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sij dysfunction/ achilles tendinosis
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sij dysfunction/ achilles tendinosis - December 11, 2005 12:48:00 PM
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ginger
Posts: 647
Joined: February 26, 2005
From: Melbourne Victoria
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sharing my observations and regimen for fixing one case of achilles pain.
A 45 year old woman, fit strong , plays regular basket ball b grade.72 kilos 167 cms.
Complained of occasions of R foot pain in longitudinal arch area, as well as periods of achilles pain, recent period of three weeks. Had stopped playing due to achilles pain.
OBS.
SIJ movements nil L equals R ( observed with 'stork' test)
Hypomobile R>L L5 S1 facet joint, some palpable tenderness at L4 and to a lesser extent L3.
Flexibility good to very good, hams, calves, quads.
Not complaining of low back pain, or other problems.
Slightly pronated R>L feet, observed standing, with similar loss of neutral foot postures when walking.
Rx.
1. Mobilise L5S1, firm pressure 10 minutes, L4 and L3 R and L.
2.Mobilise SIJ, Foot placed over patients sacrum lying in prone with small pillow under pelvis. Therapists body weight ( 80 kgs) applied to sacrum with 30 seconds by two mobs.
Reassess to confirm full SIJ mobility restored.
Reassess after 3 days. Patient reports considerably less Achilles difficulty, played with little discomfort, now able to run.
repeat step one treatment.
Reassess after 3 more days. No pain , good SIJ movements, , no treatment required.
Referral for orthotics provided. No further Rx anticipated.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: sij dysfunction/ achilles tendinosis - December 11, 2005 2:52:00 PM
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Barrett
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From: Cuyahoga Falls, Ohio
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You stood on her?
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http://barrettdorko.com
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Re: sij dysfunction/ achilles tendinosis - December 11, 2005 3:00:00 PM
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ginger
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From: Melbourne Victoria
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stood on her, then mobilised with bodyweight. I know of two other usefull means to restore SIJ function , but the one described is by far the quickest and most reliable.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: sij dysfunction/ achilles tendinosis - December 11, 2005 6:12:00 PM
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nari
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From: Australia
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Ouch!
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 1:21:00 AM
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Jon Newman
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From: Amherst, WI
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Didn't I see that technique in the movie Geisha?
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 2:52:00 AM
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FLAOrthoPT
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From: West Palm Beach
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lol
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 3:35:00 AM
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JLS_PT_OCS
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Ginger-
I think you should write this up as a case report for a journal.
It might be a good way to get your ideas out to the general public.
Especially the standing mobilization, I would like to see that one.
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: sij dysfunction/ achilles tendinosis - December 12, 2005 4:36:00 AM
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johngoodrich
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To Jon and Nari, I wonder if there is a more helpful response in there; I don't want to misinterpret the sarcasm. Seems to me that while one may argue the merits or concerns of a technique, this is a reasonably thought out evaluation and treatment process, and is also reasonably consistent with EBP principles. Thanks.
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 5:27:00 AM
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Jon Newman
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From: Amherst, WI
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Standing on someone is reasonably thought out? How did he know to use 80Kg? Am I to assume that I therefore need to hold a certain amount of weight in my arms so that I weigh 80Kg if treating a similar person? Is 80Kg the appropriate amount for a 50 Kg woman? Why the foot and not some other method? What if they are 72 Kg but a body mass index of >25? Ok that would be unlikely but you might get the point. What are the theoretical underpinnings or evidence that lead one to stand on their patients?
I thought I could convey my thoughts about the unconventionality of the technique with my reference to Geisha, the only other profession I could think of that is known for such a technique to relieve pain.
Still, you are correct that we can do without sarcasm. I'm trying but old habits are hard to break.
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 5:41:00 AM
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Bournephysio
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"reasonably consistent with EBP principles."
????
No established validity of the "stork" test.
No established validity of assessing mobility of a singles spinal unit let alone one facet.
Unknown efficacy and safety of mobilizing the SIJ with 780N of force.
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 6:40:00 AM
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johngoodrich
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That's better. And points are well taken. While I'm not considering standing on someone's sacrum,she did determine that the lumbopelvic region was hypomobile, addressing it made a difference, and she was able to release the patient after 3 visits. Compared to some of the other anecdotes I've seen here, this one intrigues me more, at least in principle. The specific points raised by bourne can at least be discussed in the context of a common language (it was not necessary to identify specific segments,the stork test is not specific nor valid, other manual treatments might have been selected -- although she did comment on this, etc.). Studies have shown that manual therapy of the cervico-throcic region can be effective in the treatment of lateral epicondylitis. We may not fully grasp the mechanism of this response, when it occurs, but at least it makes sense, and I can use it.
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 6:43:00 AM
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Shill
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From: Madison WI USA
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How do you propose that the orthoses will help her facets?
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 8:16:00 AM
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nari
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From: Australia
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I said 'ouch' because I have been mobilised via bodyweight (years ago) and it is not a nice procedure to tolerate. It does work, but the ethics seem a little odd to me with regard to safety issues.
Mobilisation of the cervical region for lat.epicondylitis has been done for years; it works sometimes and not other times, but is worth trying.
