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Shoulder Instability

Shoulder Instability

When Shoulder Instability was first Recognised:

Shoulder instability has not been new , and has been recognised over 3000 years ago on Papyrus in Egypt. Hippocrates used the old fashioned technique of placing a heel in the axilla of the unfortunate injured person and applied traction and with various degrees of success helped to “put the shoulder back in the right place. 

Dynamic Anatomy of Shoulder Instability

There are a group of Static stabilisers including:

The Dynamic Stablisers include:

  1. Bony
  2. Labrum
  3. Glenohumeral Ligaments
  4. Coracohumeral Ligaments
  5. Capsule
  6. Negative pressure (which helps “suck in arm to shoulder”.
  1. The rotator cuff
  2. Biceps
  3. Scapula stabilisers.
  4. Proprioreceptors

Anatomy of Instability

Instability happens when one of the above structures goes wrong eg the labrum a soft tissue lining that cloaks the joint may weaken, as it also is the anchor for ligaments.

There is good news as when we age this shoulder bone stiffens and becomes stronger reducing the propensity to disclocation.

The ligaments above the joint (the superior glenohumeral ligaments act as a restraint fo inferior/ posterior translation

The middle gleno humeral ligaments act as a restraint for inferior translation and also limits external rotation.

Testing the Shoulder

For any shoulder issue a general range of motion is done to see how far the shoulder will move, along with seeing how strong all the particular strengths and range of movements are: (external rotation, internal rotation, flexion and extension).

A very simple test is to just see how far down you can pull the shoulder instablility shows if the joint can be pulled down and show a dimple in the shoulder. This is called the sulcus sign.

The patients overall laxity must also be assessed. Generally as an overall test for laxity the mobility  of fingers, thumbs, elbows, knees and palms to ground is assessed.  A score of above 6 indicates hyper-mobility. This is often found in conditions such as Marfans and Ehler’s – Danlos syndromes.

The other tests that are done are X Ray , MRI arthrogram, and CT arthrogram.

Types of Instability

 Shoulder instability leading to anterior dislocation is at 90% the most common, which affect 2% of the population, around 90% of these occur under the age of 20, 14% recur after the age of 40.

Posterior dislocation comprise only 2 -5% of shoulder dislocations in such cases patients are unable to externally rotate their arm.

 Surgery For Recurrent Dislocations

 If a shoulder dislocates too often or recurs then surgery should be considered. This is particularly the case when there is structural pathology and when this occurs ligaments can be  tightened , and any looseness of the joint capsule repaired.

What Can Be Done Before Dislocation?

If a shoulder shows signs of instabilty there are plenty of shoulder strengthening exercises that can be done to address this issue.

Osteopathy and Acupuncture

Are very useful tools that can help both help ensure better stability, and is helpful in the post surgical rehabilitation where there might be residual stiffness and awkwardness in movement.

The SacroIliac Joint. What can help?

The SacroIliac Joint. What can help?

The SacroIliac joint is the joint that attaches the spine via the Sacrum to the pelvis. It is a joint with cartilage much in the same way as the hip or knee.

The Sacroiliac joint also demonstrates movement in all directions, and the Sacroiliac joint and its surrounding areas has a lot of nerves, which help transmit pain.

Function of the Sacroiliac Joint

Its main function is to provide stability, motion and to also provide protection of internal organs and structures.

It is a rather immovable joint. In women its mobility increases during pregnancy to allow the passage of a baby, which helps open up the pelvis during childbirth.

Prevalence

There is a 13-30% incidence of SacroIliac pain in patients with low back pain. The SacroIliac joint can also become diseased in a inflammatory condition called sacroiliitis. This can be the start of an inflammatory disease called Ankylosing Spondylitis where the ligaments around the spine calcify and eventually fuse.

The other interesting thing to note is that 43% of pain in the SacroIliac joint comes about after spinal fusion. So the Sacroiliac joint is a significant source of pain after lumbar fusion.

This is thought to come about because sometimes the diagnosis of Sacroiliac joint is missed! Furthermore after a fusion more strain is put opon the Sacroiliac Joint which then becomes symptomatic.

In terms of health burden SacroIliac pain is roughly equivalent to hip Osteoarthritis, Spinal Stenosis, Knee Osteoarthrits and Chronic depression 

Referral Patterns

SacroIliac pain can frequently refer into the groin, but also to the side of the leg, and occasionally down the back of the leg. 

This sometimes makes diagnosing Sacroiliac patterns difficult as low back pain and leg pain often overlap.

However with a good Osteopathic examination it is relatively straightforward to diagnose whether pain is coming from this joint. 

Treatment

Once a diagnosis of Sacroiliac dysfunction is made, then treatment can be initiated.

