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September 30, 2009
 The rotator Cuff Tendon is pinched between the Acromian Process and the Humeral Head Shoulder pain is problematic for sure. the run-of-the-mill shoulder pain is typically caused by an impingement syndrome. This is fairly typical should pain that occurs when you raise your elbow for example. You can do a quick impingement test to see if your shoulder pain is an impingement syndrome by placing your hand on your opposite shoulder, then lift the elbow in front of your face. If your shoulder pain is an impingement syndrome, then you will have pain as you raise your elbow.
The AC Joint is another source of shoulder pain. You can do a quick test to determine if you AC joint is involved in your pain by holding your arm straight out in front of your body and pulling it across your chest. If you have anterior shoulder pain, it could be your AC joint.
 Bring a straight arm across your body at shoulder height. Perhaps you have a rotator cuff tear. To rule this in our out, I like to do the empty can test – hold your hand out in front of you at a slight angle, and then turn your hand over like you are emptying a can of water. If this is painful or if you can’t do it, you might have a rotator cuff tear.
If you have shoulder instability, it is hard to do a test on your self, but if you hold your arm at with your elbow at shoulder level, your elbow slightly in front of your body and you crank rotate your arm so you are bringing your hand up and down by doing so, you might have a labrum tear or some other form of instability.
 When the arm is lifted the shoulder elevates as well. Or you might have a frozen shoulder -In this case when you move your shoulder, you find that the scapula moves way too much and your arm feels stuck and restricted.
In any event, if your shoulder is bugging you then come in for a good assessment and we can help you by designing a program of stretching and exercise to help you recover fully.
we break shoulder rehab into 3 phases: Phase 1 – get you out of trouble. This usually involves what we call Self Mobilization exercises. Phase 2 – get you strong and elastic and then Phase 3 – Make you “bullet proof” – this usually involves more intense exercise and focuses on push/pull/lift/press and so on as well as throwing.
Let us know if we can help!
Neil
September 29, 2009
When one suffers from Carpal Tunnel Syndrome (CTS), the pain can really interfere with a persons day!
First a little anatomy: The carpal tunnel is made up of small bones in the wrist called carpals on one side, and then a thick ligament called the Transverse Carpal Ligament on the other. Living in the tunnel are the finger tendons and the neuro/vascular bundle that includes the Median Nerve:
 The Carpal Tunnel In the case of Carpal tunnel Syndrome, what happens is that the finger flexor tendons get irritated enough so as to cause the Median Nerve to be compromised. This can happen for many reasons:
- The finger flexor tendons are too thick
- The Transverse Carpal Ligament is to thick
- The carpal bones are too small
The result of these predisposing factors is that the finger flexor tendons cause friction as they move over one another and the heat generated results in local inflammation. This inflammation irritates the nerve and the pain that results is what one experiences when they have Carpal Tunnel Syndrome. The reason there is so much pain associated with Carpal Tunnel Syndrome is because of the pressure on the Median Nerve. That is why it is also known as a Median Neurapthy at the wrist. In severe cases, there can be sufficent compression on the Median Nerve causing muscle atrophy andmotor weakness in turn.
The most common cause of Carpal Tunnel Syndrome is repetitive use, which is why it is most common in people who have jobs where repetitive use of the hands is part of a normal day. It was rare to see CTS in people who used typewriters for instance, but now we see quite a bit of it in peole who use computers every day. Other causes are trauma, hypothyroidism, during the period of pregnancy, amyloid, acromegaly, multiple myeloma, rheumatoid arthritis, muco polysaccharidoses.
Treating CTS involves behavior modification, as in changing the work environment by doing such things as using a pad to rest the hands on while typing, as well as using wrist splints that also splint the fingers. Remember it is the finger flexors that need to be quieted down, so a splint that does not also extend to the fingertips does no good during the day. At night, a splint that keeps one from curling the wrists up under the chin will do the trick.
Ice is good to use to reduce edema and lower the impact of inflammation, and anti-inflammatory drugs are good to take by prescription.
Once the pain settles down, then grip strength training is worthwhile, and overall upper body strengthening is a good plan.
