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Hi all just thought I'd post this case study for fun, useful study and maybe get some interesting debate going.

This lady had previously seen her GP and ref'd to other MSK specialists but had so far had no diagnosis or effective treatment. After evaluation I referred back to her GP. The attached pelvic X- ray was taken after re-referral to GP. The letter to the GP pretty much covers the case History, patient presentation, patient expectations, clinical findings, diagnoses and recommendations and initial intervention by myself.

Mrs C later reported by phone that further investigation by MSK /orthopods was scheduled and that she felt her gait and posture was much improved by the heel lift and mobs and had also reduced painful symptoms.



(Letter to GP)
Dear Dr J
Mrs C who is 74 years old has attended my clinic today complaining of lateral thigh pain and anterior shank pain and requesting an assessment of gait and posture with a view to improving and awkward limping gait and resolving pain, although pain appeared to be a secondary issue to the gait progression.

No meds, no significant medical history admitted to except general OA.

With regards to pain there seems to be several separate pathologies:

1) muscular stress, i.e. ilio tibial band and anterior Tibialis, caused by the compensations required to stabilize the limping gait.
2) Extraordinary pelvic position that requires further investigation
3) Loss of right hip Range of motion (RoM) and associated pain in the groin and knee indicates the possibility of arthritis of right Hip.
4) Loss of right hip flexion RoM and weakness in hip flexors.

1) Equinus ankles and much reduced internal / external RoM of right hip result in
excessive stabilizing strain on ITB at left swing thru. The equinus ankle and
inability to flex right hip result in overuse strain of Ant Tib muscle in order to
clear forefoot of the ground during right swing phase.

2) (and including 4) The pelvis is rotated to the right in the transverse plane so
with feet and knees facing forward the ASIS faces 30dgs to the right. The right
innominate ilium (pelvic half) appears to be smaller than the left and this may
account for some of the apparent pelvic rotation. (NB the right and left GT
appear to be aligned in the same transverse plane.) The reduction in ilium size
may also account for some of the hip flexor weakness since there would be a
reduction in moment arm (effective lever) for the Rectus femoris muscle about
the joint and the pulley lever action of ilio-psoas is reduced. However Mrs
C reports that the weakness only started or was noticeable from about
2 years ago. Therefore with the abnormal pelvic rotation in at least two planes
there may be some narrowing of the vertebral lumen (L234) and compression
of the femoral nerve. The right iliac spine and Greater Trochanter are lower than left by about 30mm and measuring from GT to lateral malleolus there is
20mm shortness in the right leg.

3) Hip RoMs are 5dg internal and external rotation, passive and active, Hip
flexion is 80dgs passive and less than 20dgs active. Passive flexion causes
pain. Mrs C reports groin pain and knee pain that is intermittent.
In walking gait Mrs C rocks from side to side and drops onto the right foot
both as compensation for the short leg and also for weak hip abductors. At present I have fitted a 13mm triple density extended heel lift in the shoe beveled to 4mm at the fore foot / MPJs. I have also mobilised the ankle joints to enable greater range of motion in dorsiflexion. These simple measures have greatly improved the gait progression. That is, the foot clears the ground more easily, the right leg is effectively the same length as the left and the joint mobilisation releases muscle tensions and improves strength in the hip abductors. She was quite pleased with these results and she may find this sufficient for her needs.

However, Dr J, I have referred Mrs C back to you for further
investigation of the pelvic position, right hip and lumbar spine / sacro-iliac condition, query arthritis. I feel it is important to establish the pathology that has led to the functional gait problems and recognize the actual anatomy here before proceeding with any extensive therapy.

Regards Dave Smith

__________________
Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.

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Dear Dave et al

Having just finished another workshop with podiatrists the following must be learnt

In diagnosing hip OA it is very simple if you remember the hip capsule rule.
Greatest loss of ROM is Internal Rotation
followed by Abduction and then
the least loss of ROM is External rotation
If this is the pattern then they have OA and thus there is no real need to perform an X-Ray unless there is a red flag

The reason for posting this is that NO hands on person knows this simple rule.

Secondly once the diagnosis is made, ie OA the patient has the gait of osteoarthritis.
That is short and painful adductors and pain over Conneely's position (humbly written)
This spot is found by side lying the patient, using the direction of the shaft of the femur, find the greater trochanter and move up 6cms in this direction and push and watch them go through the roof.

This overlies the position of the glut medius' twist.

I needle these two spots (adductor and glut) with great success.
If you get the patient earlier enough you can get about three years of treatment before the hip pain exceeds the muscle pain.
There are two very important benefits here
1. they are three years older and thus reduced the life span of the replacement
2. the odds are there is a better model available for them to have implanted.

It just shows you how poorly doctors are taught.

AN aside:
So far Since Feb 2012
Have now had 5 patients with detailed letters from specialists regarding their story and examination. Sounds great
but the patients say they were NEVER examined. Did not get their shoe off, not one of them

Stick to Conneely's rule: never believe the last person to see your patient know what they were doing or examined them until proven otherwise. It will save much angst in the long run.

Regards
Lousy weather here.more rain +++ on the way
Paul Conneely
www.musmed.com.au

Why do you think that people with OA of the hip hurt when you push 6cm above the greater trochanter?

Eric

Dear Eric
I presume you were addressing me, my name is Paul

Each time a person who has problems with their glut. medius will always lie in the most comfortable position and thus this 6 cms is fairly constant.

When you palpate this area you will find a taut band there and on compression it will be tender.
Those who dry needle tender spots will only put the needle into the tissue until they hit this spot.

This will work in reducing their pain but not stopping it.
The key is to use a 75 or a 100mm acupuncture needle so you can hit the periosteum. when you hit this they will tell you that you are on the money!
I use 2-3 needles here and leave them in there for 15minutes.

I suppose the glut gets into trouble for several reasons. One is that it is antagonistically opposing the adductors.
Two as the patient gets older the muscle gets weaker
three it is grossly disadvantaged in the first place.
EG. If you weigh 100Kg, the quads only have to do 88 KG of effort, mechanically advantaged.
the gluts on the other hand have to do 178Kg of effort, grossly mechanically disadvantaged even when healthy.

This is why sprinters who stand up too soon (less than 68 metres) never win a race. The more you can stay low the angle of your trochanter vs the glut origin the more efficient it is.

Glut failure is dime a dozen. Just look around in the supermarket at how many women have to lean on their trolley to move it around as they put more groceries into their trolley.

This simple technique gets so many women out of the hip pain they cannot sleep on that drives them nuts.
Regards
very wet here, 100mm last night.
Paul Conneely