Burwood Road, Concord 160 Belmore Road, Randwick Dora Street, Hurstville

Transcription

1 Burwood Road, Concord 160 Belmore Road, Randwick Dora Street, Hurstville

2 WHEN SCIATICA IS NOT SCIATICA, WHAT DO YOU LOOK FOR?

3 What do you look for, where? Low Back pain Lumbar spine Buttock pain Hip Posterior thigh pain Pelvic structures

4 Lumbar spine Facet joints Disc disruption (annular tears) Fractures Overuse(pars) Insufficiency Spinal stenosis Neural irritation can mimic sciatica Low back pain tends to be predominant Stenosis: claudication, pain better with flexion Nasties (tumour, arthropathy, infection)

5 Hip joint Groin pain more than buttock Loading (upstairs) Anterior thigh more than posterior thigh pain Limited flexion (shoelaces difficult) Loss of ROM Flexion Internal Rotation Solid endpoint Painful overpressure

6 Posterior pelvic structures Hamstring related Dr John (second) Best Posterior pelvis (SIJ) Buttock to hip (i.e. trochanteric area) Postero lateral thigh Calf(lateral, posterior) Not past the ankle Around the hip to the groin ( grabbing sensation)

7 History Acute trauma Fall on buttocks MVA(hit in the rear) Repetitive microtrauma Dismounts (gymnasts) Landings (hurdlers, jumpers) Throws (javelin, shotput) Heavy lifting Pain worse with Sitting Standing Stairs Car travel Changes of position, Turning in bed Sometimes dyspareunia and urge incontinence

8 Assessment of the SIJ 1. History 2. Clinical examination a. Evidence based specific tests now available and reliable b. clusters more accurate (Laslett) 3. Imaging a. X Ray, CT, MRI: poor yield for mechanical function b. SPECT CT, a window on the biomechanics of the pelvis

9 Clinical Examination (evidence based) Stork test (Hungerford) Posterior pelvic pain provocation test PPPP or P4 (Ostgaard, Sturesson) Active Straight Leg Raise, ASLR (Mens) Palpation of Long Dorsal Sacro Iliac Ligament, LDSIL (Vleeming)

10 Clinical Examination (other tests) Standing forward flexion test Feel femoral head dipping in or not Patrick s FABER test SIJ Glide test (D Lee) PA Longitudinal Gaenslen s test

11 Posterior ligamentous attachment to ilium Dumbell effect

12 Adductor & Hamstring enthesopathy Increased soft tissue uptake in superior, posterior regions) Hip impingement

13 Adductor enthesopathy Osteitis pubis + hamstring entesopathy

14 Approach to treatment Default: muscle recruitment failure (force closure failure) Specific core stability programme start with TA, multifidus, downtrain compensating muscles adductors, hip flexors, hamstrings, excessive pelvic floor If after three months no significant improvement: prolotherapy/prp of DIOL Occasionally SIJ fusion

15 Staging core stability exs. 1. Isolate TA, MF, Pelvic floor, diaphragm 2. Combinate Build on the initial platform 3. Functionate Functional exercises for ADL and sport specific

16 Results 80% improve significantly with targeted exercise programme 15 20% require prolotherapy or PRP to DIOL Initial results suggest PRP superior to prolo Less than 1% need fusion Usually high speed trauma (MVA)

17 In summary More frequent than initially thought Diagnosis not difficult but Subtle changes Consider it always as DD in athletes with Low back pain Buttock and lateral leg pain Chronic groin pain Recurrent hamstring or groin problems Treatment strategies available, but need to be specific

18

19 Thank you