Scott literally changed my life. He is the only therapist that has helped me manage my chronic issues in the long term. I have seen so many body workers, and he is the only one that I have kept going back to over the years. He truly cares about his clients and is interested in getting us moving better. Don't even hesitate- just book with him.
Cooped up hints
So here we are, most of us locked in our homes, either off work or working from home.
There are many sources of information online helping you to be fit and healthy during this time. I have been getting a growing stream of emails from my patients, with questions about a variety of issues. So what I am going to do is list of a few bits of advice I can give you to help you mentally and physically come out ok on the other side of this pandemic. Some of these you have probably heard before, great, some of them you may think are silly, that’s cool too.
Just a few things to think about. Trust me, there are many other things that are also important at this time.
Be good to yourself, any questions you can email me at firstname.lastname@example.org and we can try and solve problems electronically until we can meet face to face again.
Scott's Rules of Strength Training for Adult Athletes
I have seen my average patient age go up over the past 10 years, I believe the majority of my patients are now over 40. These people are not just athletes, they are parents, business owners, all kinds of interesting things. And they still are active as much as they can be. Some are doing remarkable things, such as ultra marathons, Ironman triathlons, etc.
There is a common trend I believe with these older but still intense athletes. If they are not involved in some form of strength training along with their activity of choice, then they start to break down with overuse injuries at a higher rate. It appears to me, without any research to back me up, that around the age of 40, we have trouble maintaining a full body baseline level of muscular strength. This does not mean you are unable to do tremendous things. However, if you want to run great distances, play hockey, or go on canoe trips, as we age it is of greater importance that we undertake the appropriate muscle training to support that activity.
So, what should we all do as we age?
Don’t Stop. Keep being active, it will decrease the aging rate. I have patients in who are 70 that look 50, which we have to at least partially attribute to an active lifestyle. Conversely, I have had 40 year olds in who look 60, and they consistently have a more sedentary lifestyle.
Strengthen your whole body. If you are a runner, don’t forget to work on your upper body. Maybe not for running, but for the rest of your daily activities, you will need it. To stick with runners, leg strength is a big deal, and using another stimuli for those muscles besides running would be beneficial. That will apply to any activity, we need to stress muscles in more than one way for best results.
Don’t forget to rest. At all ages, rest/recovery is usually undervalued, sometimes flat-out ignored. I am still amazed/puzzled/perplexed by youth sports having players training almost every day, sometimes twice a day, for most of the season (soccer, I am looking at you). These kids can sometimes get away with it because they are teenagers, they recover quicker than any other age group. Again, I have no research but my own clinical observations, but recovery time from activity or injury starts to take longer after the age of 21. The farther away from 21 you are…. well, you get the idea. So listen to your body. If, after training or competing, something feels tighter or more sore than usual, it probably is. Not allowing the body to recover is a good way to end up in the clinic with some kind of injury. So work in some peaks and valleys in the training schedule, get some sleep, and you will get better results from your training time.
Balance. Proprioception. Call it what you want, those quick reactionary movements that keep us stable are very important for all movements we do, from running to golf to skiing. They will be adversely affected by injury and lack of activity. We are commonly talking about some kind of stability exercise, such as standing on a BOSU ball, balancing on all 4’s on an exercise ball, etc. These muscles need to be stressed at the appropriate level to get the best results. What is the best level? Something challenging but not impossible, if it’s too easy you are kind of wasting your time. Best to start easy and build up, some of these things can have very sudden endings if not done properly.
So those are 4 simple rules, they are pretty vague, and that is on purpose. If you have a solid background in strength training, you can flush out the details of what to do pretty easily. If you do not know what to do, talk to a personal trainer. There are lots of quality people out there who can design a program for you, that you can either work directly with or just pay them for the program and go do it on your own. There is no cookie cutter plan for all people, each person will need some variances based on their fitness level, goals and available time.
Lets Talk About Feet
When was the last time you thought about your feet? Not what to put on them, but thought about how they are holding up to the pounding they take from us every day. If we pay attention, we can learn a few things about our body mechanics from what our feet show us.
I was speaking to a group of runners at a local running clinic this week, and we spent almost our entire time talking about how to assess your own foot health, and also to self analyze your walking/ running mechanics.
One of the things I always hope our patients will learn from us is how to prevent their injuries from occurring again. We could just keep fixing things over and over again, but people get tired of that really quick. Lets empower people to stay healthy and active so we can have a healthier society.
