An osteopath needs to be aware of the consequences of a patient's fractured bones. A Colle's fracture, fracture of the distal end of the radius, is one of the commonest fractures and so it is likely to present at an osteopathic clinic.
Colle's fractures are normally the result of a fall on the outstretched arm. If the wrist is strong the impact of the fall is likely to reach the shoulder and may dislocate it. However, if the wrist is weak such as in people with osteoporosis then it can result in a fracture. For this reason it commonly occurs in women above the age of 40.
The fracture occurs transversely roughly 2 cm across the distal end of the radius. The fractured segment is displaced posteriorly and laterally resulting in the classic “dinner-fork” deformity. Colle's fractures usually recover rapidly but the functional results are often dissapointing. This suggests that the extent of the soft-tissue injury in Colle's fractures are an important consideration to acheiving a positive functional outcome.
The tendon of extensor-pollicis-longus curves around the dorsal radial tubercle and over the radial wrist extensors to the thumb so it is naturally a place of abrasion and wear and tear. Rupture of extensor-pollicus-longus can occur naturally but occurs more frequently between 4-8 weeks after a fracture of the radius. Rupture of extensor-pollicis-longus leads to the inability to extend the distal joint of the thumb.
Osteopathic treatment may be able to improve the recovery by helping to restore flexibility to the wrist and tendons which are likely to have scar tissue and tension after the fracture. Osteopathic soft tissue massage to the wrist extensors and flexors combined with articulation of the carpel and radio-ulnar joints could improve the blood supply, facilitate recovery of the soft tissues and help to restore good function and reduce abrasion.
For more information:
http://www.osteopath.co.il/home-eng.php
http://www.osteopath.co.il/elderly-heb.php
Monday, November 14, 2011
Wednesday, September 21, 2011
Pancoast tumor and its similarity to musculoskeletal conditions.
When a patient complains about these kind of symptoms the osteopath should consider the possibility of a Pancoast tumor. A Pancoast tumor is an extrathoracic tumor of the lung, plaque-like, located in the upper apex of either lung usually found in smokers. It is the location of the tumor and not the pathophysiological changes in the lung tissue that result in the symptom picture, and so one rarely sees respiratory symptoms with this condition. The symptoms that do present are the result of the tumor invading adjoining tissue in the confines of the thoracic inlet compressing intercostal nerves, the lower roots of the brachial plexus, the stellate ganglion and the sympathetic chain.
Patients with a Pancoast tumor will most likely complain to the osteopath about shoulder pain and pain radiating down the medial border of the scapula, not an uncommon complaint in any osteopathic clinic! The invasion of the tumor into the lower roots of the brachial plexus (C8) and upper thoracic trunk (T1, T2), may also result in pain radiating down the ulnar border of the arm from the elbow (T1) and ultimately to the ulnar surface of the forearm to the small and ring fingers of the hand (C8).
The osteopath should examine the patient's hand muscles checking for weakness and atrophy. Reflexes may show a reduced or absent triceps reflex on the affected side (C7). Since the tumor may also involve the cervical sympathetic ganglion and stellate ganglion, sympathetic involvement leads to ispilateral Horner's syndrome (hemianhydrosis, enophthalmos, ptosis and miosis) on the affected side of the face. If the tumor invades the recurrent laryngeal nerve there may be hoarsness and a bovine cough associated with the symptoms.
The patient is often in extreme pain with postural change creating little relief. The patient may tell the osteopath that supporting the elbow of the painful arm with the unaffected hand in order to take the tension off the painful area is the only position that brings relief. The patient will most likely be taking narcotics.
The overlap of symptoms between Pancoast tumor and musculo-skeletal symptoms should now be evident to the osteopath. However, unlike an ordinary neck-shoulder condition or nerve root compression the osteopath may discover on questioning that the patient also experiences malaise, fever, weight loss and fatigue emphasising the importance of a comprehensive osteopathic case history.
