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Members of the NeuroCentric Approach Online Academy meet regularly on Zoom for an informal, online coffee chat and case study.
Below you can find transcripts of this meeting and watch the video from YouTube if desired. To learn more about becoming a member, click below.
Femoral Leg Pain
Transcripts from the video above are below...
Welcome in guys. It's time for another Zoom Facebook Live for the neuro centric Approach Coffee Club.
Just getting things set up here.
As you can see from my Intrepid five dog, rough girl, it is a bit cooler here in Portland.
We had our first frost last night.
Five had her sweater on matching my pajamas that my wife maybe.
Yes. So if I thought Rough girl is joining us for our talk this morning or we will cover a case from previous week through a neuro centric approach lens and we'll talk a little bit about other things that may or may not matter in our lives. Things like weather. God, it's gorgeous,
absolutely gorgeous outside. Those of you that are on Zoom and have me here can't quite see it. Those of you on Facebook over here can, you can see the the incredible fall weather we're having out there and I hope it's nice where you guys are too. Yeah, first Frost of the year last night and we are likely lose a few plants but as I used to say in the country where I grew up, that first frost makes the collards nice and sweet, huh.
Let's see what else. Had a lovely time with my friend and NCA cohort Dr. Mark Heller yesterday. He's visiting family here and the Portland and Vancouver area and went out and spent some time with he and his lovely wife Beth yesterday. It's good to see Mark and also my father-in-law. Victor Truax turned 87 this past week and we all went out in mass last night to Thai restaurant in Vancouver and had a lovely dinner together.
So as folks are coming on here, I will go ahead and we'll talk a little bit about a case conference for this past week.
So this week's case through a neuro centric approach lens is 50 year 58 year old female who presented as a new patient with a complaint of left lateral hip and knee pain of six weeks duration and slow insidious onset, no clear provocation.
She notices the pain 100% of the time when she's being physically active.
That includes walking and it's fine at rest. Completely resolves with rest.
As far as radiation component, it goes only to the anterior part of her thigh to her knee and reliably goes there when she is physically active. But she points to an area over the greater trocanter on the left side as being the primary area that she feels the pain in and her symptoms are, the quality of the pain is dull and achy.
The severity of the symptoms that she's feeling is relatively mild. It's only about a one or two out of 10 on severity and really doesn't get much above that. Her chosen exercise is Orangetheory classes, which she took up with her daughter who is 28 and I also spent some time with in the clinic and her,
her daughter got her into arms theory classes going back to January of this year. So she's got about nine months of Orangetheory classes on board before she started feeling symptoms in the left lateral thigh with radiation into the knee.
Her past health history was somewhat interesting as you'll see in the the case her past health, his history was interesting for and twice previous diagnosis of melanoma without metastasis.
Also interesting for a diagnosis of at age 58 osteoporosis that was diagnosed a couple of years ago.
She had subsequently had three DEXA scans done at six month intervals and all of them had been about the same level.
So those DEXA scans, given that they were at the same level, she's a bit aversive to taking medication.
So she decided against taking medication and decided instead to try exercise, which is part of the reason why she was doing the Orangetheory classes with her daughter. She very much enjoyed that community, very much enjoys the workouts, very much wants to get on the other side of her left lateral hip and knee pain so that she can continue them and hopefully get some improvement in her bone mineral density over time.
Let's see, other issues, she's highly educated, she's PhD in biotechnology, she's biotech consultant, a principal in three different companies that are targeting, primarily getting various drugs to market.
Her undergrad was in molecular biology and neurophysiology so I figured we could geek out together and have some fun and indeed we did so on our, that pretty much concludes our history as we moved on to our physical examination with the patient.
And on the physical she was relatively height, weight proportional. She didn't exhibit any overt antalgia but I did notice a slight length favoring the presenting leg as she walked back into the office and standing her ranges of motion in the trunk were pretty much WNL for flexion extension and rotation with no provocation of symptoms with any of those movements.
When I asked her to squat, she had a reproduction of her knee pain on the anterior knee. Now in my world, most of the time when I do that, the patient has that characteristic knee pain. I usually, depending on what my suspicions are from the history, I'll go one of two routes or possibly both routes.
