, but I have often thought that the foot alignment measures may or may not be seeing skeletal variation.

Cory

[nari]

Just to throw in a filip - (which I often do to the annoyance of others!?)

Once you have found the structural deviation/anomaly which shows up during golf or whatever....

what do we do next?

Can we change anything in a functional sense?


Nari

[BB]

Howdy,

Bernard: A retroverted hip will have apparent limited internal rotation and excessive external rotation. This could also be true of soft tissue restrictio. But if it is present in both prone with the anterior structures on tension, and in sitting with the posterior structures on tension, then it is likely a retroverted hip (I will try to post the research soon). This has been compared favorably with radiographic testing.

Nari: I will answer yours in another post. Gotta go!

Cory

[Diane]

Good tip, Cory, thanks. Feel free to post any other tips you have!
Diane

[BB]

Hello again,

Nari: to answer your question, I think that there is a lot we can do functionally. (and I don't find your question annoying :D )
Let me try to paint a picture,
Our male golfer presents with L knee, hip, and back pain. We notice he has findings consistent with a retroverted hip. He also stands with his knee in hyperextension. When he turns his trunk to look over his L shoulder with his feet pointing straight ahead he has lots of spinal motion compared with turning R. (this is actually a presentation I saw a couple of years ago in a patient).
The excessive trunk motion is a result of the limited hip internal rotation when the foot is pointing straight ahead. Lumbar compensates. Knee hyperextends because when walking with toes straight ahead his knee actually points medially and has stretched out the knee capsule.

So, ways to address this functionally
-teach him to walk and perform other functions including golf with his toes pointing out slightly so that he is in a more neutral hip orientation
-address the lumbar hypermotion that is now a habit
-address knee alignment and stability

Some other common functions that would be important to check this:
baseball/softball/cricket swing
Racquetball players
kids who "w" sit
I'm sure there are lots of others.

Cory

[nari]

Thanks Cory

Actually in the past, (1983+) we did heaps of this correction of dysfunction, and sometimes it worked and sometimes it did not. In those days we blamed the patient. Today we blame our ignorance!

I moved away from doing postural corrections some time ago as the improvements seemed temporary. and I was so bored. A person would go off, come back and report he could bowl, putt, tee off, watch TV, jog, do pushups, drive a car more comfortably and on paper the ROM looked better, but the pain often stayed.

hence the birth of cynicism!

Nari

[BB]

Here is a reference, sorry no abstract

Physical Therapy Volume 84 · Number 6 · June 2004
Update
Determination and Significance of Femoral Neck Anteversion
Michael T Cibulka

Cory

[Diane]

Nari, I wonder what sort of flavor of "correction" PTs were using in 1983.. my mind goes off into manipulation and coercive technique like that.

The body "corrects" beautifully with very little effort from the practitioner, and lots of slow motion, with many pauses, to allow for brains to re-combobulate the info coming in with the info going out. I like to think of myself as a Neuromodulator rather than as a manual therapist, these days...

I don't think good techniques will ever go out of style or be completely eclipsed or made irrelevant by nervous system understanding. They will only be honed to greater perfection.

Thanks for the reference Cory. Any good tricks for examining other body bits?
Diane

[bernard]

Hi All,

Cory, now I'm understanding but many structural problems have functional consequences and to reply to your original question, I try to look at these things.

As I stated, I try to compensate the functional imbalances because they mask often these structural aspects.

As Diane, I am now a slow/few movement maker and I do not search a correction but a smooth achievement.

ps: Cory, the reference paper points to many abstracts. Maybe you'll find some good ones?

[nari]

Diane

True, physiotherapy was very much into no-choice do-as-you-are-told in the 80s. Everything was so new and exciting. Maitland had invented (or thought he had) passive mobilisations, someone discovered Trans Abd but called it bracing, headaches were being treated actively, and so on.
So physios became master technicians, and very much into passive remedies.
In the 90s, as far as I could tell (I had left that musculoskeletal scene, thankfully) there was a move towards more discriminatory application of techniques, and clinical reasoning came into standard expectations. Everyone stopped being scared of chiros and osteos. Much better.

Sublties of movement seems to be a growing wave in the 2000s, rather than whambamgetonwith it approach...though that still exists. And under that umbrella is the kind of subtle correction you talk about; hope that stays around.

