​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  

People ask me what I most often treat.  The glib and osteopathic answer is 'people'.  If I'm going to be reductionist and nominate a body part then ribs are surprisingly high up there.  Why surprising?  Well?  How often do you think about your ribs?  The amount of patients who say 'I have ribs at the back too?' or 'that far up/down'.  You break them or bruise them but rib dysfunction with no traumatic onset?

I'm being a little disingenuous here, because, most often it is not the rib itself that is the problem but the joint or joints attaching it to the spine and to the sternum (breastbone).

Most people have 12 pairs of ribs.

The top pair are the 1st ribs, uniquely they only have one joint at the rear with the spine

Ribs 2-7 have two joints at the rear, all of ribs 1-7 are true ribs and have a joint at the front with the breastbone

Ribs 8-10 are false ribs, they don't come all the way to the front but join to cartilage which then combines and  joins to the 7th rib
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Ribs 11 and 12  are floating ribs, they only have the two joints to the spine and the front end 'floats' but not very freely as t is held in place by muscles.

So what can go wrong?  Well the ribs are subject to loads of forces in different directions.  Obviously they move when you breathe...you may never have thought of that..and when you move your thoracic spine they have to move to accommodate that and then there are the shoulder movements that basically require your ribcage to deform to accommodate those too.  Each time a healthy rib moves all of the joints between it and your spine and sternum should move a little too, but like every other joint, they can get irritated, inflamed, restricted, stuck and the whole rib can end up out of synch with the spine and with the other ribs around it.  Which can cause the joints to get very inflamed and painful.

and can cause the muscle overlying the rib to be held on stretch for long periods, which then makes the muscle sore and or tight.  So many of those 'knots' you get in your upper back between the shoulderblades are not knots at all but instead some muscle stretched over a prominent and unyielding rib below.  Then there are the muscles between the ribs, you know, the tasty bit in spare ribs, they are intercostal muscles and can become too tight and feed into the dysfunction by pulling the ribs together unevenly like badly ruched curtains and then there are muscles attaching to the top and bottom ribs, at the top, particularly the scalenes, these are the muscles that run up the side of your neck and they attach to the first and second ribs, poor rib function there can lead to the scalenes becoming tight resulting a stiff and painful neck, not to mention the effect it can have on the nerve and blood supply to the arm.  At the other end the 12th rib attaches to quadratus lumborum and psoas, as well as the diaphragm and dysfunction here can lead to low back pain, even hip problems and problems with the nerve supply into the leg. 

I rarely treat ribs in isolation but, I treat them with most patients and they deserve to have more attention paid to them in general

Leg and yes, the gluteal region too.  Sciatica is one of those terms thrown around with varying degrees of accuracy, so I thought it might be time to talk about what it is..and isn't...and of course what osteopathy may be able to do to help.

The idea behind sciatica is irritation of the sciatic nerve causing pain in the leg.  Let's get the annoying 'know it all' stuff out of the way first...
1. There is no sciatic nerve...Really!   What we call the sciatic nerve is actually a sheath containing 2 completely separate nerves, the tibial and fibular (or peroneal) nerves.
2. A slipped disc, disc protrusion, herniation etc cannot press on the sciatic (or fibular or tibial) nerve, these nerves are what are called peripheral nerves and are formed outside the spinal column (hence in the peripheral, not central, nervous system).  What can get irritated in the spinal column, by a slipped disc etc, is a nerve root.  These exit in pairs at each spinal level and then send branches which join in plexuses (plexi?) to form peripheral nerves

Phew!

OK, so lets assume we are talking about nerve pain, numbness or weakness in the buttock, maybe down the outside or back of the thigh and sometimes into the calf and foot. 

Where are the main places that the nerve can be irritated?
The first place is in the spinal column.  A disc bulge can press on the nerve root and cause pain down the leg.  Typically L45 or LS discs are particularly prone to herniation and can bulge and press on l5 or S1 nerve roots which cause symptoms in these areas

Overtight buttock muscles, especially piriformis can compress the sciatic bundle and irritate the nerves contained within.   Typically this is felt as pain along the route of the nerve in the thigh and often doesn't extend beyond the knee although it can go all the way to the foot.

The common fibular nerve is prone to injury and entrapment where it winds around the fibular head (the bony lump on the outside just below the knee).  Relatively minor knocks here can stop the nerve gliding smoothly meaning that it can get stretched and harder bumps (hit by a car bumper etc) may lead to loss of power from the muscles it supplies, and foot drop.

