Sport Injuries and Wellness Ottawa

The Popliteus Muscle – Why does the back of my knee hurt? Part 2

2010-01-16T09:18:00.000-08:00

As stated in my previous blog there are numerous reasons why manual therapist, trainers and athletes should consider the Popliteus muscle in the rehabilitative process. Here we will discuss some exercises which can be used to rehabilitate the Popliteus muscle.

Often people think rehab is about getting stronger and will do an old approach of taking a dysfunctional muscle and simply exercising it. The problem is rehabilitation isn't often about strength as much as it is about educating muscles. You can have the strongest muscles in the world but can get injuries if you dont teach them to fire properly or to work in the manner they should. The Popliteus is a great example of this concept as you never see people "working out" their Popliteus.

As mentioned previously the Popliteus is a muscle used mostly for kinesthetic awareness and stability in the knee. When an athlete pivots quickly or changes direction the Popliteus is put to work. When observing the picture below you can see how the muscle acts as a connection between the medial and lateral knee structures.

This means as the medial compartment experiences tension and the lateral side experiences compression the Popliteus receives this sensory feedback and stabilizes the knee. The opposite is also the same when the lateral side experiences tension and Medial experiences compression. This type of interaction occurs in the knee constently as an athlete brings the knee from flexion to extension and when performing pivoting moves.

So we need to rehabilitate it in a way that allows it to learn this function. However, how do you teach this function without putting stresses on the knee in an injured patient?

Exercises for the Popliteus

Exercises should consist of non-weight bearing and weight bearing exercises.

1. Using a resistant band attach one end to a stable service and the other around the forefoot of the affected leg. Using a wall for support begin the exercise with the affected leg unsupported at the patients side. From the start position begin flexing the knee and bringing the foot behind the stance leg as if attempting to touch your toe to your opposite hip. This creates flexion of the knee and internal rotation of the tibia. This motion will contract and activate the Popliteus. Now return to the starting position slowly to also train the Popliteus to contract eccentrically as well.

2. Stepping task - This exercise is used for progression and performed to challenge the Popliteus in a more functional manner. Using a small step up place one foot on the step allowing the knee to be maintained in a slightly flexed position. With the opposite leg off of the step bring yourself to a fencer type of stance.

Now while maintaining the supported knee in flexion begin different stepping manouvers. First going to 3 oclock back to start, 12 oclock and then 9 oclock. This exercise trains the Popliteus on how to prepare for cutting motions which will involve a forceful planting of the foot and manoeuvring in different directions.

The exercise can be further challenged by using verbal or visual cues to create a spongtanoise stepping action as apposed to the patient knowing where they will be going. Tossing a ball or using a racket can also make things more sports specific depending on the athlete. In addition, one can challenge the exercise by adding a blindfold to remove visual stimulus.

Once a patient displays proper technique in this exercise they may now progress to the same exercise above but using an unstable service.

3. Stepping Task Unstable Surface

4. The last exercise is done to train the Popliteus in a manner that challenges it to receive tension and then create a reflexive contraction. This involves a series of jumping task using pylons.

Standing alongside a pylon with one foot supported the patient jumps to the opposite side. The patient now has three options upon landing.

a) Land on the opposite leg they took off from allowing the Popliteus to be trained concentrically
b) Land on the same leg they took off from allowing the Popliteus to be used in a concentric to eccentric manner
c) Do option b followed by quickly jumping to the opposite side of the pylons allowing the Popliteus to be trained concentrically to eccentrically and then quickly concentrically again. This emulates a very quick stopping task or explosive take off manouver which man occur in multiple sports.

In summary, these are just a few quick exercises that can used in preseason training for athletes or any patient with knee problems. Dr. Wayne Button, BSc, DC

Nyland, J. (2005). Anatomy, Function, and Rehabilitation of the Popliteus Musculotendinous Complex Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2005.1414

The Popliteus Muscle – Why does the back of my knee hurt?

2010-01-09T14:24:00.000-08:00

The knee is one of the most complex joints in the human body. It is impossible to summarize such a topic with the understanding of only one muscle. However, certain muscles in the human body appear to be more important then others. With regards to the knee the Popliteus is one of these muscles. In this column I will attempt to explain the importance of the Popliteus Muscle in an injured knee and the rehabilitative process.

Anyone can open an anatomy textbook and retrieve the basic information about a muscle so how about I save you some time?

Popliteus Muscle:

•O – Lateral Surface of the lateral condyle of the femur

Attachment to the lateral meniscus

•I – Upper part of the posterior surface of the tibia

•A – Medial rotates the tibia

•Inn – Tibial Nerve (Moore, 2006)

Basic anatomy has its importance but to truly understand injuries one has to grasp the concept of muscles working in synergy together. Sometimes this ideology is referred to as the Kinetic Chain.

Some of the most important anatomical aspects of the Popliteus muscle will not be found in your basic textbook but in research. The Popliteus muscle is one of the most researched muscles in the knee and is always being debated upon its main role. Here are some important anatomical concepts you should know.

1. The Popliteus muscle plays an important role in “unlocking” the knee joint. When flexion and extension occurs the Popliteus is involved in rotating the Tibia and Femur. This action allows the two bones to deviate from one another and now the bones will not “collide” or “lock”. This mechanism leads to a smooth movement of flexion and extension throughout the knee.

This gives good indication to the importance of soft tissue therapy to the Popliteus muscle. When patients present with injuries that don’t allow a smooth or full range of motion the Popliteus muscle could be the culprit. With a knee that is “catching” the Popliteus muscle should be “released”. Releasing the Popliteus muscle can be done with heat, stretching, Myofascial Release Therapy, Active Release Technique or Graston Technique. (Manual Therapy Techniques)

2. The Popliteus muscle is what we call a “feed forward” muscle. Other “Feed Forward” muscles include the Multifidus in the back and Supraspinatus muscle in the shoulder. These are muscles that can actually “turn on” or “fire” before movement even occurs amongst the joint. Furthermore, these muscles have a high amount of receptors making them very important for proprioception and balance training. This is important to know because any patient who has an “unstable” joint or a past knee dislocation can vastly benefit from a rehabilitative program which exercises the Popliteus muscle.

In addition, this knowledge is a good indication that athletes may benefit from a preseason exercise routine, which involves the Popliteus muscle. By training a muscle involved in proprioception this may lower the incidence of knee injuries. This same concept is already being explored with preseason prevention of ankle injuries and acl tears by certain workout regiments.

3. The Popliteus muscle also works in synergy with the posterior cruciate ligament (PCL). Anatomical studies have shown that by actually cutting the Popliteus muscle tension increased in the PCL. The same is true otherwise that by increasing the force through the Popliteus, tension has been lowered in the PCL. This concept makes sense when you observe the following picture. When you look at the Popliteus and PCL together they almost both make a hammack for the knee joint allowing the bones to rest on their surfaces. It makes sense that if you were to injury, tear or have one weak the other would need to support the load.

This details the fact that by maybe strengthening the Popliteus muscle PCL injuries would decrease. Furthermore, if you have a weak and dysfunctional Popliteus you may develop PCL insufficiency or obtain an injury in the future.

Need more details? The Popliteus also:

- helps in movement of the lateral meniscus

-Is involved in posteriorlateral stability of the knee

-Plays an important component in down hill running

-Has attachments to all of the following

–Distal MCL

–Fibular Head

–Lateral Meniscus

–PCL

–Femur

–Tibia

These are just a few concepts of why I believe the Popliteus is thee most important muscle of the knee. Even if the muscle itself is not injured addressing it may give significant results. The old concept of only treating what is injured is dead and understanding the body as a whole is starting to evolve.

So how do I exercise/rehabilitate the Popliteus muscle?

Tune in for a rehab protocol of the Popliteus next blog

Nyland, J. (2005). Anatomy, Function, and Rehabilitation of the Popliteus Musculotendinous Complex Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2005.1414

Ehler-Danlos Syndrome- I am wayyyyyy too flexible.

2010-01-02T17:07:00.000-08:00

Inspired by a past patient

Most of the time patients will come to us with a specific complaint in one general location. "My neck hurts when I'm working" or "my knee hurts when I run" and so fort. However, every now and then a patient will come in and tell their story. They will describe the number of doctors they have seen, the MRI's and CT Scans they have gotten and the information they have read on the internet. It almost seems as if their injury is a story and no one is able to provide a happy ending. These patients are often chalked up as "exaggerating", "hypochondriac" or "malingering". However, until proven otherwise it is my job to believe everything their saying. The patients long history of injuries, symptoms and signs are painting a diagnostic picture.

Ehler-Danlos Syndrome - Rare Diagnostic Case of the Month:

EDS is actually a group of conditions which have different signs and symptoms related to abnormalities in connective tissue. These abnormalities are caused by a genetic mutation in collagen. Collagen is like the glue our joints, muscles, ligaments and skin needs to stay together. There are 29 different types of collagen which is placed in numerous different areas of the body with different purposes. This is one main reason why EDS presents with such a slew of different symptoms. Essentially EDS is a heritable disorder that can affect skin, ligaments, blood vessels and internal organs.

If it's a genetic condition why should I care?

Many of those with EDS do not get diagnosed by walking straight into a geneticist office. It takes knowledge from someone as a primary care physician to suspect such a syndrome and refer them out. This means although it is not your speciality, one should be well aware of the diagnosis. Furthermore, EDS can be masked by a number of different MSK injuries which will appear as a "normal" patient complaint. Such examples include:

-Flat feet (55% of EDS patients)
-Long history of shoulder dislocations
-Carpal instabilities
-External Snapping Hip Syndrome
-Scoliosis

In addition, five of the six subtypes of EDS have variants of being hypermobile. This means people who present with multiple joint instabilities, extreme flexibility or easily bruising are often just deemed "hypermobile" or may be associated with their sport such as gymnast. In reality this person may be suffering from EDS and go years without ever being diagnosed.

So what's the difference between hypermobility syndrome/general ligament laxity and EDS?

The difficult part is some say there is no difference and find the two to be synonymous with one another. There is actually one form of EDS known as type 3 and is deemed hypermobility EDS. Due to the fact there is so many varieties of EDS and general hypermobility in people, a clear distinction has not fully been made and is often debated. To my knowledge this means one can have hypermobility syndrome or be deemed "hypermobile" and yet not have the genetic link to EDS. Confusing I know....

So how do I diagnose it?

Keep in mind there is multiple different major and minor types of EDS and we are mainly discussing here the hypermobility type. Often manual therapist use a system known as Beighton hypermobility criteria. This consist of a number of different joint findings which obtain a numerical value. The total score one can achieve on a Beighton scale is 9, with 5/9 or more being deemed as someone who is "hypermobile" [see image below].