One will be that it's a medial knee pain and the I will go in and do a little dermal traction method along the S saines nerve on the, just above the inside of the knee and just below the inside of the knee and see if that makes it better. And her, her symptoms were a little more at the s patellar tendon attachment to the kneecap and also to the, just lateral to that. So I chose option number two to intervene right there and see if it changes anything.
And option number two, what I mean by that is I go through the functional approach rather than focusing on structures there for a moment and I just coached her through rooting into the floor in the same way that we have our power lifters from kabuki do it. And the way that I coach that is I'll have the patient drop down with their hands on their knees and I say, play with me for a moment thanks to McGill for that cue.
And then I'll have, okay, hands up and ready.
And I tell them, now I want you to to think about your feet and I want you to imagine that your feet are glued to the floor right now and you have a desire to un to detach your sticky feet from the floor, but you're going to do it by rotating your feet out. So you're going to root out and then I'll demonstrate and use the hand gesture to make sure they're getting the right thing. And if they don't then I'll give a kinesthetic cue to the thigh and rotate each thigh outward so that they can get a sense of that. I'm avoiding in that trying to go to some of McGill's older cues for trying to get this kind of gluteal activation on the squat where we would put our hands on the outside of the knees and have the patient to push into those.
What we've learned over the years in working with athletes at Kabuki that that cube gets a person to roll up onto the outside part of their foot and when they do that it takes the ball of the foot, the base of the MTP there or and rolls it up off of the floor and it becomes less weightbearing. So that can wind up causing some injuries in a clinical environment and also in a gem environment. When we see that a, that an athlete is riding on the outside part of their foot right there with a lot of weight on 'em, that is probably gonna cause an injury to the knee at some point.
So in her, when I coached her to do this rooting, just letting folks into the chat here and welcoming everybody in welcome Chad. I see Mark here as well on his drive back to Ashland today. Howdy, howdy and hello Brian up in North Dakota and looks like Alex is in as well. Hello Alex and Chad. How in the heck are you talking to us? You're on, you're on. Are you on a plane on the way to Sweden right now?
I'm in the airport in Munich.
Oh, very nice. Well thank you for joining us on this. What are you headed to Sweden for? Me?
are you headed? Headed to Sweden for
what you said.
What are you doing on your trip to Sweden?
I have to meet with a company. I'm gonna start working doing some ambassador work with a bed company out there. So I'm going to the factory and meeting the CEO and doing all that crap
Far out. Sounds like fun. Sweden oughta be lovely right about now. Get some nice crisp weather and some leaves changing. I
Alright, well good to see you my friend. Let me get back to our case here. So the, this particular patient again to recap those of you that are coming in a little bit late, I've got a 58 year old female with a presentation of dull and achy low severity. We're talking one or two out of 10 pain in the left lateral hip with pretty much all activity.
She, her past health history is significant for two x melanoma diagnosis without metastasis and also interesting for a diagnosis of osteoporosis. Three DEXA scans performed over the course of six months between each one was no change. So she's unmedicated to try to change her bone mineral density.
She started her, her attempts to make her bone mineral density improved by taking Orangetheory classes beginning about nine months ago.
The pain began insidiously and she wants to continue her exercises so that she can improve her bone, her bone health.
So we're back
to, Hey Philip, can I, can I throw in one little thing here?
Sure. Go with it Mark.
Yeah, there's a fabulous new book out. I believe the title is Strong Bones and it's by a guy I went to school with Dr.
R Keith McCormick, who's a chiropractor who is a world class athlete. He was alternate to the Olympics, develop severe osteoporosis in his forties and developed this whole model of how to test for and how to help people with osteoporosis with combination of the actual medicine and medications. So just, just something for people to know.
Alright, cool. Mark, tell me what that name of that was.
I believe it's Strong Bones and the author is R Keith McCormick.
I've heard that name before and I'm looking at maybe Great bones. Yeah,
That's It. So I'm pulling up, yeah, I'm pulling it up on Amazon and I will drop the link to that Looks like it's a paperback and on Amazon. I'll drop a link to that in the chat room for those of you that are here soon as I could figure out how to get to the chat room. There we go.
