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Old 05-02-2008, 10:03 AM   #31
Bryan Veis
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Re: Rehab Help? Two Questions

Session 8 yesterday: Pretty much the same stretches and manipulations as before (all of them), plus phonophoresis at the end. I really don't think that phono is doing much for, so we will probably stop. At this point, progress seems very uneven -- two steps forward, two steps back. There are times when the pain is significantly less, but they are unpredictable. The one thing I have noticed most, though is that I have significantly less pain at the origin of my hamstring when walking up an incline. The PT says, and I agree, that the imbalance in my hips seems to be markedly better. (Previously, the right hip was positioned noticeably forward of the left.) The hip joint capsule seems to have stretched some, as well. There's not as much resistance to forward pressure when she stretches it. If anything, though, I tend to have more back discomfort when I tire my hamstring.
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Old 05-04-2008, 11:34 PM   #32
Jeff Alexander
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Re: Rehab Help? Two Questions

Bryan,

I do extensive work with self-therapy to relieve trigger points and other muscular issues. I am not a doctor, so I tend to defer to doctor's orders. You're right in that the Vas. Intermed. is difficult to get to. However, I have had extremely good results with a massage ball about the size of a tennis ball, but firmer. With your surgery results, the location of applied pressure will be very important, but you can easily tell if the following technique is working and more importantly you can bail out at any time.

An easy test to see just how locked up the vastus intermedius is requires that you raise your knee almost hip level, grab your ankle and try to pull your heel to your glutes. The farther away your foot is from your rump, the more knots you have in the V.I.

To address knots in the the vastus intermedius (also known as the "great frustrator"), lie on your stomach on a firm surface. Tilt to one side and place a tennis ball (the Trigger Point Technologies Massage Ball works best) under the center of your affected thigh. DO NOT USE a golf ball, baseball or other very hard object, as very hard objects used with high pressure can permanently damage your soft tissues if you are too aggressive. The tennis ball is extremely safe, although it doesn't push quite as hard as the aforementioned massage ball so it won't get quite as deep. Once the ball is under your thigh, lie as flat as possible with your hip on the floor. Try to get your thigh to absorb the ball into the muscle, and let your knee cap touch the ground. It sounds easier than it is. As the muscle relaxes, the ball sinks in a little deeper, and the tension there caused by contractile knots gradually decreases allowing circulation and recovery to improve. Do a series of 5-10 breaths in one spot, then shift your body about 1 inch to another spot and repeat. Continue until you can place the ball anywhere around the center of your thigh and maintain contact with the floor with both your hip and knee.

Get as close to the inflammation as possible with the above technique without applying pressure to the exact area of inflammation. Work every bit of muscle around the inflammation and that will open up your circulation to help reduce the inflammation more quickly.

Although I do not have any man-made parts in my hips, I work with many people that do. Every one of them has seen improvements through the same or similar massage techniques to relieve excessive residual tension (hyertonicity).

Good luck, and feel free to contact me if you need further assistance.
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Old 05-04-2008, 11:49 PM   #33
Jeff Alexander
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Re: Rehab Help? Two Questions

Brian,

One other thing...on second look it sounds like your rectus femoris is pretty locked up, too. It attaches at the Anterior Inferior Iliac Spine (AIIS) and when it forms knots it tends to tilt the hip forward, thus putting the hamstrings on a permanent stretch. This loads the lower back by making you bend forward, and makes the hamstrings weak and prone to injury.

With you still in recovery from the surgery I hesitate to recommend myofascial compression techniques for the Rec. Fem., but once you are healed enough to do them, they will "cure" lower back pain caused by this unique quad. I worked with one woman in particular that couldn't drive her car for more than 5-10 minutes because her back would "go out." The tops of her quads at the AIIS were like golf balls in there. After 20-30 minutes on each thigh, and weekly 5-10 minute follow-ups, she is pain free and can drive as long as necessary.

I know your PT has you in good hands, I wish you a speedy recovery.
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Old 05-05-2008, 07:36 PM   #34
Bryan Veis
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Re: Rehab Help? Two Questions

I had another session today. We agreed that the phonophoresis was not having any appreciable effect, so it has been discontinued. Lots of stretching, massage, etc. Everything seems to be loosening up.

Jeff, thanks. That sounds very interesting. I have another PT session on Thursday -- I'm going to print out your posts and show them to the PT. She's been very frustrated trying to figure out additional methods of getting at this.
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Old 05-06-2008, 09:39 AM   #35
Bryan Veis
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Re: Rehab Help? Two Questions

Jeff,

I tried your foot-to-rump test this morning. I don't have any problem getting my heel to touch my butt, so I don't think the problem is knots in the VI. I suppose I could be some kind of outlier here, since I am more flexible than the average 56-year-old guy due to decades of taekwondo. The PT and I have great difficulty finding ways to stretch the VI and other muscles in the hip area .

There is a lot of fibrosity (is that the word?) at the origin of the sartorius. How would that relate to the rectus femoris? Lower and more lateral?

