Hi peeps
need some thoughts on this case:confused:
client history- female late 20s, works at airport, stands around for most of the day and patrolling inside the airport, never had any major illness or injuries, apart from a small amount of medial meniscus removed on left knee about 12 years ago but causes no problems now.
the case - gardening at wkend, doing lots of digging. afterwards lower back ached and pain down left leg with numbness on front of thigh going down to knee from hip also complianed of hip pain. When she came to see me 6 days later, the numbness had gone, she was walking fine although a little slower than normal and would sit down in a protective manor.
after several tests only the slump test proved pos (bi-lat) and quads & hams where both tight. Glutes seemed weak also. ITB was tender and very tight.
after massage to quads & hams both showed good response and could gain good flex/ext with no problem & no pain. also gained good ROM to hip/glutes after treatment, there was so sign of numbness throught the treatment or tests. after treatment she moved about more freely with no pain and seemed very happy:D
i suggested she consult her Dr again and ask for an x-ray on her back (due to pos slump test) i gave her a list of all the tests i performed with results (around 20 tests) to show her Dr.
I got a call yesterday from her, saying that Dr wont reffer her for x-ray, Dr said her back is fine, problem is in her hip due to lax joints (they looked fine to me:confused:) and gave her some drugs that would take pain away. Drugs havent worked only damped down the pain but still there, she is complaining of feeling weird while on the drugs:(
my initial thought was a L5 impingment on fem nerve:confused:, i told her to gently work on her glute muscles to strengthen them and work on the right firing pattern of hams glutes back.
she is coming to see me again next week
any thoughts please
you will get these cases every spring time when people go out and spend a day in the garden when they have spent the last 6 months sitting on their ar5e, it is the extra work load that has the detrimental effect, prior to that there was just poor conditioning and poss some postural problems that will contribute.
Muscular protective responses can also refer pain so a nerve/compression/ disc may not be the cause, most people like to hear it though as it means they can sit round on their ar5es for longer and the problem will get worse.
it is likely that some basic range increasing exerc ises will benefit the client, there are also physiological and psychological gains to be made on this front.
regards
BGFL
you will get these cases every spring time when people go out and spend a day in the garden when they have spent the last 6 months sitting on their ar5e, it is the extra work load that has the detrimental effect, prior to that there was just poor conditioning and poss some postural problems that will contribute.
Muscular protective responses can also refer pain so a nerve/compression/ disc may not be the cause, most people like to hear it though as it means they can sit round on their ar5es for longer and the problem will get worse.
it is likely that some basic range increasing exerc ises will benefit the client, there are also physiological and psychological gains to be made on this front.
regards
BGFL
totally agree big guy:D i just asked her to get checked out (x-ray) to make sure all was ok, i did say to her most prob muscle problem as she did respond well to treatment, but better to be on safe side when reffering to the spine:o
im sure you know how hard it is to get clients to exercise when they leave you, so can you suggest anything while im treating her
As BGFL rightly points out, but I would phrase in more general terms, you have a person who spends most of their time becoming adapted to one situation, then suddenly working hard in another situation they are unprepared for.
My first question to this lady would be does she wear high heels for work? This creates all kinds of patterns of tension in the limb, anterior tilt to the pelvis, deep lordosis. Once failure of any of the various structures begins there easily follows a complex of action and reaction.
If not heels, what about bag on one shoulder, laptop case, etc etc. What about orthotics in shoes? These can play havoc with the low back and don't always achieve much for the feet. Unless there is a clear need like a significantly shorter leg then best to leave them out. What about previous injuries, eg fractures to the limb, sprains etc.
If her job is looking at screens, or meeting and greeting, then the head posture comes into this, as the pelvis must stabilise a stick waving around with a melon balanced on top - a fantastic achievement when we think about it really.
In any case, numbness of anterior thigh is usually not discal in origin, meralgia paraesthetica is more likely, ie compression of the anterior cuteneous nerve of the thigh in the space deep to the inguinal ligament. More common in overweight people, but certainly points towards tilts, twists and turns in the pelvis. As do aches and pains in the thigh and leg which typically are referred from sacroiliac joints, hip muscles etc etc, which can become tightened and strained through trying to shore up a structure that is teetering on the verge of collapse.
So in a sense the doctor is right, but only to a point, in identifying the hip. In reality, this is most likely deep muscles and not so likely the joint itself at her age. I agree that laxity is unlikely to be a factor, as I would expect a more chronic awareness of a problem. Just the opposite, infact. I would hazard a guess at trigger points galore in the glutes and deep hip rotators.
Don't just get stuck in with your elbows, however, as there is undoubtedly more to this, and those strains may be due to the brave effort of stabilising a structure that is out of equilibrium. Mess with all the tight supporting muscles without regard for leverages, and sure enough, by the time she gets to a MRI scanner in 3 months' time, it really will be a ruptured disc - a high price to pay for a few hours' relief now.
