So how do we justify our approach as cost effective?  

a drug may contain multiple ingredients and  testing those ingredients in isolation may not give you many clues regarding the drug's effectiveness, moreover, if the drug has been designed specifically for that patient, it may not tell you how well that combination will work for another patient, in addition there is the placebo effect

Is it time to recognise that the placebo as a reference against which to measure non-chemical interventions is nonsense?  When we try and break down a complex and unique intervention into individual elements so that they can be tested against someone having ostensibly a similar experience minus that intervention that becomes so artificial it is pseudoscience and importantly disregards the nature of osteopathy.  Osteopathy is not defined by 'cracking' joints or by craniosacral therapy or by any particular technique.  It is not the same thing to everyone...which makes things very difficult...but it is not about the techniques used, at least not at a granular level.

Without looking up the latest agreed definition (which probably comes from the US where they do both more..and less... as osteopaths than the UK tradition)  I would say that at its heart osteopathy is about using non-pharmaceutical techniques to treat people with dysfunctions that are  largely (but not exclusively) musculoskeletal.    A T Still the originator of osteopathy created it in response to the deaths of three of his children from meninigitis and saw it as a full system of medicine in opposition to the brutal heroic medicine practiced at the time and believed that a body free of osteopathic lesions would be a body that could resist disease in all its forms.  There are many possible applications for osteopathy and the boundaries of what it is appropriate to say we treat are contentious...so lets start with the basics...musculoskeletal issues.

Whilst I said that osteopathy is not the sum of the techniques used I think it is useful to think about they might constitute:

• soft-tissue techniques (to work on muscles etc, perhaps massage, MET, stretches)
• articulation (repeated and gently increasing movements through a joint's range of motion)
• techniques applied to joints and muscles (functional, strain-counterstrain, Still techniques perhaps medical acupuncture)
• exercise prescription
• lifestyle advice
• referal to other specialists
• retraining concious  thinking about health beliefs (it is safe to move, I am not my pain)
• retraining the nervous system to allow movement (subconcious it is safe to move)
• manipulations/high velocity thrusts ('cracking' joints to overide inappropriate guarding)
• cranial osteopathy / involuntary motion / craniosacral
• pharmaceutical intervention  - only applicable to osteopaths who are also medcal doctors, few in the UK, nearly all in the US

All bar the last three are fairly uncontentious within our community and would to a greater or lesser extent be part of the armoury of most osteopaths.   There are; however, schisms about the last three, such that I would argue adherents to each provide a subtantially different service to those who don't, so whilst I don't believe in testing different techniques separately I do think there is some mileage in testing the major types of osteopath separately .

I want to separate out pharmaceutical intervention.  It doesn't form much of UK practice whereas it is almost ubiquitous in the US.  It is not part of the uniqueness of osteopathy even if at some time it would be useful to understand how effective co-treatment could be.

Cranial osteopaths and those who use lots of manipulations are almost mutually exclusive, both eyeing the other with a degree of suspicion and in the middle there are osteopaths who may use little or none of either and can sometimes be quite sniffy about both

Where I am heading with this is that it would be useful to classify osteopaths into different cohorts, in order to assess their effectiveness for patients with particular and that perhaps the faultlines broadly fall into three categories

1. Those who often use manipulations and rarely use cranial osteopathy
2. Those who often use cranial osteopathy and rarely use manipulations
3. Those who rarely use either

These could be worked up into statements about the type osteopathy we practice and osteopaths could be encouraged to choose the statement that best suits them.

