Case Study: Temporal bones and ureters - dealing with global origins of pain

I expect that most of us here reading this, if not all, are not the kind of providers who hears their patient say they have a bad knee and then proceed to only to treat the knee like it was indeed, only a knee problem. I tend to think about my work as half focused on finding as much of the what and why as I can (instead of just "chasing pain") with the other half being treating the problem itself.

In my own approach paradigm I am looking for the body's local compensatory strategy (what is directly mechanistically causing our symptom), the global/regional strategy (what the brains overall approach is to stabilize the body, which may include many 'locals'), and the reason WHY this is having to happen in the first place (what is it protecting against with these compensatory strategies?).

I have one case from a couple years ago that I think illustrates these concepts beautifully. The patient was a woman in her 60's who has had both knees replaced and a history of many decades of skiing, among other knee intense activities. Her most recent knee replacement had just not been improving, with so much stiffness that it was significantly impacting her sleep, in addition to just not trusting it for basic use like taking the stairs, let alone sports and exercise.

Dealing with the 'locals' of her knee replacement and previous knee traumas dealt with about 80% of her ongoing knee symptoms, but it's rare that these issues happen on their own, with most being 'core'/midline issues at a minimum, and the chances are that given time, the symptoms would worsen again if we left it at that. The two main issues we've found with her include one that is pretty typical but widespread for a lot of folks, and one a bit more interesting.

Starting with the latter, she was born with her right ureter being too short, leading to constant irritation and repeated UTI's, which they treated by keeping antibiotics on hand for the next inevitable fever until her biggest period of growth was over at age 6 when they surgically lengthened it. Because of the repeated irritation and damage, she retains only about 30% of the function of her right kidney, nearly 60 years later, so the physical trauma of this situation was significant.

Visceral components are often overlooked in musculoskeletal cases because it is not, strictly speaking, meant to generate or distribute musculoskeletal force for locomotion itself. But they can be very fragile structures that are still affected heavily by musculoskeletal use, as well as restrictions; find restriction in a rotational/spiral line and you'll likely find the same restrictions in the visceral tissues along this line.

So something broadly vertically aligned, such as with her anterior oblique/functional or superficial anterior line, and something relatively fragile and previously injured is going to cause inhibition of function that may exacerbate it (the intestines do well being stretched, but things like the ureter and bile ducts...these are far more fragile). So when we checked her right ureter, it had almost no extensibility at all and any increased tension shut down the anterior function of her left knee. Manually giving it some slack elicited a robust response instead.

My approach for treating these takes some explanation, though PDTR therapy folks will see some crossover though I prefer a parasympathetic vagal stimulation instead of a PDTR stimulus, but the main point is dealing with these neurological artifacts that the brain is protecting against. In this case it meant primarily the stretch on the right kidney, through the ureter, to the bladder and the surgical repairs. The scars from the surgery itself left her umbilicus out of a midline position, which did largely correct with our work.

Our brain is in large part there to perceive and avoid potential dangers and will quickly inhibit things that it finds counter to any protective compensation strategies it finds necessary. Show it that the threat is gone and it no longer has to maintain that compensation strategy and that compensatory pattern can drop away (or at least, the given thing you have treated is no longer contributing to that compensation strategy and you can turn to the next component) .

On the more common side she also had her eardrums punctured for draining as a child due to a significant ear infection. These are incredibly impactful and pervasive injuries, which while they can add a lot of overall load and disrupt a lot of directional aversion affected function (think spinotectal audio and oculomotor involvement, among others), most of all affect spiral/rotational lines of tissue and function. Sometimes lateral, but always rotational.

Sensory/sensory adjacent injuries like this are also complicated in that it isn't just irritated by the original type of sensory input, such as positive or even negative ear pressure that caused the original incident, which exacerbates the resulting persistent compensations. Having audio input to that ear, vestibular input, light pressure or tapping (impact simulation) to the temporal bone, or even visual cueing in that direction will also be a strongly exacerbating input that we will want to individually deal with.

These situations show up even more easily with increased subjective irritation when you have a patient who has significant regular inputs that affect the temporal bone and its related structures (like professional dancers who have heavy vestibular input, divers or flight personnel with ear pressure changes, etc.), but will also be irritated by simple ADL's. What may be a small but annoying contributor to one person, may be disabling to someone else when it's loaded heavily enough for long enough.

So now for this patient we have a wide range of sensory inputs that are part of daily life that can rile up a rotationally focused compensation, which in the Anatomy Trains parlance, means triggering these 'red flagged' stimuli around her right ear absolutely wrecked the function of the left knee. As good as the knee was functioning after concluding the locals and the ureter topics, that function would drop as soon as we added any of the above stimulations to the right ear or temporal bone. Lightly hold around the ear and the knee is great, even right after irritating stimulation, since we are manually stabilizing it.

These two issues were crucial to keeping her knee working well after we dealt with the local contributors as she continues to live an active life. Our bodies can seriously change how they work and what they let us do/recruit when it finds it necessary to keep us going. As I tell my patients: your body is not concerned with your ability to climb mountains at 90, but surviving this week, month, and year, and will change what it has to to safely do so...so we need to show it that it does not have to keep protecting against previous traumas, electing to run your body with plan B, C, Z instead of A, and this means more than just treating issues local to their symptoms.