The tibial nerve can get trapped behind the knee, under soleus muscle and in the foot, in a structure called the tarsal tunnel, which can become congested due to poor foot mechanics.

How do we know where the problem is?
Sometimes it is very obvious from the history, where the injury took place and what kind or injury it was, sometimes examination and basic orthopaedic testing will find an obvious derangement and treatment of that will reduce or eliminate the symptoms.   An MRI would be required to confirm a disc bulge and/or nerve conduction testing can show whereabouts a nerve is damaged.  Beware though 80% of 40 year olds with no back problems or sciatica will have disc bulges on an MRI.  So you may have a disc bulge and sciatica but it may not be the cause, or may be part of the cause and resolving an issue elsewhere may be enough to eliminate the symptoms

What can an osteopath do?
It depends...as always.  If you have herniated a disc, nature may have to take its course, most disc herniations become asymptomatic within 12 weeks (sadly, not all).  That said, sometimes even sciatica due to an apparent disc bulge may respond to treatment, either the treatment reduces local muscle spasming, postural issues or fluid congestion around the nerve root thus decreasing compression and irritation, or working elsewhere along the root of the nerve increases it's capacity sufficiently to reduce symptoms.  If the problem is due to tight muscles in the buttock we can work to loosen those and, more importantly work out why they have overtightened and work on those factors also.  Problems in the foot and further down the leg are often very amenable to osteopathic treatment.  Finally, if you are suffering from sciatica it is probably affecting how you sit, walk etc and that will have a knock on effect on other tissues in your back and possibly in your other leg.  We can work to minimise those disruptions, so that when your sciatica does go, you aren't left with a whole pile of other problems 

Picture

• Author: K. D. Schroeder
• Sciatic nerve2.jpg from Wikimedia Commons
• License: Creative Commons Attribution-ShareAlike 4.0

Osteopaths treat all sorts of musculoskeletal mechanical disorders and patients seem to come in waves with disorders of particular areas of the body…this week it has been feet.
I have to confess I always approach someone’s feet with trepidation.   They aren’t always pleasant and perhaps more importantly they can be tough old things to sort out.  We stand on them, and they bear our weight, they’re strong.  Similar to the hands I find that I am actually using my hands to make the changes I want, rather than gravity and my bodyweight with other areas of the body, and as a result after treating someone’s feet my hands are usually bright red.  As a positive aside I don’t seem to suffer from cold hands as much as I used to before practising osteopathy!
So they’re hard work and not always pleasant to work on but feet are so important, for those of us who can stand and walk, they are our foundation and yet we treat them with disdain.  When did you last look at your feet to make sure they’re OK?   Do they match?  Have they changed?  Do they move how they should?
Patient 1 had a stress-fracture of their 2nd metatarsal for no apparent reason 6 months ago, no bone density problems.  It got better and then she started getting pain under the metatarsal heads (the pads just before the toes).  When I looked at her foot the medial (inner) arch of the foot was all flattened and the whole foot was twisted so that excessive pressure was being placed on the big toe…and that had responded by developing a valgus (toe bends inwards towards foot at joint) and a bunion, this takes the pressure off the 1st toe and puts it on the 2nd particularly if they have a long 2nd toe, known as a mortons toe…and may explain the fracture.  Shockingly the podiatrist prescribed insoles without touching the patient’s feet.  The patient was worried their toe had fractured again. 
I was able to articulate the medial arch to reform but the patient still had pain however we were able to identify it was no longer where the fracture had been, I then worked on the transverse arch, this is the arch across the foot where the pads are just before the toes.  Sometimes these can drop and some gentle encouragement can persuade them to pop back into a nice arched shape and voila, no pain.  The next step (pun intended) is to see if the foot is capable of holding this improvement without orthotics, and if not, to try with orthotics.
Patient 2 had pain in the outside aspect of her left foot, which she had been told was due to an avulsion fracture 2 years ago.  On observation the foot had an overly high arch and the toes pulled back almost like a cats claw ready to pounce.  She was very hypermobile in her hands and feet, that means her ligaments had much less recoil than usual.  She’d been to see a range of practitioners and nobody had questioned this hugely deformed foot, suggesting the pain was just down to a detached bit of bone and she’d have to live with it.  Perhaps they thought the foot was like this due to a developmental deformity, it certainly looked like it but I asked the patient about it and the foot hadn’t always been like that, so I decided to see what could be done.   Below the talocrural joint there is a joint called the subtalar joint.  When we sprain our ankle, it is usually the talocrural joint but can sometimes be the subtalar joint.  The subtalar joint was stuck twisting the foot inward and the rest of the mid and forefoot was twisted the other way so the front of the foot could present flat to the ground.  After I had released the restricted joints the arch normalised and most of the toes released and sat almost flat, I then massaged the short toe flexor muscles in the arch of the foot and the longer toe flexors and extensors in the leg.  The foot straightened out, almost entirely, this crippling condition apparently 90% resolved with 10 minutes work.  I think that the patient had just sprained her subtalar joint and in order to protect the hypermobile foot in this less stable position the nervous system had activated both flexors and extensors to hold the foot rigid.   Again we need to see how much of the improvement is maintained but even if it starts to revert, this opens new avenues of treatment to explore.
The moral of this story is, look at your feet and get problems resolved (including that revolting athletes foot) because feet that function well don’t just help protect against foot and ankle pain but they absorb forces to protect the rest of the leg, the knees, the hips and even the back.  Don’t necessarily expect other professionals to identify resolvable biomechanical dysfunctions.  Orthopaedic surgeons are primarily looking for things that require surgery, a podiatrist who is an expert in orthotics will probably make you some lovely orthotics.  I’m not sure this should be seen as criticism…I’d do a lousy job of removing your bunion and you’ll be pleased to know I wouldn’t dream of trying.  “Render unto Caesar…” and all that, there’s a place for podiatry and for surgery but I hope you will now consider that there’s a place for osteopathy in the care of your feet, even if that does mean I have to handle more of the darn things.

