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Re: Hip Impingement Syndrome
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Re: Hip Impingement Syndrome - April 21, 2005 6:20:00 PM
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nari
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From: Australia
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Timothy
What 'pain' generator do you have in mind?
And could you explain why the 'normalise function/normalise pain' is flawed?
Just interested in your views.
Nari
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Re: Hip Impingement Syndrome - April 21, 2005 10:21:00 PM
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Randy Dixon
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Barrett,
If I asked my massage therapist, she would say that she released the fascia or improved the flow of cerebral spinal fluid or something like that. We all know that this is bunk, but what I am trying to understand is how did it work?? The only viable theory that I've heard to explain it is yours.-Sara
First, I'm not sure I would agree with you that the reasoning given by the MT would be "bunk". Second, I'm sure you're familiar with GAS, global adaptation syndrome, I believe. In short, you have a bunch of stressors, these stressors cause facilitation or sensitization of the nervous system until a "breaking point" is reached, at this point physical problems you were able to deal are no longer being dealt with and you have pain/altered mechanics, histology etc.. Massage has an autonomic effect and a psychological effect which reduces the stressors and you are now able to deal, adapt, with the hip problems better.
I think this is a possible explanation, and I think Barrett would agree that explains some of his approach. Many models use this approach besides Barrett's though. Where his is unique, as far as I can tell, is the ideomotor component, which I don't think is required in the explanation above.
On the other hand, you said "I didn't move", I can't imagine recieving a massage and not moving at least subtly, and if it is unconsciously, well, you wouldn't be conscious of it. The body is really great at working on achieving homeostasis, it doesn't seem unlikely this ability would extend to our neuromuscoskeletal system. (that's not really a word, is it?)
Homeostasis, Chaos and Order and the perfect path down the middle, Solitons. See how nicely they all metaphorically fit together. I'm a simple guy, I like my metaphors really easy.
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Re: Hip Impingement Syndrome - April 21, 2005 10:24:00 PM
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Timothy
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I think imaging is important as part of the whole clinical picture. I don't think people should be sent off for MRI without a clinical examination. Jason, I can see that there are flaws in my argument-but I feel that, in chronic conditions such as this one, you need to gather all the information you can. I'm not particularly knowledgeable about the things that might come up in imaging the hip-so this is more of a generic argument.
In my opinion, the whole area of diagnosing musculoskeletal pain problems (aside from things like fractures...) is a massive grey area and I wish that the profession was more open to that (I don't know what it's like in the states, but in Australia I feel that therapists are overly confident in their diagnosis).
As for the normalise function/normalise pain approach, I feel that this is a helpful but limited model. Pain and function feed off each other, like a circular argument! A normalise pain/normalise function approach would be equally as appropriate, I feel. For example, someone may have a loose body in their knee that is causing them symptoms-I imagine there would be a raft of neuromuscular changes that would accompany this. They may, however, have no symptoms after having the loose body removed-no amount of muscle work will do this...
Mmmmm can of worms anyone...
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Re: Hip Impingement Syndrome - April 22, 2005 4:07:00 AM
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JLS_PT_OCS
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Good points, Tim.
I agree that we need both the pathoanatomical approach to diagnosis, and other models such as neuromuscular patterns, or any number of other paradigms of thought.
I think our strength as a profession is our willingess to look outside the pathoanatomic diagnosis box in finding solutions to problems, something it seems our colleagues in medicine aren't trained to do.
While the pathoanatomical model has demonstrated good success in many areas, in many others it leaves much to be desired, and in some, such as spinal pain, is almost worthless. I would think anyone looking at the human body and attempting to treat it would be able to use several different windows or paradigms of thought in their approach, I just don't see too many people other than us PTs doing that.
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 22, 2005 8:42:00 AM
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srcase
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From: Michigan
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Jason,
Maybe other professions don't look outside the box because there is no deep model for doing so. We all know how much lack of evidence there is in our profession, so we have less of a foundation to stand on, not more. I agree that ecclecticism (is that a word) in PT can be a strength, but I personally struggle with integrating all these different paradigms into one cohesive theory, and wish things were more clear cut. Of course, when dealing with the human body, complexity is the norm.
Randy,
I take back that statement about not moving. The more I think back on it, the more I realize I most likely was moving (I was breathing of course), just not consciously. There is a big difference. So, I understand how the massage may have contibuted to a heightened adaptive potential in my system.
