Physio Charlie

I have a new website!!

 

http://physiocharlie.vpweb.co.uk

 

 

 

 

http://www.youtube.com/watch?v=_1RARwli_Zs&feature=related

 

SI jt Ax:

http://www.youtube.com/watch?v=Eu9JaM9S0Ak&feature=PlayList&p=4C3ECA6E484A19AF&playnext=1&index=1

http://www.youtube.com/watch?v=ifO9SgdEfgk

http://www.youtube.com/watch?v=sPgVu2NjVHE&feature=related

I found this on youtube about SI manip; "Chicago"

http://www.youtube.com/watch?v=y9-dRk91AXI&NR=1

Also: Taping for anterior innominate

http://www.youtube.com/watch?v=QPppVRgdORE&feature=related

Piriformis release:

http://www.youtube.com/watch?v=UFXWrYoS9ho&NR=1

http://www.youtube.com/watch?v=uuozn0i-De8

Flouroscopically guided SI injections:

http://emedicine.medscape.com/article/96054-media

 

 

 

 

 

 

Vleeming et al, (2007) European guidelines for the diagnosis and treatment of pelvic girdle pain, European Spine Journal, DOI 10.1007/s00586-008-0602-4

http://www.backpaineurope.org/web/files/586_2008_602_Onli...

Analysis and interpretation of evidence for the use of acupuncture for pelvic (including low back) pain in pregnancy:

http://www.interactivecsp.org.uk/uploads/documents/Acupun...

Protocol

 

1.        Acupuncture for pelvic pain must not be offered until the foetal gestational age has reached 13 weeks. Gestational age of the foetus is calculated from presumed ovulation date. [The length of uncomplicated gestation is 274 days in primiparas and 269 days in multiparas (Mittendorf et al., 1990).]

2.        Patients should have attended either an obstetric advice group or an individual appointment with a physiotherapist before acupuncture is considered.

3.        A basic pelvic assessment and appropriate treatment for pelvic pain should be carried out before assessment for acupuncture is undertaken.

4.        In obtaining informed consent to acupuncture from the patient the possible side effects, reported in relation to this type of intervention, must be given. These include local pain, haematoma, heat/sweating, ecchymosis, nausea, tiredness and weakness. The physiotherapist should reassure the patient that if they experience any local pain then the needle in question would be removed.

5.        The patient must be advised that they should not experience strong stimulation. If they do then they must inform the physiotherapist immediately so that stimulation can be stopped and if necessary the needle(s) involved can be re-sited or removed.

6.        Points SP5, KI6, GB34, GB39, GB40, ST36, ST40, ST44, TE5, and GV20 should be palpated for tenderness by the physiotherapist and points selected according to tenderness if possible. No more than 4 needles to be used at the first treatment session, and no more than 8 needles to be used at any time.

7.        Superficial or intramuscular insertion, where appropriate, may be used. If intramuscular insertion is used then some attempt at obtaining deQi sensation is permitted but should not be prolonged. Avoid obtaining strong deQi.

8.        Needle diameter and length may vary according to patient size and needle site. Smaller diameter needles will produce less stimulation to the nervous system but the patient may need adequate stimulation to produce a clinical improvement in pain relief.

9.        Needle retention time should generally be for 25-30 minutes, although a shorter session is appropriate at the first treatment.

10.      Gentle stimulation of the needle at intervals through the session is permitted.

11.      A balance of points above and below, left and right is to be aimed for.

12.      A course of treatment needs to be 2 to 3 times a week for at least a month to maximise effectiveness. This needs to be agreed with the patient and adequate staff resources available to implement such a programme of treatment. In order to maximise effectiveness patients who are 35 weeks or more into their pregnancy should not be considered for acupuncture.

 

References

 

Grieve, G (1979) Mobilisation of the spine. Edinburgh, Churchill Livingstone.

 

Lundeberg T and Stener-Victorin E (2002) Acupuncture handbook of points, Stockholm.

 

Mittendorf R, Williams MA, Berkey CS, Cotter PF (1990) The length of uncomplicated human gestation. Obstet Gynecol. Jun; 75(6): 929-32. Comment in: Obstet Gynecol. 1990 Oct; 76(4): 732-4.

