I’ve just been on a course that challenged my thinking about how joints move. We were asked to think about how many ways a spinal joint can move.
Classic thinking is that it can flex (bend forward), extend (bend backwards) side bend left, and right and rotate left, and right. Thinking a little harder and the joint can also translate, that is traction or compression can be applied and obviously it can have varying combinations of the above.
But, in order to achieve left rotation at the C3-4 joint, that is C3 vertebra rotating left relative to C4 vertebra there are 5 different things that could be happening
C3 could be rotating left on a fixed C4
C4 could be rotating right under a fixed C3
C3 could be rotating left and C4 could be rotating right
C3 and C4 could both be rotating left but C3 is moving faster, and
C3 and C4 could both be rotating right but C3 is moving more slowly
That works for all of the directions of motion.
Why is that important, beyond an interesting brain teaser?
Firstly it can give us more information. If C3 won’t easily rotate left on C4 but C4 will rotate right on C3, perhaps the problem isn’t with C3-4 but instead C3 cannot rotate right under C2
Secondly, it gives more treatment options. If you can’t turn your head to the left without pain, perhaps, instead you can fix your stare on a point and reach forward with your left arm, rotating your shoulder girdle to the right. That is still rotating the top part of your neck to the left relative to the bottom part but is coming at it bottom up, rather than top down. This can be incredibly powerful and can be applied in all ranges of motion throughout the spine
Knots are part of the massage lexicon, they are little swollen, hard tender bits of muscle and are thought to occur when there is injury, possibly in response to increased calcium in the area causing localised bunching of muscle fibres with an inflammatory response. Except sometimes...
It's a rib! - ribs 2-10 start at the spine and wrap around to form your ribcage before joining your sternum at the front. These ribs start out pointing backwards and to the side and then after approximately an inch there is a sharpish corner, after which they point to the side and even a little forward. This corner is called a rib angle and at this point the rib has a joint with the transverse process of the vertebra. If the vertebra is twisted to one side then that costotransverse joint will be prominent on that side, or if the joint isn't functioning properly the rib may sit a little out of line, or indeed there may be inflammation that can be palpated, all of these will feel like a 'knot' between the spine and the shoulder blade and they will be covered with muscle that may be sore, because it is being permanently stretched over a lump.
When it's an inflamed facet joint! In the neck, the little joints on the back of the spine can be felt...and when they are inflammed the soft tissues of the joint swell...and make a lump...that feels like a knot
All in all, whilst knots may appear over joints, the chances are that if there is a lump localised over a joint it is related to that rather than the overlying muscle. working on the muscle over the joint may release the joint and resolve the issue but...the issue was not a knot!
I hate this question...but completely understand why patients ask me...and do my very best to answer it honestly...or as honestly as I can. It goes with "is it better this week?" in the category of difficult questions.
As an osteopath I satisfice, that is to say I am not looking for perfection, I am looking to do enough to allow you to get back to normal activity with no, or minimal pain. I do that by finding dysfunction and working to resolve it...Or do I? To the osteopath your body isn't made up of discrete structures, joints, muscles etc which can be checked for dysfunction, repaired and ticked off, that would be lovely but that was of looking at things is completely at odds with the core principles of osteopathy.
Firstly, one of the principles states that "the body is capable of self-regulation, self-healing and health maintenance", or alternatively "the body is its own medicine cabinet". Now don't get me wrong,I don't believe that we understand how to unlock the body's potential to heal all insults and indeed I doubt that is possible but, I do believe that the treatment I give, is not really the cure, it is, merely removing impediments to the body curing itself. Realistically, sometimes that is as near a cure as makes no odds. If a structure is being held awkwardly and a technique releases it then to all intents and purposes it is a cure, but more often the process takes time and there are stages by which treatment allows more normal movement and then that normality of movement improves tissue health and in turn allows treatment to further increase normality of movement. This change occurs on many levels:
So, when someone asks whether it is better than last week, the only person who can answer that is them..really. I can point to improvements in movement and in tissue tone and texture, but only they can tell me whether they are nearer to achieving their goals and indeed, only they can identify those goals in the first place. How many sessions you need depends on your goals, your starting point, and how you respond to treatment, mentally as well as physically...as well as effective treatment of appropriate tissues.