Then, part two,  we need to work out what they are treating, and in this we should avoid over medicalisation.  Luckily this is already happening.  Diagaoses such as non-specific low back pain are more honest than trying to pin the cause on a particular structure or tissue, at least when there has been no trauma 

Thirdly there are different cohorts of patients, do we split them by age, lifestyle factors, health beliefs, chronicity, co-morbitities etc

It's a pretty complicated matrix but in my opinion if we want to truly test how effective an osteopathic approach to treatment is then that is what we need to work towards , in the meantime my fear is that a less granular approach risks throwing the baby out with the bathwater and that would be a terrible shame...and not evidence based medicine

Osteopathy, when performed at least moderately competently is reactive, not prescriptive.  The osteopath is constantly monitoring the structure, the tissue on whch they are working feeling for a return to normality, or the sense that no further change will be forthcoming, the technique, used by the practitioner to achieve the change may well be constantly changing fractionally in response to the perceived needs of the patient's body.

Moreover osteopathy tends to treat very widely, both physically, 'the knee may have a strain of the medial collateral ligament but is that because there is a problem with foot and ankle mechanics and that is causing a gait pattern thatcauses that or is preventing it from healing...is that also then causing an assymetry in the back which may be leading to other problems?'...and beyond, 'is this patient cycling and reinforcing this bad pattern, have they recently split up with their partner and sleeping on the sofa and the poor sleep is affecting their recovery?' (note I am not saying we do the work of counsellors but we do provide a listening ear).

This creates a problem.  How do we measure the effectiveness of interventions so that we can compare and understand what works and what doesn't?  Our interventions are complex and multifaceted.  What is the active ingredient in osteopathy and what is placebo?  How do we determine which part of our treatment is effective and which part is a waste of our time and the patient's, insurance company or NHS's money?

It is made all the more complicated by the fact that osteopathy is a broad church.   There are some osteopaths who only use very gentle techniques such as functional techiques and cranial osteopathy, others including me prefer, where it is safe to put some force through a joint or work on it persistantly until it starts moving.  I've had effective treatments from both modalities but I've also had patients who have had multiple 'gentle' treatments to no effect and have improved massively from one treatment using more direct techniques.  Is that down to the previous osteopath's personal competence, the general effectveness of those 'gentle' techniques or just a mismatch between that patient's need and the type of treatment they got...That may include some element of 'placebo' as they felt like I was doing something, whereas they were not convinced the other treatment did.   (I do treat more gently when the patient doesn't want or isn't appropriate for a direct approach...and sometimes refer when I tihnk they would be better suited elsewhere).

So how do we measure osteopathy?   More on that next time

Every now and then a patient comes in and when I ask what they want from treatment they answer some variant of "I've got bad posture" "I've got a hump" "fix my text neck" etc, or worse, "I've seen this video online, where they take this boy and straighten him out".  I am going to confess now.  I think I came to osteopathy based on a false belief.  The mother of a boy in my year at school, who lived in the same road as me, walked with a terrible stoop and one day that stoop was gone.  I think I asked my mother what had happened and my Mum said thought she had been to the osteopath.  I was impressed...but with hindsight, I think my Mum was guessing (they weren't particularly friends).  I suspect she had surgery and a rod put in to correct a very severe kyphosis.  The thing is that a deformity (I tried to think of another word, but this was an extreme variation from the norm and will have drastically affected her quality of life) like that held for years will have changed the shape of the structures - caused the vertebrae to become wedge shaped, shortened muscles ligaments etc at the front and lengthened them at the back - even if the initial injury was reversable at the time.  That is why the surgery is not just a release but a rod is needed to hold the back in position.  

By the same token, even if we can release tight tissues, stuck joints etc holding something in a sub-optimal position without surgery, the stretched ligaments and lengthened muscles on the outside of the curve aren't going to ping back with magical elasticity.   Something that has built up over years will take time and concerted effort to correct and indeed it may only be reasonable to manage it rather than completely reverse it.

If this all sounds very negative, it isn't!  We can usually correct things that have happened recently and we can often improve older injuries to improve function and reduce pain.  Osteopathy can also play a part in significant postural change but as a part of a wider program, over time.  I keep banging on about Pilates because it helps you to strengthen your postural muscles, including reinvigorating tone that has been lost by being stretched over time.  I am still slowly correcting my own assymetries and imbalances, using osteopathy to periodically release tightened and stuck tissues and joints and to integrate change, as well as Pilates, swimming and strength training to build new tone

Oh and by the way, if you've seen those videos, no I don't do the osteopathy with a plank and hammer, or one yank on a chin strap

I'm a great believer that regular exercise and movement will mean fewer visits to the osteopath.  Not only will you suffer fewer injuries but they are likely to resolve more easily.