So how does thinking about your feet prevent injuries?
Well, the thing I always look for in movement patterns is symmetry, and if your feet are transferring your weight smoothly and properly in the direction you are going, then they should look and feel awesome. Blisters, bunions, calluses, damaged nails, toes that sit on an angle instead of straight are all signs of a potential movement problem. Where? Could be lots of places, tight ankles, hips, lumbar spine are the most common spots. Also, look to see if the previously mentioned problems are the same on both feet. Having a large bunion on one big toe but nothing on the other is a sure sign of an imbalance in your movement patterns.
Well, it depends on what you want to do for activity. If you are a runner, then putting a large volume of high pressure on legs that do not move equally is a path to some form of injury. Lets take this example. If you have an ankle that is lacking in dorsiflexion (lifting toes off the ground while heel stays on ground), then you will not be able to transfer your weight from heel to toe without excessive rotation through the hip and knee. Repeat this several thousand times over a season of running and I can almost guarantee sore knees are in your future, that is way too much stress to put on your patella. This rotation is also one of the common causes of bunion formation in active people. This is because instead of pushing off with the end of your big to, as we are designed to move, the final push off occurs through the side of the toe. This is not mechanically proper, and the body responds by depositing calcium in the area to make it stronger, This is the bump, and it will become irritated and painful as you continue to irritate it. So, if your feet are starting to build up a callus on the side of the big toe, take a look at how you are moving, it could be foreshadowing both bunion formation and patellar tracking problems.
The same result will potentially happen for non-runners as well, it will just take a little longer to build up the mileage to cause the damage.
Now, if you are a high mileage runner, then you will have aches and pains in your feet sometimes. That is not unusual with lots of running, what is not acceptable is when these aches and pains occur only on one side. If you did a speed workout last night, and this morning your achilles and arches both hurt, we can probably chalk that up to hard training. But if only one side hurts, then one leg is working differently than the other. We need to find out what is going on and see if it can be corrected.
The point of this is your feet can often tell you when you are setting yourself up for an injury, you just have to look and listen to them.
Now, I would be remiss if I did not talk a bit about a few of my favourite foot maintenance techniques. Your feet keep you connected to the ground, you need to look after them.
What I hope you take from this is not how to diagnose what is wrong, but just that something is wrong. Then you need someone trained in assessing these problems to take a look for you and help you treat the cause.
How your Jaw can ruin everything
So in the past few weeks, we have seen a rash of people with TMJ problems. That is not new. What is neat about that is most of them had no idea that their jaw was even an issue. Many of them were having headaches, neck pain, shoulder problems and one of them was having foot pain. All of these problems we traced back to their jaw.
Just think of all the things you do that will have a negative affect on your jaw function. Stress is one of the major causes, someone grinding or clenching their teeth at night is usually a by-product of stress. Then there is physical trauma, such as a direct blow to the chin or face (faceplant on ground, fist, ball, etc) that will alter movement patterns. Another common cause is dental work, not the actual procedure done, but just having the jaw open for extended periods of time can stress the joint beyond its normal capabilities. All of these causes have potential to negatively impact your TMJ function.
Some of the common treatment strategies people are using now include a night time splint or mouth guard, botox treatments, massage and other forms of therapy. Some of these work for them, some do not. For many of the people that end up in my office, these treatments are not working.
Lets look at some of the causes again. Number one is stress, which can come from many sources: work, family, schedule, noise, holidays just to name a few. If this is one of the main causes of your TMJ problem, until you deal with that cause of stress, no treatment is really going to work. Now dealing with it does not have to mean eliminating that stress from your life, that is often not an option. We need to work, we should not try to remove annoying family members, some of these things are going to be there. What we need is a way to process this stress, instead of letting it stockpile on our system.
There are several techniques and programs to help you deal with stress. Exercise is often used successfully, various forms of meditation, yoga, knitting all have been used. The common thread in my opinion is the person enjoys doing them, they are totally separated from the source of the stress, and can be non-competitive (although not always). These actions do not have to require long periods of time to be effective. Lets face it, if someone is stressed out by a lack of time in their daily schedule, telling them to exercise 1 hour a day probably will be ignored, either politely or with a mocking tone.