Like a boss.
All right, so that's in the chat room. For those of you that are over on Facebook, that's
great Bones Taking control of your osteoporosis by R Keith McCormick. Thanks for that Mark. I will check it out.
So now moving back to our physical examination, Cardinal ranges of motion in the trunk for WNL but squat, squat rise reproduce the one of the chief complaints of her pain in the the left anterior and lateral knee. When I had her to functionally try to root into the floor to see if this was, you know, a tendency for a painful valgus position in the knee, it actually made her symptoms worse.
So, hmm, I'll commonly see that. Fix the pain right there and then we at least know what our functional fix is going to be over time.
And then we can, you know, just focus a bit on some palliative work over the, the tissues themselves that are unhappy. Most of you that are on here that have taken any of our coursework on the, the neuro centric Approach online academy where we've got a 30 plus hours of continuing education for a stupidly low price, go check it out. You can become a lifetime member like many of the people I'm talking to over here on the Zoom conference when you are persistent and fortuitously engaged with us here because periodically like, I don't know, maybe a Black Friday sale or something like that, I might toss that lure in the water again to try to see if we can get some more lifetime members for a low low price. But no one will ever pay less than my original lifetime members.
I give you all a big hug over here.
So this particular patient had pain when she rooted to the floor, which make made me want to go over and do my, my first mention thing of a little bit of DTM along the thigh and see if that make made her symptoms any better. And when I did that she had a jump sign. I mean it was a total three over four or possibly four over four kind of hyperalgesia over the anterior thigh, over the medial aspect over the course of the saphenous nerve.
So then I worked along the course of the saphenous nerve and we're talking just a gentle pinch with lots of lots of tissue gathered up and as I worked down the medial side of the leg, it was a jump response the whole way down the leg. And as many of you already have seen with the patients where you're using palpatory findings as a screening tool to see if you have mechanically sensitive neurology in your case presentation, the patient says Yeah but you know, you're pinching me so that must be it. So what do you do then?
Well you reach over to the other leg and you do the same thing. Does that hurt over here?
And she's like, no, that doesn't hurt at all. And then she has that interesting moment of, wow, I didn't even notice that that was that sensitive.
Alright, so now I've got my spidey sense on it suggesting that we've got a very normal kind of saphenous nerve presentation that you all know and love and some of you on here that have taken the free knee course on the neuro centric approach online academy have even seen some of that.
But do I just stop there? No.
What is the, the spinal derivation of the or the upstream nerve mixed motor. Mixed nerve derivation of the S saphenous nerve. That's e femoral derivative. Right. So I continued my exploration by just going around with the same kind of pinchy movement across the anterior thigh and as I worked along her thigh it was clear that she had similar tenderness all the way across the front of the thigh and it, and that was all the way down from where her presenting complaint of the knee pain was and it went all the way up to the lateral part of her thigh where her symptomology was initially noted there.
So now we've got some more interesting involvement. I've got a saphenous nerve that is apparently hot and I've got what appears to be other femoral derivatives that are off it also hot.
So almost as in a way of dermatome mapping, which I will sometimes do using a a paper clip you can just take a paper clip and flip it out so you got one pointy end and use that to kind of lightly stroke over an area and then use an ink pam of the patient's permission and you can dermatome map a pain presentation and then show it to them on you know, a a standard dermatome map and sometimes that moves them out of the meat idea that something going on in their presenting area is a meat-based problem rather than a nerve based problem in her. She's sophisticated enough with her educational background to clearly know that we're talking about a nerve there.
So I'm like you, you can see that this is an, is something going on that's pissing those nerves off, right? He's like, yeah.
So we've got a dermatomal map that broadly looks at the entire front of the thigh and as I work laterally it goes away over the IT band, it goes away.
And next up in our clinical rubric and the way that we do our lower extremity exam, I've got the patient standing there, we've just gotten through with the sit, the squat rise.
