In 1994, at the age of 26, Mrs. A underwent a tibialis anterior decompression at her left ankle for persisting lower leg pain related to tibialis anterior tendinopathy. Prior to the development of the tendinopathy she had been undergoing training for a half marathon. Following the surgery, the pain only worsened and she experienced twelve months of severe pain, swelling, coldness and tightness of the left ankle which eventually settled as she worked with her musculoskeletal physician using multiple methods such as counter-irritation, gradually increasing movement in the ankle, choosing supportive shoes and medication. Mrs. A believes medication was never very helpful and is averse to using any.
Musculoskeletal pain is the third most common cause for presentation to a General Practitioner (GP). Of these presentations, shoulder pain is among the most common. Indeed, up to 95% of those with shoulder pain are treated at the primary care level.
Complex regional pain syndrome (CRPS) is a relatively uncommon, but painful and disabling condition. It is characterised by limb pain with sensory, vasomotor, sudomotor, motor and dystrophic changes, usually occurring after injury. The diagnosis can be difficult to make, as it lacks an objective test. The diagnosis is therefore based on clinical findings. The Budapest criteria are the accepted standard for this.
Lumbar spine pain is the most common musculoskeletal complaint we see in practice. The disc has been found to be the most common source of lumbar spine pain. A disc prolapse occurs when the nucleus of the disc protrudes through a torn annulus. Disc bulges and prolapses can often cause irritation to an adjacent nerve root, and may cause radicular symptoms down the leg. Disc prolapse is often preceded by actions involving bending and lifting that place some pressure on the disc. The annular ligament is a layered structure and layers may sequentially tear, hence the final force that causes the nucleus to protrude may be minimal such as bending over. Disc prolapse accounts for diminished quality of life, as well as associated costs financially from medical care and lost earnings.
Academic blindness occurs when researchers and reviewers, believing their confirmation bias, obtain or support further research funding and waste that funding on error laden hypotheses and research programmes. This paper addresses three examples, one internationally recognised whiplash research study and two examples of erroneous internationally recognised chronic low back pain (CLBP) research. The researchers persist in pursuing these false models despite confirmation bias errors being repeatedly demonstrated. The secondary problem of many peer reviewers also blinded by academic and confirmation bias is identified. The author uses his personal experience, primary care observation, analysis and clinical research of the underlying anatomy, physiology and whole body function models to identify where the errors exist and why they need to be corrected. By considering the results of this primary care research, new and simple explanations for the results seen in whiplash injuries and CLBP can be more readily provided with explanations and managements developed in primary care, and immediately applicable throughout the world. Further interpretation of the results has led the author to propose a better, simpler hypothesis leading to an understanding of the importance of enthesis damage and periosteal biomechanical injury in the onset and persistence of musculoskeletal pain, fibromyalgia (chronic widespread pain syndrome), chronic low back pain (CLBP), vertebral or bony degeneration and osteophytes, or spur formation visualised on imaging of the spine and other bony tissues. These identified issues form the often ignored pain elephant in the room. Pain researchers have frequently been enticed by confirmation bias and trapped by fiscal servitude, merely for academic survival. Those asked to peer review appear to have also suffered from similar bias. The author raises the issue of research funds being wasted on programmes involving confirmation bias (confounded by academic blindness) and promulgates a potential method to prevent further inappropriate fund application approval.
Achilles tendinopathy is commonly encountered in clinical practice yet can be quite difficult to successfully treat. Relative overload is the precursor to most presentations, while systemic conditions can decrease the amount of load that triggers overload. While there is evidence for the use of eccentric exercise, it is not recommended in isolation for most presentations of Achilles tendinopathy as it fails to address strength and kinetic chain deficits, which can leave the individual vulnerable to recurrence. Insertional tendinopathy requires a tailored management that avoids dorsiflexion, as this position compresses the tendon onto the calcaneus. Purpose: This masterclass summarises the tendinopathy continuum and articulates the authors' clinical reasoning and hands-on experience managing Achilles tendinopathy. We outline graded loading concepts while emphasising that relying on recipes is likely to fail. We also provide a perspective on the role of central pain processing and peripheral input from nociceptive fibres in the context of tendinopathy. Inplications: Rehabilitation should be tailored to address identified impairments (muscle bulk asymmetries, kinetic chain dysfunction, tolerance of energy storage and release in the Achilles tendon), and progressively work toward movements and activities relevant for the individual's sport or daily activities. Within the three-stage rehabilitation sequence, stage 1 aims to reduce pain and increase calf muscle bulk; stage 2 focuses on improving power within the whole kinetic chain, and movement control during jumping and landing; and stage 3 begins to retrain sport specific load, and carefully introduces movements that require energy storage and release within the tendon.
The following two case studies from a clinical myotherapy practice are described to distinguish between piriformis syndrome (PS) and lumbar radicular leg pain (sciatica). The differences in etiology and symptoms will be outlined as well as the administered treatments. Patient identity has been changed to preserve confidentiality.
Persistent spinal pain is a common problem in the community, affecting around 10% of the Australian population. It is one of the most common causes of work insurance claims and causes of disability. Care of these people is often left in the hands of primary care health practitioners. These patients often fall outside the scope of specialist care in that they are most commonly suffering from a non-operative, non-rheumatologic condition.
The dermatome is a fundamental concept in human anatomy and of major importance in clinical practice. There are significant variations in current dermatome maps in standard anatomy texts. The aim of this study was to undertake a systematic literature review of the available evidence for the distribution of human dermatomes. Particular emphasis was placed on the technique of ascertainment, the location and extent of each dermatome, the number of subjects studied, and methodologic limitations. Our findings demonstrate that current dermatome maps are inaccurate and based on flawed studies. After selecting the best available evidence, a novel evidence-based dermatome map was constructed. This represents the most consistent tactile dermatomal areas for each spinal dorsal nerve root found in most individuals. In addition to highlighting the orderly arrangement, areas of consistency and clinical usefulness of dermatomes, their overlap and variability deserve greater emphasis. This review demonstrates the validity of an evidence-based approach to an anatomical concept.
Back pain is an enormous clinical, social and economic problem, with up to 85% of adults experiencing back pain at some stage during in their lifetime.1 Chronic low back pain has many causes that can generally be divided into degeneration of the intervertebral discs (39-42%), facet joints (31%) and sacroiliac joints (18%).2,3 Although disc disease is implicated in all ages, sacroiliac and facet joint arthropathy are more frequently seen in older patients.
There are no precise prevalence rates of adults with generalised joint hypermobility (GJH), and in a recent review the prevalence for adults varies from 2% to 57% depending on age, gender and ethnic origin. For children the prevalence varies from 7% to 36%, primarily depending on the tests and criteria (especially the cut-off points) used for diagnosing GJH.
Review(s) of: Emergencies in sports medicine, by Dr Julian Redhead and Dr Jonathon Gordon, Oxford University Press, Oxford, UK. 2012, Available from Oxford University Press or Amazon for around $47.95 plus shipping.
The endocannabinoid system is an endogenous lipid signalling system in all vertebrates. It has multiple important functions including the modulation of pain and it could have a significant role in the future in the clinical management of both acute and chronic pain. It consists of several receptors and ligands, with the most studied components being the receptors CB1 and CB2 and the endogenous ligands AEA and 2AG.
Over the last two decades, the sacroiliac joint (SIJ) has increasingly been recognized as an anatomical source of pain that figures in the differential diagnosis of a patient presenting with low back pain (LBP) and/or buttock pain with or without more distant referred pain.1-7 The SIJ is innervated and thus has the potential to be a source of pain.