As a rule of thumb, I expect to see significant improvement by 3 treatments (often sooner) but everyone is different, long-standing problems often take more treatment, often the patient gets a lot of benefit from the first few treatments but then the additional benefit from each treatment tapers off...but not always...and sometimes there are additional breakthroughs where significant improvement occurs after a period of relative plateau. The important thing is communication, I need to understand whether you are feeling benefit and I need to be honest about my best assessment of what can be achieved in the short and medium term and that puts you in control, of what you allow to be done to your body and how much time and money you are prepared to spend.
The most important job we do is screening for serious conditions that require referral. Much of our training revolves around the identification of serious pathologies and the case history, even more than the examination, is designed to spot them.
So, what clues are we looking for? We are looking for:
Onset - Was there a trauma, that makes a mechanical, musculoskeletal injury more likely, of course, if the trauma is severe, the patient may have fractures which are a contraindication to treatment, so judgement is still required
Progression - are the symptoms worsening for no apparent reason?
Location - Musculoskeletal problems don't tend to occur simultaneously in multiple places
Comorbidities - Are there other siulatneous symptoms which could suggest infection, neoplasm or another systemic disease process
Aggravating and relieving factors - most musculoskeletal pain is aggravated and relieved by position and/or movement. Inflammatory pain is helped by anti-inflammatory drugs
Nature and site of pain - Is there a musculoskeletal structure which causes pain in the right place and with the right characteristics?
It is with this in mind that I was presented with a 75 year old woman who spoke no English and whose daughter translated for her. She looked very unhappy and actually cried as she described her symptoms. She had pain in both arms and shoulders of two months duration, which was worst on waking and was progressing. She felt her grip was reduced and she couldn't raise her arms above the horizontal. She also described pain in b hips and down legs to feet. She was advised by the GP to have and x ray which showed some wear and tear in the neck. At this point I am thinking 'no way is this musculoskeletal' and I am wondering whether I should stop her there and send her for blood tests for, amongst other things, polymyalgia rheumatica (PMR), a not uncommon condition affecting mainly women over 50 and affecting the hip and shoulder girdles. We continue with the case history and it emerges that she had a fall a couple of months prior to the symptoms commencing, landing on her left outstretched hand, but was fine after a little physio. Critically the patient wasn't getting any headaches or visual disturbance (more of that later).
Upon examination the woman was very kyphotic and the shoulders were very protracted, her upper rib cage was hard and unyielding and some of the ribs were prominent and causing the shoulder blades to tip forward.
I explained that the onset of symptoms in multiple places suggested that there might be something systemic behind this and that blood tests might be required but that I would be happy to try a gentle treatment, if she was, to see if there was a musculoskeletal element. Crucially the lack of headaches made it very unlikely that, if the condition was PMR it was not yet accompanied by its dangerous bedfellow giant cell arteritis (GCA), which can cause blindness, and so urgent further investigation was not required.
I treated the patient using articulation techniques to get the upper back and ribs moving, bearing in mind that the patient was very kyphotic and of an age where I needed to treat her as though where she may have osteoporosis . This week I saw her again and she was all smiles. The left arm still hurts in some positions but she can raise both arms and feels her grip is returning, the right arm feels almost back to normal...and the legs? I don't know if it was mistranslation or just exaggeration born out of fear and pain, but it appears that the problems in the legs are just around the knees and are caused by varicose veins and that there is no problem in the hips.
I haven't ruled out something systemic, all diagnoses are provisional, but it looks like this was a case of a mechanical problem masquerading as something more serious. I'm glad I took the chance to treat and see.
I'm not talking about the old word for homosexuality. I'm talking about your ankles. So what does inversion mean in respect of you ankle? Technically inversion is a movement in one plane only, meaning sidebent inwards . In reality, most of the time we are taking about about supination, which is a movement in 3 planes of motion, if you know your anatomical terms then it is made up of inversion of the hindfoot, adduction of the forefoot, and plantarflexion of the talocrural (ankle) regions. If not, don't worry just think that inversion is a pure movement at one joint in the heel and supination is the more complex movement that occurs more often in reality.
Your foot tips into inversion/supination much more easily than it does into eversion/pronation...try it, it turns inwards easily and a lot and outwards not so much. As a result most ankle sprains and twists are into inversion.
I have been surprised how many of my patients presenting with all sorts of issues have one or two ankles which are held in inversion, that is to say that either the hindpart or the whole of the foot can't present straight to the floor.