I go over and have her put her hands on a little shelf to support her weight, go up on her toes and then lift one leg and then do toe raises or toe stands and try to get 20 reps there. So I'm testing the S one myotome there and she had subjective and objective deficits on the left side on the affected side over S one and then when we retest, when we tested the L five myotome by having her rock back onto her heels on two and then pick one leg up and then toe tap five times, she was quite challenged in that as well and we could see that there were some deficits there in that particular myoma as well. So now I've got clinical evidence on the exam and this is all tested relative to the unaffected side. I've got clinical evidence on the exam of objective and subjective weakness over probably three different myotome myotome slash dermatomes. I've got ephemeral and I've got two sciatic involvements.
So I continued the exploration per that NCA a flavor of lower quarter examination that we do by having her sit down. And I did a slump test in sitting and her slump test.
Interestingly again sciatic derivatives here didn't do anything for her symptomology. Remember those of you that took the lower quarter course if we've got knee pain, don't only think of femoral derivatives because the sciatic nerve actually sends a couple of shoots up to the bony structures of the joint and contributes to the innervation pattern there in the knee. So if you've got knee pain, don't immediately rule out that there could be sciatic involvement. So we do the slump, no reproduction of any of the knee pain, no reproduction of hip pain, we do a seated compression test to see if there's a hot disc, no reproduction of symptoms given her prior history of osteoporosis.
I sat behind her with a reflex hammer and tapped the spinous processes along the the spine and I fully expected to see something show up as hot there.
Absolutely nothing, nothing was hot there when I flipped her over and we did palpation in the inner spinous spaces, a little bit of tenderness but nothing really significant.
I had her go up into a prone prop position, it was well tolerated, did not reproduce any of her symptoms.
I had her move into prone press-up, we did 20 reps that did not really change her symptoms either.
And when I say change her symptoms, what I'm referring to there is, as you guys well know, we use an index test right? And our index test on this was her squat rise. So each time I would try an intervention I would then have her stand up and reproduce that that squat test and the slump didn't, excuse me, the prone press up intervention did not change the pain that she was having with that while I've got her there in that prone position. Now I continued my pinchy pinch testing the palpatory testing for mechanically sensitive neuro and I went along other upper level spinal neurology pathways and did pinch pinch in flank and along the structures on the, the lateral part of the, the abdomen and the posterior part of her body. And I didn't really get any jump sign or anything there and I kind of expected that the ileal inguinal and ileal hypogastric nerves are gonna be a bit hot but remember where they come off of, they're a little higher up in the lumbar spine aren't they?
They're like L one, L two, L three.
So now when that's ruled out, that starts to make me think more about something probably L three-ish, L four-ish is where our symptom presentation is. It's not an active fracture because the bone itself is not tender to percussion or for that matter I did 128 hertz tuning fork test on there and a poor man's stress fracture test and I didn't get anything there either.
So given the presentation, my next go-to when I think that something is potentially needing screening at the IVF nerve root level are gonna be openers for Michael shack lock's work. So I laid her on her side, did I mention motor testing? We did a repetitive sit stand motor and she could not do a single one on the affected left side. She could do three on the right side but you couldn't do a single one on the left.
So I did test her on a femoral nerve tension test and that interestingly did not reproduce her presenting symptoms in the knee, but she did have a change in the symptomology with neck movement on that whereas she did not have any change on the other side. Okie do.
So I put her in the opener position and we did five reps held for 30 seconds each of static openers for that side, had her stand back up and do her squat rise and she had no pain, no knee pain with the squat rise while she's standing there I could do the little pinchy pinch stuff and she's like wow that's not tender at all now. So that's like cool. So we've got sensory changes and the squat rise is kind of hard to tell whether that is sensory and motor or if that's just sensory. So I had her go back to our motor test and do the sit stand on a single leg and she could get one full rep out that time.
So we've got observed motor changes and observed sensory changes by providing an opener at the area of the lumbar spine that I think is probably impacted here.
So trying to put a narrative together as to how this makes sense.
I don't think we've got a, a patient that's had a, you know, an overt compression fracture from like a slip fall under the butt or something of that. We've probably got something that looks like an insufficiency fracture probably from exposure over nine months of a rounded back posture on a whole lot of ER positions in that orange theory class.