A Pancoast tumor is just one example of a life-threatening pathalogical condition that mimics a musculo-skeletal one. The osteopath needs to be fully aware of these conditions in order not to make the mistake of treating the condition and potentially delaying the appropriate treatment
http://www.osteopath.co.il/
Tuesday, September 6, 2011
The shoulder complex through the eyes of an osteopath
A unique quality of being an osteopath is the approach to biomechanics and the shoulder is no exception. The function of the shoulder is to guide the arm through space and hence it requires a considerable range of movement, in fact the shoulder is the joint with the largest range of movement in the body. It achieves the range of movement in a number of ways. The main factor is the incongruity between the head of the humerus and the glenoid fossa which allows the joint a massive range of movement due to its reduced bony apposition. This does however make the joint vulnerable due to lack of support. The shoulder compensates for this with a complex network of muscles and secondary joints and most importantly a tightly bound capsule that keeps the head of the humerus in apposition with the glenoid fossa.
The secondary joints are the acromioclavicular joint, the sternoclavicular joint and the scapulothoracic joint. The acromioclavicular joint keeps the scapula suspended away from the body and allows for changes in the position of the scapula and therefore the axis of movement of the glenohumeral joint. The scapulothoracic joint allows for a large degree of play by sweeping around the thorax and allowing the scapula a large degree of movement. The sternoclavicular joint attaches the scapula to the axial skeleton keep in the shoulder complex firmly attached to the body.
Finally the muscles involved in shoulder function can be divided in to three groups. The suspensory muscles, that is, the muscles from which the scapula and glenohumeral joint are suspended. The suspensory muscles are latisimus dorsi, trapezius, rhomdoid major and minor posteriorly and anteriorly, pectoralis major and minor. The extra-conal muscles or prime-movers of the shoulder joint are middle fibres of trapezius, deltoid, teres major, biceps and triceps whose job it is to move the shoulder in its anatomical directions. The final group is the periarticular muscles, the rotator cuff muscles, supraspinatus, infraspinatus, teres minor and subscapularis.
As osteopaths it is important that our examination and treatment incorporate the role of each of these areas to the patient's shoulder condition. Any alteration due to postural change or trauma can affect the different categories of muscle or joints listed above. As osteopaths it is our duty to view the all the structures and treat them accordingly. The osteopath needs to integrate his knowledge of biomechanics and apply them to the structure of the shoulder and of the body as a whole and treatment should be given accordingly.
For more information on osteopathy and the shoulder:
http://www.osteopath.co.il/sports-injuries-heb.php
http://www.osteopath.co.il/sports-injuries.php
The secondary joints are the acromioclavicular joint, the sternoclavicular joint and the scapulothoracic joint. The acromioclavicular joint keeps the scapula suspended away from the body and allows for changes in the position of the scapula and therefore the axis of movement of the glenohumeral joint. The scapulothoracic joint allows for a large degree of play by sweeping around the thorax and allowing the scapula a large degree of movement. The sternoclavicular joint attaches the scapula to the axial skeleton keep in the shoulder complex firmly attached to the body.
Finally the muscles involved in shoulder function can be divided in to three groups. The suspensory muscles, that is, the muscles from which the scapula and glenohumeral joint are suspended. The suspensory muscles are latisimus dorsi, trapezius, rhomdoid major and minor posteriorly and anteriorly, pectoralis major and minor. The extra-conal muscles or prime-movers of the shoulder joint are middle fibres of trapezius, deltoid, teres major, biceps and triceps whose job it is to move the shoulder in its anatomical directions. The final group is the periarticular muscles, the rotator cuff muscles, supraspinatus, infraspinatus, teres minor and subscapularis.
As osteopaths it is important that our examination and treatment incorporate the role of each of these areas to the patient's shoulder condition. Any alteration due to postural change or trauma can affect the different categories of muscle or joints listed above. As osteopaths it is our duty to view the all the structures and treat them accordingly. The osteopath needs to integrate his knowledge of biomechanics and apply them to the structure of the shoulder and of the body as a whole and treatment should be given accordingly.
For more information on osteopathy and the shoulder:
http://www.osteopath.co.il/sports-injuries-heb.php
http://www.osteopath.co.il/sports-injuries.php
Friday, April 1, 2011
How an osteopath views knee mechanics.
