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Re: Patella Tendonosis or 'Something Else'?
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Re: Patella Tendonosis or 'Something Else'? - July 7, 2006 11:37:00 PM
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Pete.
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Thanks Nari. I'll give it a go.
Pete
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Re: Patella Tendonosis or 'Something Else'? - July 11, 2006 1:35:00 AM
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Pete.
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Thanks to everyone who has responded to my post about my knee. I've been resting it completely and taking lots of NSAIDS, but it is still sore most of the time and waking me up at night. I went to see another physio for a second opinion this morning, whose verdict was:
(a) it doesn't appear to be tendonopathy or a meniscus problem
(b) there is some rough cartilage on the lateral side of the patella/femoral joint
(c) there is some swelling (I hadn't realised this)
(d)I need to see an orthopaedic surgeon and get an MRI to find out what is going on in this knee.
His last words were "we haven't reached the end of the road yet", which I didn't interpret as particularly good news. Does anyone have any encouraging insights - 6 weeks of near constant soreness has ground me down, and I'm having a hard time seeing how there might be a positive outcome to this.
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Re: Patella Tendonosis or 'Something Else'? - July 11, 2006 5:37:00 AM
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Tom Reeves DPT ATC
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Try medial glide patellar mobilization. Place your knee in an obtuse angle, relax your quads and push the patella towards the midline. Hold it for thirty seconds each time you poop. Vary the angle that you push, sometimes a little toward your feet, sometimes straight across.
I stubbed my toe yesterday Ginger, and my R big toe hurts today, which spinal level do I need to mobilize? Sorry, I am being snotty.
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Re: Patella Tendonosis or 'Something Else'? - July 11, 2006 8:39:00 AM
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Pete.
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Thanks Tom! A couple of questions: presumably obtuse angle means with the leg straight? And, er, "Poop"?
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Re: Patella Tendonosis or 'Something Else'? - July 13, 2006 4:29:00 AM
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Tom Reeves DPT ATC
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Not necessarily straight, just greater than 90 degrees.
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Re: Patella Tendonosis or 'Something Else'? - July 13, 2006 11:07:00 AM
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MikeBptatc
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From: North Attleboro, MA
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Tom,
Point out in Pete's history where his knee pain STARTED with being "stubbed".
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Re: Patella Tendonosis or 'Something Else'? - July 13, 2006 1:31:00 PM
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Tom Reeves DPT ATC
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it doesn't. I am out of line. I am truly sorry.
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Re: Patella Tendonosis or 'Something Else'? - July 13, 2006 5:17:00 PM
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Tom Reeves DPT ATC
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Mike, the point is that it seems that Ginger doesn't seem to believe that any mechanical pain cannot be treated simply by mobilizing the spine. I for one, believe that if someone has a flat foot, their knee moves into valgus. When that happens the patella moves laterally. When that happens the lateral patellar facet ultimately gets soft then sore. The lateral retinaculum gets tight and magnifies the compression and therefore the pain.
If you keep reading the posts or go back and read other threads, you will see what I mean. Ginger has a great sense of humor but I personally find some of her treatment methods hard to believe.
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Re: Patella Tendonosis or 'Something Else'? - July 14, 2006 2:15:00 AM
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SJBird55
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Tom... ginger is a he...
Depending on the patient you are both right in your treatment approaches... toss in the work by Christopher Powers and he's right too with certain patients. McConnel is probably correct with certain patients. And then, there are probably a few patients that need an eclectic approach with bits of all of the approaches.
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Re: Patella Tendonosis or 'Something Else'? - July 14, 2006 3:27:00 AM
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Tom Reeves DPT ATC
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I agree. Sorry Ginger. I keep imagining you on an island with Maryann and Gilligan.
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Re: Patella Tendonosis or 'Something Else'? - July 14, 2006 11:07:00 AM
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MikeBptatc
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I agree with...BOTH points of view. In the presence of a clear peripheral origin to acute reasonable pain the disorder can sucessfully resolve with peripheral rx. For me the peripheral disorder has to be clear. I am not going to make something up and stick with it just to justify my rx. The outcome to my rx always directs furthe rx.
However, when the pain persists beyond a reasonable timeframe, or when the pain seems to be amplified or there is not a clear biomechanical cause the spine is the place to look. In my opinion Pete can never give me every detail as to where I should look to resolve his pain because he is not sitting in front of me for me to view him as a patient. With that being said, the one phrase that sticks out the most from his report is his first sentence: "My problem is that I've had left knee pain/discomfort for some time which got dramatically worse four weeks ago." This implies a pre-existing condition that was later "stubbed" and subsequent flare of pain that has not resolved.