 

Smith C, Crowther C, Beilby J (2002) Acupuncture to treat nausea and vomiting in early pregnancy: a randomized trial. Birth: Mar 29(1); 1-9.

 

Smith C, Crowther C, Beilby J (2002) Pregnancy outcome following women’s participation in a randomized controlled trial of acupuncture to treat nausea and vomiting in early pregnancy. Complement Ther Med: June 10(2); 78-83.

 

 

I have a patient at the moment who presents with symptoms similar to Osteitis Pubis, I did some research:

OSTEITIS PUBIS                                                        

INTRODUCTION

Osteitis Pubis (OP) is considered to be a painful non-infectious inflammation involving the pubic bone, it’s cartilaginous joint the pubic symphysis and the surrounding structures. Palastanga (2000) states that one pubic body slips in relation to the other at the pubic symphysis joint.  It is one of the most common musculoskeletal causes of groin pain in athletes and has also been described as a complication of various obstetrical and gynaecological procedures.  It was first described in 1924 by Beer, a urologist who wrote a paper on a patient who underwent suprapubic surgery.

However, practitioners must be aware that OP presents with a wide range of non-specific symptoms, involves a vast differential and has a generally unclear aetiology.  The full occurrence and distribution of OP has yet to be evidenced conclusively.  Therefore it is essential that practitioners are aware of this disorder especially in relation to patients with persistent groin, abdominal or pelvic pain.  Misdiagnosis is common.

EPIDEMOLOGY

According to Vitanzo and Mcshane (2001), the true prevalence of this condition has yet to be conclusively determined, however OP has been associated with:

§         Athletic activities.

§         Complication of various Gynaecological and Obstetric procedures including Parturition (childbirth)

§         Microtrauma

§         Pelvic surgery:  prostrate, bladder neck and urethral surgery

OP can occur in all age ranges and fitness levels, it is most common in men aged 30-40 years.

AETIOLOGY

The cause of the disease is undetermined, but both inflammatory and traumatic causes have been discovered.  However, Vitanzo and McShane (2001) suggest that one common cause stems from unusual biomechanical stress to the pelvis and Palastanga (2000) suggests that OP may be related to abnormal stress across the symphysis.  Activities that include twisting, cutting, pivoting on one leg, excessive side-to-side motion or multidirectional motions with frequent acceleration and deceleration, create acute or continuous shearing forces across the pubic symphysis.  This presents itself particularly in footballing injuries, especially in sprinting associated with kicking or a sudden change in direction.  The rotational stresses on the joint may cause it to become lax and partially dislocate.  As mentioned above, OP occasionally follows pelvic surgery and complications in gynaecological and obstetric procedures.

 

PATHOLOGY

OP is an inflammatory lesion that occurs in the region of the pubic symphysis joint and is the outcome of repeated micro trauma.  OP is eased by rest and after an extensive time period, is self limiting (heals on its own).

HISTORY/MECHANISM OF INJURY

As mentioned previously, a history of activities which place a repetitive stress across the pubic symphysis joint will cause OP.  These include football, rugby, gymnastics, basketball, running and other similar sports.  Sports that involve sprinting alongside kicking or a sudden change in direction have a significantly higher chance of causing OP.

SIGNS & SYMPTOMS

Vitanzo and McShane (2001) assert that patients presenting with OP have a variety of nonspecific symptoms which therefore makes an accurate diagnosis of OP difficult.  Signs and symptoms include:

§         Pain (especially on hip abduction) states Vincent (1993), and pubic tenderness.  Palastanga (2000) states that pain relating to OP is usually referred to the hip joint and there may be some loss of hip mobility, especially medial rotation and sometimes lateral.  Pain is also experienced in the unilateral or bilateral groin (inguinal canal), medial thigh, testicular, scrotal, perineal, suprapubic and anterior pubic area.

§         The type of pain is described as sharp, stabbing or burning.

§         Pain is exacerbated by running, kicking, twisting, climbing stairs, valsalva manoeuvres, pivoting on one leg and general exercise.

§         Pain is eased by rest, but not entirely.

§         Patients may describe a “clicking” sensation at the symphysis pubic joint with movement.

§         Difficulty in ambulation and is characterised by the “waddling gait”. 

§         Sometimes a low grade fever is present.

