Adding insult to injury
I have been taught like a good British School of Osteopathy graduate to come up with a diagnosis.
I listen to your explanation of where the injury is located, what happened when the injury occured, what has happened since, the nature of the symptoms etc and then I examine you, looking for physical signs of injury or inflammation, or infection, or just musculoskeletal assymetry or altered movement patterns. All of this is to determine the tissue causing the symptoms.
Except there is rarely one tissue causing the symptoms. So I use the time-honoured format of including pre-disposing factors and maintaining factors in my diagnosis. The pre-disposing factors are those which are musculoskeletal and maintaining are others, such as lifestyle factors, poor mattress, stressful job etc.
Sometimes the list is extensive and it is like the song 'there was an old woman who swallowed a fly' with the problem getting bigger and bigger as insult piles upon injury, except that to make it more complicated you're often not quite sure in which order the injuries happened.
I only have to look to my own body for an example I have a flexed area between t5 and t8, I've had problems with my shoulders, painful ribs and also pain lower in my back at the TL and in the left sacroiliac joint...oh and tight hip flexors. How do I, or my osteopath, deal with all of that? We could either treat them as unconnected or try and find a plausible story to link them together. Why would that be useful?
It is useful to understand which problems are connected because one may have been caused by another and in turn may prevent the other from resolving fully unless it receives attention also, likewise if the initial insult isn't dealt with the newer problem may recur, even if it has been fully resolved, the pre-disposing factor hasn't been removed. It makes sense to me to prioritise the newest injury first, that way you are returning to a state you know the body was able to inhabit for a while, even it it may not be sustainable in the long-run. Removing the initial insult, if possible, would be to take the body to a new condition and may result in further compensations and new injuries.
So how does this apply to my body? I think there are 2 groups. I think the Sacroiliac Joint, hip flexors and TL are the newest group, dating back to an SIJ injury in Jan 2017. They are almost self-contained...except the TL dysfunction causes both twelfth ribs to, for want of a better word, get stuck and increase the tension in my rib cage related to the rib problems higher up
The T8 area relates to an injury about 5 years ago and actually appears to be one joint rotated left and another rotated right and both pulling in opposite directions
the T5 area injury is a joint that is stuck flexed (unknown timespan, at least 8 years) with associated ribs either side which sit are pushed proud of the bulk of the rib cage and cause tight intercostal muscles, and tipping forward of the shoulder blades, this in turn causes muscle pain from muscles which are permanently on stretch, I feel this most in the back part of the armpit where it joins the torso. The tipping forward of the shoulder blade also causes mechanical disadvantage to the shoulder and increases the chance of subacromial impingement and inflammation and also of muscle injury, particularly to the rotator cuff muscles and lo and behold I have had exactly those problems.
So where to start? Start with the newest problems, so the Sacroiliiac joint, hip flexors and TL, as a discrete set of problems they are quite manageable as a group for treatment and I am pleased to say have nearly fully resolved. The Problems around T8 next, they are very near to resolving also. Meanwhile work on the ribcage has been much more productive since the TL issue and the associated twelfth rib mediated tightness has gone, the 5th ribs are sitting a little flatter and the shoulderblades are less tipped. All this means the shoulders are starting to recover...but I'm well aware that this can't stop until the T5 issue is resolved, otherwise I will always be prone to bad shoulders and it may even be that the lack of movement through T5 area was a predisposing factor for the T8 TL or even the left SIJ injury.
So don't be surprised if you come to me with a bad shoulder and I'm interested in your pelvis. I may need to find the spider to remove the fly!
Why all the questions?
I allow an extra 30 minutes for your first visit...Why? To ask you questions.
I'll be asking you all about the issue that has brought you to me and also about your health in general. Why is that?
