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Low Back pain post hip replacement
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Low Back pain post hip replacement - September 9, 2005 5:20:00 PM
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eam
Posts: 293
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From: New York, NY 10028
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Hi everybody!
I would appreciate some input on a patient I am treating. I will be brief. An 80+ woman s/p right hip replacement 8 yrs ago. About 1 yr ago, developed significant low back pain with radiation into the left leg. Has been to PT in her home state, from what I have gathered-mostly exercise and some traction. No relief at all. Diagnostic testing revealed some spinal stenosis.
Is in NY for 3 weeks, gets referred to PT. Unable to walk for more than 1 -2 minutes before the leg pain sets in. Standing tolerance is about 2-3 mins. Lumbar movements are frankly WNL and pain-free. I was not able to reproduce her sx's except with the walking and standing.
However, she has a LLI of, literally, 2 inches. Right leg longer. I swear! No one has really corrected this at all. It was so glaring, I could not believe it. Her surgeon told her to leave it alone! Her PT referral came from a Physiatrist who is a good friend of the family.
She stands with her right leg in significant flexion. Compensates with left Lumbar SB. When she is sitting, if she SBends right she is unable to do this. She has to rotate to the left. Her referring MD wants the approach to be a biomechanical one. She also has significant trigger pts (and I mean trigger pts!!) on her left lumbar p/s with referral into the leg.
She now has a 3/4 " lift in the shoe, which has helped her walk. Obviously this is not enough but we are starting conservatively. I have done alot of soft tissue to the QL, psoas etc. Joint mobilization etc. Standing and walking tolerance are better.
I am trying to picture the biomechanical implications from standing and walking this way for so long. She only has 1 more week of PT here and I just wanted some input from others here on the forum. I would be happy to answer other questions.
Thanks in advance.
Erica
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Re: Low Back pain post hip replacement - September 9, 2005 6:50:00 PM
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Synergy
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From: Texas
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Erica,
Have you performed and arterial/vascular testing of her lower extremities? Any history of heart disease, PVD, etc.? Wouldn't a battery of vascular tests be appropriate at her age? Pain with walking and then subsides after rest...intermittent claudication perhaps? I'm not saying the biomechanical issues are not causing her pain, but I'd at least want to know for sure.
_____________________________
Chris Adams, PT, MPT
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Re: Low Back pain post hip replacement - September 10, 2005 3:25:00 AM
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eam
Posts: 293
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From: New York, NY 10028
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Good point Chris. She does have a pacemaker. She is very well connected to the medical community where she lives. I don't know if any formal diagnostic workup has been done like that but I will ask her. The LLI was so glaring and unbelievable that I felt that needed to be addressed initially.
I would appreciate any other input!
Thanks!
Erica
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Re: Low Back pain post hip replacement - September 10, 2005 3:44:00 PM
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jma
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From: NY
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I would think that the LLD could be playing a big role here. Vascular claudication vs. spinal stenosis.
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Re: Low Back pain post hip replacement - September 10, 2005 6:18:00 PM
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ehanso
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From: Minnesota
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Does she have a hip flexion contracture? Strain Counter Strain Iliacus or anterior lumbar tender point? Also need to consider SIJ involvement. I have seen this in a few pts who have chronic back and hip pain after hip surgery. I am not sure of the mechanics but I rationalize it as the impact of seating the acetabular component during surgery. The forces have to go somewhere and the SIJ seems to be the recipient. Most of these did get better with some SIJ work.
Another interesting and challanging pt. Thanks Erica
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Re: Low Back pain post hip replacement - September 10, 2005 9:55:00 PM
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FLAOrthoPT
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From: West Palm Beach
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sounds like SI to me, not only from mechanism of biomechanical etc, but even the tightness in the hip would cause excess motion to occur somewhere else up the chain. I see this a lot. Typically it is a good combo of SI and Lumbar stenosis causing neural impingement. I woul dfirst have them ride 5 mins on the recum. bike to rule out vascular causes, that is if not too hard or pain not the same when riding than with walking, we are dealing SI or neural. Where does the pain go, past the knee? See if you can do the battery of ASLR tests per Diane Lee and see if self or external stab decr pain or makes test easier, of so you are dealiong with SI for at least part of the pain, then re-check a real postional test into maximal extension side bend left rot right, `close that quadrant way down, sitting or sidelying. If pain not reproduced and only in standing I say SI and possibly lumar instab, or longitudinal neural tension, so then check out slump, etc...seems pretty easy straight forward diff diagnosing actually. You should have your answer within 10 mins, just put your mind to it.
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Re: Low Back pain post hip replacement - September 11, 2005 3:33:00 AM
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eam
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From: New York, NY 10028
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Thanks everyone for the suggestions. I think the LLD is a huge problem for her with corresponding triggers in the QL, which shoot pain down below the knee. She must have some form of hip flexion contracture since she stands and walks with her right knee (longer side) in flexion. I have done a psoas and iliacus release on her already. Not familiar with the SCS tech. but I have the book so I can check it out.
