Letter to the Editor: Trochanteric Bursitis Protonics
Published in J of the Section on Women’s Health 27:3, December 2003
Letter to the Editor
This letter is in response to the article titled "Management of a Woman Diagnosed with Trochanteric Bursitis With the Use of a Protonics® Neuromuscular System" from Volume 2, 1:12-16, April 2003 issue of JSOWH. The stated purpose was to describe a woman with trochanteric bursitis who had 3 physical therapy visits which focused on achieving neutral pelvic position via unilateral hamstring recruitment using a Protonic® Neuromuscular System. The authors are to be commended in significantly reducing the signs and symptoms in 2 visits which were 6 weeks apart. The next visit a year later revealed that the client was significantly improved from the symptoms that had plagued her for 2 years. In the conclusion they state: "Attention to pelvic positioning using the Protonics® resulted in successful outcomes for this woman with trochanteric bursitis." This is such an important case report because it raises many issues.
I appreciated the author's theoretical development of the problem of trochanteric bursitis in the introduction section of the article. In the section titled Purpose the authors' state that "The theory behind the case was that the trochanteric bursa was irritated and compressed by the ITB because of the asymmetrical pelvic position and restoring a position of symmetry would abolish the symptoms." A detailed evaluation was performed and I will focus on several positive findings. Hip rotation was measured in sitting and the difference noted was 5° (20 left versus 25° of external rotation). Assuming a possible standard 5% error rate the actual difference might actually be 2.5°. In addition to observing a possible functionally shortened left lower extremity, 6 special tests were pictured and described as "being used to assess pelvic femoral position." The tests are: the Ober Test (bilaterally positive, more so left), and Modified Ober, Thomas Test and Modified Thomas Test (positive left), and supine Left and Right Lower Trunk Rotation (restricted to the left). These findings were purported to suggest a left anteriorly rotated inominate (ilium). The focus of the case was stated, which was "to correct faulty mechanics through the kinetic chain by correcting the pelvic asymmetry to a neutral position." An alternate explanation could be that the limitation of left lower trunk rotation could be due to limited left hip abduction/flexion/external rotation or the opposite motion in the right hip, or both instead of the lower trunk, though it was not discerned. It is certainly surprising and perhaps controversial, that no attempt was made to directly evaluate the strength and endurance or facilitation/inhibition of the muscle group that was targeted for strengthening or recruitment. No attempt was made to compare it to the asymptomatic side prior to and after intervention.
I struggle with the author's conclusion of an anterior left ilium based on the hip and trunk tests mentioned. Several of the books referenced in the article contain chapters detailing evaluation of the sacroiliac (SIJ/SIJs), hips, and pelvis (as a unit). In this study, there was no observation of the pelvic posture, which is typically performed anteriorly and posteriorly in the following postures: standing, sitting, supine, and prone. I believe that
confusion has surrounded the pelvic structure and a brief survey of the writings in our own profession and in others will affirm this. The SIJ joint has 5/6 synovial characteristics and therefore should be evaluated in the same manner as other synovial joints. Many passive motion tests (spring tests) have been developed or adopted and modified for grading passive accessory motion of SIJ joints and symphysis pubis, and thettraditional palpatory evaluation has also been expanded upon.' The pelvic evaluation described in the article literally shies away from direct palpation, direct observation, and direct motion testing of the pelvis and SIJ, instead utilizing rather indirect hip and lower trunk motion, and hip muscle length tests. The author's did state that these tests were "thought to suggest an anteriorly tilted, forwardly rotated, left l inominate and a left femur that moved with it into passive internal rotation." Since this is a distinct departure from the norm of SIJ/pelvic evaluation, additional details explaining the rationale are certainly warranted. On that basis I reviewed the only study from the article that addressed this issue via research.' This was a student project with a sample of 10 measuring pelvic angle with an inclinometer before and after intervention with the Protonics® strengthening device. The mean anterior pelvic tilt was 19.9° (SD=6.9). Five subjects experienced a change of 3.2° (SD=5.3) of unilateral pelvic tilt and 2 subjects experienced worsening of anterior ilium and the 3 remaining were unchanged. While changes were determined to be significant, it is important to interpret these results in terms of clinical practice and ask if 3.6° of change is clinically relevant. The study might be judged as weak on this basis along with the small sample size. Unfortunately, pilot testing was not performed to determine the degree of intratester reliability, thus the measurements are in question. The authors brought this relevant topic to the forefront, by performing a relevant first study and these issues can be addressed in a future study.
