Cranky right ilium pain

[Thomas]

Would appreciate any ideas or suggestions with a recent client who presents with cranky (painful) spot just medial to her ASIS.

Clinical picture:
:arrow: 30 y/o female accountant - outgoing, jogger/exercise type in
good physical condition with c/o per above started 10 months
ago; Thinks a car accident in 12/03 may have triggered it or
perhaps running (pt unsure)

:arrow: Describes pain as dull aching pain from 4-6/10 with symptoms
aggravated with any stretching manuever (backbending) and
worse with prolonged walking and especially running

:arrow: Exam- lumbar spine ROM is normal except back bending and
sidebending to the left which pulls painfully in this spot above
approx. 2 finger widths medially to right ASIS which is very
tender to palpate (also tender distally from spot but not as
painful). Hip flexors and quads on right show no contracture
just pulling pain. (ITB position poorly tolerated due to stretching
pain in this region).

On exam she presented with a pelvic upslip which was corrected but had
no influence on her complaint. She had tightness of her right quadratus
which was relieved with S/L and Hanna type treatment, but no effect on
her pelvic pain. She also complains of chronic lumbar stiffness with poor
tol for hip extension. Tried some of Dianes tips (thigh over bolster skin
pulling and gentle distraction type things, and counterstrain per Jones book
which felt better in supine, but Sx returned in standing). Today added in
some sidelying knee flexion nn. mobs with right leg supported on bolster
with which the patient could only bend her knee about 30 degrees before
pulling pain sets in . (gave as home program).

Sorry to ramble, but her symptoms do not appear to be muscular in
nature so am suspicious of nn entrapment stuff. Any advice of how to
proceed with this patient or other tips would be greatly appreciated.

Cheers..........Thomas :P

[Diane]

Hi Thomas,
Could be a quad or femoral nerve thing if prone knee bend is restricted..
I'd also check for a in/out flare of the illium. There is so much attached to that particular bowsprit on the sailboat of the body.... Treating the "flares" if they exist takes care of abnormal ab pulls. The inguinal ligament, sartorius, TFL (through its tendon attachment) quads, lesser gluts, many cutaneous nerves, all these are in the vicinity and can end up contributing to pain on the side of the pelvis or the ASIS. The quad tendon passes directly beneath the inguinal ligament, and if quads are misbehaving, can 'roll' it through various membranous attachments, usually cranially through its axis then tug the whole shebang caudally. Not good of course for everything else in there, all the assorted tubings, like femoral artery/vein/nerve and lymphatics, also all attached/suspended from the inguinal ligament. I think the psoas tendon hates the quad tendon. They have to pass beside each other and go opposite ways.. if one is a culprit the other is usually the victim. If the pain is over psoas, the quad/femoral nerve is most likely hung up.. I'll lay odds.

(Please note: I'm not actually thinking like a Cartesian here. I'm not really thinking that muscles hurt, but they do have "behaviors" like being too tight and pulling on everything else, including everything else's innervation. When I use the names of muscles I am seeing a map in my head with convenient areas/landmarks that are muscles, since I learned these before I learned the nerve highways around and through them. Sorry for any apparent inconsistancies.)

I would likely go to the quad from the signs you've outlined and loosen all the neural tunnels, including the obturator, femoral, sciatic, til they all glided better and check out her knee while I was at it, especially that pestiferous saphenous nerve, check out her foot, look at them both to see if they are a matched set, all that sort of stuff, not necessarily in that order.

Nari, however, will likely have some slick little glide to tell you about, that the patient can learn to do for homework that will melt all the (t)rubble away. Bernard will likely be along shortly to suggest some simple breathing/movement ideas that will melt her (t)rubble in about 20 seconds. (Why do I still work so hard?..)
:),
Diane

[bernard]

Hi All,

It is fascinating to see Diane's brain working so far. She has a fine and delicate approach that I can't have. I'm a blind man using his hands to see what is going wrong in the patient body.

It is true that I ever, now, begin a session with breathing because it learns a lot on the patient and it reduces painful areas to single spots. Then, it's easier to hunt these ones. As Diane told us, I'm a lazy man, I try simple (normal here) things before complicating the chase.

