Joined: July 29, 1999
From: Cuyahoga Falls, Ohio
Do you really think that all these changes are even remotely predictable given the complexity of the body? Aren't there movable parts aside from the joints?
This litany of possible changes sounds impressive, but I know of no evidence indicating it ever actually happens. This is speculation only.
Why would an "itis" change with the kind of speed indicated by the original post? Wouldn't it make more sense to assume we were dealing with a mechanical deformation? I think the "pedipulator" (just made that up but it seems appropriate) got lucky.
Joined: May 9, 2004
From: West Palm Beach
Barret I agree with you 100%. I still wanted to point out how the pelvis could influence the achilles, but my post was 100% mechanical/biomechanical in nature. For this specific incident, the pedipulator must have been addressing some nerve compression or irritation issues in the sacral plexus most likely. By stepping to high like on L3-5 it would have cause side flexion and extension which would close around the nerve and chances are this would make any radiated pain to the achilles worse, but stepping right on the ilium or sacrum could I guess cause a slackening of either anterior or posterior fibers of the SI thick connective tissue matrox which could reduce any ischemic conditions or nerve irritation/stretching grinding/flossing that may have been going on just long enough for some good blood to get in there and clear some issues up. So, I would say that if the patient really did get better that quick it was either because they were sick of someone standing on them and just said mercy, or they were having pain in the achilles not related to the muscle as Barrett is suggesting but more because of nerve type pain mediated centrally. I guess a better eval would have told us with isometric testing etc, if the pain was truly an itis or not. So, I would say this was one of those cases where we as therapists got the patient better by mistake. Go figure- Ben Galin, MPT, OCS
Joined: February 27, 2005
Phew, arrived late with not enough time to fully evaluate and respond appropriately to those who have responded. Thank you all for taking an interest. Jon , your sarcasm is just as welcome as any of your other treats. Nari, cervical mobs work for me every time with"lateraL epicondylitis", you must be doing it wrong. Shill. Orthotics are a means to normalise the forces that create SIJ dysfunction in those who pronate, thus leading to a normalised bio mechanical picture . In so doing I am able to complete a treatment process leading to my redundancy as far as a chronic spinal pain picture is concerned. Bournephysio. The stork test is in my view the only valid test of SIJ function. We are talking about a massive pair of joints that have a biomechanical purpose, any test that fails to assert this pair of joints FUNCTION will be useless.The stork does this with accuracy and repeatable and easily observable value. Jason vegetus Silvertail, I can't help having a bit of a laugh when I read your responses Jason , forgive me. You are as difficult to take seriously as it appears you find me. More when able
Joined: February 27, 2005
And just quickly, Flaorthopt, your piece of cause/effect reminds me of many of my students attempts to see every problem as a complex array of interposing elements where relationships between each is as complex as can be. The trap for any eager mind , clearly ready and able to put their considerable intellect to use , is to believe that all problems that appear complex, are complex. Occams razor needs to be taken to your ideas of massive over complexity. Its easy really. Not to put forward any suggestion that your views or notions of cause /effect are without value, just exhausting and in my view, unnecessary. Love your work.
Joined: December 1, 2004
jwg, Welcome to the forums, and thank you for pointing our that our posts should be understandable to the newer members, and not full of inside jokes and inuendo/sarcasm. I hope you were not put off by our casual style here, and that you will contribute more in the future. Your posts are very thoughtful and you bring up good questions. As for referred pain patterns, I don't think anyone is denying that pain in the Achilles area can be referred from proximal structures in the lumbopelvic region. They are questioning the assumption that an exact structure is referring the pain. I don't think one can prove that it is a facet joint, or sacroiliac joint, or L5 disc or whatever. There needs to be a lot more research in this area. Ginger, maybe your evaluation included more than you wrote up here, but I would be curious about subjective history, pre and post measurements for neurodynamics, myotomal tests, and reflexes to begin with. I usually try not to rely on just one test (stork test) to make a diagnosis. Motion-palpation techniques are not reliable, and palpation of tenderness can also be misleading. (Did you palpate her Achilles to see if that was tender??) Your results are intriguing however....three visits and she is painfree and running. Do you give her a home program? Where did you come up with the standing on the sacrum technique and do you use this on any other areas?? Lastly, if I followed your plan of care in the U.S. for a diagnosis of Achilles tendonitis, the insurance company would probably not reimburse because I didn't treat the prescribed body part (ankle), not that there's anything wrong with that. Just some food for thought. Gotta love you Aussies! Sarah
Joined: February 27, 2005
Hi Sarah, I don't do neurodynamic testing, (whatever that is )Stork test is invariably indicating poor or nil movements of SIJ when pronated feet are in the mix, as was so with this woman. Nil function in fact , restored to full function immediately post body weight mobs.