A well known osteopathic principle developed by the founder of osteopathy Andrew Tailor Still is “structure governs function” and so as an osteopath my starting point is always the function of the joint. Evolution has adapted body structure according to its function and therefore once the osteopath understands the joint's function, structure is simply an adaption to meet the demands of the environment. Furthermore, as an osteopath I consider how the patient uses his body, that is, what kind of environment do the joints have to cope with and how pathophysiology may be developing under the circumstances. The knee joint is one of the most interesting joints in the body since it has two mutually exclusive functions which it has to perform; motility and stability. Unlike the shoulder, the king of joint mobility, the knee is a weight bearing joint. Unlike the hip, the king of stability, the knee needs to be highly mobile. Therefore there are structures unique to these 2 joints that we do not see in the knee. However, the knee is similar to the shoulder in that it requires a degree of mobility and it is similar to the hip in that it requires stability and it shares some of the structural features common to both. The knee like the shoulder lacks congruity and so has muscle and ligamentous strength to support it. Just like the hip the knee propels the body forward and therefore has structures that increase its congruity providing stability with mobility.
So, the knee has multiple function, but probably the most obvious one is that of propelling the foot forward in order to make contact with the ground to allow the leg to propel the body forward.
If the knee were a regular hinge joint like the elbow, one can imagine how much trouble the leg would run into. Therefore unlike the elbow the knee allows for a degree of rotation in order to allow for uneven surfaces and pivoting.
If we appreciate for a moment the weight bearing function of the knee we will see that if all the ligaments and the muscles were removed from the knee joint it would essentially collapse in a medial direction. The reason for this is the q-angle. The femur which attaches to the pelvis extends laterally from the body in order to increase the range of movement of the hip. However, in order for the feet to face forwards the femoral condyles are more medial than the hip joint. The result of this is that most of the body weight is transferred to the medial aspect of the knee and therefore this has to be more stable than the lateral side.
The knee is split up into two compartments essentially. One compartment is designed for stability, that is the medial side of the bit – fem joint. It has a much wider surface area, it is much larger than the lateral side of the tibial plateau. The medial meniscus is much less mobile, it is deeper and the medial side is stabilised by the medial collateral ligaments, a structure which holds the medial side of the tib fem joint tightly together allowing only a small degree of valgus to occur. Furthermore, the medial meniscus is attached to the medial collateral ligament reducing its mobility further. The horns of the medial meniscus are attached further apart from one another resulting in a lot less mobility of the meniscus itself which in effect limits the mobility of the femoral condyle on the tibial plateau.
The stability of the knee joint is mainly contained on the medial aspect of the knee as mentioned above. The knee joint compared to the hip and to the shoulder has a complex latticework of ligaments which stabilize the knee in more than one direction and which support one another. In addition to the ligamentous support the muscles act as flexible elasticated ligaments with semitendinosis, gracilis and sartorius acting to support the medial collateral ligament and tensor fascia lata, biceps femoris and popliteus acting to support the weak lateral collateral ligament.
The bony structure of the lateral tibial side of the knee on the other hand is much smaller as is the femoral condyle. This smaller contact point does however have a greater range of movement than the medial femoral condyle. It not only flexes and extends but pivots and rocks around the tibial plateau under the guidance of the ligaments and meniscus.
So there we have it a medial condyle which is stable and a lateral one which is mobile. This allows the knee to perform its function of propelling the knee forward but at the same time supporting the body weight.
Before we move on to the menisci let us take a look at the centrally fixed cruciate ligaments which have the function of controlling the axis of movement of the knee. Most people are aware of the functions of the cruciate ligaments – preventing anterior and posterior shift but they are less aware of their function in limiting internal rotation of the tibia on the femur and guiding the femoral condyles smoothly into position on the tibial plateau during extension.
If we look at a graph of the tensility of the ligaments we tend to see that all the ligaments are at their most tensile during extension. Due to their origins and insertion around the femur and tibia all ligaments tend to become more taut the further into extension the knee goes. This results in a “tight-packing” of the knee which allows for no rotation of the tib-fem joint at all when locked in full extension. Therefore the knee is most stable, least mobile, during extension and least stable when the knee is flexed. The close packing is due to the increased tensility of ligaments and the squashing of the menisci whose job it is at this stage to increase the congruity of the knee joint.
