Osteopathy Blog

Bra size and Musculoskeletal Pain

Bra Size and Musculoskeletal Pain

Musculoskeletal Pain around the neck, shoulders and back is more likely to affect women with bra size D or bigger. As the large bra sizes were found to affect the mechanics of the spine, both the thoracic kyphosis and the lumbar lordosis angle were higher in women with bra size D than in women with bra size A, B, or C.This is because  women with macromastia adopt a corrective posture due to the effect of the breasts on their center of gravity and possibly in a subconscious effort to conceal their breasts (Lapid et al. 2013).

Poor Fitted Bras can cause neck, shoulder and back pain

70% of women wear bras that are incorrect sizes or poorly fitted. The elevation of the breasts in a bra increased downward forces on the outer scapula (shoulder blade). Where posterior (back) straps of a bra act as pulleys over the shoulders, effectively doubling the total downward pull on both shoulders  (Wood et al. 2008).

The associated neck, shoulder and back pain could then, at least partially, be attributed to fatigue in muscles that reverse scapular depression (eg: trapezius, serratus anterior). Bra-strap pressure is only somewhat linked to bust mass: small busted women with tight straps may experience considerable downward pressure on their shoulders (Wood et al. 2008).

Osteopathic Treatment of neck, shoulder and back pain associated with bras

Reference List

Lapid O, de Groof EJ, Corion LU, Smeulders MJ, van der Horst CM (2013). The effect of breast hypertrophy on patient posture. Arch Plast Surg. Sep;40(5):559-63

Wood K, Cameron M, Fitzgerald K (2008). Breast size, bra fit and thoracic pain in young women: a correlational studyChiropr Osteopat.  Mar 13;16:1

Otitis Media Manual Therapy by Osteopaths

Otitis Media

Otitis media is one of the most common infections in children. It has been estimated that, in the United States, there are more than 20 million physician visits annually for otitis media in the pediatric population.1 By 3 months of age, approximately 10% of infants will have had an episode of acute otitis media (AOM). By 3 years of age, 50% of children will have had more than three episodes of AOM (Degenhardt and Kuchera, 2006).

Between 6 and 8 years of age, most children “outgrow” persistent otitis media with effusion (OME) or recurrent episodes of AOM (Degenhardt and Kuchera, 2006).

The most common complication of AOM is persistent middle ear effusion (MEE), which is associated with short-term hearing loss, impaired language acquisition, and behavior problems (Steele et al. 2014).

The Eustachian Tube

Eustachian tube dysfunction, considered by some researchers as the most important factor underlying the etiology of middle ear infections, may be the key to why otitis media is primarily a disease of childhood.10,24 Anatomic variation between the adult and pediatric cranium demonstrates some interesting differences. The adult eustachian tube has a crosssectional area 2.25 to 2.75 times larger than is found in a 2-year old child  (Steele et al. 2014).

The intrinsic characteristics of the eustachian tube in early childhood appear to make it especially vulnerable to dysfunction, causes for eustachian tube dysfunction may also result from the interplay of other unique pediatric structural features. The cranium in the human infant is quite different from that of the mature adult in that it is made up of thin, single-layered, isolated bony tissue surrounded and interconnected by flexible membranous and more rigid cartilaginous connective tissue. Individual bones in the mature cranium are divided in the fetus to allow for compliance during the demands of delivery and the rapid growth of the brain in the first few years of life. For example, during infancy, the frontal, sphenoid, and temporal bones consist of two bony segments, while the occiput consists of four (Steele et al. 2014).

Goal of Treatment

The goals of treating patients with recurrent otitis media are to reduce the frequency of pain and fever; minimize hearing loss; reduce the cost of physician visits, surgery, and medications; reduce patient and parental anxiety; and prevent longterm sequelae

Treatment Protocol (Steele et al. 2014):

  1. Treatment of the sacroiliac joints bilaterally using BLT
  2. Treatment of thoracolumbar junction and diaphragm using MFR
  3. Treatment of the rib cage using MFR or Treatment of the rib cage using BLT
  4. Treatment of cervico-thoracic area (thoracic inlet) using MFR
  5. Treatment of cervical area using BLT
  6. Treatment of cranio-cervical junction using suboccipital inhibition
  7. Venous sinus drainage technique
  8. Occipital decompression technique
  9. Sphenobasilar symphysis decompression technique


A standard OMT protocol administered adjunctively with standard care for patients with AOM resulted in faster resolution of MEE at 2 weeks than standard care alone. These results support the clinical observation that OMT is an effective, nonpharmaceutical, nonsurgical, adjunctive treatment for young children with MEE. Larger studies with a sham treatment group are needed to confirm these results (Steele et al. 2014).

Osteopathic evaluation and treatment was shown to be beneficial in treating 5 (63%) of 8 subjects in this cohort with documented recurrent otitis media. After three weekly sessions of OMT, at least 50% of those subjects who experienced their first episode of otitis media during their first 6 months of life had resolution of their symptoms at 1-year follow-up (Degenhardt and Kuchera, 2006).

Is Treatment Effective?

We are unsure if treatment is effective for everyone and there is currently not enough research that explores the effectivness of Osteopathic treatment for Otitis Media. Though it would be interesting area of research to explore in the future.