Other signs and symptoms of type 3 EDS include:

-History of recurrent joint pain, subluxations and dislocations
-Patient may easily bruise and considered "clumsy" their whole life
-Chronic limb and joint pain which can be debilitating with normal imaging
-Joint effusions
-Premature osteoarthritis
-Extremely elastic skin
-Delayed healing of injuries leading to atrophic scars

There is no current biochemical or genetic markers to be identified for the hypermobility subtype. (Too my current knowledge). Other forms of EDS and variants can often be diagnosed with a simple urine test, skin biopsy or genetic testing.

Other groups of EDS consist of:
-Vascular
-Classical
-Kyphoscoliosis
-Arthrochalasia
-Dermatosparaxis

So the next time a patient comes in and considers themselves to be just "flexible", "clumsy" or a "slow healer" don't rule out EDS. After all you could be the one person that provides them with a happy ending to their medical story. Dr. Wayne Button BSc, D.C

Callewaert B, Malfait F, Loeys B, & De Paepe A (2008). Ehlers-Danlos syndromes and Marfan syndrome. Best practice & research. Clinical rheumatology, 22 (1), 165-89 PMID: 18328988

Schroeder EL, & Lavallee ME (2006). Ehlers-Danlos syndrome in athletes. Current sports medicine reports, 5 (6), 327-34 PMID: 17067502

Merry Christmas

2009-12-21T09:50:00.000-08:00

Hey guys just a quick note wishing everyone a Merry Christmas and a Happy New Year. The blog will be taking a small break for the next two weeks. I don't know if i'll be posting anything over Christmas because of lack of time but if so keep checking in.

These last few months have been great as the start of my new blog. What originally was a pass time to keep me up to date on research and current has lead to over 2000 viewers a month. I expect great things for 2010 and have a list of future blogs. Any ideas or questions please feel free to email me and ill work on those blogs for 2010.

Thank you for all the patients, friends, viewers and other professionals which have made comments on the blog. Everyone have a great Christmas. Dr. Wayne Button, BSc, D.C

Patellofemoral Pain Syndrome- Where exactly is the pain coming from?

2009-12-13T21:39:00.000-08:00

The knee of an athlete is often a diagnostic dilemma. The knee obtains important biomechanical function and is supported by an array of ligaments and muscles. For these reasons it can be difficult to pinpoint the specific structure which is injured. Such a concept is to be blamed for the creation of Patellofemoral Pain Syndrome (PFPS),

What exactly is PFPS?

When you think about it what exactly does this diagnosis tell you? Essentially all that this means is we know there is pain and we know it has something to do with the Patella-Femoral Joint. In my opinion this is not a real diagnosis. What if we made clinical conclusions like this for everything? Chronic Neck Pain Syndrome or Sore Elbow Disease?

In reality, PFPS is an umbrella term to describe any possible causes of pain which can be attributed to the Patella-Femoral Joint. Such as:

-Chondromalacia Patella - Softening of the cartilage under the patella
-PatellaFemoral tracking problems
-Infrapatellar Fat Pad being impinged (Hoffa's Disease)

This is why I often tell colleagues and those which attend my seminars to not worry about the diagnosis. What you need to find out is WHAT EXACTLY IS CAUSING THIS PAIN?

Originally many used to take a structural approach to PFPS. Measurements of one's Q angle or a patient's knee valgus was observed and often chondromalacia patella was diagnosed. However, if structural abnormalities were deemed the cause how does one explain the benefits from conservative treatment? The patients Q angle has not changed. Furthermore, not everyone with a high Q angle has knee problems?

Researchers are starting to progress away from the structural approach of PFPS and asking what is actually causing the pain?

Ok so what are my options?

A biomechanical fault, muscle imbalance or pathophysiological process which leads to:

1.Inflammation of the synovial lining
2.Inflammation of the fat pad
3.Increase in intra articular pressure

4.Hyperinnervated Lateral Retinaculum

To fully understand you have to address the signs and symptoms

PFPS can be exaggerated with running and climbing up and down stairs. This mechanism of injury is simply due to overuse or excessive force. Such activities as climbing stairs can produce forces 3 times one's body weight. A loss of Tissue Homeostasis occurs and now the joints synovial lining becomes inflamed (#1). This concept is a pretty easy one to understand.

However, how does one explain the movie sign (Pain in the knee with a prolonged period of sitting)? One does not put excessive force through the knee as they sit. There are two leading theories for the movie sign. While sitting we may predispose our knee to change normal position and now structures my impinge a once swollen inflamed synovial lining (#1). The second theory is that as we sit our knee's intra articular pressure increases and thus creates pain (#3). Studies have shown that the knee is an extremely fibrotic and capsular entity. When put in prolonged flexion we may impede venous outflow and increase arterial blood flow to and from the knee. This change in blood flow can increase the pressure within our knee as we sit.

Reasoning for these causes of pain is the popular treatment called McConnell taping. This is a taping method which has shown to relieve pain. However, the results are not always consistent and many wonder why. It can be purposed that by taping the patella in a more neutral position we are preventing it from impinging structures and thus resolving the patient's pain (#1, #2).

Lastly a maltracking patella has also been associated with PFPS. What studies have observed is anatomically those who suffer from PFPS have a hyperinnervated lateral retinaculum. Furthermore, these subjects presented with more nociceptive fibers within the nerves. The theory is the patella tracking medially (usually) will produce tension along the lat retinaculum. Now the nerves are put under traction and start to experience myxoid degeneration. In an attempt to heal itself the body now produces more neural drive and stimulation to that area thus creating a hyperinnervated structure and pain is produced (#4).

Still Don't Believe Me?

Check out the article posted below by Scott F Dye. This is one of the most intriguing and interesting articles I have ever read. Scott which is an orthopedic surgeon (I believe?) has actually been diagnosed with chondromalacia patella in the past. He attempts to cut himself open and inspect the cause of his knee pain. When probing his patella cartilage no pain is felt. However, pain is accentuated when probing his synovial lining and Hoffa fat pad. Furthermore injecting himself with saline increases his intra-articular pressure and produced extreme pain. This article has given valuable premise to support 3/4 theories of what causes PFPS. Imagine... the things we do for science (Left probing cartilage, Right probing synovial lining).

In summary, as professionals we need to steer away from umbrella terms such as PFPS. As a student I found this diagnosis extremely confusing and more so difficult to explain to patients. It wasn't until exploring the mechanism of pain in which I become more inclined to make such a diagnosis. To create consistency in research and amongst colleagues we need to address the actual form of PFPS were discussing. In addition, exploring this notion lays great premise on how we can guide our treatment. This is one condition where the diagnosis may actually be made after treatment is initiated. Dr. Wayne Button, BSc, D.C

Dye, S., & Vaupel, G. (1994). The Pathophysiology of Patellofemoral Pain Sports Medicine and Arthroscopy Review, 2 (3), 203-210 DOI: 10.1097/00132585-199400230-00004

Sanchis-Alfonso V, & Roselló-Sastre E (2000). Immunohistochemical analysis for neural markers of the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A neuroanatomic basis for anterior knee pain in the active young patient. The American journal of sports medicine, 28 (5), 725-31 PMID: 11032232

Naslund, J., Walden, M., & Lindberg, L. (2007). Decreased Pulsatile Blood Flow in the Patella in Patellofemoral Pain Syndrome The American Journal of Sports Medicine, 35 (10), 1668-1673 DOI: 10.1177/0363546507303115

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Low back pain while running..a real pain in the but. Part 2:

2009-12-12T07:36:00.000-08:00

Refer to past column Low Back Pain while running..a real pain in the but. Part 1:

Inspired by my own past experience.

So how do I fix this?

To help fix this problem you have to train yourself to achieve an efficient running style. You need to combine loosening your tight Psoas and activating your inhibited Glut Max.

1. The tight Psoas - There are multiple ways to loosen up a muscle before activity. People can use heat, massage, different soft tissue therapy techniques and stretching. Opinions on stretching differ significantly. Some say it''s beneficial and some say it isn't. The truth of the matter is there is no conclusive answer. However, if a muscle is relatively tight or leading to pain I recommend doing specific stretches before a run.

Stretches for the Psoas:

2. The inhibited Glut Max - Ever watch elite runners before a race. Often you can see runners pounding their fist against their Gluts. That's because their trying to wake their Glut Max up before attempting to use it. I know it seems weird but before your next run try hitting your Gluts with your fist to wake them up. This action can stimulate proprioceptive and biofeedback to the muscle.

One should also try incorporating basic Glut Max exercises into their training program as well. If too many of these exercises are done before running it may actually fatigue the Glut Max and exaggerate the problem. However, just a few simple repetitions to stimulate your Gluts should suffice.

Glut Max Exercises

3. Putting it all together - Before running try to emulate your running technique when warming up. Against a wall for balance, just try swinging your leg or performing kick backs as if you are running. You want to teach your back to stay neutral as all the movement is carried by your hips. Doing this before hand also allows you to gauge the flexibility in your hips and awareness of your Glut. If still not suffix try a few more stretches or exercises. For training purposes this can also be done with a resistance cord or ankle weights.

In summary, a few simple stretches and exercises before a run or race can help a lot. If your problem persists get it assessed by a trained professional. Dr. Wayne Button, BSc, D.C

Liebenson, C. (2009). Functional training of the gluteal muscles☆ Journal of Bodywork and Movement Therapies, 13 (2), 202-204 DOI: 10.1016/j.jbmt.2009.01.004

Low back pain while running..a real problem in the but? Part 1

2009-12-09T10:43:00.000-08:00

There are a number of causes of low back pain in recreational joggers. However, what many people may not know is often the pain can be attributed to other areas rather than the low back.

To believe the body works as different compartments is a false notion. Our body works as a complete unit and in synergy together during exercise. Jogging and running is no exception to this concept. This is why back pain usually can be caused by problems in your hips and buttock region. That's right ...your low back pain could be significantly reduced by addressing muscles in your but.

I don't understand??

1. Your Gluteus Maximus is the biggest muscle in your buttocks area. Although this muscle has many roles in running it is involved in extending your leg through the swinging phase. When the muscle is not firing properly or inhibited, your leg will not extend to a full range of motion it is capable of. Inhibited simply is a term used to describe a muscle which is weak not due to pain or neurological cause.

When the Gluteus Maximus is not as strong or efficient the body has to compensate by finding other ways to achieve the range of motion it would like. So what runners will do without even realizing it is extend or hike their back to gain that extra range of motion.

2. A second muscle involved in this type of faulty running behaviour is the Psoas muscle. This is a muscle which crosses the front of the hip joint. While running the Psoas is involved in flexing the hip forward. Needless to say the Gluteus Maximus and Psoas are contently battling against one another as you run. One helps bring your leg forward as the other brings it back..over and over again.

This is why a Psoas muscle which is tight can also decrease the extension you achieve in your hips. Thus causing you to compensate again by arching your back.

3. Putting it all together - This combination of a weak Glut Max and a tight Psoas muscle will lead a runner towards a compensating gait. Now your back is exposed to extra forces it does not need on a consistent basis.

Its important when running to allow most of the movement to occur from your hips and allow the back to stay neutral. By creating this running technique back pain may be prevented and decreased significantly.

