ISSUES WITH PAIN & RANGE:
Note: The following is information was written in response to my own life challenges and experiences teaching and so may have not reflect other peoples teaching/learning experience or challenges. However as the material may be relevant and interesting in developing WHOLISTIC UNDERSTANDING with assessment and treatment, I present it for your investigation – I hope find it useful, best wishes, Paul.
The following is in reference to text books and teaching presentations or approaches which focus mainly on technicalities of pain and range of motion assessment without encouraging a counterbalancing awareness on QUALITY of motion analysis and upon the predisposing patterns of dysfunction which may predispose and set up symptomatic or dis-eased tissues and thus slow the recovery process. This is in reference also with techniques used to treat pain or range alone. I will attempt to show with some case examples how this can, when not placed in perspective with the whole picture, distract from effective assessment and treatment.
The main issue in reference to purely focusing on symptomatic assessment and effects is that;
By cutting out a good general wholistic assessment it trains students, via omission, to not even think of and assess for ANATOMICAL RELATIONSHIPS (i.e. the predisposing, maintaining and/or causative patterns of dysfunction in the whole) elsewhere which may be dysfunctional and thus may be interfering with and slowing recovery. This will obviously affect success of treatment. By over focusing on relatively irrelevant technical details such as assessment of pain and range (or overcomplicated language or research in relation to these details) it neglects and distracts from uncovering these true DYS-FUNCTION patterns setting up the symptomatic area. This over focus on certain symptomatic details then unnecessarily complicates what would otherwise be a very simple, and easy to follow, general and regional assessment process.
Reason = DYS-function tells us what we can treat – This is assessed via QUALITY – not range or pain.
For example – a restriction at the origin of Latisimus Dorsi muscle to the pelvis and lumbar spine may create a drag and limitation at the other and of the muscle inserting to the inter-tubercular groove of the humerus at the shoulder – thus limiting shoulder abduction and external rotation. Range of shoulder movements would be limited (IN RANGE) but the QUALITY at the shoulder may be actually still be OK throughout this range (if we bother to assess it) – it just having a limited muscular end feel perhaps due to muscle shortening or alternately, the shoulder being in internal rotation may cause some impingement of the greater tubercle of the humerus during abduction, thus limiting the range and giving a more bony end feel block (and subsequent pain due to impingement).
If quality is OK – even if range is limited – then there is no dysfunction. If no actual dysfunction – then there is no indication for treatments, articulation or otherwise. Limited range alone is not an indication for treatment. Therefore, all treatment techniques (such as articulations) which focus purely on improving range alone and alleviating painful tissues would be irrelevant and of no useful effect in treating this problem (especially long term) – being directed as they often are to the effected end of the problem and not the causative end.
Any true thinking practitioner would be aware of these anatomical relationships (i.e. that the muscles have another end worth exploring) because he knows all the anatomy that can possibly impact on the shoulder. A general postural assessment would easily detect that the true dysfunction in the above case is at the pelvic and lumbar attachment because it would show up on all 3 of (General & Regional) OBSERVATION, PALPATION and MOTION (ACTIVE & PASSIVE Motion) tests. But of course a practitioner WHO DOESN’T THINK OR BOTHER TO ASSESS THE WHOLE WOULD NEVER EVEN NOTICE THIS AND SO WOULD OBLIVIOUSLY ADDRESS HIS TREATMENT TO THE SYMPTOMATIC AREA AND TISSUES – probably addressing range and pain with NO CONSCIOUSNESS of the FACT of QUALITY at all whilst performing their techniques.
IT could actually be considered NEGLIGENT and CONTRAINDICATED in this case to treat the SYMPTOMATIC tissues as there is no true indication of any REAL dysfunction – but there is pain and so the unconscious reaction is that we must do something to the painful area, mustn’t we? OR SO we think (or possibly not think).