Her achilles was palpably tender around the calcaneum to 3 inches proximal in the achilles tendon and surrounding sheath. This tenderness was reduced by 60 percent or so immediately post treatment. As is almost always the case .Followed by a resolution of that tenderness and the pain associated with calf/achilles stretch after 24 hours. This case is typical of my approach , and the results also typical of those with achilles tendinosis. My practice deals with about 200 cases like this a year. Results are very similar. Why anyone would treat the achilles tendon without first dealing with the very likely prospect of referred events is beyond me.
Joined: November 15, 2003
ginger, all I can say is:
I doubt if anyone would treat the 'tendon' first off without testing other structures...would they? Testing would include neurodynamic tests, and the other stuff as indicated: Joe Blow's sacral test, hyper/hypomobility of the inner third of the transverse process, Fred's test of movement in the 49th facet joint...pardon the sarcasm, but an awful lot of assumptions are being made here!
Unless you can prove beyond all reasonable doubt what actually occurs that makes a person feel better and look better, there is no room for dogma; and assigning improvement solely to what you have physically done is not satisfactory.
I may well have been doing the mobs wrong - I'm not perfection personified. I'm sure I have done lots of things wrongly, but perfection is in the eyes of the beholder. :p
Joined: May 9, 2004
From: West Palm Beach
ok, Ginger, i will bite. During your eval, did you find any resisted isometrics painful in any part of the range, in an active or passive disadvantage position, at mid range, was it more painful with more contraction force, was it painful throughout, was it painful only with eccentric loading? What I am getting at is was there anything to actually rule out muscular pathology before jumping to the spine?
Like I said, you may be winning by mistake here. For example, I may think that pink water balloons thrown at fires help put them out, and be convinced it's because the balloons are pink, but not even realize it is because of the water inside.
To be more apropos, you admittingly are ignoring neural testing, that is, the possibility that neural impingement/irritation somewhere along the path, not necessarily at the spinal foramen, could be the underlying factor here. And that by you in your head mobilizing her SI joint is helping, you may really be helping by reducing neuralfascial impingement and improving longitudinal neural mobility and thereby reducing her nerve irritation symptoms. That is, your pink ballon of the SI joint was coincidentally there when the sacral plexus got some relief with the water of the neural mobs. Your treatment is not so much in question, which it is to some, but so much your rationale for her pain and the corresponding rationale for what and why you did what you did.
I am sure you are an amazing clinician, but I feel like you exude this aura of unwillingness to adapt and change to new ideas. I shutter to think how I used to treat patients back in the day, and am sure I will chuckle about how I treat patients now compared to my beliefs five years from now. Maybe your treatments are effective, but if they are working for a reason other than you think, wouldn't you want someone to open your eyes to that? I think that is one thing that rubs some people the wrong way, just that you seem to think you are on a plane of no more to learn. I think this is a dangerous pedastal to be on.
The world of neural dynamics is not responsible for every painful dysfunction, but wow does it play a major role in a good majority. I think that by simply ignoring this you may still get patients better, but not on purpose. Shouler pulley's for a painful shoulder may help to break up scar adhesions, improve muscle tensibility, but maybe it is helping because it is reducing neural impingement in the brachial plexus and for the fleeting moments the patient has their arm abducted over shoulder height they are reducing the strain on the nerve. Similar to the person who naturally holds their hand behind their head with their elbow and arm in the air, probably a body's known protection or relief for the neural stretch.