How do I know I have this problem?

Well any type of back pain should be addressed by a trained professional. This is because there can be multiple causes for the pain. It is important to rule out a serious pathology. However, there are ways to see if you have this particular problem. You may need a partner or again someone trained to observe different movement patterns.

1) Your gait - Sometimes this subtle hiking of your back can be seen from a partner while watching you run from a side view. Videotaping patients while running on a treadmill is a great learning tool to use as well.

2) The tight Psoas - You may just feel the tightness in general but can still use different test to see if it is tight.

On a gym bench or table lye on your back with your buttock at the end of the table. Allow your legs to hang off the bench freely. With your hands take one leg and bring your knee towards the chest. If the opposite leg comes off the table almost immediately or in an excessive range this can indicate a tight Psoas. This same test is often used by manual therapist and is called the Modified Thomas test.

3) A inhibited Glut Max- This is something that is very tricky to test for. That is because it is hard to assess how the Glut will function in isolation from other muscles. Seeing how much you can squat is not exactly a reliable measure. It's important to assess how does the Glut Max work in motion which resembles a running gait. Many manual therapist use what is called the Janda Prone Hip Extension Test (named after the famous neurologist Vladimir Janda).

This test should be assessed by someone who is trained to analyze movement patterns. Start by lying on your stomach upon a bench or table. While maintaining this position slowly extend one of your legs up towards the ceiling just a few inches off the table. A faulty movement pattern will be either a bent knee, hinging of the low back or a delayed response from your Gluteus Maximus. A normal test should show a smooth pattern of leg extension with the Glut Max doing most the work. When the back hinges or the knee is bent this is signs of other muscles helping the Glut Max or worse doing its job (Top Right & Lower Left faulty patterns)

In summary, back pain and running injuries can be a complicated manner. The answers are not always this easy and should be addressed by someone who is trained in such a topic.

How do I solve this problem? Stay tuned for Part 2.

LIEBENSON, C. (2007). Hip dysfunction and back pain Journal of Bodywork and Movement Therapies, 11 (2), 111-115 DOI: 10.1016/j.jbmt.2007.01.005

I sprained my ankle months ago and it still hurts?

2009-12-06T19:25:00.000-08:00

A sprained ankle is the most common sports injury. However, it usually is easy to diagnose and will eventually always heal. Sprained ankles are expected to be back to 90% recovery within 6 weeks (This may vary depending on the degree of sprain and other associated factors). However, what if it doesn't get better? What if your symptoms have not resided by that time? Believe it or not, a simple sprained ankle can often lead to long term problems.

1) Osteochondral Lesions/Osteocondritis Dissecans of the Talus

Often when an ankle is sprained there can be a sudden loss of stability. This can cause bones within the ankle to impact or collapse into one another causing an osteochondral lesion to form. An osteocondral lesion is when the cartilage surrounding a bone is torn, crushed and in more rare causes forms a cyst. Cartilage is the cushioning our bones and joints are surrounded by to help with impact forces. With the cartilage now torn or disrupted it may break off with a small piece of bone and be wedged or displaced inside a joint.

Symptoms often include persistent pain with activity. The pain may be deep within the joint and can occur long after the pain felt from a sprained ankle has resided. The ankle may also experience catching, snapping or locking which it hasn't experienced before. There have been reports of asymptomatic cases and individuals healing spontaneously, but this is often amongst a younger population. Furthermore, these lesions can at times progress to create osteoarthritis within the ankle joint.

Do not assume you do not have this injury because you had radiographs taken. The lesions are small (2-5mm) and flake like. Furthermore, special views are commonly used to spot the injury which will often not be included in a normal series of ankle radiographs. Observe below (A & B no lesions is shown but can be seen on view C). Needless to say this injury is difficult to spot. If easily accessible an MRI should be taken as it has shown optimal diagnostic value.

Osteocondral lesion can be treated conservatively and surgically. However, there has been a lack of research to determine what factors play into the decision making process. Most children or adolescents will resolve the lesion because of their healing properties but adults often carry out the option of surgery.

2)Complex Regional Pain Syndrome/ Reflex Sympathetic Dystrophy

There is no standard definition for CRPS, as nobody has determined what causes the condition. Essentially the syndrome can be defined by its simplistic name "Complex Regional Pain". The syndrome involves a complex array of symptoms in a particular region which leads to pain. However, CRPS has a neurological component explaining the symptoms.

The cause is often attributed to the neurological system becoming confused. When someone experiences an injury the bodies nervous system reacts by producing pain, increasing swelling, changing color due to inflammation ect. However, with CRPS the nerves now are hyper-vigilant, meaning the littlest touch or activity can set of a chain reaction replicating a more serious injury. Reports have shown incidents as small as a paper-cut to cause CRPS. Simple events such as walking or putting on your socks can be interpreted by the ankles nervous system as getting hit by a hammer.

Symptoms will include pain disproportional to the event causing the symptoms originally. Light touch or the application of any form of heat or coldness may be taken as intolerable. Nerves which innervate blood vessels and sweat glands are also affected. Symptoms of this nature may will appear as excessive swelling by the ankle, changes in color, changes to the appearance of the toe nails, hair loss and even sweating when not indicated. In Addition, muscles around the ankle with time may become weakened and get smaller in appearance.

Diagnosing CRPS isn't an easy task. Radiographs, MRI and common physical examination procedures can give a good implication of a diagnosis but not always confirm. Often special imaging is carried out to assess the bodies thermo graphic patterns.

3) Ankle Impingement Syndrome

The body works on a simple concept that when a structure gets damaged it will try to repair itself. Furthermore, whenever a repetitive force or even a constant pressure is applied to a structure it will react by growing, shaping or forming a new position to compensate for this pressure. This concept is how braces work for shaping ones teeth properly.

In the ankle there are a lot of ligaments, muscles and joints. Often when repetitive trauma or strain is applied to one of these structures it will compensate similar to what was described above. Eventually the small bit of cartilage surrounding the bones or ligaments will be pulled on or experience "traction". This constant repetitive action will lead to the formation of little bone and cartilage spurs. These spurs will also occur after repetitive ankle sprains. This process is called osteophytosis.

The spurs formed can often not present any problem at all. However, occasionally bone spurs (also called "osteophytes") will "impinge" structures such as ligaments, tendons and scar tissue from past injuries.

Signs and symptoms may include an ankle which feels unstable or weak. Tenderness or a "pinching sensation" may occur when the foot is brought through flexion and extension. A painful clicking may also be observed during certain movements of the ankle. Impingement can occur in the front and back of the ankle. Usually squatting or bringing your toes towards your head will be painful in anterior impingement. Bringing your toes downward or rising on your toes will produce pain in posterior impingement.

5) Cuboid Syndrome

The cuboid is a small bone that lies on the outside of the foot. Cuboid syndrome is when this bone experiences excessive movement or a collapsing effect. The excessive movement can cause irritation of the surrounding joint capsule and ligaments or put strain on a particular muscle which attaches to the cuboid called the fibularis longus.

Up to 4% of athletes can experience cuboid syndrome with a particular high rate in ballet dancers. However, up to 6.7% of those experiencing ankle sprains can develop cuboid syndrome. When the foot is forced into this position the fibularis longus muscle experiences tension thus jamming the cuboid bone and forcing it to shift out of place.

Patients with cuboid syndrome may present with pain directly over the cuboid and radiating down the outside of the foot. Pain is often associated with a weight bearing position but can occur otherwise. Pain can be experienced with squatting or on toe off during a running gait. Weakness can often be a secondary complaint.

The good news is cuboid syndrome has been shown to be successfully treated with conservative treatment including rehab, manipulation, taping and the placement of a small felt pad under the cuboid preventing it from collapsing.

In summary, if your experiencing new symptoms after an ankle sprain get it assessed by a trained professional. The complaint may be something completely new but sprained ankles often lead to problems down the road. Assess the problem early, listen to your clinician and take precautions on your first ankle sprain to reassure these problems don't persist.

Other injuries that may occur after a sprained ankle or be confused with previous mentioned conditions are:

-Os trigonum
-Fibularis Longus Subluxation
-Sinus Tarsi Syndrome
-Osteoarthritis
-Nerve Palsy

References

-

Choi WJ, Park KK, Kim BS, & Lee JW (2009). Osteochondral lesion of the talus: is there a critical defect size for poor outcome? The American journal of sports medicine, 37 (10), 1974-80 PMID: 19654429

PONTELL, D. (2008). A Clinical Approach to Complex Regional Pain Syndrome Clinics in Podiatric Medicine and Surgery, 25 (3), 361-380 DOI: 10.1016/j.cpm.2008.02.011

Jennings, J. (2005). Treatment of Cuboid Syndrome Secondary to Lateral Ankle Sprains: A Case Series Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2005.1596

Orthopedic Test of The Month: The Stroke Test

2009-12-02T20:01:00.000-08:00

Often when carrying out an examination multiple test will be performed. The checklist of orthopedic test can be endless. Multiple books and studies have been written regarding testing procedures. Furthermore, most test will have different names and variations which are open to subjective analysis. This is why research has shown the experience of the clinician to increase the diagnostic value of a test [1] Swelling is no exception to this rule.

How can you measure or grade swelling? What one deems to be significant swelling another may assess as minimal swelling. Due to this subjective nature it is often difficult for manual therapist to confirm or apply a grading system to swelling.

This Months Orthopedic Test: The Stroke Test (a.k.a Brush test, Wipe test, Bulge test)

When an injury occurs swelling will usually develop. Sever swelling outside of a joint can often be simple to see (See Pictures). However, whenever swelling occurs on a small level it can be difficult to assess and measure.

The knee joint normally holds 1-7ml of fluid within it's capsule. The stroke test has reported to show as little as 4-8ml of extra fluid within the knee. Occasionally when a knee has minimal intracapsular swelling the only observable feature is a puffy type of appearance. The patient may report a boggy sensation, an increased amount of pressure or assume a resting position of the knee. The resting position of the knee is when the knee will remain in a 15-25 degree flexed position. This position allows the knee capsule to hold the most amount of fluid and can be observed from the side of a patient while standing.

Multiple test have been purposed to measure swelling in the knee but no gold standard has been established. Measuring tape can lead to many forms of human error and subjective scrutiny. Although ultrasound and MRI have been deemed valuable ways of measuring swelling they are not always easily accessible for practitioners. Due to these reasons the stroke test can be a valuable method to not only diagnose swelling but to assess and be used in monitoring the progression of rehab exercises.