Focusing on the symptomatic area in this way totally distracts from the whole picture and the true cause of the problem and this is the main problem with any resource which, or teacher who, emphasises pain, range and a purely symptomatic regional focused approach to diagnosis and treatment – The whole point of ASSESSMENT AND TREATMENT IS TOTALLY MISSED (i.e. out of mind – out of sight so to speak). Thus – students are actually getting mislead and if mislead in this way (without understanding the underlying reasons for/behind the problem) then this omission gets into the teaching programs and bad habits get taught – thus propounding the whole problem and further distracting practitioners from even looking for all the other possible true dysfunctional relationships creating stress from elsewhere (e.g. neural, vascular, visceral, psychological or postural/mechanical links) that need to be resolved to take stress of the symptomatic region and thus allow it to heal.
It the clinical example above – if we articulate the pelvic and lumbar attachments of the problem and release the lower regions of the latisimus dorsi, the muscle will relax and not pull on the shoulder, thus allowing it to achieve a more ideal alignment and function. Upon rechecking range and quality of shoulder abduction and external rotation – the range would be improved and the pain (impingement, etc) gone or significantly lessened. All without treating pain or range at all.
RANGE simply indicates a problem is present – This shows up on ACTIVE MOVEMENTS – Not why it’s limited – thus it doesn’t show us what to actually treat. It really is only a good indicator for the before and after picture, to see if we have made any overall improvement – Because, if true dysfunctions contributing are dealt with, this will automatically improve range, usually without focusing on range at all.
Treating to improve range is really no different to basic stretching – which is an element of rehabilitation but even here – it’s better to stretch true primary dysfunctions and not secondary limited range effects in order for any lasting effect to occur. Practitioners can give stretches for home care BUT their role is to address the dysfunctions in the body contributing to the problem pattern, and slowing its recovery, with treatment to the DYS-FUNCTIONS. Thus allowing the patient to make more rapid improvement with his/her stretches and rehabilitation.
QUALITY Shows – Dys-function – Dysfunctions show up on passive physiological and accessory movements (in addition to altered clues in texture and symmetry) – and these can be detected early in the movement of true PRIMARY dysfunctions (and thus treated early at their bind where health moves to dysfunction, which is well short of the overall end range of the area in which the dysfunctional tissue will be found).
Secondary Dysfunctions (technically PSEUDO-dysfunctions, at least early on when they are able to adapt adequately without breaking down) are merely often adaptive to the primary dysfunctions and are often limited in their end ranges but are not actually dysfunctional in themselves. In fact they are functioning as best they can, considering the circumstances under which they are forced to work. These cannot be technically classified as dysfunctions at all but should rather be called secondary or compensatory ADAPTIONS. This will be revealed with passive (rotary and accessory) movements because although asymmetrical and perhaps altered in tension/texture – they will actually move well passively. I ask you to stop right here to think about this statement and ask yourself – Do you notice the Quality of movement or do you simply notice range is limited and thus assume there is a problem needing treatment? Have you actually paid attention to the quality of the motion throughout the range? And, do you treat simply because you have noticed asymmetry and tension or do you also observe the QUALITY of motion also? All three (of texture change, asymmetry and Quality of motion abnormality) should technically be present to indicate something worth treating. Try asking yourself these questions the next time you explore any tissue or area with your assessment tools. If you will seriously explore these questions you might discover some very interesting things about the areas you actually treat and whether you are being effective or not.
Of course – given enough time and continued stress, these compensatory tissues will not be able to bear the stress anymore and will break down in themselves and actually become Dys-functional. But they are still technically secondary or tertiary DYS-functions, etc, when related to the causative and predisposing dysfunctions setting them up. This will then cause other tissues to compensate and thus extend the chain of cause and effect until the body simply cannot cope and the patient ends up with a chronic disease state (which is simply multiple patterns of cause and effect perpetrated to the point where multiple organ systems begin to fail instead of just one or a few simple tissues). Thus, a secondary dysfunction, although dysfunctional and may need some treatment, is not the TRUE original cause of the whole pattern of Primary cause- effect – secondary cause – effect, tertiary cause –effect and so on.