I am more interested in looking at his lower lumbar spine than his subtalor jt. But I am still verry interested in his subtalor jt because that is the biomechanical foundation for motion in a standing position. He has been seen by a podiatrist who is satisfied with his gait although I will only say that I am happy with verry few DPM's.
None of us have THE answer for Pete because we cannot evaluate him. One of us may guess and get lucky but we cannot assess what we cannot see or feel.
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Re: Patella Tendonosis or 'Something Else'? - July 16, 2006 2:32:00 PM
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ginger
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It will always be so much easier when a patient is right there and one is able to deal with the what is , I can only reiterate the logic of exploration of the referred before making any connection with proposed pathology at your painfull knee pete. It really is as easy as I say , though while I'm extolling the virtues of a spinal mob approach , it will only be yet another bit of data on a web site till you are able to come to terms with it by experience.
There are plenty of Aussi trained physios in the UK, I worked in LOndon myself for a bit in the late eighties. The big trouble when dealing with UK trained folks is not that there won't be good ones , but the wide variation in skill levels. This will be particularly evident in relation to Mobilisation. Or at least this was my experience at that time and I'm given to understand by colleagues and friends this is still so.
Tom Reeves, You must be misreading my text if you can honestly believe I'm as narrow minded as you contend. Try a re read, be a little more open and a little more flexible and you may approach my work with a better perspective. In general I don't engage in conversations with fools . I believe in my own way that this site attracts very few. Were you to be as indifferent to the value of a way of doing things in reality as your jesting makes you appear, I'm sure I'd be as unwilling to help you as you would be to be helped.
I mean no offence at any time by being straight forward, I'm on about the value of physiotherapy and a host of other standards too. Because this site attracts those willing to engage in the sometimes boisterous and heady business of obtaining new as well as well honed view points, I'm only too willing to be a part. It is because of your(collective) interest that I continue to offer insights and tread the boards. Engage with me Tom , you have a good mind. I must point out however that it is not necessarily your best feature.Your hands are your best feature if you are in the business of treating patients. It will through direct experience that you gain insight, thoughts and beliefs only carry you to the door, to know is to do, to do is to be,,,, finish this song for me would you.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - July 17, 2006 3:18:00 AM
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Tom Reeves DPT ATC
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Sorry Ginger,
I tend to type things that I wouldn't when I am tired. I recognize that there are all types of interventions, many of which are defensible.
Putting my previous snotty post a different way, it just seems that your posts are driven by a central nervous system philosophy. Treat the pain by addressing the impingement of the nerve roots by mobilizing the spine.
In my practice, I try to treat the thing (or things) that is/are causing the pain. Perhaps I am ignorant in things spinal or manipulative. I do have very good success treating the way I do. As, it seems, do you.
Do you address peripheral immobility or is your practice 95% spine related?
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Re: Patella Tendonosis or 'Something Else'? - July 17, 2006 1:12:00 PM
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ginger
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On first reading many of the posts here a year or so ago , I was amazed at the apparent dearth of understanding about referred events. The intention I went with on my first series of posts was to alert readers and contributors to this issue. As far as I can tell on the strength of a number of forum posters and their apparent turn around , this has been somewhat successfull. It still does amaze and confuse me however that so little time seems to be spent by many posters on the tedious business of dealing with musculoskeletal matters without having adressed the central first. By having posted in this way and consistantly flying the central first flag , I gather it seems to some that I have just the one flag. This is not so. It is however such a vital issue in treatment that I feel I can't stop waving it and beating the same drum tlll the cows do come home. I hear only distant mooing at this stage Tom. A few lonely heifers.
Distal issues are considered AFTER first removing the likely contribution by referred effects. Any other way is just, well, silly.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - July 17, 2006 3:29:00 PM
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jlharris
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Ginger,
I appreciate your persistance. It does make me take a close look at how I'm addressing my pt's impairments. I do have a question/comment:
Do you ALWAYS (at lest the 75+% of the time) approach you pt's impairments as "eliminate possible central causes then address peripheral factors"? While doing it the other way may seem "silly" to you, I don't know any of my colleagues in the States that were educated that way.
With that, to me it would seem "silly" to first thing look central in, say, a woman that recently begun aerobic workout (with being relatively sedantary before) and after a few times developed lateral knee pain. To me, to obvious initial culprit is a musculoskelatal one, not a neuromuscular one.
Am I just picking out a case that is an exception to the rule, or would you have still treated her spine first then musculoskeletal if that didn't work??