The stroke test is performed with the patient in a supine position and the knees fully extended and relaxed. The idea of the stroke test is for the examiner to create a fluid wave and displace the fluid in an area of the knee that allows the fluid to dissipate and pool. Starting at the medial tibiofemoral joint line, the examiner strokes upward 2-3 times towards the suprapatellar pouch in an attempt to move the swelling from within the joint capsule to the suprapatellar pouch. The examiner then strokes downward on the distal lateral thigh superior to the suprapatellar pouch, towards the lateral joint line. A wave of fluid may be observed along the medial side of the knee.The test can be measured in quantity on a 0-3 scale. If performing the downward stroke doesn't produce a wave of fluid a score of 0 is given. A small bulge produced with the down ward stroke is valued at 0 and a large wave 1+. If the medial fluid returns to its position without attempting a downward stroke a grade of 2+ is given and not being able to displace the fluid with an upward stroke is valued at 3+ .

The grading system has been shown to produce a high interrater reliability amongst practitioners [2]. Furthermore, the test creates a rating scale which can be used when relaying information to other professionals. In addition, creating a rating scale allows more precise measures and more specificity to be observed when researching or examining swelling of the knee.

1. David J Magee. Orthopedic Physical Assessment. 5th Ed

2. Sturgill L.P & al. Interrater reliability of a clinical scale to assess knee joint effusion. JOSPT. 2009, Vol 39, 12 845-849.

Need Another Reason To Text? How About Losing Weight?

2009-11-28T07:40:00.000-08:00

With the rise of obesity in our society people will try almost anything to lose weight. This can include different diets, workout regiments and even surgery. The research and market exposure tackling such a topic is outstanding. However, a new study from the University of California purposes a different method to losing weight...texting?

Subjects in the study were sent 3-5 text messages a day with friendly tips and reminders on nutrition and weight control. Furthermore, calls would be carried out throughout the study to subjects by a health counselor.
Participants of the study lost on average slightly over 6lbs in 16 weeks. This was 4lbs more than those who were not texted during the study. Although 6lbs seems like a minor loss this is fairly significant considering no other adjustments were made to these people's lives.

The study purposes an interesting method of assisting people in losing weight. With the rise of child obesity and the popularity of cell phones such an idea isn't too far-fetched. New IPhone applications are always arising regarding diet tips and nutritional advice. In addition, one could use such a protocol when needing advice or motivation from their trainer which is not always present. So the next time you text your overweight friend try texting them some diet advice. Who knows........it may go over well.

Dr. Wayne Button, BSc, D.C

Patrick K, Raab F, Adams MA, Dillon L, Zabinski M, Rock CL, Griswold WG, & Norman GJ (2009). A text message-based intervention for weight loss: randomized controlled trial. Journal of medical Internet research, 11 (1) PMID: 19141433

Biking Injuries: Handlebar Palsy - Riding my bike is bad for my wrist?

2009-11-25T21:12:00.000-08:00

It is pretty hard to walk along the canal on a nice day in Ottawa and not see a herd of bicycles pass you along the way. Biking is becoming increasingly popular in both transportation and recreational settings. In China bicycling is the number one form of urban transportation.

Due to these reasons bicycling injuries are becoming more and more common. However, most of these injuries can be avoided with just a few simple tips or minor adjustments to a bicyclist form or bike.

"Handlebar Palsy" is a term used to describe a nerve injury which occurs to bicyclist. This injury is often caused by prolonged compression or repetitive damage consistently to the Ulnar Nerve in the wrist. This nerve runs along the outside of the wrist and can carry both motor and sensory components. Depending on where the nerve gets damaged can dictate which components are corrupted. (Observe Picture).

However, the motor branch of the nerve is most commonly affected. This means pain, numbness and tingling aren't presented as symptoms. However, muscles will begin to lose their strength and function leaving bicyclist curious of why an onset of sudden hand weakness has occurred.

Signs and Symptoms

Often cases of "Handlebar Palsy" occur in individuals who have performed an excessive amount of biking. Cases have been published on people biking across the country or going on biking trips. However, there is also cases of it occurring due to an acute direct trauma.

Symptoms include unexplained weakness, clumsiness and muscle atrophy of the hand. Patients have also reported not being able to perform normal hand functions such as playing piano or using surgical equipment.

Prevention

Handlebar Palsy can often be avoided by a proper placement of one's wrist on the handlebars. Those suffering from HP will usually display a faulty grip position. This can include hyperextending the wrist which will apply tension to the nerve (Picture to the left). Furthermore, one may grip the handlebars in a position which leaves the ulnar nerve exposed to being compressed. Try gripping your handlebars with a neutral wrist and leave the outside of the hand exposed. (Picture to the right)

In addition, bicyclist should always be fitted by a professional to make sure thier seat, frame, handlebars and pedals are placed properly for them. Try adjusting your seatt to place you in a more upright manner and avoid applying pressure on your hands and wrist. Attempt to take frequent breaks whenever carrying out long bike rides. When riding constantly adjust your position on the handlebars avoiding a consistent compression point. Whenever possible one should attempt to distribute the weight along the outside of their hands rather then the center of their palms. Using bicycling gloves and soft gripping for handlebars can also help reduce the force of vibrations being transmitted to your hands. Lastly, attempt different hand and wrist stretches before going for a ride.

I think I already have this injury?

Get the possible injury assessed by a health professional. Attempt to find a professional in your area who has a specialty or interest in sports injuries. There are multiple more serious neurological conditions which can replicate this injury (ALS, MS) and shouldn't go ignored without being looked at.

Cases of handlebar palsy may take weeks to months to reside. However, bicycling should also be ceased until the nerve is given time to regenerate. This is a slow process (approx 1mm a month) and will be hindered if the nerve is still left exposed to consistent vibrations. After the injury is confirmed by testing and shown to resolve one should take precautions before returning to the bike. Strength of the muscles in the hands and wrist should be returned to full form and again the patients biking mechanics should be looked at.

In summary, multiple bike injuries can be avoided with simple precautions and changes in biomechanics. We often wear helmets to protect our head but forget about the other body parts which are crucial in our everyday life such as our hands. Dr. Wayne Button, BSc, D.C

Capitani D, & Beer S (2002). Handlebar palsy--a compression syndrome of the deep terminal (motor) branch of the ulnar nerve in biking. Journal of neurology, 249 (10), 1441-5 PMID: 12382163

New Ground Breaking Research on MS

2009-11-23T17:55:00.000-08:00

New MS story--ground breaking research

http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20091120/W5_liberation_091121/20091121?s_name=W5

Does Your Pelvis Move Too Much????

2009-11-23T14:00:00.000-08:00

Form Closure vs Forced Closure and the Active SLR

Often many people wonder why the SacroIliac Joint (SIJ) is designed the way it is? The SIJ is in an area where a lot of forces are transferred from the lower body to the upper body and vice versa. Due to this reasoning one may wonder why the SIJ has such flat articulation. The SIJ is designed to deal with compressive and bending forces but not shear forces. This is why it would make more functional sense for the SIJ to be glued together.

So how does the SIJ compensate?

1. Wedged shaped sacrum stabilized by inominates

2. Not a normal smooth articular cartilage (view images)

3. Cartilage covered bony protrusions into the joint (view images)

These three mechanisms represent the SIJ's way of achieving what is called Form Closure.

But if the SIJ was molded perfectly it would have no mobility?

This is why the SIJ needs to find a perfect equilibrium between movement and stability. With the muscles, fascia and ligaments around it, the SIJ now finds a way to create what's called Force Closure. Using anatomical structures to create force and allow the SIJ to move and be stable.

How does the SIJ achieve this "SelfLocking" or "SelfBracing Mechanism"?

1. Ligaments
- Dorsal Sacral Ligaments (Nutation=Tension)
-When the sacrum experiences nutation it uses the dorsal sacral ligaments like a hammock. Resting on these ligaments now creates tension and thus provides friction/stability to the SIJ. Often this ligament can be dysfunctional or tender amongst pregnant women. This relationship explains how now a more mobile pelvis has to use ligaments around it for stability.

- Sacrotuberous Ligaments (Loading = Decreased Mobility)
- Studies have shown that by loading the sacrotuberous ligament mobility of the SIJ will be decreased. This ligament will become loaded by tension in the muscles that attach to it such as the Bicep Femoris, Glut Max, Piriformis and Tharacolumbar Fascia. Again this connection can be supported by the correlation of pregnant women having tight hamstrings. The hamstrings attempt to load the sacrituberous joint and work harder to keep this now mobile SIJ stable.

2. Thoracolumbar Fascia
- Multiple muscles attach to the thoracolumbar fascia allowing it to the act as a connection point between muscles of the lower back, pelvic and proximal aspect of the lower extremities. This fascia creates stability by producing tension when these muscle contract. The Multifidus may contract and balloon up into the fascia allowing it to tighten and thus brace its surroundings.

3. Musculature Slings
- There are multiple slings of muscles which envelope the SIJ allowing it to be stabilized. The anatomical pattern of these slings gives premise for rehabilitation to be performed on these muscles in an attempt to create SIJ stability. If one creates a rehabilitation program to strengthen these muscles the movement and pain from the SIJ may be reduced.

Three Musculature Slings

1. Longitudinal Sling

Multifidus-Sacrum-Deep Layer of TLF-Sacrotuberous Ligaments-Bicep Femoris

2. Posterior Oblique Sling

Latissimus Dorsi-TLF-Glut Max

3. Anterior Oblique Sling

Ext Obliques-Int Obliques-Transverse Abdominus-Piriformis-Rectus Abdominus-Linea Alba-Inguinal Ligament

So what if I don't have this "Selflocking" mechanism?

Problems may occur in this area if an equilibruim is not created between stability and movement.

-This can create diminished muscle power causing muscles to have to work more towards stabilizing the SIJ and not working towards other functions.

-Secondly, this may create an imbalance between muscle function and not allow muscles to work in synergy together towards other goals like creating core strength.

-Thirdly, this can create excessive ligament tension around the SIJ.

-Lastly, this will cause an excessive amount of mobility in the SIJ similar to someone who is pregnant.

Combine all these factors and you will experience a consequence of PAIN.

Is there anything else I can do?

There are mechanisms of producing this type of forced closure that your SIJ needs.

Pregnant women often try using a maternity belt for posture. Furthermore, athletes are now using what is called "Core Shorts" and getting great results.

Pool-Goudzwaard AL, Vleeming A, Stoeckart R, Snijders CJ, & Mens JM (1998). Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to 'a-specific' low back pain. Manual therapy, 3 (1), 12-20 PMID: 11487296

Self Diagnosis: Why you should tell your doctor what the diagnosis is

2009-11-19T21:17:00.000-08:00

Ever look up your symptoms on the internet? Ever have a friend diagnose you with something they have had previously?

With the internet today more and more people are taking initiative to diagnose themselves. New research shows there is some merit in telling your doctor what you believe you may have. The British Medical Journal recently published an article discussing the new phenomenon of “Self Diagnosis” or “Self Labeling”.

Reports have been made that “Self Diagnosis” can initiate a correct finding in 18% of consultations. Furthermore, the “presenting complaint” of a patient may guide the diagnosing process 70% of the time. This indicates the importance of a patient communication to their doctor. If you have multiple symptoms a diagnosis may be established by your initial complaint.

Conditions accurately diagnosed by self labeling: Urinary tract infections, recurrent uveitis, schistosomiasis and head lice.