PAIN is simply the effect of the tissues that are in stressed, strained, torn, irritated, inflamed, compressed, impinged, under traction or distension, etc. Forcing range simply often further stresses damaged tissues or compresses further and impinged structure. Mobilising a tissue in pain is simply stressing it more. Technically, treating the pain with direct forcing treatments is contraindicated and more ameliorative techniques are employed instead for purely symptomatic relief (rest, ice, medication, etc). Instead of asking what tissues are causing pain? – And stopping our investigation here – we should be asking WHY these tissues are stressed in the first place, what ELSE in the patients system is contributing to this stress? And how can I therefore apply my treatment to these other (non-contraindicated) areas to we take the stress off the damaged tissues and thus allow them to relax and heal? So again – Do you treat based on pain or range alone OR do you also notice TEXTURE, SYMMETRY and QUALITY of motion? Why not assess for all? Assessing for all these components and understanding the concept of primary and secondary dysfunctions – will help us learn to listen to the tissues and trace the effect (pain or symptom), eventually, back to its originating PRIMARY cause.
STUDENT EXAMINATION TIPS:
In regards to practical exams and assessment terms; these shouldn’t purely be set up to speculate on treatments that focus on pain or range either unless perhaps giving a self-help stretch. At the later stages of a health science course, especially – students should be challenged to actually THINK and work out what is actually wrong DYS-Functionally rather than speculate on meaningless effects such as pain or range (i.e. to explore the very concepts I have discussed above – and not stop at pain, range or even the first dysfunction they happen to find in the area of symptoms without exploring any further for predisposing, more primary, causes along the string of cause to effect). Anyone can do a technique on a tissue but only those who know why it’s in trouble and understand the relationship imbalances setting it up (from good assessment) will be able to treat it correctly (and often by not treating the painful tissue directly at all).
Rather than say – show me a way of improving range in the shoulder joint (which takes no thinking, is common sense and should have already been assessed in year one or two of a course of learning) or show me a way to treat a painful shoulder (from a case study) locally (which may in real life be totally irrelevant if the shoulder ISN’T the actual primary dysfunctional tissue), Isn’t it better at later stages of a course to ask a student how to assess via the following steps, 1) palpation (reason = to get a feel for the tissues and structures in the area that are already in trouble with respect to altered texture and symmetry prior to assessing quality and range of motion with motion testing), then 2) motion testing for quality (reason = to see if and where it is actually dysfunctional) and then, having identified the true component/structure of the whole showing A.R. and T, to demonstrate some techniques to improve function. This would more adequately test their ability to ACTUALLY FIND the REAL PROBLEM (in the region – if there at all) and then to ACTUALLY TREAT it EFFECTIVELY – in which case the results when tested after would prove without a doubt that the correct dysfunction was treated effectively, because Tissue Texture, Symmetry and QUALITY of motion would all be better. Thus, it’s now FUNCTIONING and as a result – the effect at the relevant joint or other (symptomatic) tissue will be easier – Range will then be better upon retesting active and passive movements. This would then make students techniques meaningful and also allow the examiner to assess if they actually work. This, I believe, is what we are trying to achieve in the later years of a course – the integrative element of helping students to make their ASSESSMENT AND TREATMENTS MEANINGFUL. This always comes down to GOOD WHOLISTIC DISGNOSIS FOR CAUSES BENEATH THE EFFECTS. Thus, the PROCESSES AND TECHNICAL PERFORMANCE elements are important but these should be the aim of earlier years of a course in order to educate students of range of assessment techniques (see notes on phases of learning below)
If we want to simply assess a student’s assessment PROCESS or Technique PROCESS, this is fine but a case study is meaningless here because we are testing processes and technical performance of techniques. Better to just ask for a demonstration of techniques than to relate it to a case study.