Perhaps this nondirect approach may stem from the fact that. multiple studies since the mid 1980s have shown poor inter and intra-tester reliability with respect to palpation and with gross motion testing of the SIJ via the traditional paradigm. Further-more, recent studies have shown that the standing motion tests and manipulation do not actually induce any significant motion in the SIJ joint itself, though no doubt the pelvis itself may move as a unit in tri-dimensional space.''' These studies may be discouraging to clinicians who only use the traditional motion tests and do not utilize direct passive motion testing. Fortunately, there is an approach that appears to be an improvement over the traditional approach. This approach utilizes a few additional land-marks for palpation which is performed in stable postures and also utilizes passive motion testing to grade mobility on a 6-point scale.5.6 The findings with palpation and passive motion testing when Anterior Ilium is present; are not subtle. Furthermore, in the presence of Anterior Ilium, several directions of motion would present as distinctly hypo mobile and the opposite directions would present as hyper mobile. Anterior Ilium is a motion dysfunction that occurs in all 3 planes of the body and evaluation and treatment must address all 3 planes. Motion does occur in the SIJs with passive motion testing as demonstrated with fluoroscopy.' Additionally, recent research demonstrates greater than 70% intratester agreement with most of the palpatory and passive motion tests taught by the new paradigm.' This approach acknowledges the probability that SIJ motion restriction is often due to an external restrictor such as posture of the pelvis or deep muscle guarding; which restricts movement from going through the joint, as opposed to motion restriction occurring only within the joint.
The authors in the case study used a Protonics® device to strengthen the hamstrings in order to address the pelvic posture. While studies have shown that the hamstring muscle can restrict motion in the SIJ, it typically occurs at end range, such as with straight leg raising.' In performing the literature review of the Protonics® device the authors reviewed several impressive studies that used the device for patellofemoral pain. However, without detailing any statements from the studies regarding improved pelvic position, the following conclusion was made: "From these 2 studies, the Protonics® System appears to be beneficial in managing patients with patellofemoral syndrome via repositioning of the pelvis and femur Pelvic and femur repositioning may have application for individuals having trochanteric bursitis." If the studies which were referenced reached these conclusions, it was not evident from reading the article. It would be ideal to reference the studies with more detail in order to adequately under gird the conclusions. I reviewed Timm's impressive study (referenced in case study) on patellofemoral pain."' While there was statistically significant improvement in patellar alignment and a decrease in pain, there was no speculation whatsoever regarding ilium position. It is also possible that repositioning of the patella itself, or repositioning of only the femur, or both, excluding the ilium; could also be implicated.
It is intriguing indeed that at the end of the 1st visit 3 special tests were rendered negative. In future studies it would be interesting to deter-mine how long these benefits are maintained. It would appear that the results achieved in the first 6 weeks may be due to the intervention; of course this retrospective case study could not by its very nature, be rigidly controlled. It is very difficult, however, to ascribe all or even the majority of benefits between 6 weeks and 52 weeks to the treatment paradigm, as there are simply too many confounding variables. Additional details on the presence or absence of potential intervening variables and control thereof would strengthen the case study. Nonetheless, the case report is not to be discounted and certainly gives direction for future study.
As a disabled PT with former episodes of SIJ dysfunction, I would require any treating clinician (especially Physical Therapists) to directly evaluate position and mobility of the pelvic structure rather than rely only on tests that have a greater emphasis on hip mobility and hip muscle length. I would require that the structure be evaluated in neutral, and at end range flexion and extension of the lumbar spine and hips. I would also require that strength, endurance, facilitation, and inhibition be evaluated in the involved side and be compared to the non-symptomatic side before purchasing a strengthening device. I compliment the authors for addressing pain and function and passive motion tests of the hip and in publishing their case report so that debate can occur. I am motivated to learn more about the Protonics® brace and how it can be appropriately utilized in our profession, especially with regards to patellofemoral pain. Thank you for allowing me to share my thoughts and concerns.
Sincerely yours, Jerry Hesch, PT
Founder, the Hesch Method of Treating SIJ Dysfunction
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