However, don't over estimate the power of self diagnosis. Wrongful incidence of self diagnosis can occur when treatment is initiated by the patient before consulting their doctor. Women who purchase over the counter antifungal treatment with the suspicion of having an infection are a great example. A high percentage of these women actually have a bacterial form of infection not fungal.

In addition, self diagnosis can be at times very unsafe. Cases have been reported of a heart attack being mistaken as indigestion and rectal bleeding thought to be due to haemorrhoids only to be discovered as colon cancer.

Conditions often misdiagnosed by self labeling: pregnancy, yeast infections and scabies.

So remember always consult a health professional with your problems but don’t be afraid to give them some pointers. Dr. Wayne Button BSc, D.C

Ryan, M. (1979). USSR letter: Self-diagnosis. BMJ, 2 (6196), 979-980 DOI: 10.1136/bmj.2.6196.979

Carpal Tunnel Syndrome a real pain in the neck?

2009-11-18T18:35:00.000-08:00

Often in school when we are thought the nervous system our instructors will use pretty pictures from text books. Blue represents the L5 dermatological distribution or pink is where the median nerve travels. Although these pictures give great insight towards mapping out the nervous system they can at times be diagnostically useless. This is because they are based on the belief every nerve carries out the exact same pattern in every person. In addition, it is wrong to believe every nerve which obtains a pathology will present with similar symptoms consistently.

The nervous system is one of the most complex systems the body has to offer. Studies have shown Ulnar Nerve abnormalities in patients with Carpal Tunnel Syndrome (CTS), which is a condition involving the Median Nerve.[1] Furthermore, studies have also demonstrated a decrease in pressure of the Guyon's canal (a common site for Ulnar nerve entrapment) after Carpal Tunnel surgeries have been performed.[2]

This gives premise to the concept that nerves in one area may very well affect nerves in another area. It seems the nervous system may work as a whole and not in just different subsets of entities. When considering this concept it doesn't surprise me that CTS has been shown to also relate to neck disorders. [3,4].

A recent study in JOSPT evaluated this relationship further. The article attempted to analyze if forward head posture (FHP) and cervical range of motion (CROM) is related to CTS or median nerve abnormalities. Subjects with CTS were compared with healthy controls. In addition, subjects were paired based on age, occupation and hand dominance. Occupations consisted of desk worker, housewife, cleaning lady and teachers.

Results indicated a significant correlation to both a reduction in CROM and increased FHP in the group with CTS. CROM differences ranged from 12-18 degrees less in those with CTS. Furthermore FHP ranged with a difference 8-9 degrees in those with CTS.

Although this correlation is an interesting finding it can not create a cause and effect relationship. The study also found these findings to not be related to pain or symptoms of CTS.

In summary, one cannot say CTS is caused by postural abnormalities of the neck. The authors suggest these findings may be due to the CTS itself. A similar example is when patients will often have an antalgic posture when herniating a disc in their back. This purposes the concept that we should explore the option of treating the neck in patients with CTS. Furthermore, if postural corrections are made in patients with FHP will this decrease the prevalence of CTS? Only one case study to date has assessed a multimodal approach to treating a patient with CTS [5]. Hopefully, the following study will promote more research into this relationship.

Ginanneschi, F., Milani, P., & Rossi, A. (2008). Anomalies of ulnar nerve conduction in different carpal tunnel syndrome stages Muscle & Nerve, 38 (3), 1155-1160 DOI: 10.1002/mus.21070

Mondelli M, Ginanneschi F, & Rossi A (2009). Evidence of improvement in distal conduction of ulnar nerve sensory fibers after carpal tunnel release. Neurosurgery, 65 (4) PMID: 19834374

Chow CS, Hung LK, Chiu CP, Lai KL, Lam LN, Ng ML, Tam KC, Wong KC, & Ho PC (2005). Is symptomatology useful in distinguishing between carpal tunnel syndrome and cervical spondylosis? Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand, 10 (1), 1-5 PMID: 16106494

Reading, I. (2003). Anatomic Distribution of Sensory Symptoms in the Hand and Their Relation to Neck Pain, Psychosocial Variables, and Occupational Activities American Journal of Epidemiology, 157 (6), 524-530 DOI: 10.1093/aje/kwf225

Valente R, & Gibson H (1994). Chiropractic manipulation in carpal tunnel syndrome. Journal of manipulative and physiological therapeutics, 17 (4), 246-9 PMID: 8046280

De-la-Llave-Rincón, A. (2009). Increased Forward Head Posture and Restricted Cervical Range of Motion in Patients With Carpal Tunnel Syndrome Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.3058

Rare Diagnostic Case of the Month: Notalgia Paresthetica

2009-11-13T19:04:00.000-08:00

The next time you buy an orthopaedic textbook take a look at the chapter list. You will probably find the shortest chapter to be on the thoracic spine. With that said the list of differentials for T Spine and interscapular pain is usually short for most manual therapist. This is why although perhaps rare, reading about Notalgia Paresthetica sparked my interest.

What is it?

Notalgia Paresthetica (A.K.A Hereditary Localized Pruritis, Posterior Pigmented Pruritic patch and Subscapular pruritus) is a sensory neuropathy which involves dorsal spinal nerves. The neuropathy usually first presents itself with extreme itchiness and then may progress to pain, paresthesia, hyperesthesia and eventually a hyperpigmented patch of skin.

What causes it?

The flaw in research regarding NP is there are multiple causes which are purposed. Most studies looking into NP denote one specific cause and only investigate that particular pathophysiology. NP has been deemed to be due to hereditary conditions, chemical toxicity, increased dermal innervations and spinal nerve pathology either due to trauma or entrapment.

The hereditary and toxicity notion is often dismayed because of the rare reports and anecdotal evidence. However, there seems to be a strong correlation with spinal changes and NP. Firstly, dorsal spinal nerves in the upper thoracic spine appear to pierce the Multifidus in a right angled manner. Such an anatomical position leaves the nerves exposed to trauma and easily being impinged.

In addition, recent small cased studies have found the majority of NP patients to have some form of T Spine pathology (7/10 & 9/12). These pathologies consist of degeneration, bulging disc and past history or prior upper back and neck complaints. Interestingly enough the dermatological pattern of patients symptoms correlated with their imaging findings. For example if a patient presented with symptoms from T1-T3 it was found they had degeneration in this particular area. In addition, these findings were discovered by a radiologist blinded to the patient's complaint.

How do I treat it?

Multiple forms of treatment have been performed on NP patients. Majority of treatment options consist of dealing with hypersensitive nerves and skin. These options are limited to paravertebral nerve blocks, epidural injections, topical creams, acupuncture and botuline toxin injections.

However, what does one do when these forms of treatment are not at their disposal? How do you treat an area which is to painful to even touch?

A recent experimental form of treatment has been published. This treatment is based on the premise that NP may be due to the long thoracic nerve being injured. Thus with such an injury the Serratus Anterior is dysfunctional and now needs to be rehabilitated.

In this particular study subjects carry out Electrical Muscle Stimulation (EMS) of the Serratus Anterior. Although results were recorded anecdotally, an improvement of 70% was found in some subjects.
More importantly this study provides insight into options for rehabilitative practitioners into treating NP.

Consider the following: If the Serratus Anterior is dysfunctional then the scapula may be positioned in a slightly retracted manner. The Trapezium and Rhomboids are now pulled under tension. This tension may apply traction or impingement to dorsal spinal nerves. This ideology may purpose a relationship between NP and Serratus Anterior dysfunction. If such a relationship is proven then this gives a rehabilitative premise for manual therapist to work with NP patients.

Additional research has also attempted to show analgic effects of using transcutaneous electrical nerve stimulation (TENS) amongst NP patients. However, results of this study were minimal displaying 30% improvement at best.

In addition, if one does find a correlation of T Spine pathology with an NP patient they should focus on the actual pathology. Degenerative changes could be treated with glucosamine supplementation and disc herniations with Mckenzie exercises.

So Remember

-Attempt to discover the cause of your patients NP. Consider taking radiographs.
-Work with other professionals such as dermatologist to relieve symptoms such as pruritis.
-Incorporate Serratus Anterior rehab exercises into your treatment plan.
-Attempt to re-educate nerves with EMS and numb them with TENS.
-Focus on the actual T Spine pathology such as a herniated disc or degeneration which may be causing symptoms.

In summary manual therapist should be knowledgeable in the diagnosis of NP. Knowing such a diagnosis allows one to consider it in their differential list. Furthermore, NP allows us more insight into other causes of neuropathic pruritis which is often forgotten and not known about. Dr. Wayne Button, BSc, D.C

References:

SAVK, O., & SAVK, E. (2005). Investigation of spinal pathology in notalgia paresthetica Journal of the American Academy of Dermatology, 52 (6), 1085-1087 DOI: 10.1016/j.jaad.2005.01.138

Raison-Peyron, N., Meunier, L., Acevedo, M., & Meynadier, J. (1999). Notalgia paresthetica: clinical, physiopathological and therapeutic aspects. A study of 12 cases Journal of the European Academy of Dermatology and Venereology, 12 (3), 215-221 DOI: 10.1111/j.1468-3083.1999.tb01031.x

Wang CK, Gowda A, Barad M, Mackey SC, & Carroll IR (2009). Serratus muscle stimulation effectively treats notalgia paresthetica caused by long thoracic nerve dysfunction: a case series. Journal of brachial plexus and peripheral nerve injury, 4 PMID: 19772656

Savk E, Savk O, & Sendur F (2007). Transcutaneous electrical nerve stimulation offers partial relief in notalgia paresthetica patients with a relevant spinal pathology. The Journal of dermatology, 34 (5), 315-9 PMID: 17408440

Diabetes: The alarm clock that wakes you up in the morning

2009-11-11T21:59:00.000-08:00

The alarm goes off loudly and stirs my slumber. Anxiously I slap the button and bring the room back to silence. I do this knowing I will fall back asleep only to have the beginning of my day depend upon my back up alarm. Soon enough the alarm attacks and makes its second attempt to get me jump started. Shamefully, it is the third alarm who is the victor. I now arise from the bed knowing this was my last alarm which I have set.

For years I have felt plagued with guilt knowing I start every day with this protocol. However, after reading some of the newest research I find myself not only disburdened but also somewhat health conscious.

Need another reason to fall back asleep?

Within the last decade studies have shown a correlation between type 2 diabetes and sleep deprivation. Since the 1960's, the percentage of the population which obtains <7 hours of sleep a night has more than doubled (15.6%-37.1%). Oddly enough a similar pattern has been observed as well with the populations rise in Type 2 diabetes.

Scientist believes this may be due to a hormone called Leptin. After eating a meal Leptin will be released by our fat cells. Our brain will then receive a message to decrease our appetite. However, people who are sleep deprived will have lower concentrations of Leptin. This lower concentration will spike our appetite and may slowly lead to obesity and eventually diabetes.