NOTES ON PHASES OF LEARNING:
Learning a health science course should fall into 3 stages:
1) LEARNING THE TECHNIQUES, KNOWLEDGE OF CONDITIONS AND ASSESSMENT PROCESSES: Knowledge is simply knowledge of the various aspects of information we need to be familiar with as part of a course of learning (anatomy, physiology, medical conditions and common signs/symptoms and traditional methods of treatment, etc). This includes knowledge of assessment processes and special tests. Assessment processes should be implemented, WHOLISTICALLY and REGIONALLY speaking, early on in a course to prepare a student for the next step of actually getting clues from their assessment processes. IF STEPS ARE MISSED OUT HOWEVER (through lack of understanding or interest) – STUDENTS LEARN TO MISS OUT VALUABLE ITEMS OF ASSESSMENT – which is why they end up later on focusing so much on symptoms, range of motion and parts. I have found that if students have a logical and thorough wholistic assessment and they actually follow it – they WILL GRADUALLY LEARN THE NEXT STEP OF GAINING MEANINGFUL CLUES FROM THIS ASSESSMENT (even if initially these clues are not yet integrated and understood), and then later still – understanding the full significance of what they have discovered. If they don’t assess in this way they will never uncover meaningful clues in any area other than the symptomatic area – and because they only understand problems symptomatically – they will not be able to treat predisposing factors effectively or even be able to explain to patients how they came to be in the state they are in, in the first place (beyond simple speculation or reasoning based on symptoms alone). Technical application of techniques can be assessed after they are taught and practiced but – actually being able to implement them effectively depends on the understanding that they must be applied and modified to suit the findings (tissue dysfunctions in need) at the right time upon a client. The concept of this can be introduced early but understanding tends to comes more fully at a later date – especially in clinic or in class assessing and treating fellow students’ actual problem patterns.
2) INTEGRATIVE REASONING: This is good to prepare students to think through and integrate all the various bodies of knowledge they learnt in phase 1. It philosophically prepares them for stage 3 to follow. Case studies are good for clinical reasoning about; a) history questions that need to be asked b) possible Differential diagnoses c) anatomy potentially involved d) assessment plans and possible tests/tissues to explore, and so on in order to gain all the relevant clues. They can also help brain storming about e) treatment and f) rehabilitation options and possibilities in order to address the symptom pictures and even g) predisposing patterns potentially present (which can also be explored in a wholistic way if we make our case studies realistic and complicated enough – which more likely mimics real life situations more than a case study on simple condition, pain pattern or effect). This last point opens students to consider other factors that may play a role in the treatment/rehabilitation process and which also would need to be explored in a wholistic assessment procedure to identify them. These type of case studies help to prepare the student to think and reason speculatively but they don’t actually test whether students can actually assess to gain meaningful information FROM their assessment processes or actually APPLY a technique effectively to an actual DYS-FUNCTION. This stage can be implemented as soon as basic training in essential knowledge is learned and can continue right through a course to increasing integrate student learning. Case studies would carry even greater reasoning and integrative potential as the understanding from phase three was simultaneously developed and understood.
3) Being able to UNDERSTAND AND TREAT WHAT IS ACTUALLY GOING ON – i.e. convert the Knowledge and reasoning in phases 1 and 2 into the actual WISDOM of INTEGRATED CLINICAL PRACTICE – with “awareness” of the interrelatedness of the component parts of the whole and of the pattern of cause and effect. Thus, to follow on from point 2) if students are to learn to actually find what is going on – we need more than a case study – we need an actual model/patient, as well as teacher who can help students understand the patterns of cause and effect underlying the symptom picture. In this way students will be more fully prepared to understand and treat increasingly effectively patients with a wide range acute and chronic DIS-EASE’s, thus improve effectiveness of health care. This can be tested by asking students to perform a full assessment (the whole and regional detail) and to describe the actual findings uncovered. The treatment element can then be explored by getting students to use/select an appropriate technique or rehabilitation technique to address the tissues in need and then apply the technique with full awareness of relationships involved and to get an actual satisfactory change for the better in the tissues and within the whole. This effectiveness is then tested by performing the very same diagnostic tests that yielded the most results earlier on in assessment and observing if the Quality of motion, Texture and Symmetry in the whole patient has improved.