One of my favourite ways of achieving this is Pilates.  What I especially like about Pilates is that a good class will see you stretching most parts of your body and conditioning many of the smaller postural muscles as well as the abdominal core.  It is also very adaptable with classes available at all levels and your teacher can also give you variations on exercises to suit your own abilities and stage of development.  I also enjoy the classes

The Pilates method was developed by a German, Joseph Pilates, during the first half of the 20th century, initially whilst interred at Knockaloe internment camp during the first world war, where he practiced his ideas with his fellow internees.  As well as mat work, often using small apparatus such as rings, balls, bands and rollers Joseph Pilates also developed a range of apparatus designed to accelerate the process of stretching and strenghtening.  The most popular of these is the Reformer...but there are a range of others, including the Cadilllac...which really does look like an instrument of torture!

Pilates's father was a gymnast and I think this shows in the practice that now bears his name.  There is more similarity than difference with yoga...but the emphasis is more directed to core strength and there is no spiritual element....although it can be quite meditative.  Pilates wanted his method to feel like a workout and I have been to some classes that burned like leg day with an evil PT at the gym...but not all classes are the same.  The accepted description for Pilates is "a mind-body exercise that requires core stability, strength and flexibility, and attention to muscle control, posture and breathing", that's quite a remit and different classes and instructors will have different areas of emphasis.  

I thought it might be useful to talk about the different classes I have attended, so that you can get an idea about what is on offer and what might be suitable for you.   I am lucky in that my Vauxhall practice is situated in Embody Wellness and I can organise my patients so that I can attend a couple of classes a week, sometimes three. All of the classes at Embody Wellness are mat based, although they do have a reformer available for 1-1 sessions. 

I started out with bodycare pilates, which is taught by John Hobbs and fits nicely with the days I work at Embody Wellness, being Tuesday and Thursday at 10:00 (he also does level 1-2 pilates on other days which is similar).  This class is aimed at anyone and has attendees in their 70s and 80s as well as beginners and those who just want a class that is about maintaining movement and flexibility and is perhaps less focused on strength.  There is not a great deal of standing work in this class although there is usually a balance, most of the work is lying down either on the mat or using the equipment to enhance the stretch or provide a balance challenge during strength work.  John likes to use all of the small equipment and we usually start with quite a pile of bits and bobs beside us.  If you haven't done pilates before I would suggest something like this or some 1-1 sessions before joining a more advanced class.   Just because I have said it is lying down doesn't make this a rest.  I struggled to start with but picked it up pretty quickly.

​Suzie Lovelock teaches at Saturday lunchtime and I have challenged myself by attending her 'dynamic pilates' class on a number of occassions.  This is of a completely different order of difficulty.  This is where I really feel the burn, usually in my legs and glutes.  Lots more standing work, poses held for longer, more demands on core strength.  This class makes me sweat, and stumble, and exposes my weaknesses both in terms of coordination and strength.  Just because I could leg press half a metric ton didn't mean I could hold a lunge whilst rotating and moving my arms!  This class has changed title to 'strength and flexibility', when I get the chance I look forward to seeing what's changed.

Kelly Balmer also teaches strength and flexibility and I have started swapping my Tuesday class to this.  The level is pitched somewhere between the other two.  Kelly's class possibly focuses on core strength most of the three and Kelly is all about form.  I'll be honest here.  I can't do a proper roll-up or roll-down yet (like a situp but a controlled movement spinal segment by spinal segment) but I'm enjoying gradually getting better.