But I am young and healthy and don't need to worry.

A correlation between sleep deprivation and a high body mass index (BMI) has been found in children as young as 5 years old. Furthermore, a loss of one hour in sleep amongst adolescents has been deemed as an 80% increase in risk for developing diabetes later on in life. Those numbers are scary when considering adolescents to be highly sleep deprived and the prevalence today of obese children.

So the next time your reach over to shut the alarm off don't feel guilty. You're simply being health conscious. Dr. Wayne Button, BSc, D.C

For more info on this topic check out the following links and videos Health Column, The science of sleep 1 The science of sleep 2

Spiegel, K. (2005). Sleep loss: a novel risk factor for insulin resistance and Type 2 diabetes Journal of Applied Physiology, 99 (5), 2008-2019 DOI: 10.1152/japplphysiol.00660.2005

Are your muscles dysfunctional? Treating neck pain: Part 3

2009-11-07T15:23:00.000-08:00

Almost everyone you talk to claims to be an expert in mechanical neck pain (MNP). Hundreds of books, articles and now even a blog has been written on the topic. Prescribing any combination of exercises and techniques may be useful. However, when establishing a protocol for rehabilitation certain goals and objectives should be considered. This column will discuss the process of treating MNP in a continuation of Part 1 & Part 2 of our series on neck pain.

How do I guide my rehabilitation for MNP?

It is important to have a treatment plan in place. Without one we would be giving exercises with no real purpose. Consider the following:

When research is used to study the effectiveness of rehabilitation often protocols can be extensive. Patients in these studies will be diligent performing exercises everyday for long periods of time. Furthermore, such studies incorporate supervision of treatment with a protocol of progression and monitoring. After all this, results still may only produce 60-80% improvement. Such a study would be deemed a success. How much improvement do you think you will achieve with a housewife of three kids? How about if you give a patient 20 unsupervised exercises?

Guiding rehabilitation is never easy but the concept of applying it is. Simply ask yourself what am I trying to do? Rehabilitation for MNP should include the following two objectives:
1) Training individual muscle groups
2) Addressing problematic functional activity.

Addressing functional activity

Here a rehabilitation treatment plan should address those activities which are problematic. The list of activities may be extensive but posture is often the main culprit.

Do not underestimate your advice when educating a patient about posture. Studies have shown those patients which are given instruction achieve a more effective correct posture then those which are not given any instruction. Furthermore, these patients also achieve better activation of deep cervical flexor muscles (Importance discussed in Part 2). [2]

Patients also usually need daily reminders to keep adjusting their posture. Every fifth phone call you receive talk while standing. Adjust your work chair every five minutes. Often patients can put little stickers on different areas of their workplace. These stickers should be placed in areas that will only be seen if they take on a problematic posture. The patient now remembers once seeing the sticker to change their posture.

Training individual muscle groups

This goal also works in synergy with addressing functional activity. This is because patients who display good muscle activation also favour a less problematic posture. These muscles now promote less of a forward head carriage or sloped shoulders.

Exercise # 1

Training deep lower cervical extensor muscles

Patient should be in a four point kneeling position with their weight distributed on their elbows and knees. Starting in this position the patient should slowly lower their head into flexion and then slowly extend back to the starting position. Most of the movement should be coming from the lower cervical region. This isolation of movement can be facilitated with proprioceptive feedback and verbal cues by the therapist.

Exercise # 2

Training deep cervical flexor muscles

Patient should be in a supine position with their head rested on a small towel for support. With the forehead and chin lying parallel with the table the patients head is now in a neutral position. The patient should then be instructed to bring their chin towards their sternum slowly while slightly lifting their head off the towel. The patient should aim to not flex the head forward (as in the starting attempt of a sit up) but merely to sustain the neck in a slightly flexed posture. This position will best facilitate the deep cervical neck flexors.

In those patients who experience MNP with upper limb activity and scapular dysfunction a program of axioscapular exercises should be implemented. (Part 2).

What intensity of training should I use?

This is a good question and often can be confusing to physical therapist. The best way to guide your intensity level is again to ask yourself the question what is it exactly you're trying to do? These patients merely want a rehabilitation program that can help them in their everyday activities and reside some of their pain.

When considering rehabilitation for MNP low-level intensity exercises (approx 20% maximal voluntary contraction) is often the best choice. Consider the following:

Low level intensity training has been shown to
-Incorporate better coordination between both deep and superficial muscle groups [3]
-Assist activation of deep cervical flexor muscles [3]
-Produce hypoalgesic affects more so then higher-load exercises [4]
-Be more transitional to daily functional activities (20-50% MVC).

In summary, one should always remain critical yet open to different forms of treatment. However, a purpose should be appointed to everything you do. This point is emphasized all the time when patients, colleagues and lawyer will question your actions. So remember the next time you treat MNP, sometimes the best way to sink a golf ball is with a good putting game and not a long drive. Dr. Wayne Button, BSc, D.C

O’Leary, S. (2009). Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2872

Schwarz, J. (2008). Recruitment of the Deep Cervical Flexor Muscles during a Postural-Correction Exercise Performed in Sitting manuelletherapie, 12 (2), 76-77 DOI: 10.1055/s-2008-1027472

Jull GA, & Stanton WR (2005). Predictors of responsiveness to physiotherapy management of cervicogenic headache. Cephalalgia : an international journal of headache, 25 (2), 101-8 PMID: 15658946

OLEARY, S., FALLA, D., HODGES, P., JULL, G., & VICENZINO, B. (2007). Specific Therapeutic Exercise of the Neck Induces Immediate Local Hypoalgesia The Journal of Pain, 8 (11), 832-839 DOI: 10.1016/j.jpain.2007.05.014

The infamies Gluteus Medius

2009-11-03T19:14:00.000-08:00

Often when we work out we focus on the muscles which get us the most attention. Everyone wants to have the six pack abs, the toned legs and bulging biceps. However,training in this manner causes us to forget about some of the more important muscles. The muscles that our body uses for stability and preventing injury.

The Gluteus Medius is a small muscle which is found along the outside of the hip joint. Despite its size the Gluteus Medius plays an important role in exercise and injury prevention. This particular muscle is involved in stabilizing the hip joint. Often when someone has a weak Gluteus Medius their hip will jut outwards while doing such activities as a single leg squat.

What most people don’t know is that having a weak Gluteus Medius has also been linked to injuries of the hip, knee and even the back. Some of the most elite athletes will get injuries because of this reason. Exercises like running and cycling involve mostly forward motion and can cause outside muscles such as the Gluteus Medius to be neglected.

Exercises for Gluteus Medius

Side-Lying Hip Abduction: Start in a side-lying position on an exercise mat. Keep both knees fully extended and your hips in a neutral position.Slowly lift the top leg upwards towards the ceiling until reaching 30°. Then return the top leg slowly to the starting position. To challenge this exercise further place an elastic band around both ankles or use ankle weights.

Lateral Band Walks Start with an elastic band tied around your ankles. Keep your knees and hips flexed 30° while keeping your toes pointed forward. Place your hands on the side of your hips. Starting with feet shoulder width apart begin side stepping approximately 130% of your shoulder distance repetitively. To progress tie the elastic band tighter or use one with more resistance.

Bridges Start by lying on your back and placing an elastic band around your knees. Lye on your back with your knees bent and your toes lifted. While attempting to squeeze your gluteal muscles together push outwards on the elastic band. Push your heels into the ground until your buttocks lift up 4-6 inches above the exercise mat. Now gradually lower your pelvic back down. Further challenge this exercise by doing a single leg bridge.

Are your muscles dysfunctional? Assessing neck pain: Part 2

2009-11-03T12:09:00.000-08:00

One should not assess mechanical neck pain (MNP) in an attempt to locate a specific structure which is flawed. Rather, MNP is often a contribution of different factors which lead to an end result of pathology. These contributing factors are dysfunctional muscles. This is a continuation of Part 1 and will discuss methods of examining MNP.

Manual therapist often will perform examinations with the goal of developing a diagnosis. Test will be performed and objective findings recorded. However, often performing examinations in this manner can produce a lot of black and white while forgetting to addressee the gray areas. With MNP the gray areas can be the most important areas.

So how do I assess cervical muscle function?

Firstly, when assessing muscle function one must understand this is an observational skill. Such a skill will improve with the experience of the examiner. There are no objective criteria which will produce a positive or negative result. Furthermore, this fact alone will create discrepancies between examiners. What one person deems as dysfunctional another may not.

1. The Cranial Cervical Flexion Test (CFFT)

This test is designed to examine and train deep cervical flexor muscles such as the longus capitis and longus colli [1]. These particular muscles play an important role in the stability of spinal segments. By using this test, examiners can indicate if these muscles are dysfunctional. In addition, we can also purpose a cause for patients MNP. Furthermore, this test can also help guide the rehabilitation process by indicating which muscles need to be targeted.

The test incorporates two important components of the deep cervical flexion muscles 1) upper cervical flexion and 2) flattening of the cervical spine. Studies have found those with both traumatic and non traumatic neck pain to lack the ability to perform the CCFT. Furthermore, while performing the CCFT these subjects displayed an increase in EMG activity of the superficial cervical muscles. This is hypothesised to be due to a compensation of weak and inhibited deep cervical flexion muscles.

To perform this test the patient must be lying supine with the forehead and chin parallel to the table. To achieve this position often the head must be placed in a small opened head rest (chiro table). The purpose of this position is to place the neck in a neutral position not favouring flexion or extension of any kind.

Instead of using an inflatable pressure sensor (as described in studies) one may use a blood pressure cuff to gage the patient’s pressure. Place the blood pressure cuff below the occiput and behind the neck. Inflate the blood pressure cuff until the space between the neck and the table is filled but not to produce pressure upon the neck.

The patient is then instructed to nod the chin towards the sternum. The movement should be done without creating flexion of the head as if one is attempting to do a sit up. This position is then held for 10 seconds and should be performed at a level high enough to raise the blood pressure cuff by 10mmHg. If testing for endurance then repeat the same movement 10 times.

Inability to do the test or to increase the pressure indicates weakness of the deep cervical flexors [2]. Observe the following Video.

Keep in mind this test can be used to also train patients who present with muscle dysfunction. Patients can be progressed by increasing pressure (4mmHg to 5 mmHg) or by simply increasing the number or reps.
2) The Link to Posture

How do I assess if there is a postural component to my patients pain?

    Patients will experience neck pain with prolonged sitting, repetitive upper limb activities or while maintaining a sustained position.

     Patients will show poor cervicalthoracic postural habits when asked to mimic the aggravating postures which create their pain. Sitting for example has been shown in those with MNP to produce an increased cervical lordosis. This lordosis occurs due to compensating for a progressive thoracic kyposis over time from prolonged sitting.

     Patients will report lessening of symptoms with postural correction strategies.