Ben-good suggestion on the bike, My guess is that it will not bother her at all. Her pain does go below the knee. When I tested her lumbar spine, I just did the sagittal plane motions. I will check the quadrant and post back.
Her pelvis has to be involved in some way b/c of the functional lumbar scoliosis she has because of her compensations from the leg length. I also did the basic SLR, not active, which was negative. I will re-check some of the neural stuff.
The glaring leg length really sent me down the biomechanical route with her. I actually read some of the Travell and Simmons stuff yesterday on tp's in the QL and a related leg length. All very interesting and pertinent to her case and since the only way I could reproduce her leg pain without standing was palpation of her left QL in s/l, I thought that was relevant.
Any other ideas?
Thanks everyone!
Erica
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Re: Low Back pain post hip replacement - September 11, 2005 3:55:00 AM
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Diane
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Erica, have you checked her "lats"? Just a thought. They attach to the pelvis, and can pull it up on one side making it harder to treat. Easy enough to check in comfortable sidely, by bringing an arm up in the air and seeing how far back it can drop. I bet one or the other or both are "tight".. ("lats" and "tight" are heuristics for, "perhaps adverse neural tension in her brachial plexus including those branches that innervate the lat muscles are creating a contributing factor to her lopsidedness.") If the lats are fine (which I somehow doubt), QL and or serratus posterior inferior on whichever is the concave side would be next on my little hit list. Why? Because the pelvis is happiest not only when it sits on two even hips and SIs, but also when it's suspended evenly on both sides.
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Re: Low Back pain post hip replacement - September 11, 2005 5:21:00 AM
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FLAOrthoPT
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I am ALL for biomechanical eval and Tx, but somewhere along the line you should get an idea of what the structure is that is causing the pain. So, of course the LLD is causing biomechanical problems altered ground reaction forces, increased impact through the knee and hip of the shorter limb increase activity of the gastroc of the longer limb, decreased hip ext of the longer limb, possible cirumducting gait, etc, etc, etc...i do not think anyone is faulting you for finding this and nailing this as the root problem. But what is causing the pain? Of course treating the LLD will help elliminate further problems but I still think you need to find out if leaning to that one side is causing foraminal impingement via side bending closing while in gait or neural tension, etc, and at the same time you correct the biomechanical fault fix that as well.
ASLR: i have modified it some to bring on or bring out some issues...but you can do the whole test in 3 mins and get tons of info..
patient supine: actively SLR "bad" leg. If pain is reproduced in SI area then repeat but this time you provide a gapping technique directed at the ASIS theoreticaly in a lateral direction theoretically closing the posterior aspect of the joint, testing the anterior fibers by making them taught and the posterior ones lax...anyway...repeat this providing compressional forces "squishing" in an adduction manner along the pelvis towards midline, theoretically doing the opposite....repeat this one last time having the patient recruit some "core" and pelvic floor muscles and then ASLR theoretically stabilizing the pelvic ring....repeat one more time with the patient forcing a posterior tilt to open the L-spine that usually wants to go into extension with ASLR...side bend torso away from "bad side" and repeat ASLR theoretically opening the space around the nerve root on the effected side...if pain is reduced significantly or "easier to ASLR" in ANY of these techniques then you have a good head start as to what may be the problem and what your first treatment steps can be
good luck
Ben Galin, MPT, OCS
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Re: Low Back pain post hip replacement - September 11, 2005 6:13:00 AM
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Diane
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From: Vancouver, B.C., Canada
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Ben,
[QUOTE]somewhere along the line you should get an idea of what the structure is that is causing the pain.[/QUOTE]The nervous system perhaps?
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Re: Low Back pain post hip replacement - September 11, 2005 6:49:00 AM
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FLAOrthoPT
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From: West Palm Beach
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sure, why not, sounds nerve root issue to me from stenosis and biomechanical stenosis, I'd bet she concurrently has some SI issues as well...
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Re: Low Back pain post hip replacement - September 11, 2005 6:59:00 AM
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Diane
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From: Vancouver, B.C., Canada
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Thank you Ben.
So, in that case, would you agree that unloading the nervous system might be a start?
And if so, how do you suppose that might be accomplished with the least amount of effort to the practitioner or threat to the patient's brain? We're talking about an 80 year old here. (I'm not talking "mind" part of the brain so much, I'm talking the great big part that is responsible for running/processing/collating all the life sustaining activity. That's the part that is so tricky to befriend and persuade into cooperating if it doesn't trust you.)
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Re: Low Back pain post hip replacement - September 11, 2005 11:41:00 AM
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FLAOrthoPT
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From: West Palm Beach
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not only a start but the treatment...yes, fix the biomechanical LLD, instruct in postural and body mechanics to bias flexion, sleeping positions, etc...positional distractional techniques i.e. gapping open the left lumbar facets close to the levels in question, try to release some neural fascial tension along the path of the nerve in question, and good old recumbant bike riding always seems to help via resuming cardiovacular performance, and overall dynamic movement of the mmuscles, tendoms, and neuralfascial tissues in an opne spine position..
ok gotta go watch more football..