If this reads like an advert for Embody Wellness please know I get a staff discount of 20% but do pay for classes and am not paid commission or to promote them.  I am writing this because I genuinely think Pilates is an excellent adjunct to osteopathy in maintaining body function.  That said I going to give them one last plug because they do offer a discount rate of £45 for your first 5 classes, click here.  I hope to see you there.

I was flicking through old articles and I came across this one, suggesting that we were not far off finding ways to slow down, pause, or even reverse some of the significant processes of ageing.  The article is looking at ageing at a cellular level and is from the perspective of a biologist who is looking drugs that reduce the cellular effects of ageing.  Don't get me wrong.  I am excited by that but it is only half of the equation.  We have it in our hands to do the best with what we've got .  Three of the four key osteopathic principles are valid here. 

1. The body is it's own medicine chest
2. Structure and function are reciprocally related
3. The rule of the artery is supreme

Don't take the first too literally but the body is pretty good at resolving most problems given a fair chance.  To give it that fair chance we need to:

1. Give it the nutrients it needs - Nutrition is such a loaded area.   It's true that there is much conflicting advice out there.  One of the reasons for that appears to be that different diets suit different people, another is that there is growing opinion that the combinations of foods can be as important as the component parts (so a Mediterranean high in deep fried food may not be as harmful because there are protective effects in the salads that are typically eaten alongside), so it is complicated and I am not going to offer my pet opinions here.  What does seem a fairly safe bet though is that you do need to eat a balance of foods and that vegetables should form a significant part of that and if you are not eating meat at all then you will need to find alternative sources for some of the substances we need that are generally found in that part of our diet
2. Don't poison it - tobacco, alcohol and excess sugar, amongst others, disrupt our body's normal processes, reducing healing, prolonging inflammation and causing direct damage at a cellular level.  I don't want to be a killjoy but if you want to live a long and healthy life quit smoking and moderate your drinking and your intake of sweet things (many artificial sweeteners seem to cause issues by fooling the body into thinking its getting a hit of sugar). 
3. Fix what you can at a macro level - Your cells need energy, nutrients and the removal of metabolites to stay healthy, your tissues need to be able to be serviced by the systems that repair damage, remove debris, challenge and destroy foreign or displaced material.  That means keeping the body's communication network operating freely and without impediment.  The 'rule of artery is supreme' was once taken to imply supremacy over venus drainage.  Now we talk about the role of osteopathy in improving fluid dynamics in the arterial, venous and indeed the lymphatic system.  The role of the artery may (or may not) be supreme, but it is the lower pressure venous and lymphatic systems which may be more interrupted by inappropriate muscle tone and which rely on body movement to generate the pumping action which drives them and that leads me to
4. Maintain movement - 'structure and function are reciprocally related' - use it or lose it.  Your body is designed to be used.  That which isn't used doesn't then receive the care it needs to maintain its integrity.  If you don't move a joint then the synovial fluid won't be wiped or pumped over the articular surfaces properly and the cartilage may become diseased, if you don't move so that surfaces between layers of fascia slide across each other as they are designed to, eventually they lose that ability to slide.   Muscles weaken and bones lose density without being subjected to load.  

So really you already have so many tools to prevent ageing.  Eat a balanced diet, don't poison your body (too much :)), keep moving with some weight bearing exercise like walking or running and something that stretches you like pilates or yoga and get small problems that don't resolve  quickly on their own looked at.  You may not live to 150 but you will have done what you can to make the life you have as healthy and therefore enjoyable as possible

So many people are working from home right now and, if we are to believe what we are told, it will be the new normal for many, at least part-time.  In some ways, that is great.  Most people won't miss the commute and in theory, at least, that is time you can repurpose to do what you want...and apparently cosmetic and deodorant sales are down, so that suggests you are repurposing some of that wash and brush-up time too.  The down side is that for most of us, at least here in London, space is at a premium...we don't have a room set up as an office...so we have to work in our living space and that might involve some compromises.  How can you make that work?