Thus, these three steps should be considered by lecturers when planning assessment items for student learning and evaluation.
ASSESSMENT SUMMARY REMINDERS:
As mentioned above; if we cut out useful wholistic assessment items from our teaching because of an over focus purely on range, pain/symptomatic tissues, assessment only ends up including those items of assessment which identify tissues DIRECTLY causing symptoms and thus misses valuable information which helps us understand why these symptomatic tissues are under stress/strain in the first place.
This is a bad habit and is not showing students consistency in assessment because if each teacher assesses only a few structures limited to a region that they may normally assess (and which can dangerous or misleading if oblivious of the whole), it teaches students to cut corners and thus omit valuable parts of the assessment vitally necessary to work out what is going on as a whole – and thus understanding the RELATIONSHIP between cause and effect.
This simply indicates that the practitioner’s who do this HAVE LITTLE IDEA/UNDERSTANDING of HOW to actually perform a general assessment or, if they do, have LITTLE IDEA how to gain meaningful clues from this part of the assessment. WHY? Because unless they were taught how to perform and gain meaningful clues from a wholistic assessment process when they learned, they may never have actually learned to gain valuable clues from it. Thus, they often pass over the general part of the screening process quickly, thinking it irrelevant because they need to get stuck more into the area with symptoms. They may not be really interested in performing a general assessment well, because it’s not their focus. If they did, even once – especially in clinic – see the relationship between the whole and the symptomatic part – they would never again make this mistake of omitting vital assessment items in their teaching.
I’ve seen this mistake so often and students and practitioners miss vital information which is blatantly obvious to anyone who can expand their viewpoint and assess even a little beyond the edges of a symptomatic area. I’m dumbfounded at the lack of common sense and anatomical reasoning ability on the part of many practitioners here. This can be easily remedied by following a full wholistic and regional assessment that includes in a simple and straightforward manner all the essential steps of assessment, even if practitioners and students don’t fully understand this assessment, as yet. As mentioned previously – it has been my experience that by simply following this process – the answers will come, as will come, eventually, integrative understanding. If we skip steps we will never find the clues, if present, nor arrive at any meaningful understanding. If understanding eventually comes from applying a logical assessment process, why not try it? Thus, we have everything to gain and nothing to lose by being more wholistic in our exploration.
Assessment should always include the following;
- GENERAL ASSESSMENT: should be carried out to I-D any contributing areas predisposing to the problem, contributing to maintaining it and/or slowing recovery. This identifies the other sections we need to perform an additional regional assessment on:
- REGIONAL ASSESSMENT SUMMARY: Includes the following:
SYMPTOMATIC AREA – SYMPTOMATIC REGION:
- Palpation – general impression + Bony and Soft tissue landmarks
- Active motion testing
- Passive motion testing (+ Accessory movements)
- Active resistant testing
- Special tests
PRIMARY AREAS OF ART CONTRIBUTING (if elsewhere)
- Palpation – general impression + Bony and Soft tissue landmarks
- Active motion testing – may already be done as part of general screen
- Passive motion testing (+Accessory movements)
- (Active resistant tests and Special tests – if applicable)
Treatment techniques focusing purely on pain and range alone can likewise be distracting and not helpful, especially in the phase two or three of learning mentioned above. Although we all need text books to aid our learning, I have noticed that some books tend to focus on either or both of 1) painful tissues, conditions (which are names for a collection of symptoms), limited ranges and technicalities of technique applied to a body parts or tissues in isolation or 2) the principles for good assessment for primary dysfunctions and treatment to restore harmonious relationship. I realise both are needed but information on point 1) above are only useful once point 2) information is uncovered first. Phase 1 learning would introduce to students the technicalities and techniques mentioned in books which cover point 1 above but when students are at phase two or three learning (i.e. the more integrative and application phases) I prefer to teach students;
1) To understand FUNCTIONAL (i.e. relationship oriented) Anatomy
2) The Principles of using and applying techniques correctly
3) The several components of movement: The 3 rotary (flexion/extension, rotation and Side-bending) and 3 translatory (A-P and lateral/medial glide and compression/distraction) movements and breathing. All true dysfunctions will have components of dysfunction in a combination of all or a few of these movement components.