My second point is often a relaxing phase because tight muscles are a component of pain and as a such component, I must understand why and how tone is produced? As a start or as a consequence. Then I will follow my thinking/questioning with habituated postures, gait...

When I'm in expectation and some things aren't as bright as I thought, I try to relax the whole back with my favourites. It may help to sense your patient while he's moving and understand why some weird problem appears?

[Diane]

Hi Thomas,
A couple more ideas:
1. Check posteriorly on the opposite side. Often problems/tension patterns have a zigzag pattern through a segment, front to back diagonally. If you encounter a big gob 'o gristley-feeling tissue on the back of the left pelvis, spend some time stretching it out in the supine bolstered position. It can then allow the right side more "space" in the body.
2. I've noticed that for anterior pelvis pains like you've described, one can nuance the 'tug through the thigh' treatment that I outlined already elsewhere, by pressing the front of the thigh into the bolster, then "rolling" it slightly medially (internal rotation) or laterally (external rotation) relative to the femur. The inguinal ligament seems to love that. Find which way it loves best, and hold it for a long time.

Diane

(PS: Thanks Bernard :))

[Diane]

Hi there,
I thought I'd pop this onto this thread:
http://education.yahoo.com/reference/gray/illustrations/figure?id=823

Until I saw this picture I had no idea that an accessory obturator nerve existed.. although I knew that nerves could grow weird and wonderful ways.

(Maybe Bernard will wizard it onto the board as a picture, like he did the picture of the cutaneous innervation of the back..)
Cheers,
Diane

[bernard]

Diane, maybe? :wink:

http://www.somasimple.com/images/gray/823.gif

[Thomas]

Update on the young lady with right cranky ilium.

Pt returned today with modest improvement of her symptoms, but with
CC of right ASIS and medial pain.

Rx today: hooklying on bolster with right thigh (psoas) supported with
gentle pressure to release psoas and medial rotation which
relaxed symptoms (extended hold)repeated 2 x,
Sidelying left with gentle hip extension knee flexion for femoral
nn. stretch repeated 6x at 7 seconds
Manual muscle energy for posterio rotated right ilium had reported this helped at last Rx.)

Client reported no ASIS pain post Rx with decreased tenderness and pain
medial to right ASIS. She isn't doing her home nerve glides , but reminded
her today.

So far so good. Thanks a ton Diane, and Bernhard for the tips and nice
anatomical pix.

Cheers...........Thomas :P

[Diane]

Congratulations Thomas!
Did her movement improve once the pain was relieved?
Diane

[nari]

I've only just absorbed some of the good stuff posted on this thread - and Diane's complex thinking and employment of a dozen different tissues leaves me out of breath, sometimes.

I think the first thing I would have done was to test PKB in prone. It is a favourite of mine - it resolves sciatic pain but I think that is more Mckenzie than anything else. What I do is just passively flex one and then the other knee, then both and look at what happens with the Lx spine and pelvis, and where the strain is felt. Then I apply upward pressure onto the lower thoracic spine (round about T9-T12) and almost always there is a significant increase in knee flexion before pain occurs. not sure why this is, and the pressure should be downwards but that is dynamically hard for me to do. Then I sometimes raise the foot (with knee in flexion) and see what happens with the pain, lumbar spine etc.

If pain is reproduced with passive knee flexion in the quads only, I do not take too much notice; but if it reproduces the pain I'm investigating, I turn it into a Rx; and the patient actively takes over, repeating the knee fleion about 5 times, using the other leg to assist if the hams threaten to cramp.

Then, in this case, it might be interesting to abduct the thighs and repeat, with tension on obturator and other stuff. The movement can be done in standing, but is much more difficult for the patient to control stabilising structures.

Worth a go?

Nari

[Thomas]

Hello Nari,

Thank you for your prone knee bend advice trick, can't wait to try it
on my unsuspecting clients ! I tried her in prone and had her bend her
knee actively, and then I did it passively, but she complained of ever
increasing tightness and pain in her low back as the knee was bent back.
Her range seemed fairly normal with more complaint of ASIS pain than pulling of the quads.