So now I've got a putative mechanism for the onset, I've got a way to provide palliation that she can do at home and we can just stack that benefit with frequency done during the day several times. So I said I want you five times a day, she works from home now I want you five times a day to do those static openers in that way and I want you to retest frequently during the day with your own fingers to palpate that area and anytime you feel that sensory change starting to happen, then do those openers for me. And all we're doing there is trying to stack benefit and as we stack benefit we give the body an opportunity to change the metabolism of that neural tract and to heal the darn thing itself without getting too sexy about what the hell it is we're doing. Just assume that patient and their ability to, to their body's ability to be able to do, do things that their body's gonna be able to figure it out.
Interestingly as well, I mentioned to her since she was bemoaning early in our history, the various financial variables that are
I guess in the way of getting drugs to market and finding someone to pay for an RCT and things like that.
I mentioned to her that if I had a wish for every single one of my female patients over the age of 40 for one exercise for them to do, it would be, what do you guys think?
What would your go-to be for improving spine and hip bone mineral density and when postmenopausal women farmers
Yep, farmers carry, love it Brian things are for the wind. We'll we'll send you a or centric approach shirt or something, some swag
at some point.
I'm thinking about a a a shopping bag with the, the DTM or excuse me, yeah the DTM logos since that one was done by one of the illustrators at Marvel, who's the first pen Thor for Marvel. He was a patient of mine and he did that DTM logo. That's so interesting.
I was thinking of doing a shopping bag for that because you know, some people have given me a little bit of pushback that all of this, this stuff that we're doing with NCA is is just ripping off other name systems and stuff and it's, it's patently not what it is, is a way to organize your thinking process and your examination process and to something that makes it harder for you to get lost in the incorporation or the integration of all of these other name systems. So I like the idea that the, a shopping bag just provides you with a way of putting all of those alphabet soups that we've all been through into something that you can carry around and you can pick out each one of those items as you need and make whatever recipe is most appropriate for the patient in front of you. More to come. Yeah, we'll open up a swag store at some point and get rich and famous. I'm sure that'll work.
Okey doke. Back to,
Can you talk about that sit stand test for the femoral nerve muscles? I I'm not familiar with that.
it's just a, it's our, as you've, you guys have noted in the past, rather than doing manual motor testing for L five S one and upstream motor derivatives by doing manual testing, you know, rating a five point scale there, which I've always kind of had a difficult time getting too excited about because there's so much subjectivity in that testing. So I, early on in my career I started to look for ways that we could make that motor testing more objective, you know, and sometimes I would do it with the patient laying supine and I would grab the big toe as they dorsiflex and I would lean my body weight into it with hands on both so that it, you know, that's one way of making the the manual test a little more objective.
But I started moving more towards things that the patient could do because then they can see clearly and can reproduce the testing at home when we have the possibility of maybe a disc and radiculopathy complaint and we need to keep progressive motor weakness in mind and the patient can clearly track that themselves at home and say, yeah I can get, I don't know, X number of toe raises on the affected leg now and I couldn't before but to Mark's question, what is the sit stand test?
It is as simple as it as it sounds patient sitting on the end of the bench and I coached him to, I want you to organize yourself in whatever way you need to to stand up using only your right or left leg to choose a leg and stand up. And then once they're up I'll say, okay, now sit down using only that leg and now give me four more of those. So I'm looking for five reps and I'm okay with them trying to get up any way they want and that's informative to me as well. If they have to launch themselves on one side with momentum relative to the other side, then that's valuable information to my mind.
And I don't have high low tables in my clinic, some of you guys I know do, but you might want to change the height of it to accommodate the patient's stature and to accommodate their ability at this particular level. And for me, I just stack AirX pads underneath them as many as I need in order to get them up to the height that I am working with. So does that make sense Mark?
Yeah, you know I I think you're testing both the hamstrings and the,
you're testing L three and L four, is that what it's that, that's my next question about it.