Thank you for your feedback. Apologize for hijacking the thread :p
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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Re: Patella Tendonosis or 'Something Else'? - July 17, 2006 4:00:00 PM
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ginger
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Seems a logical question and on topic to me Jason, and Yes I would eliminate the central first. ALWAYS. The question is not is there referred pain /dysfunction ,but to what extent. Were you to make any assumptions with your example on the knee having pathology , using tests as you would , the results would be skewed by the presence of referred events,were these to be present. Logic alone would point to the value of having test results not altered by spinal joint related referred change. Experience adds emphasis to this in my case, and would in yours and your many American colleagues , had they the viewpoints advantaged by having negotiated away many examples, similar to what you have described, by attention to the spine first.
It is with the continuous method of mobilisation that you will find the best method, in my humble view, to realise the presence of referred events from spinal facet joints.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - July 18, 2006 1:34:00 AM
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Sebastian Asselbergs
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Careful, Ginger. Lateral knee pain caused by meniscal damage is easily reproduced with McMurrays' - and any referred issues have very little effect on the outcome of that test. I do not disagree that many ce ntral neural issues have been overlooked for too many years in the general PT approach to injuries, but there are valid uses of peripheral biomechanical provocation tests. And the referred pain has very little influence on the outcome of that test - really.
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Mundi vult decipi
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Re: Patella Tendonosis or 'Something Else'? - July 18, 2006 7:24:00 AM
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steve
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Ginger,
Interesting perspective - I just wonder how repeated research identifying the reliability of spinal level mobility testing through palpation as poor and that prone mobilization of the lumbar spine at a specific segmental level causes a bowstring effect, thus mobilizing a different segmental level than the originally intended one fit into this theory of yours?
Steve
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Re: Patella Tendonosis or 'Something Else'? - July 18, 2006 12:45:00 PM
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nari
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Jason,
What you say is quite true, but you suggest that the lateral knee pain in your example is "musculoskeletal" in nature, as opposed to 'neuromuscular'. In my book, there is no difference. Most ailments that we see, regardless of events, are neuromuscular; if we experience pain, the 'site' of the pain may have nothing to do with a muscle or a ligament. It is that which should lead us to thinking both centrally and peripherally, with every person who walks in the door. The order of peripheral vs central testing is academic, it doesn't matter much in the end.
In Oz this has been standard for 20 years, and it greatly avoids the risk of concentrating on one segment (say, a sore knee) only and having little or no result. Some patients will do perfectly well with a narrow physiological focus - but they probably would have been OK anyway, without us.
Nari
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Re: Patella Tendonosis or 'Something Else'? - July 18, 2006 1:45:00 PM
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ginger
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From: Melbourne Victoria
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Good morning all, those of us whose lives are shaped each day by the influence we have over other peoples pain , will have felt both the frustration of not knowing how and the joy and having the answer to problems that come before us.
The influence that referred events have over musculoskeletal pain /tests/outcomes/diagnoses/treatments and outcomes just cannot be swept under a cloud of rhetoric. It is too important to the profession that we are all made and kept aware of the role played by central/joint/neurological/mechanisms. In particular in the effects referred events play on testing. The FIRST test that reveals the most usefull information, apart from a quick scan to check you have a human subject, is that role played by joints and nerves.
Once all the swagger and habits are overcome by those whose learning has been influenced by a century of local first evaluations, it will slowly dawn on those who are willing that there is a better way. Hoorah.
I'm not the only one as you have read here a number of times, by contributors who are less persistant than Nari and myself, to have observed remarkable effects by the central first approach.
Facet joints, now this is where my attention has been focused for twenty years, are very often involved in musculoskeletal problems and pain.
The reason I can say this so emphaticaly, and so repeatedly is that the evidence of my work reveals this on a daily basis. You are not to believe this at face value. I moight be a crank or a spook or worse, just pulling your leg.
How you gonna know?
EASY, just follow my advice , look at the pieces I've written and pick a patient, friend , wife , husband ( for god's sake even your dog, I've had great results with them , but that's another story) and put your thumb on a lateral mass associated with a soinal facet joint that is tender, relate this to the nerve associated with your pain problem and mobilise it. do this till pain and resistance falls away, then retest the structure. Ta Dahhhh. You will find changes to that pain picture just as I've said you would. Figure out what this means, go on. Then go ahead and keep doing thie same to a series of relevant joints till the jojnts are restored to pain free function . Observe the musculoskeletal pain again . It will not just be temporarily modified, not just be relieved for a short period. If this musculoskeletal pain has been as most will be, it will be GONE. Not just for a week , but gone.
How simple is that. Now get off your collective arses and just prove it for yourselves and put your arguments into a perspective based on the reality of this as shown by your own clever sensitive hands. You got em, use em.
Now get back to me when you've done that.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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