Thank you, everybody, for the comments left on our FB post. It is great to see active engagement of therapists who practice the clinical aspects of MT. Many causes of the condition initially described in the post were mentioned. Let us summarize them: tension in the lumbar erectors, quadratus lumborum, piriformis, iliopsoas, adductors, fasciae latae muscles, misalignment of the sacroiliac joint, lumbar disk pathology with radiculopathy, etc.
Ironically, all therapists who commented on this clinical situation were correct. Indeed, the patient exhibited all these symptoms. However, they were the brain’s protective reactions to a completely different cause, which had been missed by the different health practitioners who had previously worked on this patient. The real cause had hidden behind layers of secondary symptoms, which were clinically pronounced and hid the real trigger. So those readers who mentioned hip joint pathology were right on point.
Science of Massage Institute
MEDICAL MASSAGE vs. HIP OSTEOARTHRITIS
The patient is a 45-year-old IT specialist who works from home. He came to the clinic with complaints of left lower back pain and left lateral and anterior hip pain that radiated to the groin. The pain in the left hip was especially sharp when he got up from a chair or during his first steps in the morning. The level of pain decreased with active movements. These symptoms had started approximately a year ago and had slowly got progressively worse.
Initially, the patient had visited a chiropractor, who took an X-ray of his lower back and detected the presence of slight right-sided Lumbar Scoliosis and narrowing of the L4-L5 and L5-S1 intervertebral spaces. The doctor correctly considered this curve to be so-called compensatory scoliosis, and a diagnosis of Degenerative Disease of the Spine was established. After combined therapy by the chiropractor and a massage therapist, the patient was almost completely pain-free for 2-3 weeks, but the same symptoms eventually came back.
The patient went to his PCP with an already established diagnosis, and the doctor sent him to physical therapy, which again helped him a lot, but the same symptoms eventually came back. He was also treated by an acupuncturist and another massage therapist with similar results.
VISUAL EVALUATION
The patient is moderately overweight, and he slightly limps on the left side when he walks. His foot is in outer rotation (Freiberg’s Sign), which indicates significant tension in the piriformis muscle.
TESTING AND PALPATION
The patient exhibited tension in the lower back in the superficial fascia, lumbar erectors and quadratus lumborum muscles on both sides, but the degree of tension was more prominent on the left. An active TP was registered in the left piriformis muscle.
Various Compression Tests indicated local tension, but they didn’t provoke neurological reactions. The patient had never experienced numbness or ‘pins and needles’ sensations in his lower back or left lower extremity.
Palpation of the soft tissues on the lateral and anterior hip and groin immediately triggered withdrawal. The tensor fasciae latae, rectus femoris, iliopsoas and especially the adductors harbored active trigger points. The patient also exhibited very active and painful periosteal trigger points at the muscles’ insertions into the greater trochanter, iliac spine and pubic bone on the left.
Palpation of the anterior hip above and below the inguinal ligament was very painful. Examination of ROM indicated restricted abduction and inner rotation in the left hip joint. Fig. 1 illustrates significant restriction of passive abduction in the left hip joint.
The measurement of the patient’s left lower extremity indicated almost half an inch of shortening. Considering that the patient had been unsuccessfully treated for various pain syndromes in the lower back and pelvis, it was obvious there was something else causing his pain and dysfunction. All signs pointed to Hip Osteoarthritis, which no one had even considered. We suggested that the patient see a physician in our clinic who would examine his left hip joint. The X-ray indicated moderate Degenerative Joint Disease (OA) of the left hip joint with joint space narrowing and spur formation inside the joint (see Fig. 2).
TREATMENT
After the diagnosis of left Hip OA was established, we used the full power of the Medical Massage protocol for hip OA. The goals were to decompress the joint, decrease pressure on the already compromised cartilage and slow down or stop further development of OA.
Each session started by addressing the lower back to eliminate pain and dysfunction there and restore correct lower back/pelvis dynamics. However, the main part of the therapy was dedicated to decompression of the left hip joint. The therapy sequentially targeted the soft tissues in the gluteal area, the lateral hip (tensor fasciae latae muscle with the IT band), the anterior hip (including the iliopsoas muscle) and finally the area of the adductors. We combined elements of Lymph Drainage, Connective Tissue Massage, Neuromuscular Therapy, Trigger Point Therapy, Myofascial Release, Muscle Energy Technique and Periosteal Massage.
After soft tissue release in each part of the hip, the joint itself was stretched along the axis of the joint and along the axis of the lower extremity. The patient used supportive therapy at home, which included frequent stretching, hot showers, an inversion table and light repetitive exercise in the swimming pool. Fig. 3 illustrates the patient’s hip abduction after 5 sessions of Medical Massage.
After 5 sessions, the patient no longer had lower back pain and had stopped limping. However, he still experienced moderate discomfort after getting up and during the first several steps. We continued the same treatment routine for five more sessions. Fig. 4 illustrates the degree of passive abduction at the end of the therapy. At that time, the patient didn’t exhibit the original clinical symptoms. You may also see that his passive abduction on the left is now greater than on his right, unaffected side.