3) The Link to the Scapula

Patients with MNP have been linked to dysfunctional axioscapular muscle activity. These are patients who will experience their neck pain while performing repetitive task of the upper limb. Muscles such as the upper Trapizium and the Levator scapulae can be the source of this connection. These muscles have the ability to produce abnormal forces through spinal segments due to the scapula dysfunction.

Scapular dysfunction can be assessed in multiple ways and would require an additional column. However, a good test is to first have a patient perform an aggravating activity which involves upper limb movement. Often I will try to reproduce the patient’s pain by having them bounce a ball repetitively against a wall with their arms elevated overhead. A connection can be made to their neck pain if pain is reproduced.

Now have the patient perform the same task as before but with their scapula repositioned in the proper manner. This repositioning can be performed manually with either the scapular retraction test or scapular assistance test. Both test are often used to test shoulder pathology and purposed by Kibler. Another method to help reposition the scapula is the use of tape. If the patient now can perform the same task but with symptoms lessened or resolved this indicates they may benefit from scapular setting exercises in their treatment plan.

In summary, one should be aware of multiple observational strategies to assessing MNP. These three valuable points will be overlooked if a practitioner simply focuses on objective findings and questionnaires. Pain may be resolved but could reoccur if these factors are not addressed. So remember don’t just examiner but assess and observe.

Falla, D., Jull, G., & Hodges, P. (2004). Patients With Neck Pain Demonstrate Reduced Electromyographic Activity of the Deep Cervical Flexor Muscles During Performance of the Craniocervical Flexion Test Spine, 2108-2114 DOI: 10.1097/01.brs.0000141170.89317.0e FITZGERALD, K. (2008). D.J. Magee, Orthopedic Physical Assessment (fifth ed.), Saunders Elsevier (2008) ISBN 978-0-7216-0571-5 1138 pp., Hardback, illus, CD-ROM, AUD 124.00 GBP 48.99. International Journal of Osteopathic Medicine, 11 (2), 69-69 DOI: 10.1016/j.ijosm.2008.02.002 O’Leary, S. (2009). Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2872

Book Review: Low Back Disorders

2009-10-30T13:29:00.000-07:00

Low Back Disorders: Evidence-Based Prevention and Rehabilitation. 2^nd Edition. Stuart McGill, PhD. Human Kinetics, 2007. 312 pages.

Dr. Stuart McGill and his immense research based out of the University of Waterloo, Ontario can be summarized in this 2^nd edition of Low Back Disorders. Although, the back is often seen as complex by many health professions alike, Dr. McGill’s book helps to put things into a perspective which is easy to understand. The book is divided into three parts. Part 1- “Scientific Foundation”, part 2- “Injury Prevention” and part 3- “Low Back Rehabilitation”.

Although deemed to be the driest aspect of the book, the “Scientific Foundation” section helps set forth groundwork in understanding the low back. Here, the reader can grasp the concept of whom, how, and why people develop back problems so frequently. With his thorough evidence-based knowledge, McGill sets the record straight on the myths and realities of low back disorders. However, despite the validity in these concepts, much of section 1 can be eliminated for the common clinician who doesn’t want to be overwhelmed in the details of research and lab instrumentation.

The “Injury Prevention” section provides light at the end of the tunnel when assessing common risk for low back injuries in chapters 8 and 9. Here clinicians are provided with knowledge that can be recommended to almost every patient. Although ergonomics is not the cause in every patients back problem, McGill helps evaluate multiple scenarios to minimize forces and injury to the spine.

The most appealing part of the book is found in section 3 Low Back Rehabilitation. Rehabilitating the spine is often one of the greater challenges when handling problems of the low back. This section provides great exercises that can be implemented for the most common sufferer of low back pain. Furthermore, McGill provides readers with an array of tools and tests that can help clinicians determine which patients are in need of these exercises. This section alone is worth the money and time spent in reading the book.

This book is an important read for any health professional that deals with the low back. Although 312 pages of research and science can appear daunting, this book saves many clinicians the ample time it takes to research and understand the back. However, there is much more to understanding a patient's back pain and many factors have to be considered. It should be advised that Low Back Disorders should be used as a stepping stone in comprehending what a patient is experiencing and not to be deemed the complete guide in low back health. The book also tends to saturate many of the key points which can be simplified into a few pages. Constantly, referring back to itself in past and future settings the book appears to drag on leaving the reader at times uninterested.

In comparison, to the 1^st edition not much more is amplified as it is stated in the book. More recent research is referenced, and there are additional photos and information provided, however nothing that appears to make the book significantly more valuable. The 2^nd edition simply updates points which were already stated to be important in the 1^st edition. With this being said, the 1^st edition can be just as valuable to the curriculum as the 2^nd. However, no matter which edition, Low Back Disorders can be recommended to enhance the insight of any clinician, scientist, or student in tackling the issue of low back injuries. Dr. Wayne Button, BSc, D.C

Boyd, K. (2003). Low Back Disorders: Evidence-Based Prevention and Rehabilitation Physiotherapy Canada, 55 (02) DOI: 10.2310/6640.2003.37832

Chiropractor Myth # 4 - Chiropractors only treat the back

2009-10-29T13:35:00.000-07:00

This myth is a common mistake because of the disparity in the chiropractic world. Some chiropractors claim to only treat "conditions of the spine". However, like me the majority of chiropractors welcome all kinds of injuries into their practice.

So what injuries should I go see a chiropractor for?

The majority of injuries which chiropractors deal with focus on muscles, nerves and joints. Observe a list of conditions me and colleagues of mine have treated and rehabilitated in the past:

Tennis Elbow Golfers Elbow Shoulder Instability

Sprained Ankles Osteoarthritis Ulnar Impaction Syndrome

Muscle Strains Spondylolisthesis Facet Syndrome

Migraines ITB Syndrome Piriformis Syndrome

Trigger Points Plantar Fasciitis Carpal Tunnel Syndrome

ACL Sprains Acetabular Tears Hamstring Strains

Disc Herniations TMJ Syndrome Adductor Strains

Sports Hernia Tendinopathies Turf Toe

As you can see by the prior list of conditions, injuries can span from head to toe. However, one must also not underestimate the power of a diagnosis. Often patients will present with condition which can't be treated by us. Furthermore, conditions can be found accidentally on x-rays by a chiropractor. Whether or not patients are referred back to their medical doctor, a specialist or a surgeon a diagnosis can still be a rewarding experience for a chiropractor. Observe a list of conditions myself and colleagues of mine have diagnosed.

Kidney Stones Gall Stones Abdominal Aortic Aneurysm

Hyperthyroidism Hypothyroidism Multiple forms of Cancer

Multiple Sclerosis Polymyositis Ehler Danlos Syndrome

AS Reiters Syndrome Cushings Syndrome

So why the confusion?

Much like other health professions chiropractors have different beliefs and philosophies. Some chiropractors are subluxation based chiropractors. I am not a subluxation based chiropractor so cannot speak on their behalf. However, this particular group of chiropractors believe sickness is due to misalignments in the vertebral column known as subluxations. This is why we are commonly associated to only treat the back or the spine. However, there are multiple chiropractors who do not practice this type of philosophy.

So how do I know which chiropractors treat more than the back?

Often best methods is to simply ask. Also, viewing a chiropractor's website or calling their office can often give you a good indication on how they practice. Furthermore, friends have no incentive to misinform you on the chiropractor they go to. So asking another patient of a chiropractor about their philosopies can be very informative.

In summary, chiropractors can treat a wide spectrum of conditions and injuries. During my internship in school I actually got more shoulder patients than any other form of injury. This was a great learning experience and made me more proficient in this area. So next time your hurt in an area besides your back don't rule out a chiropractor as a reliable option. Dr. Wayne Button, BSc, D.C Chiropractor Myths 1-3

Are your muscles dysfunctional? Understanding Neck Pain: Part 1

2009-10-28T14:08:00.000-07:00

   I have always been a firm believer that when it comes to diagnosing conditions one has to find the specific structure causing the pain. However, neck pain is not always so straight forward. To truly understand neck pain you have to embrace the concept that muscles work in synergy together.

   Have you ever looked deeply into the statistics regarding neck pain? If you have you might start to think nobody knows what their doing. Neck pain has been estimated to have reoccurence rates as high as 94% in some studies. This means if you were to get neck pain there is a 94% chance of you getting it again. These numbers pose a valuable question.

How do mechanical neck pain (MNP) sufferers differ then the normal population?

   There are a number of different entities which separate those which suffer from MNP and those which do not. However, for purposes of this column we will be looking at muscle dysfunction.

    Firstly, what many people may not know is those who experience MNP have been shown to experience physical changes in their muscles. While in pain you often fail to use muscles you once used efficiently. This can lead to changes in those muscles.
    For example, studies have shown whiplash sufferers to actually have a pronounce amount of fatty tissue in their suboccipital and multifidus muscles. These muscles particularly play an important part of proprioception. Proprioception is the necks way of understanding where the head is in correlation to the rest of the body. In addition, those which experience chronic neck pain have muscles which atrophy due to disuse.
    These physical changes may explain the high reoccurrence rate of neck pain. Professionals may be focusing too much on addressing eliminating pain but not on these physical changes in the muscles

   In addition, people with MNP often have been shown to have changes in their muscles behaviours. Your body now finds a way to completely reorganize its muscular activity. Muscles that once worked in synergy together now work at different times.

    There are two main groups of muscles in the neck, global muscles and local muscles. Global muscles which are fairly superficial are used mostly to produce strength, force and overall stability. Local muscles are commonly deeper muscles in the neck. Local muscles are often used for proprioception and stability of the vertebral column. Basically picture local muscles as a sleeve around your vertebral column trying to protect it and keep it upright and stable. Both groups of muscles work to help keep your neck stable. What happens when one of the muscle groups aren't doing their job? The other muscle group takes over and this can lead to overactive muscles and thus pain.

    Studies have exemplified this theory again and again. Those suffering from MNP have been shown to have highly overactive global muscles. Secondly, those with MNP have also been shown to have deep cervical muscles which are inhibited. This means these muscles have a slower reaction time to firing. Such results indicate that the global muscles commonly compensate for the local muscles in those MNP sufferers.

Why is this important?
    Well now that you are using the more superficial muscles (anterior scalenes and sternocleidomastoid muscles) these particular muscles become fatigued quicker than normal. Although, all this happens at the subconscious level it can still be detrimental.

    A great analogy used by Stuart McGill is the example of someone getting back pain while shovelling their driveway in the winter. While shovelling muscles now have to choose between being used for respiration or stabilizing the back. Obviously, they choose respiration and now the person's back may give out or experience pain.

    So now the muscles have physically changed and altered their normal behaviour. This combination can affect a muscle's ability to produce force and function as it once did. Those with MNP have been shown to have deficiencies in maximal strength, endurance, power and efficiency in contracting muscles. What is more interesting is these deficiencies usually are evident in activities which require 20-50% maximal muscle force. This range of force is what most daily activities require. Daily activities like turning your head as you pull out of the driveway, raising your head for a sustained period to do overhead work or even just tilting your head slightly to watch TV.