4) How to DIAGNOSE DYS-FUNCTION in each of these several components – using passive motion testing, accessory and rotary (in addition to an observation/palpation assessment for regional impression and local bony and soft tissue landmarks – to I-D potential tissues within the region that may be dysfunctional – be they bony, soft tissue or joint)
5) Several different hand holds to assess and treat all the potential dysfunctions within a region, for each region (this is where the pictures in text books can help a little here – to give ideas for holds and basic positioning)
Then they can assess all the various tissues and joints in the investigated region for the tissues that are actually DYS-Functional and apply a technique – stacking all involved components of movement in the correct directions – gently thru the onset of bind (not end range) for an articulation or from just short of bind for a MET (muscle energy technique) – or into ease after locating a tender point in relation to the dysfunctional tissue for a PRT (position and release or strain/counter-strain technique), and then performing the technique itself. If students know where the dysfunction is and all its movement components, then they (or we) can make up techniques to address them – adapting or modifying the technique and its principles to address the tissues in need. We can also perform our articulation, MET or PRT quite easily and effectively because WE KNOW EXACTLY WHAT IS GOING ON and HOW to help it regain a balanced relationship with its surrounding tissues and with the whole to which it belongs. Once you know the how, where and what of it – it’s very simple.
This has a wealth more meaning than the technical dialogue about the thousands of potential individual techniques in some text books which don’t emphasise the quality of relationship component of treatment. And once students have even once experienced how to address a real problem – they can recognise quite easily this difference in approaches.
WHEN TO USE TECHNICAL RESOURCES:
If text books on treatment technicalities to address specific tissues have to be used then the principles I’ve mentioned above must be implemented in some form so the students don’t get mislead or distracted from the details and emphasis in many books. If this were the case – then the information in it could be used much more effectively, if and when needed, in specific cases where the techniques and details described may actually be useful.
Lecture resources such as power points should be developed which also outline a more wholistic and reasonable approach to diagnosis and treatment, in addition to essential technical information, which students can access. Class should be for integrating and learning essentials, not confusing with ‘non essential’ technicalities. Students can get this from home by looking up the non-essential or more technical details (if they are useful) in their own time (i.e. the book can then be used more as a resource out of class time for extra ideas and technical information). This (subject content) will obviously depend on the aims and goals of any particular subject of learning and whether or not it is meant to be either knowledge based learning or integrative based learning.
Reminder for Assessments: What’s more important?
- 1) Pain & Range focused attention:
- 2) PREDISPOSING PATTERNS and Quality focused attention
- Pain & Range focused attention
Traditionally many texts/teachers emphasize
1) Range (when assessing and treating) and
2) Focus on pain/symptoms relief when assessing and treating.
These often are a distraction from the real causes and dysfunction’s setting up the symptoms and symptomatic structure/s
For example: Range merely tells you amount of movement, not whether it’s dysfunctional or not (quality indicates function). Range may be limited and yet Quality throughout the range may still be ok – indicating perhaps a compensatory effect of a predisposing cause elsewhere. Symptoms merely tell us the tissues under stress/load, not the reason for this stress/load in the first place.