The menisci have the primary task of providing increased congruity to the unstable tibial plateau. The differences between the 2 menisci related to the functions that we mentioned above, which is that the medial compartment maintains the stability whilst the lateral compartment creates mobility. The menisci are made of fibrocartilage which allows them to stretch and be squashed. The medial meniscus is less mobile than the lateral meniscus due to its shape, it is a C shape and less able to swing back and forth. It is tightly bound to the tibial plateau and reinforced by coronary ligaments and the medial collateral ligament. The lateral meniscus is O shaped, highly mobile, unrestrained due to loose coronary ligaments, unattached to the lateral collateral ligament and attached to the popliteus muscle which actively pulls it posteriorly out of danger when it contracts. This allows for a much more mobile surface on which the lateral femoral condyle can rest.
Finally we consider the patella femoral joint which is a sesamoid bone designed to improve the efficiency of the quadriceps. It slides between the femoral condyles creating a much stronger force during flexion and extension. It is reinforced by retinacula tissue from medial and lateral muscles, a lateral femoral buttress and finally a thick layer of cartilage posteriorly to protect it from friction on the femur.
As osteopaths we are trained to build up a detailed picture of the way the patient uses the knees. What stresses does the patient's environment put on the various structures listed above? As osteopaths we must not be hasty to rush into the examination and treatment. The more information an osteopath gets from the patient the more focused will be the osteopathic examination and the better the treatment. The patient's work may influence the knee structure. Prolonged standing with a strong need for the illio-tibial band to contract causing an imbalance of the quadriceps, a history of a congenital hip displacement or Perthes that may influence the position of the hip and thus the q-angle, prolonged kneeling, repetative strains caused by regular rotatory forces.
In short, since ligaments are designed to support, most ligamentous injuries occur when the they are at their least flexible, in extension and the result is normally a force that stretches them beyond their physiological norm resulting in a partial tear. Menisci on the other hand are designed for movement and most meniscal injuries occur during movement, slightly out of sync with the movement of the femoral condyles becoming caught in between the femoral condyle and the tibial plateau and tearing partially.
To conclude, the knee is a classic case of function governing structure and for an osteopath to treat the joint effectively a deep understanding of the biomechanics makes the life of an osteopath much easier and more enjoyable. The osteopath can develop a clearer osteopathic diagnosis, a clearer osteopathic treatment plan and a more effective treatment.
For more info on knee pain: http://www.osteopath.co.il/knee-pain.php
More info in Hebrew: http://www.osteopath.co.il/knee-pain-heb.php
So, the knee has multiple function, but probably the most obvious one is that of propelling the foot forward in order to make contact with the ground to allow the leg to propel the body forward.
If the knee were a regular hinge joint like the elbow, one can imagine how much trouble the leg would run into. Therefore unlike the elbow the knee allows for a degree of rotation in order to allow for uneven surfaces and pivoting.
If we appreciate for a moment the weight bearing function of the knee we will see that if all the ligaments and the muscles were removed from the knee joint it would essentially collapse in a medial direction. The reason for this is the q-angle. The femur which attaches to the pelvis extends laterally from the body in order to increase the range of movement of the hip. However, in order for the feet to face forwards the femoral condyles are more medial than the hip joint. The result of this is that most of the body weight is transferred to the medial aspect of the knee and therefore this has to be more stable than the lateral side.
The knee is split up into two compartments essentially. One compartment is designed for stability, that is the medial side of the bit – fem joint. It has a much wider surface area, it is much larger than the lateral side of the tibial plateau. The medial meniscus is much less mobile, it is deeper and the medial side is stabilised by the medial collateral ligaments, a structure which holds the medial side of the tib fem joint tightly together allowing only a small degree of valgus to occur. Furthermore, the medial meniscus is attached to the medial collateral ligament reducing its mobility further. The horns of the medial meniscus are attached further apart from one another resulting in a lot less mobility of the meniscus itself which in effect limits the mobility of the femoral condyle on the tibial plateau.