Manual therapy at Cam Osteopathy

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Reference List

Degenhardt BF, Kuchera ML (2006). Osteopathic Evaluation and Manipulative Treatment in Reducing the Morbidity of Otitis Media: A Pilot Study. The Journal of the American Osteopathic Association, June, Vol. 106, 327-334

Steele KM, Carreiro JE; Viola JH, Conte JA, Ridpath LC (2014). Effect of Osteopathic Manipulative Treatment on Middle Ear Effusion Following Acute Otitis Media in Young Children: A Pilot Study. The Journal of the American Osteopathic Association, June Vol. 114, 436-447.

Ear Canal Blocked (Eustachian Tube Dysfunction) Manual Therapy by Osteopaths

Eustachian Tube Dysfunction (Blocked Ear Canal)

Eustachian tube dysfunction (Blocked Ear Canal) is defined as the failure of the eustachian tube (ear canal) to open sufficiently during swallowing or yawning, causing a difference in air pressure inside and outside the middle ear. Allergies, upper respiratory infections, rapid altitude changes (eg, airplane ascent and descent, scuba diving), a narrow eustachian tube, tumors in the nasopharynx, and large adenoids can all contribute to eustachian tube dysfunction (Channell, 2008).

Ear Canal



Several symptoms and conditions can occur as a result of eustachian tube (ear canal) dysfunction, including barotitis media, serous and suppurative otitis media, otalgia, temporary hearing problems, tinnitus, and vertigo. Treatment options range from antibiotics to surgery, but simple solutions exist in little-documented osteopathic manipulative techniques (Channell, 2008).

The eustachian tube has three physiologic functions:

  1. ventilation and pressure regulation of the middle ear
  2. protection of the middle ear from nasopharyngeal secretions and sound pressures
  3. clearance and drainage of middle ear secretions into the nasopharynx

(Channell, 2008)

Anatomy of Eustachian Tube

The adult eustachian tube (ear canal) is approximately 3.5 cm in length. It is directed inferiorly, anteriorly, and medially from the middle ear. It consists of a lateral bony portion, which arises from the anterior wall of the tympanic cavity, and a medial portion, which is fibrocartilaginous and enters the nasopharynx. The tube opens posterior to, and slightly inferior to, the posterior end of the inferior nasal concha. The muscles of the eustachian tube system (ie, salpingopharyngeus, levator veli palatini, tensor veli palatini, and tensor tympani) help open and close the tube. A functional and patent eustachian tube is necessary for ideal middle-ear sound mechanics (Channell, 2008).

Blocked Eustachian Tube (Ear Canal)

Ear CanalEar Canal


The Gallbreath Technique for Blocked Ear Canal

The Galbreath technique is a lymphatic drainage technique that may be used to treat a patient of any age. As described elsewhere, the physician turns the patient’s head so that the affected ear faces away. With the other hand, the physician applies an inferior and medial force across the mandible of the affected side. This technique may be used in conjunction with the Muncie technique (Channell, 2008).

The Muncie Technique for Blocked Ear Canal

The Muncie Technique is a manipulative technique to relieve eustachian tube (ear canal) dysfunction. The procedure for treating a patient’s right eustachian tube orifice involves the osteopath inserting a gloved right index finger into the patient’s mouth, placing the finger against the inferior part of the posterior pillar of the palatine tonsil. Moving the finger tip cephalad and slightly lateral to the Rosenmüller fossa, posterior to the opening of the eustachian tube (ear canal), the osteopathic physician should apply a pumping motion with the finger pad to lyse any adhesions and, ultimately, restore the eustachian tube opening. However, this technique may cause gagging and can be traumatic for children. Patients are advised to pant through the mouth to avoid gagging (Channell, 2008).

Modified Muncie Technique for Blocked Ear Canal

The use of a modified Muncie technique, which has been used by osteopathic specialists but has not been previously described in the literature, can improve patient tolerance. It is better to do this technique with the patient in a supine or reclined position for head stabilization, but it may be done with the patient seated as well. To treat the right eustachian tube (ear canal), insert the right index finger, gloved, into the patient’s mouth. Place the finger against the posterior pillar of the palatine tonsil. Apply lateral pressure while making a circular motion into the soft tissue. This motion exerts traction on the superior soft tissue and the opening of the eustachian tube, which is directly superior to this point above the soft palate. This technique helps break the vacuum, normalize pressure on both sides of the tympanic membrane, and allow fluid drainage. Because of its indirect nature, the modified Muncie technique may require several applications. However, it is less likely to induce gagging and therefore may be preferred by patients (Channell, 2008).

Is Treatment Effective?

At this time, we are unsure if treatment is effective for everyone and there isn’t much in the way of research to back up the claim for the effectiveness of osteopathic treatment for Eustachian Tube Dysfunction (Blocked Ear Canal). Though the proposed treatment could be interesting area of research to explore in the future.

Treatment at Cam Osteopathy

For more information or to book an Appointment with an Osteopath at Cam Osteopathy, then click on the home page or book an appointment

Reference List

Channell MK (2008). Modified Muncie Technique: Osteopathic Manipulation for Eustachian Tube Dysfunction and Illustrative Report of Case.  JAOA  Vol 108 (5) May.

Piriformis Syndrome Osteopathy and Prescriptive Exercise by Osteopaths

What is Piriformis Syndrome?