I’ve written about this before…and I try not to repeat myself…but please forgive me this once as  I come to this with fresh information.

I’ve written about how uncomfortable the hard, upright seats on many modern new planes and  trains are, notably Thameslink and the new Intercity Express Passenger trains.  Im not going to go into why hard upright seats are so uncomfortable again, it's here.  It seemed to me that someone was taking perverse glee in commissioning seats that were horribly uncomfortable, except they’re not…any more.  I should explain that the seats haven’t changed, my back has!  So now I can see both sides of the story.

I have spent most of my life with a pronounced kyphosis, that is to say that the top part of my back is more rounded than average.  I remember going to an Alexander Technique taster class aged 18 and lying on my back on the floor and finding it painful because my upper back was rounded and hard and wouldn’t lie flat enough to be comfortable.  There are many reasons for a pronounced kyphosis, maybe it is genetic, maybe it is the result of having been tall at a time when I was shy and so spent my time looking at the floor, maybe it was the result of falling out of a tree onto my back aged 10 or 11 and the injury not resolving properly, who knows.

I have spent the last year and a half working hard on my own body, using self-treatment, treatment from my osteopath, deep tissue massage, swimming, focused gym work and most recently pilates, in order to get mobility into my whole back and then to start to reduce that excessive kyphosis.  The good news is it is working and I know that because, my shoulders are less rounded so I can perform lateral raises properly in the gym (I absolutely couldn’t before)…and…wait for it…The seats in the Intercity Express Train are OK, they’re not cosseting but they’re not uncomfortable either. 

So what does this tell us?  Firstly, long-standing postural issues can sometimes be reversed, but it takes a lot of hard work.  Secondly, the commissioning team for the latest train seats aren’t necessarily sadists…but they are making the common mistake that catering for the average person is good enough, it isn’t, it is poor design because it is uncomfortable for a very significant proportion of the population.

We live in a world where doors and grab rails (rightly) have to be a specified number of shades away from the surrounding colour palette and journeys are punctuated by passenger announcements, to make journeys easier for the visually impaired.   Trains are removed from service and stations remodelled at great expense because they aren’t wheelchair accessible.  Yesterday at Slough station there were signs all over the stairs on the new bridge and a really annoying announcement every 30 seconds demanding that I use the handrail on the stairs (despite that rendering the middle 2/3 of the staircase potentially useless). 

Against this backdrop, how can we think it is acceptable to introduce seats without ensuring that they are not cripplingly uncomfortable for the vast number of people in the UK whose back is more curved than average?...and if you are lucky enough to think that this is a moan about a little bit of discomfort, then I hope for your sake your back doesn't lose it's shape and flexibility as you age, because, I can tell you from experience that these seats, so innocuous for most are much more than a little uncomfortable for the kyphotic many.