She does report having a chronically tight back , but not really complaints of low back pain . ( Maybe because she works 55 hours a week as an accountant)

Interestingly, she can bend her knee much further in the prone than
sidelying position when even very mild hip extension is added, she is limited to about 35 degrees of knee bending. (no rectus tightness when checked in supine legs off the edge and pulling up contralateral knee, so am suspicious of the neural component. )

P.S> the doctor has sent her to me for "strengthening" (her legs are probably stronger than mine)

Thanks again for the education....will keep you posted .

Cheers....Thomas

[Thomas]

Hi Nari,

Just reread your thread and need to ask a question. When you are testing via the prone knee bend test which you do actively and passively,
do you passively bend the knee in prone while you are applying an upward pressure on T-9 to T-12 during the treatment ? When you say
downward , do you mean Poster/Anter on the vertebrae as you push them cranially ?

Cheers...........Thomasl

[ginger]

hi guys, sounds like this girl is suffering upper lumbar /thoracic junction referred pain. Somewhat confirmed by the femoral nerve stretch described as prone knee bend. Suggest mobilise t12/L1/2 and give a strong ( ballistic) stretch to femoral dura. Bob's your uncle.

[nari]

Hi Thomas

Yes to both questions - and essential to train control of the pelvis...

ginger -

I am not at all sure about strong ballistic stretches to nervous tissue?
but your suggestion is useful.

It is annoying the way that drs focus on strengthening...as if they think that is all we do. I hardly do any such stuff anymore, more training and education.


Nari

[Thomas]

Hello Ginger and Nari ,

Thank you for your replies and suggestions.

Saw patient today at fifth visit, reports much improved right ilium
symptoms, no longer problematic with ambulation, but patient is
reluctant to resume jogging. Now symptoms only reproduced with
direct stretching to that point. Good read on the upper lumbar vertebrae
as patient was very tender on the right side of L3 today in sidelying.

Rx- Mobilized L3, bilateral posterior inonimate muscle energy,
sidelying femoral nn. glides, and Dianes medial rotation of right leg with psoas release. Post Rx, no tenderness at right ilium and decreased LBP post Rx.

Pt improving nicely now, welcome to the board Ginger !

Thanks to all...............Cheers..Thomas :P

[ginger]

Good to hear you are progressing well with this girl Thomas,
Nari, Dural stretches are a powerful and instant means to increased dural length , and to be able to observe the dramatic improvements to range( tight" hamstrings "are almost always tight dura) and comfort following a dural stretch is compelling. Some may find the ballistic method a little daunting but I assure you in my thousands of ballistic dural stretches to athletes and the elderly alike, I haven't seen anything but instant positive results. For instance where I suspect dural involvement to the sciatic trunk, I will position the patient in long sitting, myself behind with hands on her head pushing downwards with legs straight , 8 quick pushes into flexion such that pain is felt to "hamstring"area will increase toe touching immediately and permanently. There are numerous techniques with brachial and femoral dura , but all use the principal that a quick stretch will cause muscle tightness, leaving the dural tissue to be engaged and its fibrous network, along with filaments attached to the spondylar area to stretch.

[Thomas]

Hello Ginger,

Thanks for sharing your ballistic neural glide on this site. It sounds
fascinating as have never heard it done in this manner before. Do most
of your clients with sciatica tolerate the long sit position ? Does your
ballistic neural mob work if symptoms are not increased through passive
neck flexion ? ( ie do you just add in a little bit of flexion to the trunk?)

Your reasoning for the "tight hamstrings"sounds right as new studies show that hamstring length (extensibility) correlates more with tolerance for stretch than any academic muscle length argument.

Would love to hear any other clinical pearls along this vein .

"The best time to plant a tree is 20 years ago , the second best time is
today." chinese proverb


Cheers.......Thomas

[ginger]

I don't know about any pearls Thomas, to suggest that would be to infer the recievers to be swine, if we extend the metaphor. I am sure you didn't mean this however, just having fun.
You asked wether my sciatica patients tolerated long sitting, yes for the most part, only afew are so tight as to be unable to sit this way. I don't begin any dural stretches until after a couple of effective mobilisation treatments to eliminate the pain anyway. So pain is not really an issue. As to the slump test , yes I sometimes use this to confirm my view that dural length is compromised, although in the course of many hundreds of treatments I find myself pursuing dural length even if this valuable test is negative for reproduction of the complained of pain.It is probably the look of quiet amazement that " Mrs Jones" can touch her toes after all these years that compells me. Once you have gotten over the instinctive sense of unwillingness to stretch a nerve in such a powerful way it all gets easy from there.
I don't know that I would call this a neural glide technique however, I have heard others mention these techniques , I haven't a clue what they are talking about to be honest.