1. You need a desk or table, don't spend all day working on your lap...or from bed...at least not often.  If you are short of space think about investing.  How about a coffee table that is also a dining table/desk like this or a cheaper option is a wall mounted drop leaf table like this - make sure you don't mount the drop leaf table too high (see 2.1 below)
2. Don't compromise on the chair.  You really do need a proper office chair 
   1. One that adjusts for height so that you can find a height where you can type or use a mouse with your shoulder relaxed, your elbows at 90', or just a little more open than that, and your hands slightly dropping onto the keyboard at the wrist
   2. One that swivels so that if you are looking at a screen and at paperwork you can twist the chair not your body
   3. One that rolls freely so you can get up and down without having to do that back-twinging scooch to get tucked in under the desk and vice versa.  It has been a year now, if the rug has to go...it has to go, and stop dropping your clothes on the floor, this is important
   4. If you have shorter legs or the table you are working at is high (tables are often higher than proper desks) you may want to get a footrest, they are not expensive
3. If you use a laptop either get a separate screen or a separate keyboard and laptop stand.  The former is probably better, the latter probably easier to stow away when you are not working...either is a godsend.  The distance between the keyboard and screen on a laptop is insufficient to find a posturally decent position for working.  They're fine for short bursts but if it is all day you are going to be sat with your neck and back bent and that will cause problems.  Likewise a separate mouse is probably a good idea, using the tracker pad on the laptop with the laptop directly in the right place for the keyboard puts your arm in quite an unnatural position
4. Get your eyes tested and try to avoid glare on the screen (that might mean investing on some blinds and/or using lamps rather than overhead lighting), we don't want you getting headaches
5. Take regular breaks.  At work you'd get up and move around the office to talk to people.  Do the same at home.  Set an alarm, if needs be,. to remind you once an hour to get up and stretch your legs, make a cuppa etc
6. Go home from work.  Few people work set hours these days but the commute time should be your bonus for the inconvenience of working from home, don't feel that 'should' be work time.  If you can, pack away the work stuff at the end of the day, or at least at the weekend, so your home feels like a home again.

Coronovirus, what can you do?
 
I don’t propose to repeat the advice you are getting elsewhere but I do think there are a couple of points from the osteopathic perspective that bear consideration
 
If you have a mild dose of Coronovirus and can potter around, do so, your body relies on movement to maximise the efficacy of your immune system but the important caveat here is, without exhausting yourself, remember you are not replenishing your oxygen as efficiently so don’t use up everything you’ve got

What can you do before widespread infection hits?
Try and get your rib cage working as well as possible.   Fibrosis will restrict your lung capacity so you want to get your thoracic capacity as good as possible beforehand and make breathing as easy as possible (if you are asthmatic or have other longstanding lung conditions speak to your GP before doing anything that affects your lungs).  I suggest yoga or pilates for movement or just some daily stretches at home, open book, cat camel , or an exercise that makes you take deep breaths like running (try couch to 5k) this will also improve your stamina, which is the ability of your blood to carry oxygen.

MORE THAN ANYTHING ELSE WASH YOUR HANDS THOROUGHLY AND REGULARLY AND STAY HOME IF YOU ARE AT ALL UNWELL! 

It’s January and many of us have made promises to shift the Xmas pounds (maybe from more than one Xmas!).  I am coming round to the idea of ‘couch to 5k’.   I haven’t run yet, but I’m thinking about it albeit still on the couch.
 
For those of you who are taking up running this January, I have a few thoughts for you to try and help you do it without injury.
 