The stability of the knee joint is mainly contained on the medial aspect of the knee as mentioned above. The knee joint compared to the hip and to the shoulder has a complex latticework of ligaments which stabilize the knee in more than one direction and which support one another. In addition to the ligamentous support the muscles act as flexible elasticated ligaments with semitendinosis, gracilis and sartorius acting to support the medial collateral ligament and tensor fascia lata, biceps femoris and popliteus acting to support the weak lateral collateral ligament.
The bony structure of the lateral tibial side of the knee on the other hand is much smaller as is the femoral condyle. This smaller contact point does however have a greater range of movement than the medial femoral condyle. It not only flexes and extends but pivots and rocks around the tibial plateau under the guidance of the ligaments and meniscus.
So there we have it a medial condyle which is stable and a lateral one which is mobile. This allows the knee to perform its function of propelling the knee forward but at the same time supporting the body weight.
Before we move on to the menisci let us take a look at the centrally fixed cruciate ligaments which have the function of controlling the axis of movement of the knee. Most people are aware of the functions of the cruciate ligaments – preventing anterior and posterior shift but they are less aware of their function in limiting internal rotation of the tibia on the femur and guiding the femoral condyles smoothly into position on the tibial plateau during extension.
If we look at a graph of the tensility of the ligaments we tend to see that all the ligaments are at their most tensile during extension. Due to their origins and insertion around the femur and tibia all ligaments tend to become more taut the further into extension the knee goes. This results in a “tight-packing” of the knee which allows for no rotation of the tib-fem joint at all when locked in full extension. Therefore the knee is most stable, least mobile, during extension and least stable when the knee is flexed. The close packing is due to the increased tensility of ligaments and the squashing of the menisci whose job it is at this stage to increase the congruity of the knee joint.
The menisci have the primary task of providing increased congruity to the unstable tibial plateau. The differences between the 2 menisci related to the functions that we mentioned above, which is that the medial compartment maintains the stability whilst the lateral compartment creates mobility. The menisci are made of fibrocartilage which allows them to stretch and be squashed. The medial meniscus is less mobile than the lateral meniscus due to its shape, it is a C shape and less able to swing back and forth. It is tightly bound to the tibial plateau and reinforced by coronary ligaments and the medial collateral ligament. The lateral meniscus is O shaped, highly mobile, unrestrained due to loose coronary ligaments, unattached to the lateral collateral ligament and attached to the popliteus muscle which actively pulls it posteriorly out of danger when it contracts. This allows for a much more mobile surface on which the lateral femoral condyle can rest.
Finally we consider the patella femoral joint which is a sesamoid bone designed to improve the efficiency of the quadriceps. It slides between the femoral condyles creating a much stronger force during flexion and extension. It is reinforced by retinacula tissue from medial and lateral muscles, a lateral femoral buttress and finally a thick layer of cartilage posteriorly to protect it from friction on the femur.
As osteopaths we are trained to build up a detailed picture of the way the patient uses the knees. What stresses does the patient's environment put on the various structures listed above? As osteopaths we must not be hasty to rush into the examination and treatment. The more information an osteopath gets from the patient the more focused will be the osteopathic examination and the better the treatment. The patient's work may influence the knee structure. Prolonged standing with a strong need for the illio-tibial band to contract causing an imbalance of the quadriceps, a history of a congenital hip displacement or Perthes that may influence the position of the hip and thus the q-angle, prolonged kneeling, repetative strains caused by regular rotatory forces.
In short, since ligaments are designed to support, most ligamentous injuries occur when the they are at their least flexible, in extension and the result is normally a force that stretches them beyond their physiological norm resulting in a partial tear. Menisci on the other hand are designed for movement and most meniscal injuries occur during movement, slightly out of sync with the movement of the femoral condyles becoming caught in between the femoral condyle and the tibial plateau and tearing partially.
To conclude, the knee is a classic case of function governing structure and for an osteopath to treat the joint effectively a deep understanding of the biomechanics makes the life of an osteopath much easier and more enjoyable. The osteopath can develop a clearer osteopathic diagnosis, a clearer osteopathic treatment plan and a more effective treatment.