§         Elevated sedimetation rate (the rate at which solid particles sink in a liquid under the influence of gravity)

§         Moderate leukocytosis (an increase in the number of leucocytes in the blood).

IMAGING INVESTIGATIONS

X-rays can lag behind clinical symptoms by as much as 4 weeks according to Vitanzo and McShane (2001) and it is not uncommon for an X-ray to be normal.  As the disease progresses changes seen on X-ray include: widening of the symphysis joint space, symmetrical re-absorption of the bone at the medial ends of the pubic bones, symmetrical rarefaction (thinning) or sclerosis (hardening) along the pubic rami, osteophytes and cysts may also be present.  MRI scans are valuable in detecting early signs.  If instability and partial dislocation is suspected, an additional one legged “flamingo view” X-ray of the pelvis is required.  More than 2mm difference between the superior rami of the symphysis will indicate this.

DIFFERENTIAL DIAGNOSIS

According to Lentz (1995) the major differential diagnosis is osteomylitis (inflammation of the bone due to infection); however he states that OP can be recognised by it’s self limiting nature and its response to nonantibiotic therapy.  Other differentials include:

Apophysitis Bony avulsion (gracilis syndrome) Conjoined tendon dehiscence Genitourinary infection Gout Hemochromatosis Hip pathology Hyperparathyroidism Inguinal hernia Isolated muscle tear (adductor or abdominal)

Lumbar radiculopathy Myelomatosis Nerve entrapment (ilioinguinal) Postpartum symphysis separation Primary or metastatic tumors Pseudogout (calcium pyrophosphate disease) Rheumatoid arthritis

Sarcoidosis Seronegative spondyloarthropathies (especially Reiter's syndrome and ankylosing spondylitis) Stress fracture (pelvic or femoral) Tendinitis (adductor) Traumatic pubic symphysis disruption Urolithiasis

Vitanzo and McShane (2001)

TREATMENT – Surgical/medical

Primarily, the aim of treatment is to reduce inflammation and pain by using rest, ice and physical therapy modalities (see below).  Medication may include NSAIDS, if the patient has intense pain from inflammation, oral corticosteroids may be used.

TREATMENT – Physiotherapy

Treatment is based on rest, for acute OP - stop all sporting activity for 3-4 months, chronic OP – 6-18 months.  Therapeutic ultrasound (in some cases) is appropriate.  When pain and inflammation are reduced, patients should begin a structured physiotherapy programme progressing to graduated exercises:

§         Ballistic adduction movements, rapid full range flexion and extension movements and rapid resisted work for the rectus abdominis should be avoided.

§         Increase extensibility and strength of groin adductors

§         Gentle hip strengthening exercises

§         Static/active exercises for rectus abdominis

§         Cycling, Swimming

§         In athletes, promote a progressive return to fitness through “straight line” activity, before introducing rotational turning, kicking etc.

COMPLICATIONS

If symptoms persist injected corticosteroids may be considered, but only after infection has been excluded (this should be used as a final attempt to cure the condition before surgery is carried out).  Patients who do not respond to the treatment outlined above should be considered for surgery.

PROGNOSIS

As mentioned previously OP is self-limiting.  Return to pre-injury level of functioning may take from 3-6 months and sometimes longer, however, success rates are high 90-95% according to Vitanzo and McShane (2001).

REFERENCES

Lentz, SS  (1995).  ‘Osteitis pubis: a review’, Obstetric and Gynecological Survey 1995 Apr; 50(4):310-55

Palastanga, N, Field, D and Saomes, R  (2000).  Anatomy and Human Movement, Structure and Function.  Butterworth and Heinmann.

Vincent, C  (1993).  ‘Osteitis pubis’, J Am Board Family Practice 1993 Sep-Oct; 6(5):492-6

Vitanzo, P & McShane, J  (2001).  ‘Osteitis Pubis Solving a Perplexing Problem’, The physician and sportsmedicine - vol 29 - no.7 - july 2001

Sexton DJ, Heskestad L, Lambeth WR, McCallum R, Levin LS and Corey GR (1993). Postoperative pubic osteomyelitis misdiagnosed as osteitis pubis: report of four cases and review. Clin Infect Dis. 17 (4): 695-700.