1. Literally don’t run before you can walk.  If you can’t walk without discomfort, running isn’t for you.  If you haven’t done any exercise for some time, start with a brisk walk and work up
2. Keep on the grass – or treadmill, at least to start with.  If you haven’t been running then the structures that dissipate the forces generated won’t be optimised for it.  Collagen fibres line up in response to forces.  New forces mean new lines of fibres need to organise and until that happens force transference will be less effective and injury more likely, so decrease the forces by running on a more yielding surface, and
3. Dress for success – invest in some decent running shoes.  Barefoot running may be all the rage but it isn’t for everyone…I’m not convinced it’s for anyone who is a novice at running.  Make sure you can run in a supportive, cushioning and protective shoe before trying to do without.  Not everyone is a forefoot runner and you might be dealing with flat feet, bunions, a lifetime of changes from the anatomical ideal, which brings me to
4. Get checked – Make sure your feet and ankles are working as well as they can.  This sounds like a plug, but it doesn’t have to be me, just someone competent to assess and hopefully correct your feet and ankles.  You may still need an arch support or special overpronator trainers etc but best to get the mechanics checked before being assessed for orthotic help, because
5. Injuries can occur – so make sure you warm up and down and don’t run on through injuries until you know what it is and that it’s safe to do so.  If something hurts stop running and walk for a while, if it stops hurting you can try running again, if it keeps hurting save the run for another day, bear in mind
6. Don’t overdo it to start with – increase your distance slowly, fitness is a marathon not a sprint.  And finally
7. Enjoy it!

​Some of you may have been to multiple osteopaths and may have been surprised by how different your treatment has been.   It would be fair to say that osteopathy is a broad church!  If you had asked me, before I trained as an osteopath, what defined osteopaths I would probably have said, the type of treatment they offer and would probably have said specifically the use of high velocity thrusts, or, manipulations…because that was the kind of treatment I had from the osteopaths I had visited and I felt that was what was different from massage or physiotherapy.
 
But there are plenty of osteopaths who don’t use manipulations and, of course, Chiropractors use ‘adjustments’, which amount to the same thing…in fact they have probably been using them longer. 
 
What makes an osteopath, is more about how we think than any individual technique, or protocol and it is the philosophy that sets us apart from chiropractors, physiotherapists and other bodyworkers.
 
There are 4 key principles of osteopathy

1. The body is a unit.   - This is holistic medicine writ large.   Whereas we might use our diagnostic skills to try and identify which tissue is injured and which is causing symptoms, we almost never look at those in isolation.  What other tissues and postural factors are contributing to the dysfunction or are dysfunctional in response to the injury?  What effect do the patients activities, lifestyle, beliefs and social setup have that may be factors and may be helps or hindrances to healing.   When you come to most osteopaths the treatment may well be very widespread.  Your pelvis may well be treated for a neck problem, your knee pain may be due to an ankle dysfunction, your carpal tunnel syndrome may be because your pc monitor is too low and you have a scoliosis, this is not unique to osteopathy but the widespread application of this wider thinking really does set us apart 
2. The body is its own medicine chest - AT Still believed that the body contained capacity to heal itself from any disease and that our job was to remove impediments blocking that healing.  Our viewpoint has changed in the nearly 150 years since Mr Still coined the phrase and, as things stand I don't believe that the removal of musculoskeletal lesions is likely to cause cancer or other severe illnesses to reverse.  The American Osteopathic Association rephrases this as 'The body is capable of self-regulation, self-healing, and health maintenance'.  I would say this is nearer the mark.  For me the body is capable of more self-healing than we think and interventions to help improve musculoskeletal function and overall health are more powerful than we often give credit.  So, although we can't cure cancer (as far as I know) there is evidence that treatment to facilitate movement improves the bodies responses to diseases like pneumonia.  Another aspect of this is that osteopaths don't think of themselves as performing the healing change in the body rather they allow the body to heal itself.   This one is up for discussion at the moment, there is some evidence that actually the external impetus does make the change but certainly the 2 steps forward 1 step back nature of healing would suggest that any change we make need to be integrated by the body and that sometime that integration is an iterative process, so we need to understand and work with the body's own capacity to heal.
3.  Structure governs function - Actually we think of it as more reciprocal these days.  The way your body functions dictates what you can do.  A simple example is that if your muscles are too weak you can't lift something heavy but you might also think about a more complicated but common 'example.  If your shoulders are rounded then your shoulder blades tip forward, in that position your ability to open your arms out to the side is reduced because there are now bones (acromion processes) in the way, the top part of your arms is rotated inwards, so to hold your hands in a neutral position, you have to externally rotate your forearms, constantly doing that may cause the muscles that do that to be overused causing inflammation where they attach and maybe tennis elbow.  It works the other way also.  The more you use your muscles, the bigger they get, if they are pulling on bones harder, the bones get bigger.  A really good example is the skeletons of medieval archers who have much bigger, stringer bones in their arms and shoulders on the side they drew the bow.  Typically, as children function has a very big effect on structure, so the bodies we have as adults are very much laid down by the activities we undertook as children...and as we become elderly, we become proscribed in our activities by the condition of our bodies.  Putting this into practice, we can encourage change in structure by changing our activities, either by doing exercise or stopping doing something which is promoting an adverse structure, and by changing the structure of the body eg allowing shoulders to retract and arms to open out, we can increase the function. 
4. The rule of the artery is supreme.  This one is a bit contentious.  in the UK we think about it now as fluid dynamics be they blood, lymph or even the flow of blood to nerves are crucially important.  In the past it was taken to mean that arterial flow was more important than venous (which doesn't seem to hold much water as an argument). The American Osteopathic Association has completely replaced this one with 'Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function', which seems to me to be just a restating of numbers 1-3, and I think that is a shame.  Osteopathy today, as stated above does not stray much into the realms of systemic disease beyond supporting those who may suffer with it but it has a large role in treatment of peripheral nerve conditions, carpal tunnel, sciatica etcetera.  Where the nerve is trapped and painful it is usually the blood supply to that nerve which is compromised.   We should be clear with our principles that our work on joints, muscle tone and overall posture can have very real effects on nerve and blood supply and lymphatic drainage