Osteopathy is the number one choice where stretches are made to the joint, which helps return it to normal function which in turns helps reduce any inflammatory changes.

The joint is large and is usually quite stiff and sometimes difficult on which to use manipulative treatment.

In such a case Acupuncture is used as this has the advantage of not having to use any form of manipulative treatment, helps stimulate blood flow and is effective at reducing pain in the area.

Osteopathy For a Painful Foot?

Painful foot

This short article will describe how osteopathy for a painful foot is helpful. I will concentrate on the forefoot as this is the area more commonly afflicted with painful conditions that bring patients for osteopathic treatment.

The painful foot is the basis on which all movement relies. If the foot goes wrong we are then unable to walk properly and in many cases because our walking is affected via limping and altered gait, it then throws pressure on other parts of our body eg knees, hip , and spine and these can become painful.

There are many conditions but here will talk about the most common conditions affecting the foot particularly the front.

Bunion (Hallux Valgus)

In this painful foot condition the main symptoms are:

  1. Painful swelling on the side of the first toe
  2. Limited movement as in push off when walking
  3. Pain in rest and in walking, unable to run.
  4. May have pain up the body eg knee , hip or buttock from uneven walking.

This has been talked about before on a previous blog foot problems. As an add on it should also be noted that there is often rigidity and pain on flexing the toe. This is due to osteoarthritis and though Osteopathy may help sometimes it is necessary or desirable to seek further help.

The further problem of a bunion is that a person cannot walk properly due to the pain and transfers weight to the other part of the foot for example the second toe and pain is experienced here.

In some people the pain can spread to the rest of the forefoot which is called metatarsalgia and comes about when the forefoot takes on all the weight due to the bunion.

it is for this reason that a bunion needs to be taken seriously as it can cause a lot of pain and problems elsewhere. Painful

Osteopathy For A Painful Foot

Acupuncture is helpful in reducing the pain, and inflammation as osteopathic manipulation of the toe and fore foot, helps increase mobility.

if pain though ensues or there is too much rigidity then surgery may be necessary.

Here a small amount of bone is taken away to give a more even look and takes of some of the strain on the joint thereby reducing pain

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528062/

Case of Knee Pain caused by Hip problem.

Case of Knee Pain caused by Hip problem.

In this blog I am highlighting an interesting case history of knee pain, caused by a hip problem.

I have written on cartilage tears for knee pain before. I want to write about some interesting cases whose outcome may come as some surprise.

Knee Pain

I want to write about an interesting case of knee pain caused by a hip problem. What you initially suspect is not always what it seems.

This case of knee pain concerns a 56 years old man who complained of right sided knee pain, over an eighteen month period. He had previously seen his GP, Physiotherapists, and another Osteopath.

Eventually he saw an Orthopaedic surgeon who found a tear in his cartilage.

No arthritis was found and the tear was deemed to be the cause of his pain. He was advised to undergo arthroscopic surgery. The outcome was that he still had exactly the same amount of knee pain after this surgery.

Treatment had not relieved any of his symptoms of pain and restriction, and he had difficulty walking any distance, and he walked with a walking stick.

Knee Examination

On recommendation he consulted me and the remarkable things was that his knee had a normal amount of movement and could flex and extend his knee normally.

I then examined his hip joint which was painful and restricted on rotation. This immediately suggested the possible start of hip Osteoarthritis.

I then proceeded to treat his hip with Osteopathic manipulative treatment to try and increase the movement, and lessen the pain in this area suspecting that this area might indeed be the cause of his pain.

within a few weeks all his symptoms had gone, and was able to walk without pain.

Case of knee pain caused by hip problem

This was a more unusual case in which his hip joint was actually referring pain into his hip.

This can happen as inflammation around the hip can be a cause of knee pain. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336883/

This is a good example of why it is important for an Osteopath o look around the body for tissue that may refer pain to other parts of the body.

It is always wise to have your body checked to make sure there are no patterns emerging that may lead to your body not working as it should.

If you have any niggles that just aren’t going away give a call on

020 76921818 to get your body working efficiently again!

Paracetamol for Back Pain?

Does Paracetamol Help Back Pain 1
Does Paracetamol Help Back Pain

Does Paracetamol Help Back Pain?

As recently as 2014 with regard to paracetamol for back pain there was a paper in the lancet which suggested paracetamol for back pain was of almost no effect in the treatment of back pain. (The Lancet 2014; 384(9954): 1586-1596). https://www.sciencedirect.com/journal/the-lancet/vol/384/issue/9954

Sifting through the evidence though it seems paracetamol may still have a place, which helps answer the quandy of paracetamol and back pain?”.