Sacral mobility/immobility determination is controversial, and most don't accept that the sacrum 'moves', as far as I am aware.
jwg - Ginger is not a 'she'.
Nari
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 9:20:00 AM
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johngoodrich
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Sorry, ginger. To me it is one thing to say something is worth trying because it works sometimes, and entirely another to say something is worth trying based on the evidence and my clinical exam. The issue of sacral mobility is beside the point (I only addressed it from the standpoint that the Gaeslen and POSH tests have been shown to have some validity, but the Stork test does not, and to acknowledge bourne's point; beyond that I'm not particularly interested in the issue). There is plenty here to take on in terms of ginger's approach to this case. But I wonder if there would be a difference in the dialogue if we were to break this case down to a more basic level and use as a starting point a question, for example, can manual therapy of the lumbopelvic region be effective in the management of so-called achilles tendonopathies? I'm new to this blog, and I'm still getting familiar with the process. But I suggest again that there is a great deal here that is not helpful. Shill's question is a case in point; questioning the use of orthotics, particularly after a successful response to treatment, is fair, but ginger didn't mention using them to treat facets.
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 9:31:00 AM
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FLAOrthoPT
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From: West Palm Beach
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I would say that it is always tough to know whether the floor works up or the pelvic works down, but either way we need to look up and down the whole chain, proximal and distal parts to effectively diagnose and treat. Much the same way that a pure carpal tunnel release may never help a patient but treating their neck alone may not help either. I would absolutely believe that anything that effected the ground reaction forces, such as a longer leg, or rotated leg, etc, will change the foot biomechanics and also change the forces ont he tendons. So, yes, a rotated or hypomobile, etc pelvic could absolutely cause an achilles tendonitis, as could a limp from knee pain, etc. So, no, I do not think anyone is thinking this is a quirky idea, that pelvic mechanics could cause distal dysfunctions, but the whole standing on a patient thing seems a bit odd, I think that is what most people are getting at. Hope that clears up the sarcasm..
Ben
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 10:29:00 AM
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JLS_PT_OCS
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From: USA
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JWG-
If you think Shill's question off, you've not read enough of Geoff/ginger's posts.
His very contention (correct me if i'm wrong ginger) is that most common extremity musculoskeletal problems are referred pain from protective reactions at the facet joints. Therefore, for ginger's professed paradigm of care, Shill's question is actually perfectly suited.
To link these things causally (as i believe Ben is trying to do) is a bit trickier, especially when there are established methods for treating both achilles tendonopathy and plantar fasciitis which have rather good results, and don't address the spine directly at all. I think that the idea that the causitive factor in these two problems is a lumbopelvic motion problem is very interesting.
I would be interested if anyone could put together a reasonable case as to how those two things are related. I'm not saying they aren't, but perhaps I'm not getting my mind around it just yet.
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: sij dysfunction/ achilles tendinosis - December 12, 2005 12:17:00 PM
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johngoodrich
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Jason, you're right; I hadn't even read enough to know ginger is a he. And if that (his contention that most extremity dysfunctions are referred)is the case, it does change the context significantly. And Shill, if I was out of line, I apologize to you, too. I'm glad to know everybody knows everybody. I just didn't find the direction of the conversation particularly enlightening and wanted to change the focus and tone; that didn't work very well either. To me your comments regarding causality represent the heart of the matter and would be a more helpful line of dialogue, especially since there are (as noted)some studies out there. But that's just me.
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 12:54:00 PM
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FLAOrthoPT
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Joined: May 8, 2004
From: West Palm Beach
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put these two together? sure very easy-
hypothetically/theoretically-
you have a FRS L L5. L5 and sacrum have antagonistic mechanics, that is L5 acts opposite Sacrum. Therefore in essence sacrum is stuck in extension on the right base. Now lets say that is accompanied with a right posterior rotated ilium and if you want to leave osteokinematics out, lets say you have facilitated QL but one way or another that limb is functionally shortened. A person with a functionally shortened limb HAS to change their gait mechanics to walk, one way is through supinating the affected leg to essentially functionally make it longer, or pronating the opposite foot, changing how much knee flexion, how much hip extension, changing how much rotation of the ipsilateral and contralateral hip. But can you not see how we can alter the mechanics at the foot either through rotations, pronations, supinations, and at the knee and hip all from a L5 dysfunction. Now, of course I would NEVER say that all achilles or perroneal tendonitis are related to an L5 dysfunction, but can you see how it is essential to look atthe whole chain with every lower extremity non-traumatic dysfunction. So to say that the achilles can be functionally shortened which can place strain, or functionally lengthened which could put strain and to the see how this can cause overuse strains is no leap of faith. This is the level of thought that m akes us way more qualified than ATC, PTA, or even ortho surgeons to evaluate and treat non surgical patients. Ok-
gotta go-
Ben
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 1:02:00 PM
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jma
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From: NY
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Standing on someone's back? Reminds me of, "The Jeffersons".
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Re: sij dysfunction/ achilles tendinosis - December 12, 2005 1:06:00 PM
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Jon Newman
Posts: 1697
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From: Amherst, WI
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We're moving on up!
[URL=http://www.classictvhits.com/shows/sounds/thejeffersons.wav]wav file[/URL]
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