Piriformis syndrome is a neuromuscular condition characterized by symptoms that includes hip and buttock pain. The pain is often referred down the back of the leg, sometimes into the medial foot. It is often associated with numbness in the posteriomedial aspect of the lower leg as a  the result of an abnormal piriformis muscle or compression/irritation of the sciatic nerve as it travels under or through the muscle. Given its similar presentation to lumbar disc herniation, stenosis, radiculopathy, and neurogenic pain, piriformis syndrome is often difficult to diagnose (Norbury et al. 2012).

Piriformis muscle syndrome (PMS) is defined as an entrapment neuropathy involving compression of the sciatic nerve by the piriformis muscle and entailing a number of symptoms with truncal sciatic pain, initially in the muscles of the buttocks (Michel et al. 2013).

Piriformis Syndrome Osteopath


Piriformis Syndrome may be associated with fibromyalgia and this case report should make physicians aware of neurological aspects of fibromyalgia in which the piriformis muscle is involved. Coexistence of FMS and MPS is not uncommon (Siddiq et al. 2014).

Clinical Diagnosis

The most common presenting symptom of patients with piriformis syndrome is increasing pain after sitting for longer than 15 to 20 minutes. Many patients complain of pain over the piriformis muscle (ie, in the buttocks), especially over the muscle’s attachments at the sacrum and medial greater trochanter (Boyajian-O’Neill et al. 2008)

Symptoms, which may be of sudden or gradual onset, are usually associated with spasm of the piriformis muscle or compression of the sciatic nerve. Patients may complain of difficulty walking and of pain with internal rotation of the ipsilateral leg, such as occurs during cross-legged sitting or ambulation. Spasm of the piriformis muscle and sacral dysfunction (eg, torsion) cause stress on the sacrotuberous ligament. this stress may lead to compression of the pudendal nerves or increased mechanical stress on the innominate bones, potentially causing groin and pelvic pain. Compression of the fibular branch of the sciatic nerve often causes pain or paresthesia in the posterior thigh (Boyajian-O’Neill et al. 2008)

These clinical signs relate, either directly or indirectly, to muscle spasm, resulting nerve compression, or both. Tenderness with palpation over the piriformis muscle, especially over the muscle’s attachment at the greater trochanter, is common. Patients may also experience tenderness with palpation in the region of the sacroiliac joint, greater sciatic notch, and piriformis muscle—including pain that may radiate to the knee (Boyajian-O’Neill et al. 2008).

Osteopathic Treatment of Piriformis Syndrome

The goals of osteopathic manipulative treatment (OMT) for patients who have piriformis syndrome are to restore normal range of motion and decrease pain. These goals can be achieved by decreasing piriformis spasm. Indirect osteopathic manipulative techniques have been used to treat patients with piriformis syndrome (Boyajian-O’Neill et al. 2008)

The two indirect OMT techniques most commonly reported for the management of piriformis syndrome are counterstrain and facilitated positional release. Both techniques involve the principle of removing as much tension from the piriformis muscle as possible Three tender point locations can be addressed with counterstrain—at the midpole sacrum, piriformis muscle, and posteromedial trochanter. To position a patient for counterstrain treatment, the patient is generally asked to lie in a prone position with the affected side of the body at the edge of the examination table. In performing the counterstrain technique, the osteopathic physician brings the patient’s affected leg over the side of the table, placing it into flexion at the hip and knee, with abduction and external rotation at the hip. Facilitated positional release can also be achieved from the position, with compression through the long axis of the femur from the knee toward the sciatic notch. This additional compressive force can reduce patient treatment time from 90 seconds when performing counterstrain to 3 to 5 seconds when performing facilitated positional release (Boyajian-O’Neill et al, 2008)

Direct OMT techniques can be performed using either active or passive methods. The direct OMT techniques that are the most useful in treating patients with piriformis syndrome include muscle energy, articulatory, Still, and high velocity/low amplitude. The muscle energy technique can be applied in the management of piriformis spasm, as well as for associated dysfunctions of the sacrum and pelvis. No absolute contraindications are defined for the muscle energy technique. The patient must understand the required amount of muscular force and the correct direction of this force for the technique to be effective. (Boyajian-O’Neill et al. 2008)

Articulatory OMT techniques are applied by advancing and retreating from a restrictive barrier in a repetitive manner to advance that barrier and increase the range of motion. The presence of osteoarthritis can limit the applicability of this technique secondary to articulatory pain. The Still technique, a specialized form of articulatory treatment, is begun by placing a joint in a relaxed position away from restrictive barriers. Then, with an arching motion, compression is applied to the level of dysfunction and moved toward the restrictive barrier while the patient is passive and relaxed. No absolute contraindications are defined for the Still technique. High velocity/low amplitude technique is most often used in cases of piriformis syndrome to correct associated sacral and pelvic somatic dysfunctions. Extreme caution should be exercised when using this manual technique with individuals who have osteoporosis (Boyajian-O’Neill et al. 2008)


Osteopathic manipulative treatment can be used as one of several possible nonpharmacologic therapies for these patients. Nonpharmacologic therapies can be used alone or in conjunction with pharmacologic treatments in the management of piriformis syndrome in an attempt to avoid surgical intervention (Boyajian-O’Neill et al. 2008).