Back down off my soapbox

I’d love you all to be able to come and have as much treatment as you need to make your body the very best it can possibly be.  Realistically though, many of us (I include myself) have long standing issues that require a long period of sustained and intensive therapy to fully resolve.   Apart from the investment in time that can also mount up in terms of cost.  Not everyone (I include myself in this also) can afford to commit to open-ended weekly treatment.   So what happens is, the patient comes with a problem and if the pre-disposing factors, that is the underlying postural issues are long-standing, complex and slow to resolve then the patient stops coming, once their current pain or dysfunction is resolved…but then they are back 6 months later with the same problem or something else but caused by the underlying issue not being resolved.  So how can that be minimised?   Over to you, the patient, to take some control of the issue

1. Avoid the triggers – stop doing whatever it is you do that sets off the issue, if you can and if you can bear to.  If you are a baker you probably can’t stop kneading bread and if you live for gardening, let’s try and find a way to continue, but if it happens once a year when you go skiing, which you only do to please your mates, the answer is obvious.
2. Adjust your surroundings – If your car seat gives you sciatica, change your car or get a wedge to sit on, replace that awful mattress and most importantly make sure you are sitting correctly at your desk, the rules are pretty simple.
   1. Make sure you can sit with your screen and/or paperwork directly in front of you and that your eyes don’t have to strain to see the screen and you don’t have to stretch to write or use your mouse
   2. Your seat height should be such that you can type or write with your shoulders relaxed, your elbows at 90’ and your wrists dropping onto the keyboard
   3. If your knees are at more than 90’ in this position you may need a footrest, if significantly less than 90’ you may need a higher desk, so you can set up correctly
   4. The top of your screen should be level with your eyes.  If it is not adjustable you may be able to use something stable like an encyclopaedia type book to make it higher.  If you are using a laptop, think about getting either a separate screen or a laptop stand and separate keyboard
   5. That’s the basics, simple huh! If you want to dot the is and cross the ts there’s more at www.hse.gov.uk/pubns/ck1.htm
3. Keep mobile – much of the work I do with you is about increasing mobility, either to allow for postural correction or to share the load between areas and even to increase the force absorption capacity of an area.  You can do this yourself, even if you don’t increase your own mobility you can maintain the gains from your last round of treatment
   1. Swimming – front and back crawl are wonderful for shoulder, upper back and ribcage mobility.  If you have neck issues, backcrawl is better, especially if you don’t like swimming with your face in the water so end up holding your neck up in front crawl.  Breast stroke kick can be great for hip mobility but it can be tough on the low back, especially if, again, you swim with your face out of the water and it can aggravate sacroiliac joint issues.  There’s a new council swimming pool in Vauxhall, if you weren’t already aware.
   2. Pilates and/or yoga – some prefer one, some prefer the other, both will help you maintain mobility, stability and strength, both can be very varied in their approach and in the demands they place on you.  Make sure the class you attend is right for you.  If you are a beginner and/or have particular needs and/or limitations tell the teacher about it first.  Embody Wellness run yoga and pilates classes suitable for beginners…I go to John Hobbs’ Bodycare pilates, which I highly recommend and have booked my first session at Tash Sekar’s Gentle Yoga.    
   3. Walking – Particularly for those with a bad back walking can be very beneficial.  Almost all back conditions are improved by a gentle stroll.  Try and leave your hands free to swing, so use a rucksack if you need to carry anything and buy some gloves rather than keeping your hands in your pockets.  If walking is particularly painful for any reason, then get that resolved, if you possibly can.  Life is too short to put up with that.

Following these guidelines won’t prevent injury or totally remove the need to come for treatment but it may reduce your need for treatment and more importantly improve your quality of life between sessions

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? 
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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
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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:

• The cellular level, where cellular health and function may be influenced by easier and better delivery of nutrients and removal of waste
• At the level of the local tissue, as an aggregate of cellular health
• At the level of the joint, muscle or other structure
• At the level of system, or part of system, the muscular skeletal system, the back. 
• At the level of general health
• Often even the patient's psychological and social spheres will be affected by these changes

and that is where the idea that "the body is a unit" - another core principle - comes in.  Change in the function of one joint is often not the goal.  If somebody wants to be able to pick up their grandchildren again, it is almost irrelevant whether L3-4 moves nicely because it is a very small part of that process that involves hips, back, core muscles etc even if we have identified that the twinge they feel that stops them achieving that goal comes from an inflamed facet joint at L3-4.  Actually that process includes very important non-biological inputs too, confidence in their ability along with support and encouragement.   

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.