Now, the difficult part is going to be explaining this experience, and the ones leading up to it (which have been discussed here) to my primary doctor when I see her today and she asks "How is your hip?", without sounding like a complete nut-case. (She may already think I am one). I don't think she likes PT's.
Sarah
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Re: Hip Impingement Syndrome - April 22, 2005 11:41:00 AM
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srcase
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From: Michigan
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I just have to post this story: I was at my doctor's office today (PCP) and a older male nurse was checking my vitals. He asked why I wanted to see the doctor, and I said it was a followup visits because I had PT on my hip. He started talking about his experience in PT and how it was less than ideal (big fancy place, impressive Swedish accent, but no history, no exam, just T-band exercises and backward treadmill walking for trochanteric bursitis, no manual PT), he only went for 2 days and joined an aquatic program at his local high school and is now painfree. He then asked what I did for a living......and got very red in the face. But I assured him that he did the right thing in quitting PT because he was obviously receiving "suboptimal" care (our favorite phrase). Then he told me about his wife going to PT at a different place for Colles fracture, and they actually had her doing her own ultrasound!! And we wonder why our profession is not taken seriously.
Sarah
P.S. The doctor was very pleasant and interested in my hip adventures, including the pelvic floor bit. She asked if I might be specializing anytime soon. Hmmmm.
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Re: Hip Impingement Syndrome - February 28, 2006 8:38:00 AM
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srcase
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From: Michigan
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My hip adventures have come full circle, so I wanted to update you all. I finally got fed up enough with my hip pain to go to an orthopedic surgeon yesterday. He did the history and physical exam and within 5 minutes stated that it is probably a labral tear, which I had been suspecting. Preliminary xrays showed a possible tear on the anterior/superior aspect with a possible "cyst". He ordered an MRI with contrast to confirm, which will be in three days.
The bad news is that there isn't a lot that can be done according to the surgeon. Hip arthroscopy is only successful 30% of the time, and PT hasn't helped (I've had it twice and I'm worse now than ever). I'm not a candidate for hip arthrotomy (of course) and have no arthritis in the joint....not yet anyway, because I'm still young.
I have a follow-up visit after the MRI, but I'm concerned that I won't be able to return to golf, dance, and other recreational activities including any type of cardio exercise. I am going to diligently try a Sahrmann muscle imbalance approach as stated by Jason and Erica above, but I'm not extremely hopeful.
And lastly, there was an interesting update on acetabular labral tears in PT Journal last month by Sahrmann and others. It basically stated that we don't know much about how to treat this condition in PT. I think I may have a new research topic for my DSc degree..........
Thoughts????
Sarah
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Re: Hip Impingement Syndrome - February 28, 2006 10:21:00 AM
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JLS_PT_OCS
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Sarah-
Good luck.
I have not had great success in treating hip pain of this type with any technique, Sahrmann or otherwise.
I do know of a PT in Pittsburgh PA named RobRoy Martin PT, PhD who does a lot of research on surgical and nonsurgical rehab of this problem. Perhaps if you could contact him, he might be of some help?
Good luck....
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 - February 28, 2006 12:26:00 PM
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dosrinc
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From: Bonita Springs
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Sarah C.,
I had a pt with all of the symptoms you describe and beat my head against a wall trying to treat her in each and all of the ways described above, her doc thought all of her pain was from DDD observed throughout the lumbar spine but I knew something was going on with the hip because we had been able to resolve all other DDD related symptoms in her back and other parts of her leg, finally sent her to a doc in Miami who I knew did labral repairs, he finally ordered an MRI of her hip and she had a cyst the size of a golfball on the anterior capsule. Just a thought.
Rick
PS, he removed the cyst arthroscopically and she did great for about 3 months, then it came back again., confirmed by a repeat MRI
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Re: Hip Impingement Syndrome - February 28, 2006 12:29:00 PM
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dosrinc
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From: Bonita Springs
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Sarah,
I actually posted above before I read your last post, I can get you the name of the doc in Miami if you are interested, at least for a second opinion if MRI confirms cyst vs. labral tear.
Good Luck
Rick
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Re: Hip Impingement Syndrome - February 28, 2006 3:56:00 PM
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srcase
Posts: 551
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From: Michigan
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Thanks guys. This isn't cheering me up very much though. I will let you know what the MRI shows.
