Two Sides to Every Story
Two Sides to Every Story
As massage therapists, how we develop our thoughts for therapy makes the difference of a general massage and a clinical massage. This case study is on sciatic nerve entrapment pain left over from a shoulder surgery. If you skip to the second side of this story because you think it might sound juicier, you will surely miss the point of the article. So stay with me and let the discussion begin.
In order for us to have corrective strategic massage solutions to help our clients, we have to begin by having critical thinking skills and a great deal of on-going continuous learning, studying and doing. I feel massage therapy has gotten away from critical thinking. It is in part because our society does not truly understanding what massage therapy can do for many sports injuries, left over conditions from surgeries along with several chronic conditions. The big box stores of massage have certainly increased the awareness and need for massage, plus provided jobs, but has it helped with the education to the public about the principles of soft tissue work and its original intention.
We are a driven society no doubt, so it is crucial to relax, slow down, breathe, and take a break by having a general Swedish massage. All very necessary, but that is only the tip of the ice berg when it comes to making a career choice and a path of soft tissue manipulation. I was recently exposed to a perfect example of this thought process by hiring a massage therapist who had taken courses in many techniques. The resume looked outstanding and the number of years in the business was almost 20. Yet after giving this therapist many clients and the clients complaining the routine was always the same no matter what the complaint they had presented to the therapist, I had to sit down and have a talk. Here is the conversation: :Can you tell me why you have chosen not to address the back, the hip or the elbow after the client specifically asked you to do so? On your resume and in the interview process you stated you have the ability to help out specific conditions." The response: :I do, but the last place I worked I didn't have to think, it was just repetitive massage. I will have to change my mind set and get my books back out." I am very happy to say, right after the conversation, this therapist clicked back into a corrective strategic mind and everyone has been happy ever since.
If you are reading this and have ever thought about owning your own business, even if that is a one room situational business, as the business owner, you will not be able to have a mindless approach. It really does come down to learning how to have a corrective strategic mind approach.
Every client counts, you will want to always treat them like there is no membership to back you up. They will not automatically keep coming back time and time again. A small massage business or private practice relies on consistent referrals and consistently helping clients get relief from pain in order to keep them coming back. Referrals are literally your bread and butter. Now let's use a corrective strategic mind to think through the nerve entrapment pain I explained we would get back to. This is a real situation that a girlfriend of mine has been suffering with for more than a year.
Seventeen years ago, a horse threw her into a tree after getting spooked. She fractured a clavicle and seven ribs, punctured a lung, and broke the neck of her femur. She had to have a hip replacement because the neck of the femur developed necrosis. Necrosis is a form of cell injury which results in the premature death of cells in living tissue by autolysis. She is now going to be 68. Her posture has become a perfect S curve, with an upper Kyphosis and extreme Lordosis. One year ago, she had another horse accident where she tore the rotator cuff and the labrum of the shoulder. She ended up having shoulder surgery which left her with unrelenting hamstring spasms at night with numbness and tingling down to the foot. Her shoulder surgery was done with her in a seated position under general anesthesia. She was under for approximately two and a half hours for a clean-up of the shoulder, repair of the rotator cuff and labrum repair. She didn't even realize until the shoulder started to get better that she had been left with a sciatic distribution pain and dysfunction. So what the heck do you think happened? And what will help?
There is a possibility she wasn't positioned properly during surgery or the jarring of her jumping off the horse. According to Volume 2 of the Myofascial Pain and Dysfunction Trigger Point Manual, Chapter 2, page 16 under Diagnosis: :The pain at the SI joint can be initiated by a slight fall, pregnancy, or improper positioning during general anesthesia. Occasionally, severe pain in a sciatic distribution may be the chief symptom of SI joint dysfunction and may so predominate that the patient makes no mention of pain in the back."
On the MRI, she had spinal stenosis and arthritis. There is a possibility that the sciatic nerve is entrapped by calcium at the nerve root. Again, did being out under surgery allow more compression on a nerve root in a pre-existing spinal stenosis condition?
Does the hip replacement allow for a sloppy or a poorly closing SI joint on that side which is her side of pain and is that irritating the sciatic nerve? Is her S posture causing a constant tug on the hamstring and the sciatic nerve? She has a Morton foot, which she was told to wear a lift, but hasn't. Is there a leg length discrepancy contributing to the hamstring spasms?
She loves to workout doing spinning classes. Not a good idea with her posture and history. Do you know why? She is adding more forward flexion, placing more stretch on the hamstrings, more stress at the SI joint and is contributing to a shortened tight and facilitated psoas.
Does she have piriformis syndrome with sciatic entrapment? Or does she have a combination of all the above, including peroneal nerve entrapment which comes from the spinal nerves of L4,L5, and S1. The hip replacement is more than 15 years old, has the neuromotor control changed around the joint axis as she has aged and with the added disconnect from the CNS after the surgery? Initially, on MMT she had no gluteal firing, the hamstring was doing all the work to help her walk. This went on for at least four to five months until she regained control. This would have added the extra stress on the hamstring muscle.
Along her journey, she has been seen by a chiropractor who has used active release on all of the above muscles and structures along with all of the soft tissue components addressed by me. She has shown 80% improvement. The lasting results have been when I used a counterstrain positioning to the ileum, SI joint, and QL while performing the soft tissue treatments.
How this works is explained in Dr. Jones text, Strain and Counterstrain. Jones offers two definitions of the techniques: :Relieving spinal or other joint pain by passively putting the joint into its position of greatest comfort." And second, relieving pain by reduction and arrest of the continuing inappropriate proprioceptor activity. This is accomplished by markedly shortening the muscle that contains the malfunctioning muscle spindle by applying mild strain to its antagonists."
I discussed with her getting treatment and not making exercise strategies match the therapy strategies are not helping her for the long run. Her posture is a big problem and she needs more extension exercises and massage therapy to all the flexors more often than once a month. In addition, possibly adding the lift that was prescribed for her to help with the mortons foot on that side so her gait is not so uneven would be less likely to aggravate the SI joint. Unfortunately, if there has been permanent nerve root damage or the nerve is being compressed at night from the spinal stenosis an epidural to the nerve root maybe necessary which is her next step with her medical doctor. Although this client wasn't totally relieved of the symptoms, she has achieved an 80% recovery. It's all about thinking outside of the box and utilizing corrective strategic massage solutions.