Claws are out today - hope this doesn't sound too scratchy!!


Nari

[BB]

I completely agree Bernard. We do not change the structure. Treat function. But we can give advice so that functional problems do not continue to arise.
I think that my attempt to be brief before may have taken away from the discussion and also caused Nari's claws to come out.
I'm not talking about postural correction here. How can you change a twisted bone? As you hopefully know, I dislike the passive "hold still so I can fix you" treatments as well.
Take another look at my example above. Functional problems that are related to the hip
1) back pain as a result of over rotating in the lumbar spine as a result of decreased hip rotation.
Choose your intervention here, but big picture is teach this person that they can move differently than from their L-spine in this way. Teach them why this is important.
2) Knee pain as a result of hyperextension as a result of altered hip mechanics. Great place for neurodynamics likely. Sciatic is probably being stretched big time at the hip. Teach them how they can avoid hyperextending their knee even with their existing hardware (the retro hip). Teach them why this is important.
3) Hip pain as a result of constantly being in an internally rotated orientation so that the foot can face forward. Again choose your weapon. Knock down the pain. Explain why there is pain. Explain why it is important to devote some thought to this hip.

End result is a person who WAS functioning unaware with a painful lower quarter and a retroverted hip, who is now functioning pain free and is aware of their tendencies and how to consciously control them.....still with a retroverted hip.

I think that for us as therapists, having the knowledge of the presence of that hip, gives us a better chance to intervene more effectively and have long lasting positive outcome.

Here are some of the references.

www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1738965

www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2295171

www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7180393

[nari]

Cory

Not at all! Don't think that for a moment. it was an entirely unrelated matter that unsheathed the claws!

It is how I function - wandering through the jungle, not looking for prey, but the occasional tree to sharpen wits/claws on!! :wink:

Function is defintiely the name of the game.

I will read your references at a later date - when they are sheathed!!



Nari :oops:

[BB]

Diane,

One other is tibial torsions. It is actually one main reason I posed my question. I don't like the test that I know and am interested in better ideas.

The test that I know:
Pt. is sitting. Align tibial tubercle in neutral. Measure angle of the axis that runs through med and lat malleolus.

Tough to determine "neutral" with just one landmark.
Tough to measure malleoli angle too.

Another one, also looking for input:
Tibial bowing. I deal with this one personally.
Have the pt. stand on one leg. Look at the knee. Is it is aligned without varus or valgus? Now, look at the angle the tibia makes with the ground. I think I remember that greater than 10 degrees is "abnormal" finding. Mine is 15 I think. These people will have odd foot presentations. Have to pronate hard and fast to get the foot flat. Lots of not fun forces through the foot.
Not sure yet best way to help here. For me, the best help in reducing my foot pain has been orthotics (for whatever reason is currently held as "the reason" orthotics work). Once I got them I went from being miserable after 2 mile runs or 10 mile hikes, to being sore after mini marathons and 20 mile hikes.

Ideas and additions are welcome!

Cory

[bernard]

Hi fighters!

Words may not hurt anybody on a scientific forum. We can have different opinions and we get the right to change them!

About function (since it is the heart of the battle).
Is there some structural problems? Yes!
Does a changed structure may produce a diverted function/using? Yes!
Is a changed function an insurance to get a changed posture? Often!
Does a modified posture ever a risk to carry pain? No but sometimes!
Does a modified posture may produce/increase a structural change? Why not?
If sometimes we get pain and changed posture, is there a chance to revert the problem? Yes!

Yes, because a painful state need time and invisible steps to be achieved. We pass from a normal state to an abnormal with slight changes and a slight change is only necessary to revert to a painless one!

Diane and Cory,

It will a good idea to collect these tips and put them on the Try It forum?

[nari]

Bernaaaard

Who's fighting? :shock:

Perhaps a key word is 'time'. If we are looking to change a structural and painful dysfunction that has been around for 20 years, I think that is much harder than one which is relatively recent - eg the dowager's hump, or a re-arranged pelvis post-trauma.
What about the high percentage of middle-aged and older women who develop externally-rotated iliofemoral joints and walk Charlie Chaplin style? Cause and effect are difficult to separate here; but the loss of IR is probably a cause of later OA. What interests me is why this gait pattern develops. Any ideas happily received. I have tried a number of triccks and strategies as a prophylactic measure, but nothing has changed this choice of walking.