Cam Osteopathy

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Reference List

Boyajian-O’Neill LA, McClain RL, Coleman MK, Thomas PP (2008).  Diagnosis and management of piriformis syndrome: an osteopathic approach. J Am Osteopath Assoc. Nov;108(11):657-64.

Michel F, Decavel P, Toussirot E, Tatu L, Aleton E, Monnier G, Garbuio P, Parratte B (2013). The piriformis muscle syndrome: an exploration of anatomical context, pathophysiological hypotheses and diagnostic criteria. Ann Phys Rehabil Med. 56(4):300-11

Norbury JW, Morris; Warren JKM; Schreiber AL, Faulk C, MD; Moore, Mandel S (2012). Diagnosis and Management of Piriformis Syndrome. Practical Neurology

Siddiq MA, Khasru MR, Rasker JJ (2014) . Piriformis syndrome in fibromyalgia: clinical diagnosis and successful treatment. Case Rep Rheumatol. 2014:893836.

Osteopathic Treatment Coupled With Lactation Consultations for Infants’ Biomechanical Sucking Difficulties

Osteopathic Treatment could be combined with Lactation Consultations to manage Infants’ Biomechanical Sucking Difficulties.

Mother-baby dyad care, including skin-to-skin contact of healthy infants and mothers, is an important component of maternal-newborn care. Beginning at birth,mothers and newborns should be viewed as a unit with no disruption of the parent-infant relationship.

The World Health Organization and Health Canada recommend breastfeeding exclusively for the first 6 months, and they support maintaining it for 2 years or longer with appropriate complementary feeding. Few mother–infant dyads achieve these recommendations, it is within their first month of life that babies are most at risk of being weaned. Half of mothers who stop breastfeeding in the first month report biomechanical issues  (Herzhaft-Le Roy et al. 2016).

Lactation consultants around the world have extensively studied the biomechanics of sucking, from birth to weaning. Lactation Consultants are trained to assess difficulties, correct positioning, provide emotional support to the mothers, and help babies express their behavioral sequence leading to breastfeeding from birth. However, these professionals often feel helpless when biomechanical sucking difficulties persist in infants despite their advice. Osteopathy has been used and documented by some and the approach appears promising  (Herzhaft-Le Roy et al. 2016).

Few studies, however, have explored the effect of an osteopathic treatment on infants’ breastfeeding biomechanical difficulties. Some authors have described cranial dysfunctions and restrictions of skull sutures being linked to breastfeeding difficulties  (Herzhaft-Le Roy et al. 2016):

1.  An exploratory study on the effect of birthing on 1,255 newborns, found that more than 88% of infants had cranial restrictions.

2. A study cohort of more than 1,000 babies, identified different restrictions in skull sutures and their potential effect on cranial nerves involved in the sucking process.

3.  A pilot study involving six infants ages 3 to 6 weeks that measured prefeed and postfeed percentage of fat in human milk (creamatocrit), as it has been shown that fat concentration in human milk could be a marker for effective feeding. Mothers and infants were first assessed by an IBCLC, given advice, and referred to an osteopath for 4 weeks of treatment (once a week). There was a significant change in creamatocrit before and after the month of treatment. Prefeed and postfeed fat in human milk with six infants feeding normally were then compared. Creamatocrit after four treatments was improved, suggesting that osteopathic treatments are more effective than lactation consultations alone

It is important to highlight that the scientific literature on the subject of biomechanical sucking dysfunctions and osteopathy is sparse. In addition, no study to our knowledge has been conducted to assess the effect of an osteopathic treatment coupled with lactation consultation on these difficulties (Herzhaft-Le Roy et al. 2016).


The study provides a first step to better understand how osteopaths can support mother–infant dyads experiencing biomechanical sucking difficulties. Although local practices may differ, integrating osteopaths in the IBCLCs’ network could be helpful when babies experience biomechanical sucking difficulties. These findings suggest that a single osteopathic treatment coupled with lactation consultation is effective to reduce biomechanical sucking difficulties in infants younger than 6 weeks  (Herzhaft-Le Roy et al. 2016).

The study is one of the first to bring together lactation consultants and osteopaths to address infants with biomechanical sucking difficulties. Findings support the hypothesis that the addition of osteopathy to regular lactation consultations is beneficial and safe (Herzhaft-Le Roy et al. 2016).

Key Points

  • Perinatal healthcare providers are often confronted with biomechanical sucking difficulties. Osteopaths offer treatment for these difficulties with little empirical evidence.
  •  A statistically significant improvement in sucking skills (measured by the LATCH score) was found in treated newborns compared with usual care.
  •  The combination of lactation and osteopathic consultations seems to be promising.

Cam Osteopathy

Therefore it is currently not suitable to offer osteopathic treatment for infanct biomechanical difficulties. Even the Advertising Standard Authority in the UK makes it very clear that Osteopaths should not offer treatment for this sort of presenting complaint (ASA, 2016).

Reference List

Advertising Standards Authority (ASA) (2016). Osteopathy: ASA review and guidance for marketing claims for pregnant women, children and babies.

Herzhaft-Le Roy J, Xhignesse M, Gaboury I (2016). Efficacy of an Osteopathic Treatment Coupled With Lactation Consultations for Infants’ Biomechanical Sucking Difficulties. J Hum Lact. Dec 1:890334416679620.