    In summary, one must truly understand how muscular dysfunction can cause neck pain before attempting to treat it. If you are just focusing on reducing the pain you are simply taking a band aid approach. As professionals we should attempt to not just relieve the symptoms but also incorporate a plan so the symptoms never return. So the next time your neck is in pain try to worry about what's causing it and not the pain itself. Dr. Wayne Button, BSc, D.C

O’Leary, S. (2009). Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2872

Heel Spurs? Where do these things come from?

2009-10-21T21:30:00.000-07:00

Many people claim heel spurs to be an abnormal finding. However, research dating from the early 60’s to late 90’s have reported anywhere from 11-16% of the general population to have some type of heel spur.

It’s debatable if heel spurs are strongly correlated to older age, gender and osteoarthritis. However, the debate linking heel spurs and pain has progressed to treatment involving shock wave therapy, surgical incision and even radiation therapy

The Debate: Traditionally the pathophysiology of spurs forming was based on what was called the longitudinal traction hypothesis.

Why the Traction Theory?: It was thought; the plantar fascia’s insertion creates traction and thus develops inflammation. Now from this inflammation reactive ossification is formed in the plantar fascia’s enthesis leading to the formation of a spur. Studies started to support this theory with the link of flatfooted people and heel pain. It was believed having a lower longitudinal arch created tension and thus the pain was created.

Evidence for a Non Traction Theory: 1) Heel spurs have been found to be located deep to the plantar fascia rather than at its insertion point. Heel spurs have also been shown to be closely related to other muscle insertions such as the quadrates plantae, flexor digitorum brevis and abductor hallucis. Some heel spurs are not even correlated to muscle insertions but rather found within fibrocartilage and loose connective tissue.

2) Excised plantar fascia doesn’t show histological evidence of inflammation

3) Bony trabeculae have not been found to align in a direction of traction

4) Excised spurs have been shown to reform after a surgical released plantar fascia. The alternative theory:Another theory can be one of vertical compression hypothesis (Kumai & Benjamin) which purposes a heel spur is due to compressive forces rather than traction. They suggest heel spurs are fibrocartiligenous overgrowths that occur in response to a microscopic stress fracture. These overgrowths are simply the calcaneus’s way of protecting itself from micro cracks.

Support: Heel spurs are more common in subjects which are overweight and have decreased elasticity in their fat pads. Furthermore, histological studies on cadavers have shown bony trabeculae of spurs to be vertically aligned as if compensating for a compressive force.

The research: A recent study involving 216 subjects found further support for a compressive hypothesis. Subjects were over the age of 62 and had either a heel or achilles spur. The spurs were found to be correlated to obesity (BMI), osteoarthritis and pain. However, there was no significant correlation found with foot posture (x-ray measures). Obese and OA findings indicate compressive forces may be involved. The lack of foot posture being correlated also strengthens the argument. If traction was the main culprit all those with flatfeet would have been strongly linked. To rebuttal those studies which also link obesity and a low longitudinal arch this factor may be argued to be more so related to the biomechanical properties of pronation.

The findings of pain don’t really indicate either theory. This again strengthens the whole controversy of what actually causes the pain from a heel spur. Is it the spur itself or the soft tissue around it?

What about the anatomy? Studies have found almost any variation of where a heel spur can lie in the foot anatomically. However, the more recent research supports a theory of compression where heel spurs are not always found within the plantar enthesis. The most recent study inspected 37 spurs in 20 cadavers. Multiple variations were found using different forms of imaging. This study purposed that the cause of a spur isn’t necessarily traction and much more complex then probably previously thought. They found spurs to form when surrounded by loose connective tissue. Furthermore, those spurs aligned with the plantar fascia’s enthesis didn’t always have a bony trabeculae pattern which replicated a cause of traction forces. Some heel spurs had a basket weave like patterns. This pattern supports wolfs law regarding bony articulation taking on the form of dynamic stress. In summary, we now have strong implication to believe heel spurs are more so due to compressive forces. The clinical significance of these findings is significant. One has to find the cause of a diagnosis before aiming to treat it. If the traction hypothesis is correct one may aim to limit such forces by releasing the plantar fascia with stretching, aggressive soft tissue therapy of surgical incision. However, if due to compressive forces one may aim to treat the injury like a stress fracture focusing on relative rest and an orthotic designed to decrease forces. Dr. Wayne Button, BSc, D.C

Li, J., & Muehleman, C. (2007). Anatomic relationship of heel spur to surrounding soft tissues: Greater variability than previously reported Clinical Anatomy, 20 (8), 950-955 DOI: 10.1002/ca.20548 Li, J., & Muehleman, C. (2007). Anatomic relationship of heel spur to surrounding soft tissues: Greater variability than previously reported Clinical Anatomy, 20 (8), 950-955 DOI: 10.1002/ca.20548 Menz, H., Zammit, G., Landorf, K., & Munteanu, S. (2008). Plantar calcaneal spurs in older people: longitudinal traction or vertical compression? Journal of Foot and Ankle Research, 1 (1) DOI: 10.1186/1757-1146-1-7

Meralgia Paresthetica: Finally There is A Test I Can Do On My Patient

2009-10-20T14:07:00.000-07:00

Meralgia Paresthetica (MP) is a mononeuropathy (pathology of one nerve) occurring to the lateral femoral cutaneous nerve. The condition causes paresthesia and numbness over the anterolateral aspect of the thigh. MP is a neurological condition which is caused commonly by a nerve being “entrapped” near its surroundings or origin. The nerve itself may get compressed by the inguinal ligament, tensor fascia latae and psoas.

The most interesting aspect of meralgia paresthetica is the multiple different causes. MP has been reported to be caused by obesity, pregnancy and compression from tight pants, belts, uterine fibroids and tumours. Furthermore, MP can be due to direct trauma, surgery complications and even associated with disorders such as diabetes and leprosy. [2] Recent reports have also surfaced regarding MP being causes by exercise [1].

However like most neuropathies, MP may produce arbitrary findings and examination results. It is often hard for a manual therapist to perform a test which confirms his or her suspicion of Meralgia Paresthetica. Most neuropathies don’t follow a perfectly mapped out distribution of symptoms. MP can often be mis-diagnosed as a radiculopathy or a referral pattern from pathology of the gluteus medius muscle. Nerve conduction studies can often help confirm one’s diagnosis but are not easily accessible to manual therapist. The following is a fairly new test which can be used by manual therapist to help diagnose Meralgia Paresthetica.

Pelvic Compression Test [3]

This test is based on the premise the LFCN is compressed by the inguinal ligament and by relieving this compression symptoms will temporarily be alleviated. With the patient focusing on their symptoms the examiner attempts to apply a downward and lateral compressive force on the pelvic. The pressure is held for 45 seconds and a positive result is when patients report an alleviation of their symptoms. By compressing the pelvic in this manner the two attachments of the inguinal ligament are brought closer together causing the ligament to become slacker.

This test was only performed on a small number of subjects (20) who were confirmed to have MP by electrophysiological studies. However, 19/20 patients confirmed patients received a positive test result. The validity of the test stood to have a sensitivity of 95% and specificity of 93.3% making it the only valid test to date which can be used by manual therapist. The only downfall of the test is the patient has to be presenting with symptoms in order for it to be performed and MP confirmed. In summary, the study only has a small subject size and wasn’t only designed to look at this one entity. However, due to the lack of other testing procedures at our exposure in the literature for this condition I feel it is a test worth trying. So the next time a patient comes in with symptoms down their leg see if you can relieve it. Dr. Wayne Button, BSc, D.C

Kho KH, Blijham PJ, & Zwarts MJ (2005). Meralgia paresthetica after strenuous exercise. Muscle & nerve, 31 (6), 761-3 PMID: 15654691 Harney, D., & Patijn, J. (2007). Meralgia Paresthetica: Diagnosis and Management Strategies Pain Medicine, 8 (8), 669-677 DOI: 10.1111/j.1526-4637.2006.00227.x Shimizu, S. (2008). A Novel Approach to the Diagnosis and Management of Meralgia Paresthetica Neurosurgery, 63 Kho, K., Blijham, P., & Zwarts, M. (2005). Meralgia paresthetica after strenuous exercise Muscle & Nerve, 31 (6), 761-763 DOI: 10.1002/mus.20271

Chiropractor myth #3 (4-5 to come) - Chiropractors are not real doctors

2009-10-19T19:05:00.000-07:00

Chiropractor myth #3 Chiropractors are not real doctors

This is one myth I never really understood. I had a professor when I was in University who had two PHD’s. Furthermore, this professor had extensive research publications and was even rumoured to be working with NASA on developing new thermodynamic properties for their space suits. Needless to say despite the fact he never went to medical school I always considered him a “real doctor”.

The answer to this myth is really in what you consider to be a “real” doctor. Chiropractors do not receive a medical degree and do not specialize after medical school. However, a chiropractor’s education and credentials can be quite extensive and demanding.

First, to get into chiropractic school one has to have completed at least three years of undergraduate education from a recognized university. Once applying to a Chiropractic school (only one in Canada) one has to complete the application process. This entitles going through an interview, receiving reference letters and completing an essay on an ethical dilemma.

Chiropractors in Canada go through an extensive four year program to receive their diploma. This means to become a Chiropractor one has to carry out at least seven years of education. The program consists of three years of academics and a one year internship. The program includes courses dealing specifically with chiropractic care and other scientific topics. Some of these courses include immunology, biochemistry, biomechanics, anatomy, toxicopharmocology, microbiology, physiology, pathophysiology and histology just to name a few.

The anatomy curriculum incorporates over 100 hours annually of laboratory work dissecting cadavers, laboratories analyzing histological slides and numerous exams. In addition, our radiology curriculum is not lacking either. During four years of the program we learn extensive knowledge on taking, processing, reading and even safety regulations of radiology. Examinations can cover topics from arthritis to malignant cancers. Further criteria in completing the program includes learning to take blood, reading urinalysis and blood reports, practicing emergency care procedures and even completing a breast examination.

Our internship requires a certain number of new patients, treatment visits, filled out paperwork, outreach programs and assignments to be signed off on. If all this isn’t enough there is still three different set of board exams and provincial ethics exams to be completed before becoming licensed.

The chiropractic community is diversified and often incorporates a wide range of professionals in its field. Classmates of mine were past physiotherapist, nurses, athletic therapist, engineers and teachers before entering the program. Furthermore, current colleagues of mine have completed seminars and courses in acupuncture, massage therapy and certified strength conditioning specialist. Chiropractors may also apply for a 2 year residency program in a specialized topic including chiropractic sciences, rehabilitation, sports or radiology.

In summary, the whole process is not considered to be easy. Becoming a professional in the health care field takes a lot of work. Is such hard work confirmed or denied depending on someone’s title? This is a question people should ask themselves the next time they consider this myth. Dr. Wayne Button, BSc, D.C Chiropractor Myth # 1 Myth # 2