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Permalink Reply by Small Fry on December 19, 2011 at 6:52pm

Adrienn by all means feel free to offer your prefered theories, explanations, ideas as much as you like.  But I don't think it's helpful to dismiss another practitioner's way of looking at the problem, especially as that is likely to be an approach you have not pursued, or not done so necessarily in the way that they have.  Supporting evidence in the literature or lack of it does not always compare to the knowledge and experience of people who have years of familiarity with an approach.  We all know that what makes it to peer-reviewed publication is a fraction of what is known.

Perhaps a case of 'those who say it can't be done should stop bothering those who are doing it'.

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Permalink Reply by indikate on December 19, 2011 at 10:54pm

Hi Adrienn

Its Indicate from far out footsville can you tell me where  you learned remote diagnosis on other peoples patients as it is way out there and appeals greatly.

This is what you said "It is just probably a local injury, overuse"

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Permalink Reply by farrelly14 on December 20, 2011 at 7:07am

Hi Monica,

I just thought I would throw my 2 pence in on this one. I would like to answer the 2nd part of your query with regards to treating scapular winging. Look to increase the muscular endurance of the S. Anterior (working in the range of 15-20 repetitions - if possible) starting with 2-3 sets, gradually increasing to 4-5. A suitable exercise is known as the 'plus'. This exercise has been shown to elicit the greatest recruitment of muscle fibres in the S.Anterior (http://www.ncbi.nlm.nih.gov/pubmed/10569366). This exercise can be varied depending the patient's degree of capability/disability.

In conjunction with the above it is also important to work on the endurance & strength of the lower trapezius as these two muscles work in unison to prevent anterior tilt of the scapula due to common muscle imbalances such as tight pec minor/major. It might also be useful to evaluate the upper trapezius & deep cervical flexors for hypertonicity, both of which can lead to restrictions in CDJ & upper thoracic spine, impacting upon scapula-thoracic movement.

Just to re-iterate it is important at the beginning of any re-hab programme that emphasis is placed on building endurance (& correct motor patterns/technique) before moving onto a strengthening programme.

Hope this may be of some use.

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Permalink Reply by Monica Blackburn on December 20, 2011 at 1:14pm

What a lovely bunch of responses and such varied views. This is one of the things I love about osteopathy... There's no "one" way of diagnosing, treating, or viewing patients.

I appreciate that some of the DDx's first mentioned were "out there" , hence asking for opinions from more experienced Osteopaths than I. I've just recently qualified and had "safety" and obscure diseases rammed into my head.. However, in reading the literature, symptoms such as winging scupulae can be produced from a pancoast tumour irritating the brachial plexus, autoimmune diseases, and even recent inoculations. Yes, I know theyre far fetched, but we shouldn't dismiss our role as primary care practitioners that may be the first and only people to see a patient undressed, give them the time and attention to diagnose the nasties.

That being said....
I appreciate it's hard to diagnose another's patient from "afar" but it's great to hear the different angles. I've yet to see this patient again (sadly) as scheduling is difficult around the holidays. The AC joint seemed to be functioning properly although poor muscle definition throughout the body, so overall health perhaps not the best. During the initial treatment, I treated the Csp, Tsp, sternum, ribs, trying to take the pressure and strain off the shoulder itself. (like many have suggested).

If(when) this patient books in again, I shall look forward to assessing many of the other aspects that you all have suggested and beginning a muscular rehab program too.

Cheers for the discourse! Although baffling, I do love getting these patients through the door, that make you stop,scratch your head & think and interact with the osteo-community!!

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Permalink Reply by Small Fry on December 20, 2011 at 3:01pm

Hi Monica, I'll offer my thoughts on the pathology, hopefully this will help place some things in perspective.  I agree it is scary, navigating this does get easier with experience, and hence the college approach does er on the side of caution, and rightly so.

In reality we must surely be treating people with occult pathology on occasion, because many serious pathologies do not show up until quite far advanced: yet this is not leaving a trail of destruction.  Large numbers of people are not unexpectedly developing metastatic spread right after visiting us, so that should give some comfort straight away.

Serious pathology tends either to have an identifyable aetiology (eg trauma, poisoning), or else tends to show up in more than one way, eg in several systems of the body.  So your case history and any tests will generally give further clues.  If further clues are not forthcoming then the odds are improving all the time.  And the pathologies you list do not all necessarily contraindicate treatment absolutely.  That said, if you seriously suspect nasties, or begin to suspect them as treatment progresses, then you will know what steps to take.

Cancer is supposed to be risky, because of hypothetical metastatic spread through the lympatics.  In fact there is evidence that stasis is also a risk, lymphatic drainage done on rats with tumours helps the tumours to go away.  I would say the bigger risks are of too forceful treatment (which can be risky anyway), or of overlooking the physiological significance of the situation to their general condition.  Not that I advocate attempting to treat cancer, but to point out that providing you are mindful you do not need sleepless nights over this.

But it is wise to cultivate an approach that is tolerant of error, in that you can find ways to help that will not provoke problems if your worst fears come true.  That's a huge subject in itself, so I won't go into it in depth here, but I personally advocate a general treatment approach, changing the emphasis of the treatment as needed.  Hence if we are not sure about the condition of the neck (eg after a whiplash), we can perhaps treat the pelvis, hips, thorax, shoulders; much as you have done.  Treatment will always be gentle, in that force is not used.  The body is not 'required' to change, it is invited to change, if it is not ready then it does not mean stronger methods are needed, but perhaps more patience, or more groundwork.  So some of the strong MET's, needling, elbows, HVTs we may have seen are not necessary.

Advice on, diet, rest, self-help is all beneficial, none of it will make the situation worse, and if overlooked could hold back progress, so it's all relevant.  We should never need to apply heroic or risky procedures, there is always (nearly) some part of the body that can be helped safely.

As indikate said, the process of getting started often brings you huge amounts of information in itself.  If progress is not going as expected, then something has probably been overlooked, at which stage we need to find out what it is.  Bear in mind some cases can see little change for several sessions.

I hope that helps.  From what you have said there is no obvious reason either to refuse treatment or to send for every test before getting started, but you are a better judge being nearer.  I can't see anything wrong with your treatment, providing it is done with sensitivity (I'm sure it is), and I would encourage you to look even further out than you have, to hips, pelvis, thighs etc.  Remember the great bow-string of latisimus dorsi is influenced by pelvis and shoulder, and even the lower limb, so the whole relationship is important.

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Permalink Reply by indikate on December 20, 2011 at 3:17pm

Hi Monica

Your DD pancoast tumour was the first pathology to enter my mind so not too out there.

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Permalink Reply by Monica Blackburn on December 20, 2011 at 3:59pm

Thanks Small Fry.

I think it's really important to remember the "osteopathic journey" (cheesy!!) as I know personally (esp as a newbie) it's so easy to get stuck in the test-diagnose-get better-done mentality. I'm forever telling patients that "we done aim for perfection and perfect symmetry as we don't start there" ... So all the comments that have touched on relieving the strain of the shoulder and/or global approach are spot on, in my opinion. I'm a huge fan of slings & anatomy trains, and do believe that you can wiggle the cuboid and connect it to dysfunction further up! I suppose only time will tell with this particular patient, and I really hope he comes back. But nevertheless, this reflection will make me a beter osteopath & more prepared next time :-)

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