Ankylosing Spondylitis Manual Therapy by Osteopaths

Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a long-term (chronic) condition in which the spine and other areas of the body become inflamed.

AS tends to first develop in teenagers and young adults. It’s also around three times more common in men than in women.


The symptoms of AS can vary, but usually involve:

  • back pain and stiffness
  • pain and swelling in other parts of the body – caused by inflammation of the joints (arthritis) and inflammation where a tendon joins a bone (enthesitis)
  • extreme tiredness (fatigue)

These symptoms tend to develop gradually, usually over several months or years, and may come and go over time.

In some people the condition gets better with time, but for others it can get slowly worse.

When to seek medical advice

You should see your GP if you have persistent symptoms of AS.

If your GP thinks you may have the condition, they should refer you to a specialist in conditions affecting muscles and joints (rheumatologist) for further tests and any necessary treatment.

Further tests may include blood tests and imaging tests.

Read about diagnosing ankylosing spondylitis.

Causes of ankylosing spondylitis

It’s not known what causes the condition, but there’s thought to be a link with a particular gene known as HLA-B27.

The National Ankylosing Spondylitis Society does suggest treatment by osteopaths can be applied to people suffering with Ankylosing Spondylitis

Osteopaths provide a range of treatments aimed at managing pain and improving mobility utilising massage and passive mobilising techniques. A programme of treatment can also involve exercise, self management and advce tailored to individual needs.

Spinal manipulation is not recommended by osteopaths for patients with AS. Where appropriate an osteopath will refer you back to your GP or other healthcare professional.

There is some research that shows the benefits of Osteopathic treatment of patients with Ankylosing spondylitis in particular:

Self- and manual mobilization has been shown to improve chest expansion, posture and spine mobility in patients with ankylosing spondylitis over an eight week period. The treatment involved a massage protocol incorporating mostly Swedish strokes and stretching (consistent with published guidelines), with myofascial release and trigger point therapy introduced in later sessions (Widberg et al. 2009).

Cam Osteopathy

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Reference List

National Ankylosing Spondylitis Society (N.D). http://nass.co.uk/about-as/living-well-with-as/complementary-therapies-for-as/

NHS Choices (N.D). http://www.nhs.uk/Conditions/Ankylosing-spondylitis/Pages/Introduction.aspx

Widberg K, Karimi H, Hafström I (2009). Self- and manual mobilization improves spine mobility in men with ankylosing spondylitis–a randomized study. Clin Rehabil. Jul;23(7):599-608.

Pudendal Neuralgia Manual Therapy by Osteopaths

What is Pudendal Neuralgia?

Pudendal neuralgia is a painful, neuropathic condition involving the dermatome of the pudendal nerve. This condition is not widely known and often unrecognized by many practitioners. The International Pudendal Neuropathy Association (tipna.org) estimates the incidence of this condition to be 1/100 000 of the general population. Spinosa et al. document the incidence at 1% in the general population, affecting women more than men (Hibner et al. 2010).

Pudendal nerve entrapment has been described to manifest itself symptomatically in a number of debilitating manners; therefore a clear understanding of the nerve anatomy and distribution is essential in diagnosis. The pudendal nerve carries motor, sensory, and autonomic fibers; subsequently, both afferent and efferent pathways are affected by its injury (Hibner et al. 2010).

The Anatomy of the Pudendal Nerve

The distribution of the pudendal nerve, in the perineum, is mediated by 3 branches derived from the sacral roots S2-S4. These branches are the dorsal nerve of the penis or clitoris, the perineal nerve, and the inferior anal nerve. On the basis of this pattern of distribution, damage to the pudendal nerve can result in either unilateral or bilateral pain in the female vulva, vagina, or clitoris, or, correspondingly, the male scrotum, testes, or penis (Hibner et al. 2010).

Pudendal Nerve Dysfunction

Dysfunction of the pudendal nerve, caused by entrapment or compression, is therefore not only suspect, in generating this chronic, debilitating pain but also likely to negatively alter the interaction between pelvic organs and the afferent, efferent, and autonomic signals, which mediate their proper function (Hibner et al. 2010).

Symptoms of Pudendal Neuralgia

Pudendal neuralgia is defined as a burning neuropathic pain in the distribution of the pudendal nerve, as described above. In brief, the pain is localized to the vulva, vagina, clitoris, perineum, and rectum in females and to the glans penis, scrotum excluding testicles, perineum, and rectum in males (Hibner et al. 2010).

.In those cases, it may present as vague, neuropathic pain in the area of the lower abdomen, posterior thigh, or even the lower back and can be attributed to muscle spasm. Patients with pudendal neuralgia often have associated symptoms such as urinary frequency and urgency, symptoms mimicking interstitial cystitis, dyspareunia, and persistent sexual arousal. The pain, as in other cases of neuropathic pain, is burning, tingling, and numbing in nature. Patients have significant hyperalgesia (increased sensitivity and significant pain to mild painful stimulus), allodynia (pain in response to nonpainful stimulus), and paresthesias (sensation of tingling, pricking, or numbness, commonly known as ‘‘pins and needles’’) (Hibner et al. 2010).