There are plenty of other philosophical nuggets in osteopathy but these form the core..  None of them are unique, but taken together they form the basis of our values in practice

During the first year of training to be an osteopath I spent a lot of time learning anatomy from textbooks.  These books describe structures and tell you the names, locations, relations (what is around it), blood supply and nervous supply, amongst other useful information and we (try to) learn these by rote so we can pass our anatomy exams.
Some time later…it was the third year of training for me…I suddenly realised that I could differentiate between two structures at different depths by reference to my anatomical knowledge and comparing the shape and, particularly in the case of muscles, lines of force.   My particular road to Damascus moment occurred when I felt something pulling up towards the neck from the angle of the scapula (part of the shoulderblade).  The trapezius muscle is the most superficial muscle here but I realised the fibres don’t run in that direction, whereas underneath it is levator scapulae and this line of tightness corresponded exactly with where that muscle should run.  Over time I became more and more able to differentiate between different structures using this method and I rarely think about the textbook anatomy.
 
Today a patient came in with a pain in his buttock (we joked that I should entitle this, ‘the pain in the bum patient’).  On  examination the tender bit was in the lower part of gluteus maximus, just above the ischial tuberosity (sitting or sitz bone) but the area affected didn’t run in the same direction as the fibres of that muscle, nor indeed the small internal rotator muscles that lie underneath (and provoking those muscles didn’t recreate the pain), it was also a bit too high to be ischiogluteal bursitis.  I was stymied for a moment…and then I remembered that I had read a paper highlighting that a significant minority of people had an anatomical variation whereby their biceps femoris (the outer hamstring) either additionally or often alternatively attached to the transverse ligaments of the sacroiliac joint rather than the ischial tuberosity and realised that this explained the symptoms in this location.
 
There are many anatomical variations, extra ribs at the top or bottom of the ribcage, extra or fewer vertebrae (actually just more or less of them that are not fused; kidneys and nipples often appear in greater number than is standard and sesamoid bones are non-standard parts in more than one place in the body.
 
Understanding how ‘the body’ works is a wonderful thing, understanding how the body underneath my hands is put together is even more exciting