So could there be a disc or nerve involvement? Certainly, but this may be irrelevant to what one has to do. MRI any number of random people and you will find damaged discs and compressed nerves with no symptoms. In that case we might well treat them to our heart's content and to their benefit and be none the wiser. Unless she has had a fall, xray is unlikely to offer any helpful findings, although our chiropractor friends might say otherwise.
In any case, disc involvement does not by any means contra-indicate treatment per se, but might well change the way we direct our input. So my inclination if a disc and nerve are suspected would be to leave alone the area of suspicion at first and try to impropve the environment elsewhere, allowing the area to de-stress in its own time. Pathology does not preclude treatment, but it makes the stakes higher.
Remember the first rule - don't make the situation worse. Luckily, the more severe the situation, the less you will probably need to to to make an improvement. If you do nothing at all, there is a very good chance that improvement will follow anyway. So less is more, and if in doubt, leave alone.
The fact that she is feeling better bodes well. No need for heroics, just use your best judgement, be mindful of the unknown, and don't force anything to change that isn't ready to change. Impress upon your patient the importance of time and patience in the recovery, and that what she does for herself at home is 95% of the treatment.
If you really are feeling that this is beyond your skill and scope of practice then feel free to get another opinion. The GP is of the view that this is not a case for spinal surgery, which should be encouraging, just don't turn it into one and no-one will criticise. Okay!
Good luck!
As BGFL rightly points out, but I would phrase in more general terms, you have a person who spends most of their time becoming adapted to one situation, then suddenly working hard in another situation they are unprepared for.i agree and told the client this also
My first question to this lady would be does she wear high heels for work?No (flat shoes, works in security at airport) This creates all kinds of patterns of tension in the limb, anterior tilt to the pelvis, deep lordosis. Once failure of any of the various structures begins there easily follows a complex of action and reaction. i checked ASIS/PSIS and other pelvice tests and all came out fine no problems
If not heels, what about bag on one shoulder, laptop case, etc etc. What about orthotics in shoes? These can play havoc with the low back and don't always achieve much for the feet. Unless there is a clear need like a significantly shorter leg then best to leave them out. What about previous injuries, eg fractures to the limb, sprains etc.
If her job is looking at screens, or meeting and greeting, then the head posture comes into this, as the pelvis must stabilise a stick waving around with a melon balanced on top - a fantastic achievement when we think about it really.
In any case, numbness of anterior thigh is usually not discal in origin, meralgia paraesthetica is more likely, ie compression of the anterior cuteneous nerve of the thigh in the space deep to the inguinal ligament. More common in overweight people i lean towards this also, but certainly points towards tilts, twists and turns in the pelvis. As do aches and pains in the thigh and leg which typically are referred from sacroiliac joints, hip muscles etc etc, which can become tightened and strained through trying to shore up a structure that is teetering on the verge of collapse.
So in a sense the doctor is right, but only to a point, in identifying the hip. In reality, this is most likely deep muscles and not so likely the joint itself at her age. I agree that laxity is unlikely to be a factor, as I would expect a more chronic awareness of a problem. Just the opposite, infact. I would hazard a guess at trigger points galore in the glutes and deep hip rotators.
Don't just get stuck in with your elbows, however, as there is undoubtedly more to this, and those strains may be due to the brave effort of stabilising a structure that is out of equilibrium. Mess with all the tight supporting muscles without regard for leverages, and sure enough, by the time she gets to a MRI scanner in 3 months' time, it really will be a ruptured disc - a high price to pay for a few hours' relief now.
So could there be a disc or nerve involvement? Certainly, but this may be irrelevant to what one has to do. MRI any number of random people and you will find damaged discs and compressed nerves with no symptoms. In that case we might well treat them to our heart's content and to their benefit and be none the wiser. Unless she has had a fall, xray is unlikely to offer any helpful findings, although our chiropractor friends might say otherwise.
In any case, disc involvement does not by any means contra-indicate treatment per se, but might well change the way we direct our input. So my inclination if a disc and nerve are suspected would be to leave alone the area of suspicion at first and try to impropve the environment elsewhere, allowing the area to de-stress in its own time. Pathology does not preclude treatment, but it makes the stakes higher.
Remember the first rule - don't make the situation worse. Luckily, the more severe the situation, the less you will probably need to to to make an improvement. If you do nothing at all, there is a very good chance that improvement will follow anyway. So less is more, and if in doubt, leave alone. which i did, i just eased what i could
The fact that she is feeling better bodes well. No need for heroics, just use your best judgement, be mindful of the unknown, and don't force anything to change that isn't ready to change. Impress upon your patient the importance of time and patience in the recovery, and that what she does for herself at home is 95% of the treatment.i always do
If you really are feeling that this is beyond your skill and scope of practice then feel free to get another opinion. The GP is of the view that this is not a case for spinal surgery, which should be encouraging, just don't turn it into one and no-one will criticise. Okay!
Good luck!
many thanks kvdp