Paracetamol for low back pain

Has been an over the counter medication that has been used over years to help reduce low back pain.  Studies have suggested that paracetamol for back pain is of little or no benefit to low back. These studies have not had many subjects in them to reach any definitive conclusion.

Recently studies have been done which was much larger where low back pain subjects were given ad hoc paracetamol for acute flare ups and some were given regular paracetamol.

The results showed that neither regular nor as required paracetamol improved recovery time as compared to a placebo.  There was additionally no effect on function, disability or pain and as a result there was no symptom change in sleeping or quality of life. There was also no increase in recovery time.

However, looking more carefully at the results although paracetamol does not alter the recovery from back pain it is still “mildly useful” in helping pain on a short term basis including on an “as needed basis”.

I advise patients in pain to try and see if it helps as the great thing with paracetamol is that unlike anti-inflammatories, it does not cause heartburn or aggravate the stomach.

The more noteworthy aspect is that manipulation and or Acupuncture are both superior to just paracetamol and in many cases not only reduces pain quicker but also curtails a low back event enabling a patient to get back to normal activities quicker, and as a result not having to take any medication!

If you do suffer back pain give a call and help will be there to get you off your Paracetamol.

Paracetamol and back pain
paracetamol

Sciatica Can it be helped?

SIGNS OF SCIATICA

 It is not always a disc that can cause this disturbance as it can also be caused by restrictions in movement particularly in the foraminal space (which is the space between the vertebrae through which the nerve travels) where the nerve exits the spine which can cause tethering or adhesions along the tract of the nerve which leads to  sciatica like symptoms.

Soft Tissue Compression

Compression from soft tissues which may be tight or sitting in an awkward position eg on a wallet can compress on that nerve and cause sciatica like symptoms.

Within the catchment of low back is a subgroup of Sciatica whose lifetime prevalence is 4 -5%.  Sciatica though   is a syndrome rather than a diagnosis, Very often caused by a disc compressing on a nerve in the lumbar spine which gives changes in motor or sensory feeling down the leg.

There can also be a double compression syndrome. Where two points along where the nerve runs become constricted which causes sciatica like symptoms.

The nerve itself can become inflamed causing a neuritis which again can cause symptoms of Sciatica going up and down the leg.

Sciatica like symptoms usually involve pain in the spine which refer pain down through the buttock and into a leg often going all the way down into the leg and foot. Typically, it is usually just one side that is affected. It

If Pain affects both sides or radiates down into both legs then this has to be looked at more carefully as more serious conditions may cause these problems.

Pain can be mild in character can be severe or sharp, burning, lancing or electric shock type symptoms.  Pins and needles can accompany this, burning sensations, weakness often e.g. limping can accompany this condition.

Sciatica can be short lived but, in many cases, can go on for months and sometimes years.

Sciatica can generally be helped with Osteopathy and Acupuncture is a very good adjunct to help in the painful and debilitating condition.  As nerve is affected these conditions can take longer than normal to help, and if cases don’t respond fairly quickly scans are needed to rule out other pathologies that can cause Sciatica.

If you have Sciatica do contact me and I will be pleased to advise If treatment may be of benefit.

https://www.bmj.com/content/334/7607/1313?flh=

https://www.sciencedirect.com/science/article/abs/pii/S1521694209001417

SIGNS OF SCIATICA

 It is not always a disc that can cause this disturbance as it can also be caused by restrictions in movement particularly in the foraminal space (which is the space between the vertebrae through which the nerve travels) where the nerve exits the spine which can cause tethering or adhesions along the tract of the nerve which leads to  sciatica like symptoms.

Soft Tissue Compression

Compression from soft tissues which may be tight or sitting in an awkward position eg on a wallet can compress on that nerve and cause sciatica like symptoms.

Within the catchment of low back is a subgroup of Sciatica whose lifetime prevalence is 4 -5%.  Sciatica though   is a syndrome rather than a diagnosis, Very often caused by a disc compressing on a nerve in the lumbar spine which gives changes in motor or sensory feeling down the leg.

There can also be a double compression syndrome. Where two points along where the nerve runs become constricted which causes sciatica like symptoms.

The nerve itself can become inflamed causing a neuritis which again can cause symptoms of Sciatica going up and down the leg.

Sciatica like symptoms usually involve pain in the spine which refer pain down through the buttock and into a leg often going all the way down into the leg and foot. Typically, it is usually just one side that is affected. It

If Pain affects both sides or radiates down into both legs then this has to be looked at more carefully as more serious conditions may cause these problems.

Pain can be mild in character can be severe or sharp, burning, lancing or electric shock type symptoms.  Pins and needles can accompany this, burning sensations, weakness often e.g. limping can accompany this condition.