Prevention should include interrupting your work, improving the biomechanics and ergonomics around your work, splinting at night to prevent night time compression, and use of ice daily to keep the swelling down. NSAID’s as prophylaxis might also be a good idea.
July 19, 2009
Over the years, I have worked with literally thousands of people who suffer from mechanical lower back pain. During that time, I have identified several self management tips that are worth knowing. These tips fall into the category of “management of biomechanics” during activities of daily living.
First of all, most people who suffer lower back pain experience the pain episodically. Each episode is worse, last longer and over time, starts to come on more frequently. This is typical, and is the main reason why management of lower back pain is worthwhile.
My tips are these:
- The pain is worse in the morning, and there is more risk in the morning. It is important then, to take care of the back first thing out of bed. This is true because during the night, the disc imbibes water creating increased intradiscal pressure in the disc before you get out of bed. You are indeed taller when you wake up than when you go to bed! So the first tip is to be cautious in the morning. I have advised people who have significant morning pain to actually get up in the middle of the night and walk around for several minutes as a way to mitigate the morning pain.
- Walking is great medicine. The literature points out that maintaining your activity is of no harm, and I believe necessary to overcome episodic back pain. Sub maximal exercise gets your blood circulating, relaxes your muscles and generally promotes good health. The weight bearing also compresses the disc and squeezes some of the water out, meaning less pressure on the nerves. So a good walk every day is helpful.
- Biomechanics is key. Be thoughtful about what you do. Face the things you do, keep lifting to a minimum, but when you do lift, keep the object as close to your center of gravity (around your belly button) as possible.
- Avoid prolonged sitting. And when you do sit, a firm chair with back support and arm rests is ideal. Try to use lumbar support when you sit. For instance, when getting on an airplane, put one of those little pillows behind your back.
- Use prolonged ice daily. I mean ice plus water in a plastic bag right on the skin for at least 30 minutes. The cold penetrates at about one cm every 10 minutes. It takes a half hour to numb the muscles and dull the pain. Be careful not to use gel ice packs because they tend to be too cold (if your freezer is below freezing) and not stay cold for long enough.
- Finally, get fit. Fit people have a much lower incidence of lower back pain than the population at large. This is more of a long term strategy, but if you are stronger, your muscles do a lot to support you. Along with this of course goes flexibility and core stability. Develop your core and don’t forget your back side when you do so. Core exercises include hamstring exercises, and back muscle exercises as well.
Back pain tends to be episodic, the episodes tend to be more frequent over time, they tend to last longer each time and also to be more severe each time. Reversing these trends is the goal of managing your back pain. Follow my advice and you will be able to do so!
Good luck
Neil
Filed under: Chronic injuries, LBP, Physical therapy, SI joint, SI joint Sacro-iliac joint, SI joint belt, SI joint stabilization, SIJ pain, SIJD, Uncategorized, abdominal exercise, acute LBP, acute back pain, acute pain, aerobic exercise, back pain, buttock pain, core stability, disc herniation, facet joint pain, health status, injury prevention, low back pain, lower back pain, lower cross syndrome, mechanical traction, nerve root compression, pain in the butt, physical therapy for back pain, posture, return to function, segmental instability, weak abdominals | by Neil Chasan, PT, MMT @ 11:23 am | |
Comments (0)
July 8, 2009
I have seen a number of people recently who suffer postural headaches. In the society we live in where so many people work at a desk in front of a computer monitor, this is not much of a surprise. Computer work leads to a forward head posture that causes mechanical complaints to emanate from the sub-occipital region.
Ideal posture is defined this way:
- The head should rest over the shoulder girdle rather than forward
- The shoulder girdle should be depressed and retracted rather than elevated and protracted
- The sub-occipital region should be flexed and relaxed rather than compressed and stressed
- The Sternocleidomastoid muscle should be oriented backward rather than vertical
- The Upper Trapezius should be more vertical rather than horozontal
The causes of postural headaches could be many. For example:
- Trigger points in one or more cervical spine muslces refer pain to the head
- The TMJ might be upset which in turn can cause musculoskeletal headaches as well
- The sub-occipital joints can refer pain to the head
 Entrapment of a sensory nerve in the sub-occipital can refer pain to the head- Bruxism or grinding of the teeth can refer pain the the head, especially if the Temporalis muscle is irritated by the process.