I'll give you that. Yeah. Although most patients when we're doing this are not gonna be able to get below 90 degrees of thigh orientation to the floor. So I am not thinking that I'm getting too much of the posterior chain I am, if I raise them up just a little bit more so that their thigh is not parallel to the floor when we start that, then theoretically we're getting mostly the femoral derivatives on that as opposed to the lower spinal derivatives.
So in this particular test to recap or this particular patient to recap
her index was left anterior knee pain was squatting our interventions that showed benefit.
Oh and, and her other index was the palpatory findings that we had for hypo hyperalgesia across the anterior thigh.
And we tested each one of those versus several different things to target the involved neurology from both a sensory and a motor perspective.
And the things that we found that were palliative for sensory and for motor were openers and the openers were prescribed in a frequent enough range to try to see if we can get some cumulative benefit email contact several days later with the patient.
She was saying that she was feeling a marked decrease in her pain. I'll see her again later this week and we will follow up on that. So interestingly, since I had a patient with osteoporosis and she's a researcher and I had been talking about farmer's walks and I see that Brad suggested deadlift deadlift as an intervention for that bone mineral intensity. Yeah, I like that a lot too.
Deadlifts a little bit harder to get people around or to get people accepting. I like farmer's walks as an intervention. This is one that got me and my patients through
this is one that got me and my patients through the pandemic and trying to get creative with homework and no people not having access to any available exercise equipment. I'd have 'em get a couple of five gallon buckets out of their garage and in the bucket put some water and choose enough WA weight in the bucket to challenge their grip after they'd been walking around with it in their hand for about 60 seconds. And then I'd make sure their hands were protected on those little handles on the buckets by either putting some pipe insulation around the handle and or getting some heavy work gloves and using those.
And the nice thing about the farmer's walks done that way in buckets versus using a deadlift Brad is the starting point for getting the weight off of the floor is much higher because the bucket itself is gonna be quite a bit higher than a barbell or a kettlebell when we're pulling it off of the floor and then when we flip the handles up for most people, that's gonna be a relatively upright starting position. So I don't have to go through a lot of coaching cues on position on that beyond just saying here, I'm gonna tickle you right here in your flank now or poke you right here and I want you to push that area out and make your abdominal wall nice and tight and have them generate some intraabdominal pressure there as a way to protect the spine.
So the, I suggested to her that we could potentially trial something that is very unsexy but could be very useful out there for bone mineral density changes in osteopenic and osteoporotic patients by doing bucket caries as farmers walks. And of course being incredibly careful in this particular patient because we already think that potentially she's exceeded the mechanical capacity of a one of those spinal elements. Probably a and has probably a bit of a compression at in all likelihood L four based on the presenting symptoms.
So how do we rule that in or out? Yeah, I suggested she go back to her PCP and let's get a, at least a three view imaging of the lumbar spine. 'cause I'd like to see on that oblique what the neural foramen looks like as well and what the, the pars looks like.
So we shall see what we've got when we get that information back and I'll share that with folks as well as a recap here when we learn more from that.
My go-to what I'm thinking I'll probably do this week if things have continued to progress well with the overall metabolic health of that nerve, she's done more openers is we're going to test more on the, the loading for the, the spine and see if we can get some improvements there.
Of course I'm going to go as well towards my favorite functional approach, which is ADNS functional approach.
I did not mention it, but I did note in her history that she had a prior history of inguinal, a inguinal hernia on the left side as well.
So I'm gonna go in and do some work on that area from a functional perspective over time. So over long-term function, it's gonna be making sure she can stack the thoraco pelvic canister, generate intraabdominal pressure while under load, then I'm going to load steadily to try to make the bone stronger. Trying to find a sweet spot between anabolism and catabolism on that loading locally, making sure that she's got adequate nutrition to be able to manage that with some, she's already taking vitamin D, she's already taking calcium.
Probably some collagen as well, maybe some liposomal vitamin C or just vitamin C to make sure that we've got those co-factors on board and all of that is helping as well.
So that is what I got for that one this week. Let's see, questions in the chat room here. Brian asks, did you do a straight leg raise on each side? Did one side feel heavier than the other side? I typically feel this on patients that do not have a very visible positive SLR. That's interesting.
Are you saying heavier, which you put in quotes here, Brian, from a subjective or an objective, are you meant, are you
or a passive SLR?
