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Re: Hip Impingement Syndrome
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Re: Hip Impingement Syndrome - April 13, 2005 2:40:00 AM
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SJBird55
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From: Michigan
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Me, mess with anyone? uh, huh... never!
Do you guys realize that Shirley Sahrmann will be at the APTA annual in Boston this June? There's a whole concentrated education series on movement system impairment. Femoral syndromes will be discussed on Friday June 10 from 1-4 PM. (Shirley herself is presenting the femoral one and the low back one.) She did a short presentation at the Combined Sections Meeting and really, her stuff isn't that difficult to understand - she has good videos and most of the time her treatments seem to evolve around observations (which is why the book may be difficult). With the videos, before she even finishes what the problem is, you've already identified mentally what you observed that might be abnormal.
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Re: Hip Impingement Syndrome - April 13, 2005 3:41:00 AM
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JLS_PT_OCS
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I need to get those videos, then.
She is really doing a good job at trying to specify her evaluation method, test it for inter and intra rater reliability, and get the research started on it. Some encouraging recent stuff, one paper I read noted very good interrater reliability for findings of pain and ROM loss, not as good for abnormal movement or activation patterns.
I think this is a good example of how to bring a theoretical classification system into the world of EBM.
I sure hope the videos are easier to understand, b/c her book makes me feel like a moron.
:)
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Hip Impingement Syndrome - April 13, 2005 4:49:00 AM
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SJBird55
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From: Michigan
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I believe I miscommunicated. Shirley uses videos during her sessions. I have no idea if she sells her videos. But from what I saw, the video is better than any picture because she's looking at the movement pattern. The video is worth a thousand words in this particular situation and the picture doesn't even come close in visualizing. Yes, and she does have a lot of stuff that is coming out, which is a good thing too. Again, it helps substantiate her system.
Technically, she needs to incorporate a CD or DVD in teaching her stuff - Whitman, Flynn, wainner and Magel have done that with their information. It is helpful. I'm not really against written material, but there just isn't an easy way to describe what we see in various movement patterns.
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Re: Hip Impingement Syndrome - April 13, 2005 9:03:00 AM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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Nari,
What is XR? Is that a scouring test? If so, it was negative.
SJBird: something else that does not come across in writing is humor ;)
Jason, I actually had someone look at femoral torsion when we were checking for biomechanical faults for orthotic prescription, but I can't remember if I had a torsion on the right. The left hip is anteverted (non-painful side).
I am TFL dominant, it has been sore and tight lately too. The sitting test/exercise is difficult. How long do I hold it? (I keep forgetting to bring the Sahrman book home from work, so I can sit down and read it) My iliopsoas fatigues after about 5 seconds, so it is definitely weak.
Quadruped rocking back pinches in the front of the groin, but I can get past that point and feel a stretch posteriorly.
Sidelying hip abduction has helped, but if I over-do, it flares everything up (tried it many different ways)...any other ideas for retraining abductors?
I have been doing the prone leg extensions over a small swiss ball (45 cm) to start in some flexion and also to add some core training. It has gotten easier. Interesting about the hamstring dominance....when my coworker was manual muscle testing the glute max on Tuesday, the hip "popped" when he applying resistance, it felt like it repositioned itself.
I don't stand swaybacked, but whenever my symptoms flare up, I tend to stand in more lordosis (coworkers have noticed this). Glute max strength is normal. Hip external rotators and abductors are weak, so is hip flexion.
One more questions, can this type of movement impairment aggravate the sciatic nerve, or do you think the sciatic irritation predispose me to the movement impairment (chicken or the egg). The sciatic problems were noticed first.
I am thinking I'd better get to Boston in June......thanks for all the help you guys!
Sarah
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Re: Hip Impingement Syndrome - April 13, 2005 10:16:00 AM
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JLS_PT_OCS
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From: USA
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XR probably refers to Roentgenographic Examination. You know, X-rays. :)
To treat this movement impairment, she describes in her book putting you in quadruped and using abd and er of the hip to allow you to rock further without the pinch. The idea being to rock backward without the femoral anterior glide.
I tell patients to hold the iliopsoas contraction for about 5 seconds, do an eccentric lowering, and repeat 3-5 sets of 8-12 reps.
I would use the "clamshell" exercise in sidelying to train your abd/er muscles without aggravating your TFL.
She makes note that piriformis syndrome is often part of this impairment, and that the piriformis may be short or it may be long to create the symptoms. Weak abductors also force the piriformis to do more rotation when the hip is in flexed positions, which may aggravate that syndrome.
I also found out the true meaning of "Swayback" posture from her book. I always assumed it was anterior pelvic tilt, but it is really the position of the hips forward of the line of gravity. To correct, just move the hips backward slightly, no pelvic tilt required. You will feel awkward at first.