Postural Correction
The key to reducing your headaches, if they are postural by nature, is to improve your posture. catch yourself with your head out in front of you, and try to retract your head by elevating your chest and bringing your head over your shoulder girdle.
In that position, do very gentle chin tucks repetitively to gently unload the sub-occipital region.
Also, get some aerobic exercise to help the neck muscles relax
June 9, 2009
So I am a little over two weeks out now, and these past couple of days, my knee seems to have made a sudden improvement with an increase in ROM and reduced swelling. I still can’t kneel on the knee, but each day it is getting easier to do ordinary things.
I plan to start rowing again next week since my range is essentially sufficient enough to do that, and because it is an unloaded activity.
The tear I had in the Medial meniscus was more like the radial tear shown in the Lateral Meniscus above. The surgery involved trimming it out and smoothing the remaining meniscus.
Because there was no blood supply or bleeding inside the knee in general, the recovery is fairly quick and there is little opportunity to scar. I do feel the impact of the scar tissue and the fact that the scar tissue is contracting where the arthroscopic tools penetrated the knee during surgery though, especially the scar in my distal Quadriceps muscle – but again, not a big scar and almost a non issue day to day now.
June 8, 2009
Question: How do you know if you have nerver root compression from a herniated cervical disc?
Answer: You have pain AND weakness in the arm .
Click the “play” button to listen:
In the image adjacent, you can see how a cervical spine disc herniation compresses the anterior nerve root of the spinal nerve causing motor weakness. Because the disc is anterior to the spinal cord, and because the anterior nerve root is the motor nerve root, compression leads to weakness and this is always the first consideration when motor weakness is the primary sign along with pain as a symptom.
As in this image, the herniation might or might not be an indication for a cervical discectomy. The reality is that you should allow time to pass before committing to a surgical solution. The reason I say this is that the decision largely depends on what tissue is compressing the nerve root.
If the nucleus is the primary culprit, then allow time to pass because the nucleus is made up of glucosaminoglycans (GAG’s) and GAG’s decay fairly rapidly, which means that they biind less water. As they decay, they dehydrate, and as they dehydrate, the pressure comes off the nerver root, and strength should return.
On the other hand, if the material pressing against the nerve root is part of the fibrous shell of the disc – the Annulus, then surgery mught in fact be the best option. In this case, the Annulus does not decay, and it is sort of like the reality of having a pin stuck in your arm – it hurts till you take it out. But that said, cervical traction is a good idea to try. If traction is successful, great, if not, the next level of intervention worth trying is potentially selective injection techniques. Often, the combination of selective injections with cervical traction along with aerobic exercise and other gapping activities (to gap the cerival spine, forward bend, side bend the head away from the pain, and GENTLY rotate toward the pain) would offer the best course of action.
Acutely, the position of comfort is to place the same side forearm on the forehead to achieve temporary relief of pain.
So acutely try this:
- Aerobic exercise for a half hour to soften and relax the accessory muscles of respiration
- Gapping exercises to relieve the nerve root
- Cervical traction to relieve the pressure
- Forearm on the forehead to unload the tension on the nerve and reduce arm pain
- If all else fails, then see the doc for evaluation and consideration of a selective injection
There are a couple of excellent mechanical home traction units that we use. One, by EMPI, like this one that is recommended.
 Depending on which side the herniated disc is affecting, you could position the head in alight side bending to further provide relief while under traction. It is key though, if you use this device, to allow your neck to relax before you pick up your head when you are done with the traction. as for how much traction, I suggest that the traction is pain free, but you should try to use at least 20# of traction for a few minutes when you do use the machine.
June 6, 2009
Occasionally, and typically following trauma, but not always, one can sustain an injury to the juncture between the ribs and the cartilage between the breast bone (the sternum) and the ribs. Alternatively, the irritation can arise between the sternum and the cartilage. I usually see these sorts of injuries after a motor vehicle accident where the seat belt coming across the rib cage creates the injury or when the chest is driven into the steering wheel is the cause. I have one recent case where the irritability was not traumatic at all, but came on after a case of severe and persistent coughing. Patients following open heart surgery often have to deal with this injury.