How can this occur? Well, you can have a pure supination, it can occur in the talo-crural joint (talus top bone of foot and and crus, referring to the paired leg bones) where the tenon like talus gets wedged supinated betweeen the two sides of the mortice formed of the ends of the tibia and fibula, or the sub talar joint can become restricted and hold the foot in the inverted position. In addition the tibialis anterior and posterior muscles in the shin and calf can become tight or shortened and contribute to holding the foot in this position and I have often seen a fixed twist in the midfoot as it everts to reverse the deformity and present the forefoot flat on the floor. Without correction this fixed twist will also be acting to maintain the inversion of the back of the foot. Finally, right up by the knee is you superior tibiofibular joint, if that gets stuck in a position with the fibular relatively inferior to its proper position then the whole mortise of the talocrural joint will force inversion
How do I spot this? It's very simple. When I look at you from behind, your achilles tendon should run in a fairly straight line and the bulge of your heel bone (calcaneus) should be approximately symmetrical either side, if not, something is wrong. I can confirm this by feel and by feeling whether it moves evenly compared to the other side and the range of normals I have felt over the years. If the heel has been like this for some time the insertion of the achillles tendon will even move so that it no longer attaches at the pointy top of the calcaneus but instead attaches to the side, I can feel this too.
Why is this important? Well, the first effect will be on your foot. If your hindfoot is pronated you will need to twist through your midfoot to place the front of the foot flat when you walk and that may cause problems in the midfoot and tightness in muscles which are being over-stretched in the shin, maybe even shinsplints. You may not have the midfoot mobility to do that so may be walking on the outside of your foot...or more likely as you present your foot flat your knee has to drop inwards (valgus) to compensate. Therein lies a whole can of worms.
When you have a knee valgus, first of all you are going to be stretching and stressing the ligament on the medial part of the knee (the inner part, nearest your other knee). The medial collateral ligament, as it is called, is attached to the medial meniscus, this is a cup shaped piece of cartilage which sits between your femur (thighbone) and your tibia (shinbone). If you are stretching the medial collateral ligament you are also deforming the medial meniscus and may well make it more prone to tearing. what is more the proportion of the weight taken by the lateral meniscus has increased, making that more prone to damage also
Once a structure is out of line, as with a knee in valgus then it is not supported against gravity by the structures beneath it, to stop it collapsing force is required, this is supplied by muscles.
Locally, vastus medialis oblique (VMO) is the muscle that tries to stop it dropping. Over time over use of VMO can lead to it becoming over tight or fatigued and ineffectual. As one of the quadriceps muscles it contributes to the joint quadriceps tendon which encapsulates the kneecap, imbalances in the forces inputting into this tendon can cause the knee cap to become bound down onto the structures below or to move in an irregular fashion (maltracking), both of which can cause pain, damage to the cartilage on the back of the kneecap, and eventually arthritis.
Your body also stops the knee dropping further inward by pulling the hip outward, using gluteus medius and minimus. Gluteus maximus and tensor fascia lata are also involved as, via the iliotibial band, they try to hold the knee joint close and stable. All of these muscles can become over tight or fatigued as a result of this process and iliotibial band tightness can occur, possibly leading to trochanteric bursitis.
Of course, most of us don't have symptoms, but what damage is this storing up for the future. Is this a significant contributing factor for knee, or even hip osteoarthritis? I don't have any evidence to say it is, but mechanically it seems reasonable to assume that there will be long-term effects. I also wonder how many people get a running shoe based on how they weight bear but are actually not weightbearing as they should...and most of the time this is so easy to fix. Anyway, next time you see someone from behind with flipflops on, or bare feet, take a look, you'll be surprised how many inverted ankles you'll find
A recent report in a Nature journal here talks about the discovery that many structures previously thought to only have a structurally supportive role, including the submucosae of the entire gastrointestinal tract and urinary bladder, the dermis, the peri-bronchial and peri-arterial soft tissues, and fascia, contain a sponge like interconnected network though which interstitial fluid can pass within and between organs before passing into the lymphatic system. The change to our understanding is so profound that scientists are suggesting this might warrant being being described as a new organ, so what is its significance? Simple answer, we don't know. The fluid may act as a shock absorber. Interestingly, the interstitium seems concentrated around structures that are subject to rhythmic or intermittent compression, this perhaps suggests that the fluid contained within is intended to be pumped around. Unlike the lymphatic system, which is similar and connected, the interstitium doesn't contain large numbers of immune cells but it does appear that they can enter to fight threats. There are many interesting questions about its purpose, function and whether it can go wrong, not least whether it is an important method of cancer metastasis, or indeed can be used as a useful tool for diagnosing and tracking cancer spread. As an osteopath, this is particularly interesting as any structure that uses movement is potentially something we can influence.