My wife and I both get progressive LBP when standing/walking for long periods, and I had been attempting to correct it using lumbar stabilization and holding neutral position while walking/standing. As well as manipulating her when needed. :) Well, that only lasts until your TrAbd and ExtOb get tired. So, I tried just moving our hips back to get out of the swayback position. Worked like a charm. No more LBP with prolonged standing or walking. My patients love it as well, much simpler and works right away.
So there is a lot be learned for me, here, really opening up a new paradigm of thought.
Now, if I could only understand it all...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Hip Impingement Syndrome - April 13, 2005 11:58:00 AM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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Jason,
I remember when I took Sahrmann's course a few years ago, everything she demonstrated and talked about made perfect sense (and I was still in PT school), but I pick up that book, and I feel like a dunce. I really think it should be rewritten to be more understandable. Or maybe I just can't read (XR = xrays, duh! I thought it was some weird Australian thing ;) )
I understand the swayback posture as Kendall described it, where the line of gravity is posterior to the greater trochanter. I used to stand that way when I was an adolescent, but have since corrected it with ballet and Pilates.
Sahrmann stated in her course that none of her ideas are new, but are all based on the earlier works of Kendall. Interestingly, looking at Kendall's Muscles Testing and Function book, many of the exercises she lists (pg 117 and 118) for correcting muscle imbalances, resemble Pilates exercises. Pilates even has a side leg-lifting series that I use for patients with gluteus medius weakness.
Doesn't the clamshell exercise bias the movement more toward TFL and less gluteus medius (because of the hip flexion + abduction)??
I am enjoying this discussion. Interesting what insights we have when we just get back to the basics.
Sarah
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Re: Hip Impingement Syndrome - April 13, 2005 1:27:00 PM
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nari
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From: Australia
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Sarah
The fascinating thing with techniques is that they return under fancy names - eg Trans Ab was taught as abdominal bracing, and was isolated as a functional contraction (but not proven) in the late 1970s.
I must admit that reading abbreviations on Rehab edge leaves me bewildered too..most of the abbreviations used are quite foreign to me.
Getting back to basics is useful and the old Kendall book is a useful reference to expand on.
Nari
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Re: Hip Impingement Syndrome - April 13, 2005 11:37:00 PM
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Randy Dixon
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Sarah,
You've never had a kid? It sounds like instability to me.
A good way to work on the swayback problem and forward head and other posture that isn't often looked at is to have the person stand on a stair step, place both heels off the edge and lower the heels, like doing a calf stretch. Have them push the heels fairly hard and tighten the thighs and keep them tight. Keep contact with the rail for balance. Make sure they stand up straight and they will line up in "perfect posture".
Most people think they are just doing a calf stretch but what it does is brings the COG where it belongs and forces the body to align itself correctly with it.
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Re: Hip Impingement Syndrome - April 14, 2005 8:42:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Nari,
Are you sure Kendall's book is a good resource? It is entirely unreferenced.
Virtually everything she proposes in there about posture and its supposed relation to muscular strength (and thus, "imbalance") has been shown to be in error.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Hip Impingement Syndrome - April 14, 2005 10:20:00 AM
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JLS_PT_OCS
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I think Barrett makes a good point there.
Sahrmann is quick in her book to admit that there have been few, if any, studies to draw any correlation between posture and pain. In fact, isn't there another book out there called exactly that?
At the same time, I think Sahrmann makes a good case for using Kendall as a reference to isolate and test certain muscles, and uses some extensive basic science research to discuss the differences between muscles that are short, long, or stiff; and how to recognize them and see how they might fit into a patient's treatment plan.
I am opening that book recently for the first time in a long time...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Hip Impingement Syndrome - April 14, 2005 10:50:00 AM
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chunkypuffin
Posts: 7
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From: Wakefield, West Yorkshire, England
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Barret,
you point out that;
"Virtually everything she proposes in there about posture and its supposed relation to muscular strength (and thus, "imbalance") has been shown to be in error."
Whilst studies demonstrate weak correlation between posture and symptoms I would venture to say that clinically improvement in posture often improves patients symptoms.
It is interseting to note that most neuro physio approaches are based upon optimal alignment to gain improvements in function, decrease pain and/or improve stability. Surely this will apply to the person who may not be neurologically impaired but through other factors has changes in their 'optimal' posture/alignment. After all, we understand so little of the whole pain phenomenon that it is hardly surprising that we are unable to develop 'black and white' predictive rules for the perfect posture. Each individuals tolerance is likely to vary and possibly the tolerance of each body segment may vary within an individual.