Nari

[bernard]

Nari,

The use of claws is often for fighting but I know you were joking! :wink:

About your woman cases => why do you look to loss of hip IR? Better to look at another place that may produce the same results then correct the found place to correct the consequences?

It is not my idea :oops:

[Diane]

I do almost no testing anymore of anything, frankly. I look at people. I stand them up in front of me, (with their knees exposed) tell them I'm wearing invisible x-ray goggles, and that I'm going to look at their relationship with gravity. I ask them to stand relaxed with just enough energy to keep from falling over, and to let their body assume its most comfortable position. Then I look for soft tissue bias. It tells me almost everything I need to know, to determine likely unconscious behaviors that are contributing to the pain state.

Then I look at everything. I look at verticals and horizontals and twists and torsions and which leg looks like it's carrying the most weight, try to see what they're trying to stay away from, what hurts, which side they appear to crunch down into, which way their head bends..

I do look at feet and knees. And often it looks like their two legs/feet come from two different people. On one leg, the knee will point in and the foot out, and on the other the knee will line up perfectly with the foot. One foot might look seriously pronated, and the other seriously supinated, both under load. Most of the time the lower leg will be the source of the hangup, and treating the NV bundles will result in orthotic free bilaterally symmetrical results. Sometimes it's just one leg, usually it's both; one calf will have tight structures medially and the other laterally.

I mention that it looks to me like they are putting more weight through one leg than the other (naming the leg) and they'll say... oh.. yeah.. that's true.. and will immediately try to change it and I say, no, just let your body be where it wants to be.. If the person doesn't believe me, or can't feel it, I have two cheap analogue scales that I have them stand on, one under each foot... often the discrepancy is as much as thirty pounds.

Meanwhile, I'm educating them, letting it sink in that this is probably not an ideal situation for a bilateral structure.

I ask them to let one side sag and take all their weight on one leg, while still touching the floor with the other. I ask them how that feels. Then we try the other side. They say, oh, this side feels really weird, or, I don't feel comfortable on this leg, or, I feel like I don't have as good balance on this leg. I ask, does it feel like this leg is weaker, or that you have to focus harder to stand on it? and they say, yes.. I feel like I can't trust this leg to hold me like the other leg does.

Almost invariably, they have a bias, and have spent much more time standing on one leg than the other. They come to realize their own asymmetry and their own body bias long before we get to any "treatment". I classify this "assessment" as totally overlapped and interwoven with kinesthetic education.

I move up to the pelvis, look at which way it wants to rotate. If the pelvis rotates to the right, I ask, do you like to sit with your right leg crossed over your left most of the time? and usually it will match with what they like to do. Again, this is an opportunity to suggest gently that that might be part of the "archeology" of the problem. It tells me I'll need to palpate/ check the front of the hip later.

Often (later during palpation) there is a tense, tight, hard quality to the tissue at the top of the thigh, front of the hip, where I presume the illiofemoral ligament is located. I mostly treat this area anymore with patient supine, legs over a bolster, palpating the spot with one hand while I pull the skin on the thigh toward the knee. It softens up the target spot. I just hold the skin pulled until it feels to my palpating hand that the target tissue has stopped processing. When I let the thigh skin return back to where it usually lives, the target area is now soft and homogenous, and no longer a pulling or distorting factor when I recheck pelvis in standing.

Back while patient is still standing, I look at hips. If the legs turn out I know I'll have to spend some time on hip extensors. If one turns out, and one is straight, it might be more a pelvis problem, of the "distorted" sort, like a flare or a shear. (Not that these names mean anything more than the abs are out of whack.. ) Likewise if one crest looks higher than the other.

If one leg turns in and the other is straight, I'll look more closely/more primarily at obturator nerve in the thigh.

I look at their shoulder girdle. If it looks tilted one way, I try to see if it is being pulled from the back or from the front. If it's back, I look at lat. If it's forward, I look at pec. I say these muscle names, but really I don't care about the muscles, I care about all the cutaneous nerves that have to thread their way through them.

