Joined: November 15, 2003
The PKB test is very useful for femoral nerve dysfunction. I have turned it into a treatment of about 10 seconds, just touching the 'ping' of the femoral n tension and backing off, 3-5 times. There has been good response painwise from this method; and the patient can do it themselves. As with any neurodynamics, it must be gently done, with no sustained movement at all. No stretches.
It has also resolved vague inguinal pain; this may be how the prone extension works as well, although that is just a guesstimate. Should send some good messages to the brain....
PS There will be pelvic rotation to some degree - teach the patient to control that a bit.
Joined: April 20, 2005
Pain is only present after standing and the patient is a substitute teacher 3-4 days/week. We discussed sitting with trunk flexion, R rot, and R SB, which is the complete opposite of the provoking position.
Regarding the positional stuff during last session: Patient presents with no pain; lying prone is pain free; 5 reps of prone extension induced L groin pain, cessation of the stopped the pain; prone extension with L SB and L Rot immediately induced L groin pain, and return to neutral prone alleviated symptoms; prone extension with R SB and R Rot did not produce any symptoms. All of these movements produced the exact same results in sitting (i.e., passive lumbar ext, L rot, L SB).
Diane and Nari- Thanks; I'll try the PKB test Thursday, now that I know what it is.
Well I'm new to this whole forum thing but reading your info, have you checked psoas and also quite possibly, when was the last time his prostate was checked? Pubovescicle ligamnets can reproduce that type of pain where a myofascial component might need to be addressed. Any history of prostate or bladder problems? Good luck.
Joined: February 14, 2003
From: Madison WI USA
JS, Now I see the symptom presentation more clearly. Sounds like unloading may achieve some relief in and of itself, regardless of what he does when he unloads the spine/hip. For the sake of convenience, to increase the liklihood of him doing it, he could simply sit prior to the onset of sx, if this relieves pain. Beat the pain to the punch so to speak. Current standing tolerance is two hours, he sits just prior to this, and the irritation is not enough to stimulate nociception. If sitting relieves it, and the relief lasts for another 1-2 hours, then telling him not to stand for so long will undoubtedly help. It takes whatever mechanical strain off the injured tissue just prior to perpetuation of the pain. This falls into the "well, duh" category, but certainly is a means by which he can get through his day with less irritation. I explain to the patients that they cant plow through each day allowing the pain to build, (prolonged standing) and expect to improve, when something so simple (unloading, or perhaps even just sitting down in his case) can reduce the pain consistently. Can it allow him to heal? Sure, its just stressing the healing tissue up to, but not beyond its current tolerance. His keeping track of standing tolerance will allow him to note improvement or lack thereof.
Anyway, good luck, sounds like he is doing fairly well already, given that standing is the only painful activity.
[QUOTE]His only complaint is of groin pain near the pubic symphysis and along the L inguinal ligament. [/QUOTE]Is that really all? I'd lay him on his back with a bolster under the knees, bring his cranky leg up into flexion, rest his foot up on the bolster, let his knee drop out against me, palpate the adductor up to the ramus, find the crankiest spot I could, then with the other set of fingers, about an inch distal, pull the skin away from that spot. Crankiness disappears like it was never there. It's counterstrain, applied to the superfical cutaneous nerves through the skin. Hold for a few minutes, slowly let go. Repeat laterally as necessary.. there's a whole slew of cutaneous nerves along that inguinal ligament, having to poke through it, easily trapped by it. Same technique but leg can go back onto the bolster for the rest.
Is he able to get into 4-point kneeling? If so he could do some hip unloading/loading different parts as per Sarhmann, some deep breathing and ab stretches/contractions, side to side wagging, pelvic floor disengagement from deep abs, all kinds of good stuff to change kinesthetic input/unsmudge his homunculi. Usually older guys have stiff ankles just from never using them to anything like capacity - not very good for neural slide-ability. Movement work in various positions will feed the nerves on their various sides at the local levels (ankles, knees, hips, pelvis). Those quads (and all the nerves flowing through them) likely need eccentric lengthening; again, nerves will be refreshed in their tunnels if the tunnels slide along/over them once in awhile. (They probably think that hips flexed 90 degrees is normal by now.. )
Getting the guy prone on a plinth (little towel roll or something under both hips) with his leg off the edge, knee extended, leg pressed gently around the edge of the plinth (use some padding under inner thigh) will stretch out the posterior hip easily and comfortably for him, let some circulation into all the various butt muscles/nerves.. distract the hip out of the acetabulum a nanometer or so.
Joined: April 20, 2005
Update on the patient for this case:
He returns from a 3 week vacation reporting less groin pain, which he attributes to less time spent on his feet. He taught 8 hours yesterday without noticing the pain.
Palpation to the L side of the pubic symphysis increased pain, as did prone extension and L SB and rotation.
It just dawned on me that symptoms may be coming from the attachment of the L rectus abdominus to the pubic symphysis, since stressing that structure did reproduce pain. I didn't think of this until after he left, of course, so I will investigate further on Thursday.