Typically,  symptoms are present when patients are sitting down and are much less severe or may even be absent when lying down or standing. Anecdotally, there is significantly less pain when sitting on a toilet seat versus a chair. This phenomenon is believed to be associated with pressure applied to the ischial tuberosities rather than to the pelvic floor muscles. Patients usually awaken in the morning with minimal or no symptoms; however, the pain will increase as the day progresses. Often, patients will report the sensation of having a foreign body in the vagina or feeling as though they are sitting on an object, such as a tennis ball (Hibner et al. 2010).

Causes of Pudendal Neuralgia

Pudendal neuralgia can be caused by mechanical injury to the nerve, viral infection, or immunologic processes. In the case of mechanical injury to the nerve, most practitioners will refer to the condition as pudendal nerve entrapment. This ‘‘entrapment’’ may be caused by pelvic floor muscle spasm (levator ani or obturator internus), pressure from surrounding ligaments (sacrospinous, sacrotuberous), or scar tissue from trauma or surgeries involving the surrounding areas. In patients who have undergone surgery, entrapment may be caused by mesh or suture directly injuring the nerve (Hibner et al. 2010).

In women, the 3 most common causes of pudendal nerve entrapment are surgical injury, pelvic trauma, and childbirth. In our practice most of our female patients present with pudendal neuralgia as a result of previous gynecologic surgery, particularly vaginal surgery for prolapse or incontinence. The second most common presentation, in female patients, is a history of previous pelvic trauma, such as heavy lifting, falls injuring the back or buttocks, as well as patients inserting foreign objects rectally. The least common manifestation is pudendalnerve neuralgia caused by vaginal childbirth in females. Pelvic trauma, on the other hand, is responsible for the greatest cohort of pudendal neuralgia cases in males (Hibner et al. 2010).

Treatment of Pudendal Neuralgia

The osteopath need to address the pelvic floor muscle dysfunction. The osteopath addresses muscle imbalances, spasm, restricted tissues, and other dysfunctions by focusing on palpation and manual techniques, posture, range of motion, and strength of the pelvis, back, and hips. Therapy is administered in the form of ‘‘hands-on’’ techniques, exercises, stretching, and education (Hibner et al. 2010).

Most of these patients have significant muscle spasm and subsequent muscle shortening throughout the pelvic girdle. Osteopaths use a variety of manual techniques to help release the muscle spasms and lengthen these muscles. These methods include myofascial release, soft tissue and connective tissue mobilization, and trigger point release. The pelvic floor muscles can only be fully examined and treated with either intravaginal or intrarectal approaches and to the level of patient tolerance (Hibner et al. 2010).

Reference List

Hibner M, Desai N, Robertson LJ, Nour M (2010). Pudendal Neuralgia. J Minim Invasive Gynecol. Mar-Apr;17(2):148-53

Rotator Cuff Disease: An Osteopathic Approach to Treatment

Rotator Cuff Disease

Rotator cuff disease is a common case of shoulder pain. Shoulder pain is common, with a point prevalence ranging from 7% to 26% in the general population. Although not life-threatening, it impacts on the performance of tasks essential to daily living (such as dressing, personal hygiene, eating and work), and often results in substantial utilisation of healthcare resources (Page et al. 2016).

What is the most common cause of shoulder pain?

The most common cause of shoulder pain in primary care is disorders of the rotator cuff, which comprises the supraspinatus, infraspinatus, subscapularis and teres minor muscles. These muscles facilitate both movement and dynamic stabilisation of the shoulder joint (Page et al. 2016)

Definition of Rotator Cuff Disease

Numerous diagnostic labels have been used in the literature to describe disorders of the rotator cuff (for example, subacromial impingement syndrome, rotator cuff tendinopathy or tendinitis, partial or full rotator cuff tear, calcific tendinitis and subacromial bursitis) but the terms are not standardised (Page et al. 2016)

Typical Presentation of Rotator Cuff Disease

People with rotator cuff disease often describe their shoulder pain as being worse at night and exacerbated by overhead activity, and some describe weakness or loss of function; however, there are few data regarding the diagnostic accuracy of individual symptoms in rotator cuff disease without tears (Page et al. 2016).

What is the Purpose of Manual Therapy and Exercise on Rotator Cuff Disease

Manual therapy and exercise, usually delivered together as components of a physical therapy intervention, are commonly used in the management of rotator cuff disease. Manual therapy includes any clinician-applied movement of the joints and other structures, for example mobilisation or manipulation. Exercise includes any purposeful movement of a joint, muscle contraction or prescribed activity, which may be performed under the supervision of a clinician or unsupervised at home. Commonly prescribe d exercises include range of motion (ROM), stretching, stabilising and strengthening (Page et al. 2016).

Who Can Perform Manual Therapy for Rotator Cuff Disease

Manual therapy and exercise are delivered by various clinicians, including physiotherapists, physical therapists, chiropractors, and osteopaths. The aims of both types of interventions are to improve function, promote healing, increase joint range, strengthen weakened muscles and correct imbalance in the stabilising function of the rotator cuff (Page et al. 2016).

Other Therapeutic Interventions

Often, electrotherapy modalities (e.g. therapeutic ultrasound, laser therapy) are also delivered as part of a multimodal physical therapy intervention and manual therapy and exercise may also be used in conjunction with other interventions such as non-steroidal anti-inflammatory drugs (NSAIDs) or glucocorticoid injection, or both (Page et al. 2016).

