AUTHOR: Kat Keane
The Client77 year old lady, L hip replacement 3 years ago. Client complains of L mid-lower buttock pain, extending over the GT region. She mostly feels this pain at night, upon waking and that pain increases as she fatigues with ADLs and prolonged standing. The pain at night wakes her and she is constantly changing position to relieve this pain. She has had remedial massage to the area, which she claims helps for a while but the pain never really goes away.
AssessmentVAS 7-8/10 for sleep/standing/ADLs
U/S to left hip and gluteal region found changes of tendinosis involving the gluteus medius and minimus insertions with a 7mm focus of calcification on the minimus insertion. No other abnormalities identified.
Slightly painful on palpation just above and around the GT. Painful on resisted abduction.
The TreatmentMy clients goal was to reduce the pain she was feeling, especially at night.
1. Manual treatment:
- DN to gluteal myofacial TrPs
- Frictions to gluteal tendon area (within pain limits)
3. Initial ProgressionBridging Single leg bridges
Prone leg extensions Standing Resistance Band Hip Extension
Side lying hip abduction/clams SL/Standing Resistance Band Hip Abd
Focusing on the eccentric component, 10reps x 3 daily and within pain limits e.g. <5/10
4. Sleeping:Lying on painful side= may need extra padding e.g. softer mattress or extra padding
Lying on non-painful side = place pillow/s between knees and ankles to reduce hip adduction.
As prolonged and excessive leg adduction (of the affected hip) while in a side lying sleep position can cause pain with gluteal tendinosis, use pillow/s to support the leg to reduce the adduction.
The ResultsAfter two weeks of working on the prescribed exercises and advice on sleeping positions, the client reported feeling less pain during ALDs and significant improvement at night and upon waking.
DiscussionStrategic load implementation, in the form of (eccentric) exercises, not to mention adequate rest, is key to management of a tendinopathy. Depending on the stage of tendon degeneration will dictate the treatment protocol. Understanding that there are different stages of tendon pathology is crucial and upon assessing and deciding on which stage of tendon degeneration will influence your treatment method/choices. The Article Tendon Pathology Continuum (Cook and Purdam, 2008) proposed that under periods of excessive load a tendon will pass through a continuum of damage and depending on the stage will influence the treatment. The reactive stage, dysrepair and degenerative stages all have different pathophysiological characteristics, therefore require different treatment approaches. In degenerative stages exercise appears to be a positive stimulus for tendon restructuring, hence the prescribed exercises and initial treatment focus for my client. The model presents a clinical framework of tendinopathy that aids a Myotherapist to select more appropriate treatment options and will ultimately enhance the overall effectiveness of treatment programs and client outcomes.
This is another point of difference from the Diploma scope of treatment verse a Q academy Myotherapsit. The Myotherapist will to not only use a variety of manual treatment options, but be well equipped with the knowledge and skills to prescribe exercises for such (above) pathologies.
Lastly, even though this condition maybe directly be linked to the surgery, a Q Academy Myotherapy student knows not to look at dysfunctions in isolation. A run through of the SFMA would identify any mobility/stability issues that may also be directly or indirectly related.