For more info on knee pain: http://www.osteopath.co.il/knee-pain.php
More info in Hebrew: http://www.osteopath.co.il/knee-pain-heb.php
Saturday, February 19, 2011
Understanding the shoulder joint and the rotator cuff - an osteopathexplains
The function of the shoulder joint is reflected in its unique structure in much the same way as the hip joint and as the founder of osteopathy Andrew Tailor Still believed, once the anatomy is understood, the osteopath can figure out the pathophysiology.
Let us consider the function of the shoulder joint. It is to guide the upper limb through space in order that we can use the hand to perform our daily activities. Circumduction of the shoulder joint allows a massive range of movement, much more so than the hip is capable of achieving. The hip's strong ligaments and tight capsule play a crucial role in stabilizing the joint but it is primarily the bone which limits hip movement. The deep acetabulaum provides a snug home for the femoral head stabilized by the congruence of the two articular surface. The end result is a tight-fitting stable joint whose range of movement increases only as a result of features unique to the hip that have evolved with time such as the femoral neck and various angles of anteversion to improve the range of movement.
The stability of the shoulder however is compromised for the sake of mobility. Unlike the femoral head which can remain attached to the acetabulum even after ligaments and muscles have been removed, the humerus which lacks congruence with the shallow glenoid cavity would fall away completely if not for the muscles, ligaments and capsule surrounding it.
What the glenohumeral joint lacks in bony congruity it makes up for in a complex arrangement of muscles which act as joint movers and tensile ligaments to provide added support. Furthermore, stability of the gleno-humeral joint is reenforced by no-less than 4 other joints: the scapulothoracic joint, the acromioclavicular joint, the acromioclavicular joint and the sternoclavicular joint.
The muscles that control movement of the shoulder can be divided into 2 groups, much the same way as the hip; long muscles and short muscles. The long muscles such as biceps brachii, coracobrachialis, deltoid as well as secondary muscles like triceps, pectoralis major, teres major, latissimus dorsi and trapezius. The short muscles are supraspinatus, infraspinatus, teres minor and subscapularis and are commonly referred to as the rotator cuff. Whilst working together synergistically these two groups of muscles have a different role in controlling the movement of the glenohumeral joint and any dysfunction in one group is likely to be reflected in problems in the second group.
The long group of muscles have the role of moving the shoulder joint since they have a greater mechanical advantage over a larger range of movement. Due to the glenohumeral joint's lack of congruity the axis of movement is constantly changing as it slides around the glenoid fossa. Therefore the short muscles have the job of finely controlling the movement of the head of the humerus as it ducks underneath the coracoacromial joint. They have the job of orienting the head of the humerus for the movement of the humerus and so the short muscles, the rotator cuff muscles, can be defined as the “fixers” whilst the long muscles can be defined as the “movers”. The supraspinatus muscle pulls the head into the glenoid and slightly rotates the humerus into abduction. The infaspinatus muscle rotates and slightly pulls it down,. The teres minor muscle pulls the head of the humerus down in a slightly different direction and the subscapularis muscle pulls the head into the glenoid but it is has mainly a rotatory action, internally rotating the humerus along its longitudinal action.
Having explained the unique structure of the glenohumeral joint and its dependence on muscluar support the osteopath can start to understand the unique pathophysiology of the joint. Unlike the hip which suffers mainly from osteoarthritis, the shoulder is prone to soft-tissue injuries; capsulitis (frozen shoulder), tendonitis, rotator cuff tears, bursitis and shoulder dislocation. The osteopath therefore needs to put a strong emphasis on understanding the patient's unique way of using the shoulder joint and how the day to day use may be disturbing the fine balance between the long and short muscles. First the osteopath must decide what may be disturbing the fine movement of the rotatotor cuff thus causing friction, compression or ischemia of the surrounding soft tissues and then it is the osteopath's job to try to reintegrate the structures of the shoulder joint using careful osteopathic techniques and a fine osteopathic hand.
