Musculoskeletal Medicine in Clinical Practice (eBook)

Dr Paterson’s authority derives from forty years’ experience in the field, coupled with long service to both the British Association of Manipulative Medicine, (as Hon. Secretary for eight years, and as President for three years) and to the Federation Internationale de Medecine Manuelle, (as Chairman of the Scientific Advisory Committee for five years). In addition to this, he is a co-author of five books on the subject, in collaboration with Dr Loic Burn, and sole author of another.

Table of Contents 6
Foreword 8
Preface 10
Chapter 1 What Is Musculoskeletal Medicine? 13
Chapter 2 The Scientific Bases of Musculoskeletal Medicine 21
Chapter 3 The Patient’s View of Musculoskeletal Medicine 40
Chapter 4 The Doctor’s View of Musculoskeletal Medicine 44
Chapter 5 The Economics of Musculoskeletal Medicine 48
Chapter 6 Teaching Musculoskeletal Medicine 52
Chapter 7 Headache and Migraine 60
Chapter 8 Neck Pain 67
Chapter 9 Shoulder and Arm Pain 72
Chapter 10 Chest Pain 75
Chapter 11 Lower Trunk Pain 79
Chapter 12 Pelvic Pain 84
Chapter 13 Leg Pain 87
Chapter 14 Will Musculoskeletal Medicine Work? 95
Chapter 15 The Future of Musculoskeletal Medicine 98
Envoi 105
References 108
Further Reading 111
Glossary 113
Index 119

"Chapter 12 (p. 72-73)

Pelvic Pain

The signi?cance and diagnostic pitfalls of inguinal fossa pain has been discussed in the previous chapter, in which epigastric, gallbladder, renal, ureteric, and bladder pain have also been mentioned. Each has its particular history and attendant physical signs, but the common reality of referred pain does not exclude the possibility of pains at any of these sites being of mechanical origin, most likely arising between the 8th and 12th thoracic levels, as well as the lumbar ones, even when systemic disease is at ?rst suspected.

It is equally important to remember that the teaching of cure of any of these conditions by manipulation remains a dangerous dream. So to the pelvis itself. As previously mentioned, the pubic bones, like every other structure in the skeleton, may not be symmetrical in form; indeed they are seldom so. This may result in their appearing not to be level on the two sides.

Therefore, clinically observed differences in level must be of no diagnostic value. Such an observation does not imply any degree of malposition. Of course, this does not mean that it is useless to observe the apparent differences, before and after manipulation. It must be remembered that the symphysis has a disc somewhat similar to the intervertebral disc, and that it may be damaged by excessive stresses.

Other than in complex traf?c accidents, where in any case manipulative techniques would not be contemplated, such damage is rare, though less so during and following pregnancy, as a result of the physiological slackening of all the pelvic ligaments. In the latter case it is associated with the distraction force of the infant’s head, due to uterine muscular contraction during the second stage of labour in effect prizing open the pelvic outlet. Other than these cases, I have seen one case in 40 years of musculoskeletal practice; it was due to trauma by the pommel of a saddle, in a horseman misjudging a jump.

A sudden upward blow to the converging inferior pubic rami put a distraction force on the symphysis suf?cient to separate it by disruption of the disc. It is noteworthy that the causative force in this case is diametrically opposed to that in intervertebral disc rupture – distraction, rather than compression. One of the commonest pelvic pains is that felt over the sacroiliac joints. The possibility of this being due to rheumatoid arthritis or Scheuermann’s disease has already been mentioned, as has polymyalgia rheumatica.

While the same principles apply here in pregnancy as at the symphysis pubis, the suggestion that the sacroiliac joints are common sites of origin of (nonpregnancy) musculoskeletal problems requires further thought. There are three cogent reasons for viewing this unsubstantiated belief with grave suspicion. First, the sacroiliac joints are the largest joints in the body, irregular in shape, and their articular surfaces are deeply pitted, with compensatory prominences engaging in the pits, so that their interlocking allows minimal movement, except under a strong distraction force between the ileum and sacrum. Application of such a force just does not occur, except in the second stage of labour or complex accidental trauma."