Well, more of a passive with me Pushing up and I always feel like one side's just meets a point of tension or it just feels heavier sooner, but it may not be like a, you know, we're taught in school a positive straight leg raises symptoms and all that stuff, but over the years I've just felt like one side's just always heavier on the affected side of the nerve root issue.
That's an interesting finding. You know, if I, if I put it through that lens, I think I could probably concur that, you know, the, the SLR, if you just look at the history of that examination and, and how and why it's been done over the years, it's, it's kind of an interesting test and you know, for many, many years, maybe even decades, there was kind of a, a strong cutoff at 60 degrees and anything less than 60 degrees was considered to be a positive SLR and anything more than 60 degrees was a rule out. And you know, now we're, we're of course seeing that there's a lot more nuance with that. Again, thanks to Michael Shacklock and others from sh doing things like our discriminators on that test or internal rotation of the femur, a deduction of the leg and dorsiflexion at the ankle to test for meat versus nerve as the limiting reagent in that particular movement pattern.
Yeah, what I was getting stuck with on your, your descriptor of heavier as I was thinking about what, what the total mass of the leg feels heavier and no, I know that's not where you're going, but in terms of that, I did do a girth measurement of her quads and I just went four fingers width above the, in a seated position above the patella on each side and memory, my memory is that she was 42 centimeters on the affected side and 44 on the unaffected side. So we had some evidence potentially of, of some reduced girth in the affected leg. I asked her as a follow-up what her sporting history was in her past and her handedness. Now why might I ask her that?
Those of you who were sports meg geeks, what would that matter?
So if she, if she's a right-handed, she mentioned that soccer and basketball were her go-tos. So what's the dominant leg and a right-hander and she was a right-hander. That's gonna be the left leg and that's the plant leg on the kick and that's the plant leg on a layup. And those of you to play basketball, your left-handed layup, if you're right-handed suck too, just like mine did.
So you always try to go on the left side using your right hand and you always get that crap smack back in your face. God, it used to piss me off. So the, so yeah that, that was one more finding on that. So then I'm looking at do we have some sort of potential pathological process that we need to be concerned about that has this 58 year old with osteoporosis and a prior history of melanoma and do we have some sort of pathological process that's causing a putative insufficiency fracture? Yeah and how do we kind of at the high highest level of scrutiny, check that out. We get an X-ray of that area so we've kind of got that base covered as well.
If we don't see things trending in the right direction there, I might consider some blood work as well to see what's going on and get her PCP in the loop on this. But I'm feeling pretty good about the way this one's going and I'll follow up upon it later with you guys.
Let's see over here on Facebook live. Ian Boonstra, it's been a while since I've seen your name sir. I hope you are well up in BC and welcome to Preston Hart as well. Thank you guys for joining us today. Do you guys have any questions regarding our case today or do you have any successes or some challenging cases that you're seeing that you are interested in? Alex, while I've got you on here as well, I have been handing out your, I can't remember the name of them and I apologize for that so you can weigh in here if you'd like on the chat.
But Alex is helping someone design bra strap pads for women that disperse the force of the bra strap on our busty female patients.
And I've got a few patients in that regard that have superscapular nerve involvement where their bra strap is going in right over that superscapular notch on the scapular spine and that does seem to be helping Alex on.
Thank you. Appreciate it. He's one of,
Yeah, absolutely. Yeah. So what's the name of that appliance? Alex and I can focus it's,
Yeah, it's called a shoulder shell and you can search the shoulder shell, it's made by an occupational therapist and he's actually getting ready to move to Germany so he would love to help make sure some of his supply gets out before he goes to assignment at launch tool. He's gonna be helping the military out there, but he's works for the military also with me in the pain clinic at Madigan up here at Fort Lewis.
And he's designed this because he's noticed a pretty persistent problem, especially for our military members that are carrying heavy rucks that are having difficulty with their shoulders and that are already predisposed by the issue because of the posture of the large breasts. And this has helped them quite a bit with their symptoms. So
for mentioning it Phil.