Video: Combined techniques for the shoulder
For more information on shoulder problems and sports injuries: http://www.osteopath.co.il/sports-injuries.php
For more information on shoulder prolems in Hebrew: http://www.osteopath.co.il/sports-injuries-heb.php
Let us consider the function of the shoulder joint. It is to guide the upper limb through space in order that we can use the hand to perform our daily activities. Circumduction of the shoulder joint allows a massive range of movement, much more so than the hip is capable of achieving. The hip's strong ligaments and tight capsule play a crucial role in stabilizing the joint but it is primarily the bone which limits hip movement. The deep acetabulaum provides a snug home for the femoral head stabilized by the congruence of the two articular surface. The end result is a tight-fitting stable joint whose range of movement increases only as a result of features unique to the hip that have evolved with time such as the femoral neck and various angles of anteversion to improve the range of movement.
The stability of the shoulder however is compromised for the sake of mobility. Unlike the femoral head which can remain attached to the acetabulum even after ligaments and muscles have been removed, the humerus which lacks congruence with the shallow glenoid cavity would fall away completely if not for the muscles, ligaments and capsule surrounding it.
What the glenohumeral joint lacks in bony congruity it makes up for in a complex arrangement of muscles which act as joint movers and tensile ligaments to provide added support. Furthermore, stability of the gleno-humeral joint is reenforced by no-less than 4 other joints: the scapulothoracic joint, the acromioclavicular joint, the acromioclavicular joint and the sternoclavicular joint.
The muscles that control movement of the shoulder can be divided into 2 groups, much the same way as the hip; long muscles and short muscles. The long muscles such as biceps brachii, coracobrachialis, deltoid as well as secondary muscles like triceps, pectoralis major, teres major, latissimus dorsi and trapezius. The short muscles are supraspinatus, infraspinatus, teres minor and subscapularis and are commonly referred to as the rotator cuff. Whilst working together synergistically these two groups of muscles have a different role in controlling the movement of the glenohumeral joint and any dysfunction in one group is likely to be reflected in problems in the second group.
The long group of muscles have the role of moving the shoulder joint since they have a greater mechanical advantage over a larger range of movement. Due to the glenohumeral joint's lack of congruity the axis of movement is constantly changing as it slides around the glenoid fossa. Therefore the short muscles have the job of finely controlling the movement of the head of the humerus as it ducks underneath the coracoacromial joint. They have the job of orienting the head of the humerus for the movement of the humerus and so the short muscles, the rotator cuff muscles, can be defined as the “fixers” whilst the long muscles can be defined as the “movers”. The supraspinatus muscle pulls the head into the glenoid and slightly rotates the humerus into abduction. The infaspinatus muscle rotates and slightly pulls it down,. The teres minor muscle pulls the head of the humerus down in a slightly different direction and the subscapularis muscle pulls the head into the glenoid but it is has mainly a rotatory action, internally rotating the humerus along its longitudinal action.
Having explained the unique structure of the glenohumeral joint and its dependence on muscluar support the osteopath can start to understand the unique pathophysiology of the joint. Unlike the hip which suffers mainly from osteoarthritis, the shoulder is prone to soft-tissue injuries; capsulitis (frozen shoulder), tendonitis, rotator cuff tears, bursitis and shoulder dislocation. The osteopath therefore needs to put a strong emphasis on understanding the patient's unique way of using the shoulder joint and how the day to day use may be disturbing the fine balance between the long and short muscles. First the osteopath must decide what may be disturbing the fine movement of the rotatotor cuff thus causing friction, compression or ischemia of the surrounding soft tissues and then it is the osteopath's job to try to reintegrate the structures of the shoulder joint using careful osteopathic techniques and a fine osteopathic hand.
Video: Combined techniques for the shoulder
For more information on shoulder problems and sports injuries: http://www.osteopath.co.il/sports-injuries.php
For more information on shoulder prolems in Hebrew: http://www.osteopath.co.il/sports-injuries-heb.php
Monday, January 31, 2011
Hip examination from the perspective of an osteopath
In order to diagnose back pain the osteopath needs to be aware of the contribution of the hip joint. The hip has a unique structure carefully designed to fulfill its functions in the body.