- PREDISPOSING PATTERNS and Quality focused attention
It is far more important instead to focus on:
- The PATTERNS SETTING UP THE PAIN (i.e. the predisposing, maintaining, contributing factors setting the stage for emergence of symptoms or slowing a patients recovery
- The QUALITY of Movement during assessment (as Quality indicates function and tells us if the structures in question need attention or not in treatment
Symptomatic tissues often are secondarily limited due to the stresses placed upon them from elsewhere and even if dysfunctional can’t return to normal function long term unless these stresses are also dealt with in treatment.
Why “2 elements” to Assessment: General and Symptomatic are needed
- General Wholistic Assessment uncovers Underlying Dysfunction Patterns which set up the symptom picture – and thus I-D primary contributing AREA’s of A.R.T.
Note: ART = Asymmetry, Range/Quality of motion abnormalities, and Tissue texture changes and depending on the area’s most contributing, these areas will also need a regional assessment to I-D specific structures most setting up the pattern of imbalance and resulting in the rest of the body compensating and eventually manifesting the symptoms.
- Regional Symptomatic Assessment uncovers Tissues under stress and thus contributing most to pain or other symptoms.
CASE STUDY EXAMPLE: CLINICAL REASONING – WHEN TO APPLY LOCAL TREATMENT AND WHY?
Obviously there is a place for local treatment, provided there is an actual local dys-function to treat. But, even here, treating based upon pain and limited range alone is not often needed, and can in fact be distracting.
For example – I recently saw a young lady who fell on an outstretched (pronated) left arm whilst playing soccer and presented with acute elbow pain and limitation of motion.
After assessing her whole posture and treating the predisposing and maintaining patterns that presented (some medial compression through the left side of her trunk in general and some imbalance in the pelvis and shoulder girdle areas), I still found much limitation and pain locally at the elbow. However having balanced out the predisposing factors elsewhere, it did help to help alignment of the whole arm and improve fluid flow and drainage which did take some of the inflammation and tenderness away allowing me to access the local details better.
Prior to this all I had noticed from general palpation of the whole arm (always a very informative thing to do for perspective) that there was some fullness in the upper left forearm and extreme pain and tenderness at the medial elbow especially. Active and passive ‘ranges’ of movement were unable to be adequately performed due to the pain; other than the obvious fact that she could not extend and lock her elbow. It didn’t make any sense to aggravate the pain further by trying to perform a full range at that stage nor to even treat it purely by working with the range without knowing exactly what was wrong in the first place.
After settling the rest of the body, I was able to gently perform some passive movements – for quality of motion – a lot better. This showed decreased extension and supination of the elbow/forearm. I.e. as I moved gently into extension from the ease in flexion I noticed at a certain point that the quality of extension became altered and the forearm tended to pronate as it fell into extension, or rather instead of, and thus limiting, the elbows ability to fall into extension. If I had not been paying attention to the ‘quality’ whilst I was performing passive movement, I would not have even noticed this phenomenon.
Local palpation revealed extreme pain and tenderness around the medial epicondyle. The upper arm was ok and the elbow joint was relatively ok in itself functionally speaking other than being painful. So, why the general fullness in the upper forearm revealed earlier in general palpation of the arm? What does this mean? This needed to be explored more with detailed palpation of bony and soft tissue landmarks. This revealed tension deep within the pronator teres muscle.
This explained the whole pattern. The fall had created a jolting of the arm resulting in reflex spasm and over contraction of the pronator teres muscle, subsequently holding the forearm and elbow in pronation and slight flexion respectively. Thus, extension and supination was limited because these movements stretch the hyper-shortened and facilitated muscle spindle in pronator teres pulling on the more fixed origin of the muscle to the medial epicondyle and resulting in pain and limitation of movement.