This is a difficult injury to manage because there is not much blood supply, and it is made more difficult to treat in hitting and throwing athletes because the rib cage needs to be able to rotate forcefully in those situations.
The pain is felt on the outer third of the chest wall, and is seemingly irritated with breathing deeply. Palpation of the joint line can illicit pain. The pain can be bilateral, but is most often unilateral.
The best treatment for this condition is a combination of aerobic exercise, even though it might hurt to breath at first, ice on the irritated chest wall, and a therapeutic dose of NSAID’s on board as tolerated. Physical therapy in the form of manual therapy is valuable to oscillate the joints to promote healing, but this is tricky and needs to be done very carefully. Also, mobilizing the thoracic spine through exercise is key. I really like the TRX as a tool here.
The bottom line is that this is an injury that takes a long time to heal, and is easily irritated again, so the return to sport must be managed on a gradient. For example, in the case of a baseball player returning to practice, I would suggest short toss until that was pain free, then gradually working their way to long toss before trying any hitting drills or throwing in form the outfield. As for hitting drills, swing next to a fence until that was pain free before hitting off a tee, before hitting any soft toss pitches, before hitting any regularly pitched balls, before throwing in from the outfield. In the case of tennis for example, ground strokes before overhead strokes and so on.
June 3, 2009
I recently saw a patient who suffered a ankle severe sprain wake boarding. The sprain recovered, but the ankle continued to “snap”. on closer examination, the snapping sensation was actually the peroneal tendon snapping around the lateral malleolus.
You can see how the tendons (in the image to the left) are held in place by connective tissue. When this connective tissue is stretched sufficiently, it will allow the tendons to “snap” over the lateral malleolus. It really is a snapping sensation and it is often painful. You can almost see this snapping in the following two images.
 
While is it is possible to treat this condition conservatively, in a cast boot for example, when the tendons snap over the ankle repeatedly, then sadly, surgery is the only option. The post surgical course is pretty much the same as it would be for any ankle surgery – the repair has to heal, then the joints and muscles need to be rehabilitated for the athlete to return to their sport.
It is important to repair this injury though, because the peroneal muscles play a very important role in normal foot mechanics. Peronus longus, for example, crosses over the bottom of the foot and inserts at the base of the big toe, while the brevis attaches on the lateral border of the mid foot at the base of the fifth metatarsal. Both plantar flexion, eversion and plantar flexion with eversion are impacted by this injury.
My patient who suffered the injury had a surgical repair and is back on the water without restriction.
May 30, 2009
This was an interesting case that I thought worth mentioning.
In men, the SI joint rarely is the cause of LBP in my experience. In women of course, with a wider pelvis, and the hormone Relaxin softening the ligaments during the first and third trimester, we often see SIJ related pain especially post partum.
I recently saw a 60 year old male patient who had a three month history of pain that was so severe he was unable to tie his shoes or put on his socks. The pain was primarily in his right butt cheek and also in his upper thigh. His physician had ruled out his lumbar spine as the source of his pain. He eventually came to see me when he concluded that he was not getting any better with the passage of time.
His pain occurred when he bent over with his legs wide apart to lift a heavy object. The pain remained essentially unchanged during the past three months in spite of meds and rest.
My suspicion of the SIJ was confirmed by physical exam, and confirmed again when I reduced the subluxed joint.
So the lesson is this:
- Sudden onset unilateral pain in the butt that doesn’t seem to get better with time suggests Sacro Iliac Joint pain
- Pain that comes on with an incident, traumatic, lifting or otherwise suggests SIJ pain.
- Pain that meds and rest does not resolve that interferes with weight bearing or hip flexion suggests SIJ pain
Not all back pain is back pain. Not all buttock pain is SIJ pain.
The combination of the history (which raises suspicions) and the physical exam which (confirms or refutes them) is the way to make the diagnosis. BUT, if you have unilateral pain in one butt cheek, AND there is an incident that preceded the pain, THEN you might have SIJ pain even if you are not a post partum female.
The dysfunction is easier to treat in men than women, but it can be treated in women successfully along with a stabilizing belt following the reduction of the subluxation that I wrote about earlier.
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