Picture copyright Jill Gregory / Mount Sinai - http://www.jillkgregory.com/
used under creative commons BY 4.0 http://creativecommons.org/licenses/by/4.0
Diagnosis is a funny old thing. It can tell you everything...and nothing. It comes from Greek roots meaning to 'know or recognise' and 'apart'. We tend to think of our bodies like a machine, on which we can run a diagnostic check and find the cause of our pain and or disability. A blood test for this and a scan for that. This is what is wrong and this is what we do to fix it...or not. Osteopathy has 4 central tenets and one of them is particularly relevant here...'the body is a unit'. what does that mean and why is it so important? It means that we are looking at the interaction of structures and systems, the function of the whole not the part. The reason we sometimes get seemingly miraculous results, where others have failed is because we cast our net wider, looking for (often multiple) predisposing and maintaining factors. If someone has tennis elbow (that is inflammation of the point where the tendons of the forearm muscles attach to the outside of the elbow) we can treat it with anti-inflammatories, even steroids and the pain will go away, great! But why did it occur now and in that arm? Unless there is an underlying condition and often, even then, it is because the muscles are pulling on the area too much, meaning they are too tight or are being overused and so, if we don't reduce the tension on the muscles or adjust our activity to reduce the overuse then the pain will return as soon as the anti-inflammatories wear off. OK so we massage the forearm and give some stretches and say to lay off the tennis. Why now though? I've been playing tennis for years...and I've stopped for 3 weeks and the pain went away but as soon as I started again it came back...Will I have to give up for good? Muscles rarely become too tight for no reason, something else has changed that has resulted in that, so we look at the wrist and see if it is functioning properly, because the muscles of the forearm nearly all cross the wrist and dysfunction there can lead to tennis elbow, and then we look at the shoulder. Is the shoulder, rounded, which means the forearm needs to supinate (turn out) to present the hand neutrally? If the shoulder is rounded, why? Is it because the ribcage isn't operating properly and the shoulderblade is tipped forward over prominent ribs below, is the ribcage dysfunction due to a scoliosis, is that structural (skeletal and not easily changed) or functional (functional and caused by either a soft tissue tightening in the torso or an apparent leg length discrepancy). If there is an apparent leg length discrepancy, what is causing that, is that because of a pelvic torsion, either soft tissue or an actual sacroililac joint shift or is the arch of one foot becoming flattened and is that permanent or the result of an ankle dysfunction?
So actually, the diagnosis of tennis elbow, is not that useful. The real problem is the sprained ankle that wasn't properly resolved and the knock on from that. Altogether now..."The hip bone's connected to the thigh bone"
A month ago The BBC ran an article on complaints about how hard the new Thameslink train seats are (see it here, it also features the first osteopath I’ve ever seen asked to give his expert opinion). I’ve had the opportunity to ride one of them now and can confirm that, in a modern world of uncomfortable public seating, these are the worst so far. They are very hard, very upright and quite straight in the back. “Surely sitting straight and upright is good for you?” I hear you cry…I’ll come back to whether it is good for most of the population later but it most certainly is not good for anyone who cannot comfortably hold that position.
The problem is that not everyone has an “ideal” shaped back. Many people, including myself have increased curves…they are kypho-lordotic. They are not necessarily just slouching. They may have developed wedge-shaped vertebrae, either as a teenager (common amongst those with a fast growth spurt) or in older age due to osteoporosis; others just may no longer be able to straighten, as soft-tissues in the chest (muscles, tendons, fascia, ligaments) have shortened over time as a result of hours at a desk, or even over-work of the chest relative to the back, at the gym. An upright seat, hard padding with no give and a back that cannot straighten means that the passenger will be sitting with their head tipped forward, that is 4-5kg pulling forward and needing constant support from the muscles of the neck and back. Evidently that is a potential recipe for pain and dysfunction.
On 5 March the Guardian ran an article stating that there was little evidence connecting back pain with slouching and bad posture (read it here). It was a confusing mess of clearly contradictory definitions of posture – quoting an osteopath (another one), a ballet teacher and a physiotherapist. Worryingly the article suggests that workstation assessment was about sitting up straight and that sitting up straight was not particularly useful.
My suspicion is that the journalist has got a number of different quotes and weaved them together but has confused three different things
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!
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,
Damian is the principal osteopath at Vauxhall Village Osteopathy and Oval Osteopathy