Spinal Manipulation of the Upper Rib Cage

There are two studies that explore the effects of thoracic spine (mid-back) manipulation and rib manipulation on rotator cuff disease.

Subjects with subacromial impingement syndrome who received thoracic spine manipulation demonstrated statistically significant changes in pain and disability scores at 48 hours post treatment (Boyles et al. 2009). Where thoracic spine and upper rib manipulative therapy is associated with improvement in shoulder pain and ROM immediately following intervention in patients with a primary complaint of shoulder pain. No patients reported adverse effects or a worsening of shoulder symptoms following treatment with thoracic spine or upper rib manipulations (Strunce et al. 2009).

How the intervention might work

Manual therapy and exercise interventions are hypothesised to produce a number of beneficial physiological and biomechanical
effects. Manual therapy is employed to reduce pain by stimulating peripheral mechanoreceptors and inhibiting nociceptors, and to
increase joint mobility by enhancing exchange between synovial fluid and cartilage matrix. Exercise aims to improve muscle function and range of motion by restoring shoulder mobility, proprioception and stability (Page et al. 2016).

When delivered together, it is unclear whether the effects of manual therapy with exercise represent the effects of manual therapy, the
effects of exercise, or an interaction between the two. It has been suggested that the short-term analgesic effects of manual therapy may allow people with other musculoskeletal conditions (e.g. neck pain) to perform exercises designed to produce long-term changes in muscle function and range of motion. A similar mechanism of action may occur in people with rotator cuff disease (Page et al. 2016).

Evidence Base for Manual Therapy for Rotator Cuff Disease

Page et al. (2016) reviewed 60 eligible trials, only one trial compared a combination of manual therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of manual therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with manual therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of manual therapy and exercise should be compared with a realistic placebo in future trials. Further trials of manual therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

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Reference List

Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, Koppenhaver SL, Wainner RS (2009). The short-term effects of thoracic spine thrust manipulation on patients with shoulderimpingement syndromeMan Ther. Aug;14(4):375-80.

Page MJ, Green S, McBain B, Surace SJ, Deitch J, Lyttle N, Mrocki MA, Buchbinder R (2016). Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. Jun 10;(6)

Strunce JB, Walker MJ, Boyles RE, Young BA (2009). The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 17(4):230-6.

Quadrangular Space Syndrome Manual Therapy by Osteopaths

What is Quadrangular Space Syndrome

Quadrangular space syndrome (QSS) arises from compression or mechanical injury to the axillary nerve (neurogenic quadrilateral space syndrome [nQSS]) and/or posterior circumflex humeral artery (PCHA) (vascular quadrilateral space syndrome [vQSS]) as they pass through the quadrilateral space (QS). The QS is bounded by the edge of the long head of the triceps medially, the medial edge of the surgical neck of the humerus laterally, the tendon of the teres major and latissimus dorsi muscles inferiorly, and the teres minor muscle or the scapulohumeral capsule superiorly (Brown et al. 2015).

Anatomy of The Quadrangular Space

What Causes Quadrangular Space Syndrome

Teres minor atrophy occurs either in isolation, associated with other rotator cuff muscle pathologies or in quadrilateral space syndrome. In the latter condition, compression of the axillary nerve is the likely cause; however, the anatomy of the nerve to teres minor and how this may relate to isolated teres minor atrophy have not been extensively investigated (Friend et al. 2010).

Anatomy of The Axillary Nerve

The axillary nerve has one main trunk before giving off the superolateral brachial cutaneous sensory branch and a branch to the teres minor, then continuing to supply the whole deltoid.  More recently, The axillary nerve as possessing two posterior branches, one supplying the teres minor then continuing to become the superolateral brachial cutaneous nerve while the other supplies the posterior aspect of the deltoid muscle (Friend et al. 2010).

These variations in length correlated to the position of the bifurcation into anterior or posterior branches, namely specimens bifurcating earlier had a shorter axillary nerve trunk and a longer posterior branch of the axillary nerve. The course of the anterior branch within the deltoid muscle which supplies this muscle, the joint capsule and the skin (Friend et al. 2010).

The position of the axillary nerve bifurcation into anterior and posterior branches can vary, so It is feasible that such variations may alter the risk of nerve compression in the quadrilateral space (Friend et al. 2010).

Axillary Nerve Injury

Mechanism of Injury in Neural QSS

The neural QSS can also result from hypertrophy of the muscular boundaries, an atypical nerve course, bone spikes, or space-occupying lesions, such as glenoid labral cysts, paralabral cysts, ganglia, fracture hematoma, or humeral osteochondroma. Chronic fixed nerve compression permanently displaces internal nerve contents in transverse and longitudinal dimensions, leading to long-term damage of axons and myelin (Brown et al. 2015).

SIgns and Symptoms of Quadrangular Space Sydrome

Patients with QSS manifest with various symptoms. Neurogenic manifestations may include nondermatomal neuropathic pain, numbness, and weakness in the shoulder (usually posterior), often radiating down the arm. Vascular manifestations may include thrombosis, microembolism or macroembolism, digital or hand ischemia, and the full spectrum of signs and symptoms associated with acute ischemia such as pain, pallor, and absent pulses (Brown et al. 2015).