We believe that many previously reported cases of osteitis pubis were actually cases of unrecognized pubic osteomyelitis. We advise an aggressive diagnostic approach to cases of apparent postoperative osteitis pubis including biopsy and needle aspiration of the symphysis pubis guided by computer-assisted tomography.

The CSP has found a good piece of research on Groin strain.

 http://www.cebp.nl/media/m573.pdf

Holmich, P. et al. (1999).  Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. The Lancet, 353, 439-443.

1)     Position:         lie on side - twist foot so heel on bottom leg points towards ceiling

 

Exercise:        lift whole of bottom leg off floor

 

 

2)     Position:         lie on side - twist foot so heel on top leg points towards ceiling

 

Exercise:        lift top leg towards ceiling

 

 

3)     Position:         lie chest and shoulders over edge of table / bench-top.  Feet on floor

 

Exercise:        lift both legs slowly off floor to horizontal

 

 

4)     Position:         standing side on to pulley machine / theraband attached to pillar

 

a)     outside leg attached to weights / band,  b) then inside leg attached

 

Exercise:        lift leg to side, and slowly lower

 

 

5)     Position:         standing on one leg +/- holding dumbbell in hands

 

Exercise:        bend and straighten weight-bearing leg as arms move forward and backwards - keep opposite arm and leg moving forward at the same time.

 

 

6)     Position:         standing on polished floor, wearing socks

 

Exercise:        slide side-to-side for 1 minute - repeat 5 times

 

 

 

I had a young footballer that has been puzzling me for a few weeks now.  He came in with left groin pain after playing a very tough game of football.  He had tried rest from football for 2 months but to no avail.  Palpation of the ant pubic rami was painful and the left adductors were painful and weak to resistance.  The pubic symphysis joint was aligned but the right SI jt was a little stiff on Peidallau's test, stork test was negative.  He had a previous stomach muscle injury but no evidence of any hernia. 

The footballer thought he had gilmores groin but after a bit of research I am more convinced he has Osteitis Pubis.  See research attached:

OSEITIS_PUBIS.doc

Ostetis_pubis_in_footballers.pdf

I have given him hip strengthening and core stability exercises, told him to rest from football for at least 3 months and started him on a cycling programme.  I am using low pulsed ultrasound on the ant pubic rami. 

  

I had a patient today who came in with a groin injury after playing football. 

Taken from: http://www.sportsinjuryclinic.net/cybertherapist/front/fr...

What is Glimore's groin?

Gilmore's groin involves a tear of the adductor muscles, usually high up near the attachment to the public bone. It is sometimes called the Sportsman's Hernia, there is not actually a hernia present. It is common in sports were a great deal of strain is placed on the groin and pelvic area such as soccer and results in groin pain.

Although groin pain can vary, the features of a Gilmore's groin include a torn external oblique aponeurosis (ribbon like structure), tendon torn from the pubic bone.
 

Symptoms include:

• Groin pain thats increased by running, sprinting, twisting and turning.
• After training the athlete may be stiff or sore.
• The day after training / playing the athlete may have groin pain when turning or even getting out of a car.
• It is claimed that in 30% of athletes there is a history of sudden injury but the majority indicate it to be a gradual overuse injury.
• The diagnosis of Gilmore's groin is based on the patient's history and clinical signs. The most notable clinical sign is dilation of the superficial Inguinal ring on the affected side, which can be palpated by the examining doctor when the scrotum is inverted with the little finger.
• Typically, there is specific pain on coughing and sneezing, as well as sitting up and squeezing the legs together.
  

• Although it is often possible to continue training with a Gilmore's groin the conditions is likely to get gradually worse.
• Conservative treatment involves strengthening the muscles of the pelvic region; transab and multifidus.
• See a sports injury professional and / or surgeon who can make an accurate diagnosis.

What can a doctor or surgeon do?

• For athletes that have not responded to rehabilitation surgery is indicated, which is usually successful.
• Following surgery a 4 to 6 week rehabilitation period is usually required before returning to play.
• The rehabilitation programme will be aimed at gradually improving the strength and flexibility of the pelvic muscles and will avoid sudden twisting and turning movements which may aggravate the injury.

For a list of alternative diagnoses for groin pain go to:

http://www.wrongdiagnosis.com/sym/groin_pain.htm