Practicing and Preaching and Checking My Chat

Sorry for the length of this.  I’ll do something snappy another time

The old saying goes, them that can do, them that can’t teach.  I get it.  I teach because I love an audience as much as because I have anything useful to say, although I hope one or two things might come across that prove useful.

I have always said that I couldn’t spend all day every day in clinic and as a result of my daft schedule, clinic time has suffered. This year, with business partners de-partnering and with more desk bound jobs to do, clients have crept back organically and given me a chance to check my chat.

Today was a perfect example of the chat being truly checked. A presented with chronic ‘shoulder’ pain.  I use the marks, because of the enormity of what ‘shoulder’ pain can mean to clients.  In this instance it was pain that seemed to originate in the sub scapular region, with radiating pain into the forearm along the region of the posterior cutaneous nerve.  In the building trade, he was very physically active and strong in the upper body and had been through every degree of testing and imaging and had been on the receiving end of a number of cortisone injections, from the top ‘shoulder man’ in the region.  Sigh……

Ida Rolf is credited with saying “Where the pain is, the problem is not.” Forgive me if I misquote.  It’s all very well, but most clients want someone to poke around in their shoulders, and most therapists oblige.  Sadly I am a bit more cynical and always assume that any client is only ever going to give me information they believe to be relevant to themselves.  And so I  probe a bit.  My first port of call for shoulders is always the demon dentist.  An easy target.  Bang some poor punter flat on their backs in a chair, keep their mouth open and inflict seven circles of hell involving screeching drills and then scratch your head when they get neck and shoulder pain after five sessions of root canal work. But no, this one didn’t come up trumps.  Damn. That one is so reliable.

Some minor rugby injuries many years ago and a frank exchange of views with a bouncer in a pub a few less years ago that resulted in being escorted to his carriage in a  headlock, may well have been contributory factors, but metaphorically there was a bit missing.

A motorcycle accident in 1995 provided the bit.  Smashing his tibia into several pieces had required a number of bone grafts, some of which were taken from his hip (the details are sketchy), but he had received no rehab work and the lovely scars on his leg, combined with huge wasting around the lateral gastrocs and a six inch wide achilles, all added butter to the sauce. (Cooks metaphor).   It was a nice moment.  Sitting him on the edge of the couch and resisting his leg, he had a good level of strength, but virtually all of it was coming from his upper body.  Arms across the chest and he couldn’t have kicked a balloon.

Two years in crutches and with his lower leg surrounded by a frame, had provided his upper body with every opportunity it needed to take over and take over it did.  A large upper portion of his torso and neck now successfully drags his lower body around and unevenly at that.  His lower limb and back movement all mediated from the shoulder girdle and in the middle the head struggled to play catch up.

Here was a man whose pain was almost a total compensation for the lack of strength (I don’t mean muscle) and stability in his lower body and the rigidity that he had to engage with, not surprisingly resulted in pain.  I’ll spare you the details of what I didn’t do, as to be honest there’s not much I can do until we get some resistance back in his legs.  It won’t take much, and he will probably be pain free in under a month.

The surprise here is that this kind of thing still surprises me.  Here is a man who has paid through the nose for some of the top medical treatment available, has had shoulder surgeons to the stars address him and physiotherapy from seriously clever people, and yet no-one, not one, has addressed his legs or examined his movement anywhere except his shoulders.  Play with a tripod and see what happens when you collapse one of the legs.  It ain’t rocket science people.

Death Metal, Derek and Deafness

A story of alliteration gone wrong

Pain presents in so many forms and with so much baggage of its own, that it’s often ahrd to work out where the pain has begun and why it’s settled where it is.

So the easy thing is often to treat/operate/numb/rub the area we call painful and leave it at that.  It’s not a bad approach.  It feels nice and the result is that the pain often decreases, as pains tend to.

If it stays away then all well and good, but invariably it returns, perhaps in a different form perhaps in a different place.  We call this ageing, stiffness, disease and accept it as normal.

“If I were a 28 year old elite athlete…….” says the 50 year old man complaining to the doctor about his knee pain.

“Let me stop you there,” says the doctor.  “You’re not.  In fact you never were.  You’re a slightly overweight middle aged man with dodgy knees that one day will probably get replaced. Until then deal with it.”

For knee pain, substitute back, ankle, hip, neck, you get the idea.  It’s disheartening but it’s unfair to blame age, when the bigger culprit would be the inefficient, inept and incomplete training that the doctor has undertaken.

The knee pain presentation of middle-aged man is pretty much always going to be a secondary presentation. There are all kinds of bio-mechanical assessments that we could make that would look at the position of the pelvis, the slightly flexed position of the neck and head and the compensatory aspect of the retracted scapulae/scapula, scapulahahahahaha but what if all these things are masking a behaviour that doesn’t allow itself to be tracked by such clever ‘evidenced based’ assessment techniques?

In Derek’s case it’s because he was a roadie for the famous death metal band Anarchic Skunk (made up).  14 years he spent in sound checks, bumping and crashing boxes and sets around and then being subjected nightly to a thousand decibels of ‘Eat My Groin’.

By now Derek is now moderately deaf in one ear.  He refuses at the age of 49 to wear a hearing aid and instead moves, leans towards the sound he wishes to capture.  At home he sits with his good ear towards the television and the radio and sits at the side of the table where he can hear his wife.

In social situations he stands with one side loaded, slightly inclining his good ear towards those speaking.

The years of gradual decline in Derek’s one ear has shifted his behaviour and his body has allowed him to do this.  It has laid (or lain I’m never sure which) down fibres to support his stance, thickened tissues around his loaded hip and built tension in one side of his knee to allow more weight to be transferred.

His foot on the one side has externally rotated (slightly) which gives him more stability when he presses forwards and his opposite shoulder pulls him back from over balancing.

His knee has worn. He never was an athlete, never will be, but now his behaviour is affected further and his movement becomes more limited. In turn these limit cycles encourage a downward spiral of decline and unless he gets treated he will end up with knee surgery and probably soon afterwards a hip to boot.

Does he need treatment and is this treatment going to be effective?  Yes and no or maybe.  Behaviour is the driver and what needs to be identified and modified.  Treatment is also necessary, but without a wider understanding of the bio-psycho social element, we will be seeing Derek regularly in our waiting room.

Derek no longer attends Death Metal gigs.