PS Duffy: what are you thinking for this year? steelers still going to beat the pats?
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Re: Low Back pain post hip replacement - September 11, 2005 3:48:00 PM
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eam
Posts: 293
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From: New York, NY 10028
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Hi!
This woman's joints, muscles and nerves all are in play here. Time is not on my side, unfortunately. Unloading the nervous system as well as gapping the left lumbar facets and releasing the TP's in the QL, will help. Sometimes it is difficult when you are unable to reproduce the pt's sx's and then you have to figure out what the heck you are trying to treat. Diane, I agree, her lats are most likely short.
Given her age and the pacemaker, I am thinking how far can I push this? She is also not that thin, if you know what I mean.
I will unload a battery of neural tests tomorrow on her as well as the quadrant test. When I did the IE, something in my mind said "this is not typical spinal stenosis" for some reason. I think her problem is more an overload. So that if I do one little test, it will be neg. I think I will have to sit there with her for like 5-10 mins performing the same maneouver and then her sx's will manifest.
We'll see. Enjoying this thread alot.
Erica
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Re: Low Back pain post hip replacement - September 11, 2005 5:01:00 PM
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Jon Newman
Posts: 1713
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From: Amherst, WI
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Hi Erica,
Does your patient ambulate with a walker? If not, try one to see if it helps increase walking tolerance. Sometimes it is amazing how much that helps if the person is wiling to use one.
jon
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Re: Low Back pain post hip replacement - September 12, 2005 2:27:00 AM
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eam
Posts: 293
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From: New York, NY 10028
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Hi Jon-
I asked about a cane last week and she told me that it made her worse, which is hard to believe. But I think it is a vanity thing. She attends a lot of functions, makes a lot of speeches and is on the board of many institutions in her home town, so I think the walker would be difficutlt for her image wise to use. I will try again today.
Erica
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Re: Low Back pain post hip replacement - September 12, 2005 2:52:00 AM
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avalon
Posts: 181
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Hello,
[QUOTE]I asked about a cane last week and she told me that it made her worse, which is hard to believe.[/QUOTE]Diane asked for the lats. If they are involved, it may produce this incredible result and you found they were short!
Try abdominal breathing, it relaxes the low back. Relax her shoulders and work the upper body rotation (it elongates the lats without great problem = Feldenkrais).
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http://www.somasimple.com
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Re: Low Back pain post hip replacement - September 12, 2005 1:31:00 PM
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eam
Posts: 293
Joined: February 5, 2004
From: New York, NY 10028
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Hey gang-
Lumbar SB (L) with Extension -back and leg pain below knee. Negative Slump test. Right Lumbar SB-within her limited range- (pain free)and extension -same. ASLR + at 75 degrees. ASLR with a posterior pelvic tilt-no sx's. What about the theory that although she has pain with left sb, she is "stuck" there, so to speak and cannot move further into this position. Even though she needs more range there. Clearly, there is neural compression as well as joint. You can tell I am over analyzing this one!
I treated the QL today, attempted mobs to gap the left facet joint and then had her walk. Her walking tolerance went to 3 mins. But carryover is important and she does not have any.
Does anyone have any preferences for neural mobs re: positioning. Supine, or s/l??
Thanks alot everyone!
Erica
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Re: Low Back pain post hip replacement - September 12, 2005 7:22:00 PM
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nari
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From: Australia
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Erica
I'd try s/l first - see what happens +/- pelvic tilting, then look at SLR. I would usually go for sitting, but in the case of this woman, it may be too tough for her to control. You could try her sitting in a chair with back support, with and without a small cushion at the lumbar level.
I'd introduce neck flex/ex last of all.
Sounds like flexion is the way to go, however.
Nari
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Re: Low Back pain post hip replacement - September 13, 2005 3:47:00 AM
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FLAOrthoPT
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From: West Palm Beach
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absolutely, so SLR + until posteriro tilt, tells you that when spine in flexion you have more available neural longitudinal mobility. This is a case that needs flexion, felxion, felxion..have her go into a posterior tilt and then support the hip in some flexion with your support fulcrumming at the knee and just have her actively pump the knee into extension, when it seems pretty fluid movement, bring the hip close and closer to 90 degrees, you can throw in some over pressure at the calf into dorsiflexion if you arms are big enough. She'll need a break anytime you see her holding her breath or losing her tilt, try this for like a total of 3 mins, and then go through an entire ASLR full range several time with post tilt. The have her do ASLR without tilt, you should have Sx be negative at this point and you just freed up some tension, get her on a recum boke for like 5-10 mins makking sure at some point her leg gets into full extension. Still, somehow find a way for her to not walk in that left sideflexed position, and my guess is that her Sx will sig decrease with this Tx, and it'll only take like 15-20 mins. Teach her how to lay in a distracted gapping position at home, and teach her to post tilt and go through that ASLR through partial and then full range at home, looking not to hold breath and to rest if she cannot hold the tilt. Next session add in neutral/flex tilt with blood pressure cuff or stabilizer and progress to post tilt/neutral with active leg lowering, etc..good luck
ben
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