Signs and Symptoms of Vascular QSS

Vessel thrombosis and distal embolization can present with coolness, cold intolerance, pallor, and cyanosis of the upper extremity digit, with or without splinter hemorrhages (Brown et al. 2015).

Differential Diagnosis of Neural QSS

A differential diagnosis forNeural QSS  includes suprascapular nerve entrapment and complex regional pain syndrome, overt shoulder trauma and iatrogenesis. C5 and/or C6 radiculopathy should also be ruled out, as found in the case of patient . Axillary nerve pathology can overlap with C5/C6 radiculopathy because the axillary nerve arises from the C5 and C6 nerve root (Brown et al. 2015).

Mechanism of Posterior Circumflex Humeral Artery (PCHA) Injury (Vascular QSS)

The mechanism of thrombosis of the PCHA in Vascular QSS involves repetitive trauma to the PCHA wall during AER.  This is caused as a repetitive tension effect that stretches the PCHA as it travels through the tight QS and winds around the neck of the humerus, analogous to a taut stretched rubber band leading to intimal injury and weakening of the vessel wall. The repetitive pulley movement could lead to turbulent blood flow within the PCHA (Brown et al. 2015).

Signs and Symptoms of Vascular QSS

Vessel thrombosis and distal embolization can present with coolness, cold intolerance, pallor, and cyanosis of the upper extremity digit, with or without splinter hemorrhages (Brown et al. 2015)

Differential Diagnosis of Vascular QSS

Quadrilateral space syndrome can mimic a number of other neurovascular disorders, including those that involve thrombosis or aneurysm formation in other more proximal branches of the axillary artery, such as in arterial Thoracic Outlet Syndrome (TOS). In arterial TOS, the subclavian artery is compressed between the clavicle and the first rib or anatomic abnormalities such as a cervical rib or fibrous band (Brown et al. 2015).

Osteopathic Treatment of Quadrangular Space Syndrome

First of all manual therapy therapy approach (Osteopathy) is most likely not suitable for vascular QSS and for Neural QSS caused by an atypical nerve course, bone spikes, or space-occupying lesions, such as glenoid labral cysts, paralabral cysts, ganglia, fracture hematoma, or humeral osteochondroma, as discussed previously. These causes are likely to require a surgical intervention.

The Osteopathic treatment is focused on  the hypertrophy of the muscular boundaries of the Quadrangular space  Where both or either teres minor or triceps brachii are impinging the axillary nerve and increasing the mobility of the Glenohumeral Joint.

When to Refer

At least six months of conservative management is recommended before surgical intervention is performed.During this six-month period, treatment should include NSAIDs, therapeutic exercise, manual therapy, and restriction of activities that produce symptoms. Glenohumeral joint mobilization, rotator cuff and scapular strengthening, cross-friction massage, and posterior capsule stretching have been found to provide beneficial effects (Manske et al 2009). This could be performed by an Osteopath

Effectiveness of Osteopathic Treatment

The posterior capsule should be addressed as part of the cause of a dysfunctional arthrokinematic pattern of motion. A treatment plan to address this consideration may include posterior and inferior glide joint mobilization techniques. Stretching into horizontal adduction has also been reported to provide benefit. The findings of a recently reported randomized clinical trial suggest that a combination of posterior capsule stretching and posterior capsule joint mobilization produces better results than stretching alone

Fibrous bands and adhesions can form along the posterior band of the inferior glenohumeral ligament, which may produce symptoms associated with QSS. Friction massage and soft tissue mobilization can be applied to the area around the axillary nerve within the quadrilateral space, which has been reported to provide great benefit.

Both muscles could be treated with passive stretching of the shoulder in flexion and abduction reinforced with a finger/thumb/hand contact over the muscles to create a false insertion, temporarily. Alternative massage techniques to these muscles to may reduce the hypertrophy.

Evidence Base for Osteopathic treatment of Quadrangular Space Syndrome

Unfortunately, there is very little manual therapy evidence available for the treatment of Quadrangular Space Syndrome.  For the purpose of this article, a boolean search had been performed on Google Scholar and Pubmed. Other databases could have been searched, however articles are more freely available on Google Scholar and Pubmed. There is currently a growing evidence available for manual therapy, there will evidence available in the future.

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Reference List

Brown SA, Doolittle DA, Bohanon CJ, Jayaraj A, Naidu SG, Huettl EA, Renfree KJ, Oderich GS, Bjarnason H, Gloviczki P, Wysokinski WE, McPhail IR (2015). Quadrilateral space syndrome: the Mayo Clinic experience with a new classification system and case seriesMayo Clin Proc.  Mar;90(3): 382-94

Friend J, Francis S, McCulloch J, Ecker J, Breidahl W, McMenamin P (2010). Teres minor innervation in the context of isolated muscle atrophy. Surg Radiol Anat. Mar;32(3): 243-9

Manske RC, Sumler A, ATC, and Runge J (2009). Quadrilateral Space Syndrome. FUNCTIONAL REHABILITATION ATT 14(2), pp. 45-47

Osteopathic Treatment of Knee Pain

Cambridge Knee Pain

Causes of Knee Pain

Muscle strain (hamstrings, quadriceps)
Iliotibial Band Syndrome
Patella tendinopathy
Cruciate Ligament Sprain
Meniscal injury
Capsular strain
Rheumatoid Arthritis