The hip has two main functions; mobility, propelling the leg forward, and stability, linking the lower limb to the torsoe. Unlike other bones in the body, the head of the femur is attached to its shaft via a neck. This system of levers allows increased range of movement and less muscular effort, however, it also increases the joint's vulnerability.
Hip stability is the result a multitude of structures such as the head of the femur sitting in a deep pelvic acetabulum reenforced by the acetabular labrum and strong ligaments (pubo, ischio and illio-femoral ligaments). It has a good nerve supply, the obturator nerve (L2, L3, L4), which supplies the hip capsule and serves to convey proprioceptive information to the brain about hip position. Multiple arteries, the circumflex artery and ligamentum teres provide the necessary nutrients. However, disturbence of the blood supply ultimately results in avascular necrosis of the bone, degeneration and osteoarthritis. Ironically it is the strong ligaments that surround the neck of the femur that can compromise the security of the hip by compressing its blood supply.
Conditions that affect the hip joint as a result of poor blood supply are Perthes disease and slipped femoral ephiphysis. Patients with a history of these conditions or congenital hip displacement may turn up at an osteopthic clinic many years later complaining of low back pain.
A fixed flexion deformity of the hip due to osteoarthritis is the result of contraction of the muscles surrounding the hip joint (the strong external rotators and adductor magnus), in an attempt to stabilize the joint. The body compensates for reduced hip extension by extending the lumber spine beyond its normal range leading to stress on the soft tissues of the lumber spine or compression of the facet joints leading to back pain. Other causes of back pain may be the result of referred pain from the hip's nerve supply (obturator nerve). Finally, contraction of the muscles around the hip joint such as gluteus minimus or medius may be mistaken for back pain.
The osteopath should be aware of hip invlovement when assessing back pain. As well as using the standard orthopedic tests, Trendelenberg's sign and Thomas's test the osteopath has the added skill of palpation of the hip joint to assess quality of movement and decide whether there is any shortening of the soft tissues or arthritic changes.
Video demonstrating passive hip examination.
Click here for more info on arthritis and osteopathy
or here for more info in Hebrew
The hip has two main functions; mobility, propelling the leg forward, and stability, linking the lower limb to the torsoe. Unlike other bones in the body, the head of the femur is attached to its shaft via a neck. This system of levers allows increased range of movement and less muscular effort, however, it also increases the joint's vulnerability.
Hip stability is the result a multitude of structures such as the head of the femur sitting in a deep pelvic acetabulum reenforced by the acetabular labrum and strong ligaments (pubo, ischio and illio-femoral ligaments). It has a good nerve supply, the obturator nerve (L2, L3, L4), which supplies the hip capsule and serves to convey proprioceptive information to the brain about hip position. Multiple arteries, the circumflex artery and ligamentum teres provide the necessary nutrients. However, disturbence of the blood supply ultimately results in avascular necrosis of the bone, degeneration and osteoarthritis. Ironically it is the strong ligaments that surround the neck of the femur that can compromise the security of the hip by compressing its blood supply.
Conditions that affect the hip joint as a result of poor blood supply are Perthes disease and slipped femoral ephiphysis. Patients with a history of these conditions or congenital hip displacement may turn up at an osteopthic clinic many years later complaining of low back pain.
A fixed flexion deformity of the hip due to osteoarthritis is the result of contraction of the muscles surrounding the hip joint (the strong external rotators and adductor magnus), in an attempt to stabilize the joint. The body compensates for reduced hip extension by extending the lumber spine beyond its normal range leading to stress on the soft tissues of the lumber spine or compression of the facet joints leading to back pain. Other causes of back pain may be the result of referred pain from the hip's nerve supply (obturator nerve). Finally, contraction of the muscles around the hip joint such as gluteus minimus or medius may be mistaken for back pain.
The osteopath should be aware of hip invlovement when assessing back pain. As well as using the standard orthopedic tests, Trendelenberg's sign and Thomas's test the osteopath has the added skill of palpation of the hip joint to assess quality of movement and decide whether there is any shortening of the soft tissues or arthritic changes.
Video demonstrating passive hip examination.
Click here for more info on arthritis and osteopathy
or here for more info in Hebrew
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