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Re: Hip Impingement Syndrome - February 28, 2006 3:57:00 PM
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FLAOrthoPT
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From: West Palm Beach
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arthroscopic hip surgery big time at cleveland clinic and in boston I have heard.
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Re: Hip Impingement Syndrome - March 1, 2006 4:17:00 PM
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eam
Posts: 289
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From: New York, NY 10028
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Hi Sarah-
Here is a thought-go see Shirley Sahrmann herself in St. Louis (I have the email of one of her colleagues from the APTA meeting) and see what she has to say. When she spoke at the meeting-the hip is one of her "babies" as they say. I think you are sort of close geographically. It would be a good learning experience to say the least! Please keep us posted!
All the best,
Erica
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Re: Hip Impingement Syndrome - April 1, 2006 4:41:00 PM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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Update:
I have been doing the Shirley Sahrmann exercises and it seems to keep the severe tightness and discomfort at bay. My MRI results showed a partial tear/detachment of the anterior-superior labrum. No cyst, bony anomalies or cartilage damage.
Has anyone treated this pre or postsurgically?? Any suggestions are welcome!
Sarah
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Re: Hip Impingement Syndrome - April 2, 2006 6:09:00 AM
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rwillcott
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From: Canada
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I would continue with the Sahrmann exercises as described earlier. I would put an emphasis on iliopsoas retraining in a shortened range. Also gluteus medius in sidelying being sure that TFL is not dominating. Work glut max in prone with the knee bent to ensure your hamstrings are dominating since they will cause an anterior glide. Finally, I would perform self posterior hip mobs in the quadruped position as described earlier.
Rob
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Re: Hip Impingement Syndrome - April 2, 2006 6:12:00 AM
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rwillcott
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From: Canada
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Correction: in prone make sure your glut max is firing before your hamstring since the hamstring will cause an anterior glide of the hip
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Re: Hip Impingement Syndrome - April 2, 2006 7:09:00 AM
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JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
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Sarah-
While I understand Sahrmann's point about the hip, and I would echo Rob's advice, I will tell you I have not had good success with that treatment plan.
Even for members of my own family...
I am glad you are feeling better, though, and hope that with time, it will sort itself out!
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 4, 2006 5:48:00 PM
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eam
Posts: 289
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From: New York, NY 10028
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Hi Sarah-
I also would echo the above advice-especially the 4 pt kneeling into sit back exercise-with the modified ER of the hip (ala Sahrmann). I have had a fair degree of success pre-op with labral tears. They are tough as everyone is different but have you tried some of the closed chain exercises short range of motion -glut med, max exercises with a t-band. Standing on one leg with t-band wrapped around both ankles and performing hip abd with the contra. LE and also glut max with knee flexed in same position-but really limited range of motion (like beg to mid range).
If you can manage this way-I would continue. I have not seen much success post op. By the way, was your MRI with or without contrast? Just curious?
Erica
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Re: Hip Impingement Syndrome - April 5, 2006 9:38:00 AM
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srcase
Posts: 551
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From: Michigan
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Thanks guys. I re-read this entire thread and it is a good discussion overall. I seem to have come full circle, which is interesting although a bit frustrating too. I appreciate all the input and will let you know of any new developments.
Erica, the MRI was an arthrogram (with dye injected into the joint). Not a pleasant procedure. As for the standing exercises, that is how I flared it up this most recent time, so I'm avoiding any resisted movements at the moment and just working on Sahrmann muscle re-ed/balancing exercises. But it's a good idea for progression.
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Re: Hip Impingement Syndrome - April 6, 2006 3:39:00 AM
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Shill
Posts: 1052
Joined: February 13, 2003
From: Madison WI USA
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Sarah,
Do you have the bony projections on your femoral head/neck that can lead to impingement? Your films should show these. If so, its a structural issue which will be tough to get rid of with conservative care, though if it were my hip, I would strengthen my hip stabilizers ad nauseum. Im not so sure that surgery is such a hot option either.
Heres a reference,
Skeletal Radiol (2005) 34: 691–701
DOI 10.1007/s00256-005-0932-9 REVIEW ARTICLE
Imaging findings of femoroacetabular
impingement syndrome.
Douglas P. Beall
Clifford F. Sweet
Hal D. Martin
Craig L. Lastine
David E. Grayson
Justin Q. Ly
Jon R. Fish
Good Luck,
Steve
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Steve Hill PT
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