Just a thought
Yours sincerely
Craig
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Re: Hip Impingement Syndrome - April 14, 2005 11:21:00 AM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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Craig,
I would certainly agree that tolerance is every bit as important as mechanical deformation when it comes to painful movement. I have the sense that tolerance (what I call "adaptive potential") is most closely related to our autonomic state and that this may vary wildly and rapidly. It, however, is unrelated to "alignment" as proposed by Kendall, and neither is strength.
Whatever might be going on internally to account for the painful problems we see (most likely neurogenic in nature), "proper posture" neither predicts nor reveals. If health or painlessness looks like something while the patient is standing, I've yet to figure out what that is, so I pretty much stopped looking long ago. Sahrmann herself agrees that she cannot find a study indicating that posture and pain are related in any way. Still she looks.
I don't get that.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Hip Impingement Syndrome - April 14, 2005 1:50:00 PM
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nari
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From: Australia
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Barrett
Nothing was referenced in the 50s - it was just what seemed OK at the time.
I find it useful to do a quick check on a particular muscle if I can't remember where or what it is... I am not a muscle person by any stretch of the imagination, so I don't do it often, but it fits my simplistic notion of muscle function if the need arises. I am not a believer in strength and posture, only movement and pain.
The importance of a correct posture is so ingrained in PTs that isn't Sahrmann trying to prove one way or the other that there is some correlation between postur and pain??
Maybe not.
Nari
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Re: Hip Impingement Syndrome - April 14, 2005 3:32:00 PM
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Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
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Nari,
Yes, she keeps trying, but after 30 years-no joy.
Maybe it's time to give it up.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Hip Impingement Syndrome - April 14, 2005 5:22:00 PM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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I wondered when you'd jump in Barrett. I know how you feel about Kendall. So, if posture and muscle strength are not related to pain, where does neuromuscular reeducation fit into the picture? This is something that we all do, and bill for, but what is it exactly that we think we are doing? Is it possible that the reason these postural exercises work so well for patients is that it is stimulating self-correction in another way, through external resistance and "neuromuscular re-education"?? Just wondering.
Sarah
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Re: Hip Impingement Syndrome - April 14, 2005 5:26:00 PM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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By the way Randy, no I haven't had any children ( I believe the term is nulliparous), but I am going to attend a Women's Health seminar on pelvic and abdominal dysfunction this weekend. It will be interesting to find out more about the overlooked area of the pelvic floor in these types of problems (chronic low back and hip pain).
Sarah
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Re: Hip Impingement Syndrome - April 14, 2005 6:22:00 PM
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nari
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From: Australia
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Sarah
You are possibly facilitating what would seem to be neuromodulatory influences. Sort of cleaning out some of the messengers'(NMDA and that stuff) junk mail.
I suspect this is how we effect changes in patients, anyway.
Nari
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Re: Hip Impingement Syndrome - April 15, 2005 2:05:00 AM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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Sarah,
I'm not convinced that these postural exercises work especially well. After all, half the therapists I meet have chronically painful problems and they all know about this stuff. What might I conclude?
If movement *does* help, it's either because of the neuromodulating effect (temporary) or the corrective effect on the relevant mechanical deformation. Why else would it?
My contention has been and remains that correction is naturally and therefore instinctively achieved when the essential diagnosis is an abnormal neurodynamic. The resistance to this idea is overwhelming and has reduced my own teaching to little more than an interesting idea-just another "tool" to throw at the problem if pelvic tilts don't "work."
Teaching others about Simple Contact and ideomotor activity is how I make a living, but I'm not currently under the impression that it changes anything for my students.
I'm reminded of something I once read about golf: "Golf can, in fact, be taught. The problem is that it can't be learned."
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Hip Impingement Syndrome - April 15, 2005 2:54:00 AM
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SJBird55
Posts: 2438
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From: Michigan
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LOL Barrett. My 7 year old son LOVES golfing. His movement patterns do look like a little Tiger but with a lot less power. Last year he gave me "lessons." I was supposed to go on a golf outing with the surgeons. He really was like a little golf instructor. Needless to say, I couldn't learn. For the life of me, I just could not mimic the movement pattern he has, the fluidity of it all and the smoothness, nor "scoop the ball" as he patiently described to me. For me, and sometimes I parallel my feelings to how some patients feel, I really didn't care if I hit that ball or not. There is nothing worse for me than having to keep my mouth shut, focus on hitting a little white ball, following the thing with my eyes and starting all over again - with the goal of putting the little sucker in a hole. For me, the relevancy is what?
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Re: Hip Impingement Syndrome - April 15, 2005 5:40:00 AM
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Yogi
Posts: 403
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From: San Antonio, Tx., USA
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SJ, forget about the little hole. Just whack the ball with the stick, it's quite satisfying, relieves frustraions and stress. When I worked on a golf course I used to hit balls I found into the lake when I got home. Seemed the best place for them.
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