[nari]

ginger

Using neural sliders and tensioners is a favourite method of mine, and have used them for quite a few years. It can indeed be spectacular with the relief of pain, even if it tends to return later and respond again to the same technique. A nice way of sending less malevolent messages to the brain.
Thinking about ballistic movements - you described them and I can understand what you are doing better. Have you ever advised a rocking chair for acute LBP/sciatic pain? Works well - and I guess on the same principle. Get the right degree of tension/glide (all it is: specifically gliding the nerve within its sheath, and creating movement which is neural-based, and not muscle/joint based, although they go along with the ride).

Millions of ways to do this; do you include neck flex/ext to provide tension and gliding? Do you warn patients against doing it like an orthopaedic exercise (eg 20 times) because of the unnecessary risk of flare?

Actually, I think less about the dura and more about those nerve roots, slackening and tensioning nice and smoothly....

Nari

[ginger]

thanks Nari for the info on neural glides, I can't help wondering that we are both in the same territory here but with different emphasis, I do find that with Strong dural stretches that there are permanent results however.
Also that when I stretch Dura I will also perform a certain amount of neural glide , and that when you do glides you will create neural tensions that may lead to dural stretches.
Your rocking chair idea is a good one. I often get those with poor tolerance to self stretches to do something like this , with one leg into extension while sitting with the person reaching for one foot at a time. I also accept the idea of flare up after treatment. YThis is more often evident after a long facet joint mobilisation treatment. As the results are so good 24 hours after treatment however , I counsell patients to expect this. I have strong hands and have no trouble doing continuous strong mobs for hours and hours, so I explored the benefits of this method , as have many others I'm sure. I found the results to be superior to anything else. Particularly where I suspect referred pain.
I've logged on to a site called physiobase, where I was surprised and delighted to see many references to mobilisation, with lots of entries about the the experiences of what seems like another Aussie physio. I recommend it for a look.

[nari]

Bernard,

I agree - I think PTs who 'mobilise' the FJ are kidding themselves.

Ginger,

Your techniques sound quite effective, however I would not ever carry out extensive mobilisations - I try to avoid flares if I can, although I know they are benign.

I belonged to physiobase back in the mid90s and found it rather conservative and tedious and droppped out. I tried to rejoin and found it too complex - and it kept throwing me off. I found it had improved, but nowhere near the standard of this forum, NOI and RehabEdge, so scrapped it.

Nari

[ginger]

Interesting to hear your views on mobilisation Nari, I can't imagine why you would feel disinclined to use this manual therapy however. Without this method I don't know how I would go about treating most of my people. I remember learning an assortment of movement therapies at Uni, but none of them come close to the immediate and long term benefits of good old mobs. I'll put together a couple of patient profiles to illustrate my use of Mobs and the effects I regularly get.
talk soon
G

[nari]

ginger

I think we may be at cross-purposes here - when you say 'good old mobs' are you referring to Maitland et al? Passive IV joint mobes?
I was referring to neural mobilisations - quite different.



Nari

[ginger]