As far as my recovery from surgery goes, I'm now six months out, and cleared by the surgeon for most anything I can stand. The bone is as strong as it is going to get. I think he would frown on skydiving and heavy contact sports, but people with my prosthesis run Ironman distance triathlons and participate in jujutsu tournaments, so the joint can handle a lot of stress -- much more than the prosthesis one gets with a total hip replacement.
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Old 05-06-2008, 02:57 PM   #36
Jeff Alexander
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Re: Rehab Help? Two Questions

Brian,

I've had to work on several sartorious issues. The Rec. Fem. attaches to the anterior INFERIOR iliac spine, the Sartorious attaches to the anterior SUPERIOR iliac spine a little higher up. So if anything, the rectus femoris manipulations for myofascial compression will help, and the same techniques can be used to address the sartorious from the insertion at the tibia all the way to the origin at the front, almost very top of the hip.

Sit down and place your hand on the top of your thigh with your thumb resting on the top, internal boney knotch of your hip on the tight side, fingers placed on or around the outside of your thigh. Lift your knee while slightly rotating it outward so that your foot moves toward the midline for the side with the messed up sartorious. If you feel the muscle bulging under your thumb right at the hip bone, you're probably in the right spot (the sartorious origin).

Starting at the knee just to the inside of your VMO (vastus medialis oblique quadriceps muscle), gently apply pressure a couple times every inch or two along your inside thigh while gradually making your way up and across the thigh to the origin of the sartorious (either seated with the massage ball or your thumbs, or lying face-down on the massage ball --my favorite-- and gradually sliding your leg over the ball). When you find a "sweet spot" of tension, do the breathe-relax technique I described earlier, while you apply pressure with either your thumb or the massage ball. Repeat all along your sartorious muscle, until the sensitivity is gone, for the most part working from insertion at the tibia to origin at the hip.

If the sensitivity gets worse, especially with no range of motion improvements, immediately stop and let your therapist help you. (We don't want you aggravating the problem.)

The sartorious has been an issue for several of my clients, but not without the rec. fem., vas. lat., & especially the vas. med. also having knots. Be very careful to relax, relax, RELAX your muscles as you rub them, for the more pressure you have to use to fight the muscle, the more likely you are to bruise or otherwise damage them.
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Old 05-06-2008, 06:06 PM   #37
Bryan Veis
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Re: Rehab Help? Two Questions

I ran your earlier posts by my PT today. She tells me that she has, in fact, been working on both the sartorius and rectus femoris origins during our sessions, so I think that part is covered. I am going to give your tennis ball techniques a try, though. As to tightness in the rectus femoris, she informs me that the flexibility tests she did included the r.f. and that I have greater than normal flexibility there, too.

Interesting observation on sensitivity on the inside of the thigh from just above the knee and moving up the thigh -- by comparison my right side (the bad one) is definitely more sensitive than the left. I've been doing your massage technique up the thigh with my thumb periodically this evening. I have another therapy session on Thursday, and the therapist and I will talk about it then. Actually, there will be two therapists; the one I have been working with has asked another therapist who has more experience with back and hamstring issues to come in and take a look.
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Old 05-06-2008, 09:10 PM   #38
Jeff Alexander
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Re: Rehab Help? Two Questions

Good luck Brian. Obviously, with the therapists being there with you they can provide more qualified advice than I can via the internet. Keep us posted on the results!
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Old 05-09-2008, 04:03 AM   #39
Bryan Veis
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Re: Rehab Help? Two Questions

Session 10 yesterday was educational. The second PT started with a gait analysis and then did a lot of range of motion and strength testing.

Her conclusion is that due to all those years of arthritis in the joint, the gluteus medius is severely atrophied. But, I have learned to compensate very well -- to the point that it is very hard to tell that I have a problem when I walk. Apparently, though, the result of all those years is that I can't voluntarily activate the gluteus medius. In order to walk "normally," my foot shifts my weight slightly as I stride to avoid dorsiflexion, and that put an extra load on my sartorius. I have more flexibility in my soleus than in my gastrocnemius, which leads to that slight outward weight shift. (I think I got that right.) When I squat, I unconsciously shift all my weight to my good leg just before hitting bottom and then reload it onto my bad leg.

I have been given some stretching work to do on the calf, and they are going to try electrostimulation on the gluteus medius. Next week should be interesting.
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Old 05-17-2008, 10:30 AM   #40
Bryan Veis
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Re: Rehab Help? Two Questions

The focus now is on gluteus medius and maximus activation and correcting the foot dorsiflexion problem. The PT places electrodes strategically around the glutes and hooks me up to "Old Sparky." Then I slowly do various movements while being electrostimulated -- box squats, lying abductions, single leg balancing, stepping down from a low box, etc. Homework consists of more of the same.

She also put me on a diagnostic device that showed that I tend to favor my good leg at all stages of the squat -- I really have to think about it to keep the loading even, because the strength imbalance makes me think I am loading evenly when, in fact, up to 60% of my weight may be on the good leg.

For now, my normal deep squats (I can get as deep as the pic that accompanied Friday's WOD) are out, because the way I get out of them apparently doesn't have much glute involvement and exacerbates the problem.

I'll be doing PT once a week now for the next four weeks, and then we re-evaluate.
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