No worries Alex, thanks for helping get a, get something out that addresses an issue that many of us ex experience with some of our patients. But you know, short of what you're describing here, what's the thing that most people, most women posed with that particular dilemma start to consider is breast reduction. And I've had several of those patients over the years and you know, it's something like this could have been a nice thing to, to offer as intervention that's relatively simple, cheap.
Let's see, the one thing one patient had as feedback on that was that her sports bra, which I've seen lots of women that are busty like that they gravitate towards a sports bra that has a wider profile and the sports bra was, they have more difficulty getting to fit on that and found that
when they put
used it with a sports bra, it tended to keep popping out when they were physically active. So
that's, I Appreciate that
For your mate to think about as possibly a sporty variety that has a
a wide catch that slips over the strap there.
Great idea. I'll, I'll pass that feedback on to Mr. Sanford. Cool. See what he can come up with. Thank you.
No worries. How's your dad by the way?
He is doing good. He is still running. He actually did the Portland marathon. We finished up, I did the last 10 K with him. It was, he is just, you know, he is one of those wonderful freaks of nature and keeps on teaching us how to live well and live right. So
Keep on following him,
He does all of that. How old is art now?
He is going to be 85 in December,
Far out. So for those of you that don't know, Alex's father is Dr. Art Walker.
Art was a mentor of mine here in Portland.
He was one of the first people to turn me onto Graston technique. I think I became the third person in Portland to use that after Ted comb. And art and, and art. Art actually showed me a seated T 12 manipulation that I use every single day in practice and, and and every single person is. It's like, oh wow, that felt great.
You can pass, you can pass that on to art at some point too and when you next see him, give him a big hug for me.
Delightful person. Alright, so what other questions, comments you guys have? Any, any interventions, any patients that you have worked with from an NCA perspective?
We've gotten really good feedback on the shoulder course.
The, yeah, the feedback on those. If you guys note when you take the courses at the end, that feedback is really helpful to us, both positive and negatives. The idea is gonna be to grow this, this thing over time into something that is more effective and has better outcomes. And I don't have all the answers of course, and, but collectively we can kind of crowdsource some of this information and make it better.
What I, one thing that is coming up as well that I think those of you that are members should concern yourselves with is, as this grows the term neuro centric is going to be more popular and you, and we should capitalize on that again, neuro centric approach is a registered trademark.
So the, that combo platter of those two words together is ours.
But the word neuro centric is gonna get busy out there. For those of you that are bothered by social media and marketing on social media and marketing your clinical presence, part of what you're doing with this process, with neuro centric approach is trying to, one, just be geekier and learn more so that you can help people better. But I freely suspect that many of you are also trying to do this to help position yourself in your community as being someone that's got a little bit of an edge, something that's different from the other people in your community. And indeed what you'll find over time in the same way that I have is that that information, whether you want it to or not, will get out. Patients will start talking to their doctors, their doctors will start referring in, you know, I stood in front of the whole physiatry department at Kaiser Permanente 25 or so specialists and told 'em about dermal traction method once upon a time, based on a similar kind of patient that was scheduled for surgical intervention for a hip and one, one treatment using DTM.
And their hip pain dropped from a nine out 10 to a, a one out of 10 and then they took the rest of it away in the next day or two.
So as you start to do this, the word will get out. So in your, in your blog posts, things that you do on your own sites, make sure you start to mention the word neuro centric so that as patients start to look for that, you are the one that shows up in your community as having some attachment to that. And feel free to provide a link to our site, which those of you that are savvy in all of this, know what that means is that we start to get back links as well. So it all starts to support everybody involved here. Okie doke.
So we are one hour in, I see the, the children encroaching in some of our lives back there and the background for Brian. So we, we, we've all got our respective lives to get on with and unfortunately Spencer drops in here. Spencer Bell on the tail end of this. Good to see you, my friend. I hope things are good up there in Canada.
I think you're still in the Toronto area if I'm correct, but I wish you all the very best. We'll do this every weekend at 9:00 AM Pacific.
Grab a cup of coffee, bring your questions, bring your comments, and let's make this thing a little better and be able to help people out there a bit better. I wish you the best. Take care.