I think I making sense here, but I am sure this is erudite and long winded. I just want to try to open your eyes to the world of neurodynamics. While I do not post on Barrett;s forum nor do I even understand what he or Nari or some of the others talk about sometimes, I know that it is not to be dismissed and I know that it is as real a treatment option as a bike may be for knee problems. To simply be ignorantly blissful is not what will push our ptofession forward, to be confident in what you know is very nice, but to acknowledge what you do not know is even better.
Just be open to the ideas that your treatment techniques may be working for reasons other than you believe, and be open to the ideas that many of our treatments may work for reasons beyond what we think. Have a wonderful day, I still look forward to your approach and techniques, just want to try to let you see it from another perspective. Love these fierce conversations- Ben Galin, MPT, OCS
Joined: February 27, 2005
Oh dear Nari, you musn't think me a stinker because I'm abrupt , think me an unwilling participant in long winded beatings of the bush when a few words will do. I bear you or your methods absolutely nothing but respect, I've gone a long way to opening up my mind to your methods, and like you , am definitely on a path to further learning. I do most honestly apologise for the hurt if I've offered this inadvertantly.
Ben , seems I've been winning by mistake for a very long time. Seems to me you could make as many and your patients will love you for it. (LOL)
Joined: November 15, 2003
Quote:.."think me an unwilling participant in long winded beatings of the bush when a few words will do."
Couldn't agree more. Musculoskeletal topics are very long winded beatings of the bush, in general. That's why neurodynamics can solve issues, very simply, without digging deeply in search of numerous recalcitrant structures.
I'm not in the least hurt - why should I be? I just unsheath claws occasionally.
I am very pleased to read that you are considering looking into the world of the CNS, etc. I can also recommend David Butler and Lorimer Moseley's text "Explain Pain".....
My achilles tendinosis patients are the wrong ones! They get better with completely different treatment - mostly education..... Now, of course, when the diagnosis is not REALLY "achilles tendinosis", the story changes. Fibular nerve entrapments affecting the lower leg muscle control, occult lumbar radiculopathy, subtalar joint dysfunction, sural nerve problems etc etc. Yes, here we need to treat "away" from the tendon. Ginger, you have not indicated you followed up after 4 and 8 weeks to see if everything is still fine. Any hands-on (or "foot-on") treatment has an effect on patients - even if it results in: 'I'm going to say I am better, so he won't stand on my poor behind again..." - and the effect of a technique should be seen with that aspect in mind.
Well, I'm awaiting the published outcome studies from Ginger. With a complete resolution of every single -itis case with a few simple mobilizations and standing on people's butt's he is going to be world famous.
Joined: January 31, 2005
Randy, he already is. He has 200 patients every year with achilles tendonosis fixed with the foot on the butt technique? That would be a great case series...oh, wait, what am I doing talking about evidence in the same thread as people going over wildly unsubstantiated claims of efficacy and the famous FRS at L5... Perhaps I wandered into the wrong room?
ps Nari - nice to see those claws. I was wondering if you had any, but suspected all along. Excellent points as usual.
Joined: February 14, 2003
From: Madison WI USA
Ben, I get the biomechanical picture of how orthoses could, in a theoretical, hypothetical being, lead to some sort of change at the facet. I simply wanted Ginger to supply something regarding how these magical devices would wipe away the need to bang away at the facets.
[QUOTE] This litany of possible changes sounds impressive, but I know of no evidence indicating it ever actually happens. This is speculation only. [/QUOTE]Thank you Barrett, for putting so eloquently into words what I have been trying to say for a number of years. Many of us think (and lots of us used to think) this way, as the search for cause and effect is drilled into our malleable minds during our education, and little is done to reverse the drill. It does indeed sound impressive. To require my skilled care, someone must have a problem this complex, right? Im not so sure.
Joined: April 6, 2004
From: San Antonio, Tx., USA
jwg, welcome, RE is up to over 6000 now, it was 4000+ plus when I started, other than yourself and Sarah I wonder where everyone is. Excepting Ginger who has livened things up considerably. Jon, I don't remember anyone teaching how many pounds of force to use in joint mobs when it was taught. I knew a Dr. years ago who used to have his wife walk barefoot on his back. I don't know if it was the Geisha technique or not, but I suppose if it needed to be done often, it was like the Geisha technique, a palliative treatment.