In standing, I ask them to stand on say the right leg, and stick their right arm up into the air and stretch it up. Then the left leg/left arm. Invariably, one whole side of the body is "stretchier" than the other. On one side the ribcage will naturally shear over, and on the other side it won't be able to because of tight lat. I get them to notice this movement.

So, I ask them to go to the less stretchy side and practice stretching, with their thumb turned back, all the weight on the same side foot, and do abdominal breathing with full inhale and full exhale, at least three deep breaths, about once every hour (because of the insertion of lats on the last 4 ribs, not so much that I care about TrA or any other cultlike stabilization stuff..)

I tell them, in three days, this side that right now feels like it has a steel cable running through it, that cable will turn into something that starts to feel like it has give, like a bungee cord. then that bungee cord will feel like it gets longer and longer and more stretchy until it doesn't stop you stretching anymore, and your ribcage will be able to stick out over here on this side just as easy as it does on that side.


About tibial torsions etc, I spot them first in standing, then look at them in nonweight bearing. Lots of them are because of preferred leg crossing behaviors. Almost none of them are truly "orthopaedic". I've even seen some people who have flattened spots on the fibular side of the leg, from the opposite knee pressing in over decades of asymmetric relaxed sitting. I treat them in supine, by lowering the leg over the side of the plinth, slight knee flexion, so that the edge of the plinth contacts the inside of the tib plateau, then pressing the lat mal in toward the bed. Very good leverage, don't need a lot of force, have to go very slowly. Easy to moniter tissue at the back of the knee. It will soften, and along with the tib torsion improving, so will excessive tension at the back of the knee, "baker's cyst" pain, all that stuff.

I ask people to moniter their own behavior. I ask them to notice when they sit, what position they like then to start spending a few moments practicing the opposite position, every single time. I tell them it will feel uncomfortable, but to do it frequently for short periods of time, until their bodies have "learned" to be comfortable on either side in any given habitual position; lying, sitting with legs tucked up, legs crossed, standing on one leg, etc. (I am getting them to use their mirror neurons..)

In my opinion, these daily positional behaviors are where we can intervene the most effectively. And we have to convince people that they can be their own therapist 24 hours a day, and that they can work through the discomfort to develop resilience and have to endure way less pain in their lives.
Sorry about how long this long post is.. I got quite carried away with my little reverie.
Diane

[BB]

Not fighting, just a discussion. I appreciate the attention to my question!

Fine with me to move it Bernard.

An interesting item in your reply concerning function contributing to changed structure. "Does a modified posture may produce/increase a structural change? Why not? "
Makes sense. Hard to determine to what extent it contributes sometimes.

Cory

[bernard]

Hi Somasimplers,

The topic will be moved to the Try It section. A better place for something we use in our daily practice.

Diane,

A perfect human being examination!

Cory,

I was thinking loud to our disc degeneration disease. :wink:

[BB]

Diane,
Thanks for the great description.

Again I say, it would be fun to watch you work!

Cory

[rolf]

Hi Diane!
Espessialy during my physiotherapy education,and during my mauelltherapy education(some years ago) we did a lot of biomecanical evaluations on healthy students and on students in any cind of neuromuscular pain.BUT we didnt find that the paingroup had any more stuctural abnormalities (dynamicly or static) then the painfree group!
Its quite interesting that you(we) do our examination in standing,when "man"is mostly sitting ,and walking.!?
Any comments?
RIN

[Diane]

Hi Rolf,
we didnt find that the paingroup had any more stuctural abnormalities (dynamicly or static) then the painfree group!

That might be true, but then you have to start somewhere.

Its quite interesting that you(we) do our examination in standing,when "man"is mostly sitting ,and walking.!?

I agree. That's why things show up best (are more highlighted) when people stand.
Diane

[bernard]

Hi All,

I had a 29 yo woman, yesterday who presents a structural variation since her early age (genu valgum) knee pointing to int side.
But when she was lying on the table, the deformation was quite unimportant but external rotation of feet was reduced.

She said that nothing may correct this problem and she wears orthotic soles without success.
I thought it was only a functional posture and tried to relax internal rotators of hip and psoas. After a trial on the R leg, external rotation gained 20°. She was dubious about that but the fact was there => A foot was more externally rotated than the other one!

Of course, we acted on the left one!
So it is perhaps to act on a bad posture even if it is old?