Now, I could treat the painful origin at the medial epicondyle but this is the effect of dysfunction in the belly of the muscle (where the real dysfunction was). Apart from pain I was finding no actual dys-function at the epicondyle or elbow joint to indicate anything needed any treatment here. Treatment here would have no effect because the movement limitation is due to a neuromuscular dysfunction with the dysfunction in the muscle belly and not a Humero-ulnar or radio-ulnar joint dysfunction.
Articulation of these joints would most likely miss affecting the pronator teres effectively unless we inhibited the pronator teres muscle belly with one hand (thumb or other contact point) at the appropriate point and the other gently supinated the forearm to, and just through, the initial bind in the muscle (not end range movement for the joints themselves) – i.e. at the actual dys-function site and not the effected painful site. Otherwise, as with any dysfunction, movements carried out obliviously tend to move around the dysfunction without actually addressing it; thus compensatory tissues are often worked and not the real primary tissues.
In this case I gently inhibited the pronator teres and applied slight gliding movements at the primary site in the pronator teres muscle belly, using slight supination to more effectively focus my forces to the appropriate site.
Thus AWARENESS of the actual dysfunction is required so that we can effectively focus the corrective movements to the correct site of the dysfunction and not merely its compensatory effects. This often requires we adapt and modify our basic techniques to suit the tissues in need and these modifications aren’t usually explored in traditional text books, especially those that focus on symptoms alone without accounting for the actual dysfunction which is identified by assessing for QUALITY of motion.
In this case, applying my treatment in this way achieved a release in the pronator teres and when I then rechecked elbow extension and forearm supination they were over 95% improved. The elbow was able to fall into extension without tending to pronate and pain had significantly diminished.
Isn’t this an example of pure clinical reasoning based upon results of a wholistic screening procedure (based upon observing texture, symmetry and QUALITY of movement) as well as a sound knowledge of anatomy?
Isn’t this a clear example of why we must treat the true DYS-FUNCTION, (at its initial bind in all three planes of movement – i.e. rotation, flexion/extension, abduction/adduction, translation anterior-posterior, medial-lateral and compression-distraction – in correct amounts of each), and not simply apply our treatment based upon limited range alone?
Does it not make sense to treat primary predisposing and maintaining dysfunctions in the whole posture/being that contribute to secondary compensatory imbalances at the local symptomatic site (unless the primary problem is in the symptomatic area of course) in order to help align the effected structure and otherwise set it up (via neural, vascular, lymphatic or other channels) for a more speedy recovery?
Does it not make sense in the local area to address the true primary dysfunctional tissues and thereby allow an improvement in function in the area we want to improve?
And finally, is this not a clear example that pain and range are merely effects which can often distract from identifying the true primary dysfunctions setting them up and thus are not true indications for effective treatment (short or long term)?
I hope this case study has provided interesting food for thought, Paul Turner.
ADDITIONAL NOTE on my Publication “Wholistic Integrated Assessment, A Teacher – Student Guide”, 12 DVD set and manual:
The above information is discussed more thoroughly and is practically explored in my publication “WHOLISTIC INTEGRATED ASSESSMENT, A Teacher – Student Guide”, 12 DVD set and manual. This is specifically designed to help with the phase 2 and 3 elements of learning mentioned above and also to counterbalance the over focus on approaches which focus on specific research and technicalities on parts of the whole. This is the reason why it was developed and also why it is needed.
It is my hope that readers and reviewers, upon investigating this material, will find the principles and practice of Wholistic Integrated Assessment, treatment and rehabilitation, refreshing, enlightening, logical, simple and easy to follow. Once its usefulness is realised (as it has by those who have taken the time to view it so far and have found that it covers all the essential elements which make learning and training meaningful), these ideas should logically start to flow into the teaching systems.
Why? Because it’s SIMPLE, EASY TO FOLLOW, THOROUGH, WHOLISTIC and can be applied by all Health fields, especially those involved in manual therapies.
By Paul Turner