sorry Nari , I should have been clearer, yes I mean intervertebral facet joint mobs, ala Maitland et al, though I think I may have dropped and amended some of Maitlands protocols to suit myself. For instance,
Patient A, 76 year old woman complaining of Right ankle pain , felt at or near the lateral malleolus, surgeon threatening to arthrodese ankle after three months of difficulty walking. No injury per se. X-ray NAD.
Tense and palpably tender L4 with similar tightness and pain with palpation at L5 3 and other places generally in her lumbar spine. Observed antalgic gait favouring L ++.Poor lumbar flexion range with limits by pain and muscular tightness of lumbar spine.
Treatment> Mobilise with unilateral grade three/Four to L345 L .and R. twenty to twenty five minutes. three treatment sessions over ten days with reports of progressive improvements to freeedom comfort and gait pattern with each treatment, ankle progressively less painfull. Last treament as above and addedd US to piriformis with stretches to same. Pain eliminated, gait normalised, follow up after three weeks no return of symptoms.
Patient B,
26 year old male complaining difficult shoulder while weight training. Progressively worsening with pain felt at anterior aspect of G/H joint over three months plus. Taking nsaids. Had seven treatments with other therapist with U/S to shoulder and strengthening(!) regime for shoulder "stabilisers" with no good effect.
Treatment. Mobilise C34546 on side of pain ( right) two session with grade three to four facet joint mobs in prone of twenty five minutes each. Pain completely gone and not returned after four weeks, returned to pain free training.
These are typical of each days patient group , mobs are quick, effective and give long term benefit, I would love to know if you have anything that would work better, though I can't imagine , other than the magic wand.
Love to hear your thoughts and ideas though . Thanks

[Diane]

Hi Ginger,
mobs are quick, effective and give long term benefit, I would love to know if you have anything that would work better, though I can't imagine , other than the magic wand.
Love to hear your thoughts and ideas though . Thanks

I gather that you are a relatively fresh PT out in the world; it sounds like mobs are your only tool right now, or that you love this tool more than all other tools. I suggest that you go right ahead and learn everything you can while your hands hold out...

The trajectory usually is that the "harder" you use your hands, the less time they will last. I suggest that the more you learn, the better, because it will give you the insight you need for later. You will need to figure out how to work "lighter" on the body, if you want to preserve your own.. (smarter, not harder).

Personally, after 35 years or so in the biz, I find that my hands are still holding up very well. I stopped with the mobs holus bolus (I still do them once in awhile, maybe only one or two patients a year, with ankles, knees, radial heads, not spines..) about two decades ago, when I switched to a soft tissue/ more neuro type approach to orthopaedics. I highly recommend it. With spines I use positional release or muscle energy techniques which are much kinder to both parties. Conceptually I have found that I'm not dealing with warm stretchy corpses filled with bones anymore, instead I'm engaging in an interactive kinesthetic conversation with a human nervous system. It takes the input from the 'conversation' and does whatever it wants with it, usually creating more energy efficient and economical movement, with much less pain or completely pain free. It's educative interaction rather than coercive interaction.

The more you learn about the nervous system response to touch the more you realize that way less is actually way more. The more your own brain learns a kinesthetic language that is unique to itself, the more effective you can be with less effort. It's called personal evolution.. good luck in your career! :)

Diane

[ginger]

thanks so much Bernard , Dianne and Nari for your responses to my questions . Very thought provoking indeed.
Bernard I find your thoughts easy to grasp in general and have no real difference of opinion with your ideas on spinal muscle involvement , innervation and sensitivity etc.
If there is a quicker way to achieve good results then I am all ears .

Dianne I wonder , if you have the time , could you possibly outline a typical treatment or two for me?, indications for treatment, duration of treatment, expectations on outcomes , techniques and positions etc. I am fascinated to hear of your experiences and would love to understand these methods better. I realise its a big ask.
Should we start another thread?, I look forward to reading more.
Thanks
G

[Diane]

Yes, I think another thread is a good idea. We've been piggybacking on Thomas' thread here for quite awhile!
Diane

[Thomas]

Hello Diane et al.

The young accountant has very little if any pain discomfort in her right
pelvis / ilium thanks for all the valuable insight on the post, learned some great stuff including the prone nerve glides and the medial trochante stuff.

This young lady continues to have poor tolerance for any extension of her
spine at this time and complains of a chronically sore back. Reading your
new post Diane, maybe she would be a good candidate for belly dance
type movements ? Tried some McKenzie type stuff in prone, but not really
with good results, and some Hanna pelvic rolling stuff to relieve the pain from the active extension.

Would greatly appreciate any ideas in this realm, as I feel a bit stuck on how to get this spine able to extend freely again. She did report chronic back stiffness since an auto accident in 12/03.