Currently, we see the patient once a month for supportive therapy. The same results have been maintained for the last four months.
DISCUSSION
Let’s go over the clinical reasoning for this patient.
- It is a clinical mistake to concentrate on the lower back, as was done before, because the tension there is the result of the brain’s protective reaction to the hip joint’s degeneration. In these patients, the therapist is going to observe different degrees of local tension in the lower back and various postural changes (limp, tilt of the pelvis, etc.) that formed secondarily.
- Let’s restore a logical chain of events. For different reasons, the cartilage that covered the bones of the left hip joint became thinner. The receptors inside the hip joint informed the brain about cartilage degeneration and the brain took necessary actions. The brain has a limited number of tools to help the suffering joint at this point. To minimize further degeneration of the joint, the brain started to alter the patient’s gait, change the position of the pelvis, form compensatory scoliosis, etc., without him being aware of it. All these compensatory tools allowed the patient to function for a while, or, in other words, he was in the compensatory stage.
The fact that the patient started to feel pain indicated that these compensatory tools had failed, and he had entered the decompensation stage. It meant that in some small areas the cartilage was dangerously thin and the subchondral bone (i.e., the bone that supports the cartilage from under it) was under excessive pressure.
As soon as the subchondral bone came under increased compression force, during even regular walking, the nociceptors (previously known as ‘pain receptors’) became activated and formed the alarming sensory input to the brain. Only at this moment did the patient start to FEEL pain in the left hip, because the sensory cortex formed a pain sensation based on the data obtained from the nociceptors. At that moment, new compensatory reactions (a.k.a. new pain syndromes) developed in the soft tissues that participate in hip stabilization and active movements. As a result, a multi-layered somatic pathology developed, further clouding an already complex clinical picture.
Since each sensory input to the CNS should produce motor output, the brain’s new strategy to help the compromised joint was to prompt the patient to contact his chiropractor. The doctor correctly identified the most obvious components of the clinical picture he observed, but he and other health practitioners were facing the secondary compensatory reactions, which were layered on top of each other and hid the real cause.
- The legitimate question is: how stable are the clinical outcomes of Medical Massage? There is no way that Medical Massage, or any other modality, can restore damaged cartilage or remove osteophytes. So, further hip degeneration is expected as the patient gets older. So why is Medical Massage beneficial for this patient, and wouldn’t immediate hip replacement be the ultimate and quicker solution?
The answer to this speculation is quite simple. On average, the current lifespan of a modern hip endoprosthesis is 15-20 years. The patient is 45 years old, and if the hip joint continues to degenerate, early hip replacement surgery will be needed. In such a case, there is a very big chance that the patient is going to need another surgery at an age when his health is going to decline due to the normal process of aging, and there is a greater chance of further complications after the second surgery (endoprosthesis’ instability, osteoporosis, scar tissue formation, etc.).
A proper regime of supportive Medical Massage therapy in combination with other somatic modalities (chiropractic, acupuncture, exercise, etc.) and regular homework guarantee that hip replacement surgery can be postponed to a later age, and in such a case the surgery’s results are going to be clinically stable. There is also a slight chance that the correct management of his hip joint may ‘freeze’ its further deterioration.
LESSONS
- Please use the same strategy of analysis in each case of chronic pain and dysfunction, because if there is no previous trauma in the history of illness, the therapist more likely faces secondary compensatory reactions that pile on top of the initial trigger.
- If the patient presents with a chronic abnormality, the pain itself is not the pathology but rather a ‘cry for help’ from the patient’s CNS. Do not treat pain – identify and eliminate it at the source!
- Some therapists mentioned in their comments that our post was inappropriate, since we promoted establishing a diagnosis, which is outside therapists’ scope of practice. That is a very unfortunate and erroneous position which undermines the clinical power of Medical Massage and other somatic manual modalities. It is simply an outdated concept which greatly narrows therapists’ performance and undermines a vital part of medicine.
Let us give the following example: the patient was in a car accident, and after that he went to his PCP, and a diagnosis of ‘Whiplash’ was established by the doctor. According to the ICD-10 medical coding system, this diagnosis has the S13.4XXA code, and the medical office gets paid by the insurance company accordingly. Later, the same patient was referred to a massage therapy or physical therapy clinic, and the patient comes there with the same diagnosis. We are curious: how is the diagnosis ‘Whiplash’ going to help the therapist (who is against diagnostic evaluation of the soft tissues) in formulating a correct treatment strategy?
The ‘Whiplash’ diagnosis didn’t specify whether it was the trapezius or levator scapulae muscle that was traumatized, whether the fascia was damaged, or whether the greater occipital nerve was compressed, triggering severe headache as a result of whiplash, etc.
Diagnostic evaluation of the soft tissues IS within the scope of practice for those who accumulate enough knowledge and clinical expertise. Daily, our former students conduct diagnostic evaluation of soft tissues while working with physicians and chiropractors who value their professional input. So, don’t diminish the clinical possibilities MT offers to patients, therapists and physicians.
Category: Blog
Tags: JMS 2020 Issue #3