1. To make sure your issue is appropriate for osteopathic treatment today
Osteopathy started out as a form of medicine for all systems of the body...but I am trained to use osteopathy to help patients with mechanical musculoskeletal problems, and whilst I am very happy to support patients who have other conditions, I don't purport to treat those conditions, so it is my responsibility to refer patients outside my remit. Many systemic conditions present with musculoskeletal symptoms and the case history I take is designed to detect these, so if you are complaining of low back ache and I seem interested in whether you have problems urinating I am thinking about the possibility of a kidney problem or prostate cancer that has metastasised to the lumbar spine. If you are a woman and I am asking about your periods then I might be wondering if you have fibroids. There are few absolute barriers to treatment but an example might be someone with calf pain and the history tells you it started after they returned from holiday...a quick look and very gentle touch to confirm that there is a pulsatile mass and straight off to A&E to investigate for Deep Vein Thrombosis.
2. To determine what forms of treatment are appropriate
If you have had a lifetime of steroid use, or long term anorexia, or a series of broken bones for relatively small knocks, I need to know because it suggests you may have lower than normal bone density. If you have low bone density, I will use more gentle treatment, even if it means results take a bit longer. If you have problems which suggest you might have some cardiovascular disease then I will be even more careful when treating your upper neck, I don't want to run the (tiny) risk of breaking off an atherosclerotic plaque.
3. To identify what the problem is.
By asking you questions about how the problem occurred, how it then progressed, what aggravates it or relieves it, where it hurts and the nature of the pain, I am usually able to work out what is likely to be wrong before I even start to examine you. The examination is designed to add weight to the diagnosis. I don't have X-ray or MRI eyes, or access to nerve block injections so my diagnosis is provisional and the strongest piece of evidence for what is wrong with you is usually the case history. I'll give you an example. A man, in otherwise good health, walks in with low back ache. The pain is worse for movement, especially extension and rotation, standing is painful but sitting not so much, no pain into the legs. The injury occurred in the gym 2 days ago when he bent over a little and felt it go, he was in instant pain and couldn't straighten up, the pain has got a bit better since.
The injury had a clear onset and was as a result of movement. It is also aggravated by particular movements and the man is otherwise in good health, this tells me that the problem is almost certainly musculoskeletal and mechanical in origin. I think it very unlikely it is a herniated disc since the injury happened at partial flexion, not full, the pain was instant rather than taking several hours to develop, no pain into the legs (disc bulges often press on the peripheral nerves, which, in this area, innervate the legs), pain in all ranges of motion, not just flexion, pain not worse for sitting (or all weight-bearing activities) and starting to recover within a couple of days. All of these point me away from a disc injury. I also doubt it is a muscular or ligamentous tear as it didn't occur when under heavy load, so I am thinking that it is likely to be a facet joint injury, some further testing and I am able to confidently estimate recovery time and i can use this knowledge to inform the treatment I use
4. To get to know you
I could send you a health questionnaire and save time and room hire fees. I don't because sometimes I get additional information about a person, that they wouldn't put on a form. Our health, or otherwise, is determined, not just by our physical presence or absence of dysfunction but also our psychological state, our social relationships and our lifestyles. This isn't airy-fairy. If you are stressed you pump out cortisol. Cortisol is designed to keep you keep you ready to fight or flight, this process reduced the resources available to repair injuries. If you have just changed job and the seat is uncomfortable. If you have a 2 year old who is heavy but demands to be carried. Whether you smoke, drink too much, eat poorly, or are a paragon of virtue. All of this information is important to me and is difficult to get from a questionnaire.
Just as importantly though, it is a chance to get to know me a little too...it is an ice-breaker. It is uncomfortable enough, for many, to undress to their underwear for examination. At least this way we are not quite strangers by that stage,
Don't run before you can walk!
Christmas is over and the turkey wasn't the only thing that got stuffed. Many of us over-indulged in both food and alcohol and have come out the other side swearing to shape up...but we should be realistic about the shape we are currently in, and chose our exercise regimes accordingly! I am specifically thinking about the suitability of running as exercise for the unfit, overweight, or under-prepared.
Don't get me wrong, running is clearly fantastic exercise, it takes the weight off, gets the heart pumping, helps maintain bone density and improves general fitness but it is also high impact. That means it has the potential to impact heavily on a number of structures and do us more harm than good, so here are a few things to think about
So how does this depressing litany help us train smarter and more safely?
Damian is the principal osteopath at Vauxhall Village Osteopathy and Oval Osteopathy