Thanks again to all :P

Cheers....Thomas

[Diane]

Hi Thomas,
How about 4-point kneeling a la Sahrmann, doing 'back sag' during 3 or 4 abdominal breaths, moving up into a humpyback camel and 3 or 4 more ab breaths, repeating a few times each, progressing to a "Z" with the knees more bent, more back arching and cuurling and breathing in the new leg position, then all the way down, arms fully elevated, nose to floor, more arch/curl/breathe...etc.. as tolerated/as comfortable..

It's a good position to start getting good extension control because it's gravity assisted and the patients hips are flexed.

Advancements could be lifting alternate legs (hip extension) while controlling pelvis (brings in multifidous.) Then a leg and opposite arm (again multifidous) Include breathing..

Just some ideas. Glad her hip is feeling better.. :)
Diane

[expatient]

On exam she presented with a pelvic upslip which was corrected but had no influence on her complaint. She had tightness of her right quadratus which was relieved with S/L and Hanna type treatment, but no effect on her pelvic pain.
So which side that upslip was diagnosed before?

What about SIPS levels in standing/supine? Other leg shorter when supine?

Sounds like SIJ upslip to me. Cant' say for sure, but sounds like left SIJ upslip. It shortens left leg and in standing right leg seems longer, lifts right hip higher and stresses the right side of pelvis and low back.

Can even be both SIJs upslipped. That is quite common with women...

[Bas]

"Can even be both SIJs upslipped." ?!? Now how would anyone be able to evaluate this one? SI "imbalances" or "dysfunctions" are most often tested by side-to-side comparison (osteopathy, chiro, ortho-manual techniques) - if both are equally positioned, equally tight - HOW would one even make the conclusion of "bilateral upslip"!? In other words, sacrum jammed down into pelvic halves.....

expatient - on rehabedge.com and here in the past, pelvic motion tests and techniques have been thoroughly scrutinized and found very much wanting in reliability - both in testing and in logic....

[bernard]

You're right Bas,

http://physicaltherapy.rehabedge.com/m_41463/mpage_1/tm.htm

Expatient,

Welcome, you're promoted to the Mutes' usergroup.

[anoopbal]

I hope this is thread is related to my question.

Can novel movements, like, yoga acheive the same benifit as neural glides and relieve pain? To put differently, I am assuming movements which make you move in certain ways you have never moved help oxygentae the nerves better and keep it healthy. I assume thet if you could move like a 3yr old, your nerves should be bloody healthy.

I have read from David Butler and Louis Gifford that chronic pain behaves much like a long-term memmory, and anything resembling the actvity which initiated the pain can re-ignite the pain episode. So my question is, besides the nervous sytem manipulation thriugh exercise, should the patient be advised abt performing the very activity which brings pain by using the graded approach?

Thanks
anoop

[EricM]

Anoop, with regards to your first question I think movement based activities, such as yoga or any other activity, have the potential to allow someone to move in a way that reduces their mechanical deformation. This would be particularly so for someone whose daily routine of movement is limited in scope and variety. However it is up to chance whether they move themselves through the sequence of movements that are just right for them. When someone does achieve relief, the risk is that they attribute their relief to the "yoga" and not to the "movement," and therefore assume that doing yoga cures a particular problem, when this simply wouldn't be true for every individual. It's a roll of the dice, sometimes you get lucky.

[anoopbal]

Thanks, Eric. Makes a lot of sense. what about the second?

anoop

[EricM]

should the patient be advised abt performing the very activity which brings pain by using the graded approach

Sounds reasonable to me.

Glad my first responce made some sense, I'm not sure it came out the way I wanted it to.

[nari]

I read somewhere a paper (sorry, I cannot find it :thumbs_do) that the graded activity approach did not work well, for groups.

However, a graded approach to the one activity which poses a threat (and which may have caused a pain response in the first place) sounds logical. It certainly would achieve better responses than activating the dreaded fear-avoidance meme.

Nari

[EricM]

Now that's interesting Nari. Maybe if you ever track that reference down you could start a separate thread for it? Seems to have big implications for many pain/occ rehab type programs where group everything seems to be the norm.
So pain education in groups is OK, but the movement work needs to be individualized. Just makes sense.