Sciatica can be short lived but, in many cases, can go on for months and sometimes years.

Sciatica can generally be helped with Osteopathy and Acupuncture is a very good adjunct to help in the painful and debilitating condition.  As nerve is affected these conditions can take longer than normal to help, and if cases don’t respond fairly quickly scans are needed to rule out other pathologies that can cause Sciatica.

If you have Sciatica do contact me and I will be pleased to advise If treatment may be of benefit.

https://www.bmj.com/content/334/7607/1313?flh=

https://www.sciencedirect.com/science/article/abs/pii/S1521694209001417

Pinched Nerves

Laurens Holve briefly describes trapped nerves and nerve

Nerve pain is a very common form of pain and often results from disc problems, causing pain to radiate often from the neck and into the arm of if from the lower back travelling down into the legs. The pain is often described as like an electric shock or like warm water travelling down the limb and is often accompanied by numbness and tingling.

This sort of pain can often be relieved by a combination of mild Osteopathic manipulation and Acupuncture and so injections or even surgery are often avoided.

MIGRAINE HEADACHES

MIGRAINE HEADACHES

Migraine Headaches is a leading cause of lost work time and disability in the UK. It is more common in women at nearly 1 in 5 and 1 in 20 in men.

In the UK some 10% of people use Acupuncture to treat their migraine, whilst in Germany it is the most common form of treatment to treat migraines.

A definition of reduction of migraine headaches is a decrease of 50% based on criteria from the International Headache Society. This is in people having two to eight migraine attacks per month.

Recent studies have demonstrated that Acupuncture was associated with clinically and statistically significant improvement in clinical outcomes compared with no acupuncture.

Added to this can be the therapeutic protocol of adding Osteopathic treatment to the mix as this is a way to help loosen neck restrictions which can culminate as one of the major factors leading to headaches.

Very often pain in the trapezius on top of the shoulder can also be a big factor in causing headaches. Very often just pinching these muscles can lead to a pain referral into the head, and these points are called trigger points which can be effectively reduced as a migraine causing feature.

Certainly posture should always be looked at to try and maintain neck in an easy posture whereby strain is minimised especially looking at a computer screen.

Exercise is also very useful in helping minimise headaches and a lot of research has been done is establishing a link between exercise and headaches.

If you do suffer migraines give us a call on 020 7692 1818 or email me at lholve@camdenpractice.co.uk and ill be happy to discuss whether treatment might be of benefit.

Some References:

Diener HC, Kronfeld K, Boewing G, et al., for the GERAC Migraine Study Group. Efficacy of acupuncture for the prophylaxis of migraine: a multicentre randomised controlled clinical trial

. Lancet Neurol. 2006;5(4):310–316.

Streng A, Linde K, Hoppe A, et al. Effectiveness and tolerability of acupuncture compared with metoprolol in migraine prophylaxis. Headache. 2006;46(10):1492–1502. 11. American Academy of Medical Acupuncture. Frequently asked questions about acupuncture.

 http://www.medicalacupuncture.org/acu_info/faqs.html. Accessed February 24, 2010.

Common foot conditions: Part 1

Foot Conditions

Over the coming weeks I will be going through common foot conditions that many people suffer sometime in their lives. Today’s includes the common foot conditions of Morton’s Neuroma and Bunion…

Morton’s Neuroma

This is a condition that manifests itself as sharp burning pain which radiates into the toes, usually between the third and fourth toes. It is due to hypertrophy (enlargement) of a digital nerve which becomes entrapped and undergoes compressive forces against the deep transverse ligament which traverses the forefoot.

This condition can be reasonably easily diagnosed by pressing on the foot which elicits a click (Mulder’s Click), and of course the unique symptoms this condition presents

Investigations

This can be done by ultrasound or MRI scanning, ultrasound, where the overgrown nerve can be visualized, in a clinic situation positive Mulder’s Click. The latter is easily undertaken in an osteopathic setting where the forefoot is drawn together to see if a click can be elicited.

Treatment

Should someone attend with this problem, there are a variety of ways in treating this: Acupuncture, Osteopathic manipulative treatment, orthoses can be of help. However, if these don’t work then steroidal injections can help reduce symptoms and then surgery can be used to remove the fibroconnective tissue.

Ref: https://search.proquest.com/openview/4475cbba9889e577396015907e8dad14/1?pq-origsite=gscholar&cbl=39729


Hallux Valgus (Bunion)

This is where people have a bump on the big toe, with some deviation to the side. There is usually pain associated on the inside of the toe and because of pressure symptoms

Orthoses do not help this condition, and the only suitable treatment for this condition is surgery. However, Acupuncture can help reduce pain and may well enable the person to continue normal movement

Ref: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007809.pub2/abstract