Any physical trauma will, as mentioned, potentially mess up how the joint moves. The surrounding musculature which opens and closes the jaw can be strained just like any other muscle. There is also an interesting articulating disc inside the joint. This disc is actually attached to a small muscle, so that when the jaw opens and closes, it moves to allow proper congruency of the joint surfaces. If either the disc or the muscle affecting the disc are damaged, then the integrity of the joint will suffer, causing symptoms ranging from clicking and uneven movement patterns up to severe pain and limited range of motion.
Dental work can put abnormal stress on the joint. If the jaw is open for a long period of time, it can compress the articular disc and damage it. Also, it can fatigue the surrounding muscles and that can affect mechanics for a short term as well. This is why your dentist will often give you breaks during their procedures to let you move. The work they are doing has to be done, so they hope to minimize any side effects.
So, you have a brief overview of what can affect the jaw in a negative way. How does this cause so many odd symptoms? Why does your headache, shoulder pain and hip pain come from your jaw?
To answer that, we have to look at the anatomy of the area. Lets start with muscles. Most of the muscles on the front the neck are involved in opening the mouth. The muscles that close the mouth attach onto the sides of the skull all the way up to your eyebrows. That covers a large amount of sensitive tissue: Nerves, arteries, several vertebrae, suture joints, etc. These tissues all function in co-ordination with each other, so a problem in one will affect all the others.
I have talked before about compression or irritation to a nerve in one area of the body will affect other parts of the nervous system, they are all connected. In many of our TMJ clients, we have been finding major nerve dysfunction in one of the nerves around the jaw, the Mandibular, which is a branch of the Trigeminal nerve. With a quick treatment on some of the tissue causing the nerve to be in dysfunction, we can remove restrictions on dural tension through out the body. In some instances, with the removal of this pressure, nerve based pain in various body parts will disappear, as if by magic.
One of my favourite cases was a soccer player and teacher who was having nerve pain in her foot, it was not making sense, and was not getting better. She came in one day with a headache, so testing showed nerve problems with the jaw. After treating this for 5-10 minutes, her foot pain had instantly decreased to almost zero, when she was limping when she walked into the clinic. It was awesome.
This is just one of the anatomical structures that can be negatively impacted by your jaw letting you down. It is an often overlooked area that can have a massive impact on the body and your daily comfort levels. If things do not make sense with how your body is working and how you are feeling, have someone check your TMJ, it could be the missing link.
We had a moment of reflection a few weeks ago, when my students were wondering what some of the most memorable cases I have seen over my career. This was around a campfire with beer at one of our staff meetings, so it turned into a story time/trip down memory lane discussion. I like to have pretty low stress staff meetings.
Just to be clear, I have been doing this for quite a while, I don't even want to guess how many people I have treated over that time, but it would be a couple thousand easily. What follows are some of the ones I could recall off the top of my head, I know there are dozens more that have been shuffled to the back of my memory banks. Now, I do not use names for any of these patients, neither here or when telling stories, that would be un-ethical. As my patients will attest, when they are telling me one of these great stories, I will stop them and say "By the way, this is a case I would love to talk about with my peers, but you will remain anonomous." Then they know they have acheived legendary status.
I think the best way to answer that question is to categorize my answers.
Lets start with memorable causes.
I remember one person who fell off their mountain bike and impaled their leg on a tree stump that had been sharpened by a beaver. That one was kind of neat. I always enjoy hearing about weird causes, like tripping over your cat and dislocating your knee cap. Or dislocating your shoulder while giving someone a high-5. Or hurting your shoulder throwing slime out of your garden pond. Then there was the guy who hurt his back playing darts. There have been a shockingly large number of dog related injuries….
Now, what about cool symptoms?
I had one patient who would get uncontrolled muscle twitching in her arms and legs whenever I touched the back or top of her skull. She was fantastic to work with, although it was a bit unnerving the first time. She has fully recovered I am happy to say. We had one hockey player from Quebec who had a concussion, then spoke perfect english afterwards while he thought he was speaking french. That was fun.
Some cases we just found really cool results from the weirdest treatment.
I remember one girl, she was having horrible pain in her foot, between her 2nd and 3rd metatarsal heads. I felt it was a type of Mortons Neuroma, her Dr. thought plantar fascia, the orthotist felt it was ligamentous. Whatever, none of us could fix it. So one day we were looking at her shoulder, I noticed a rotation in her T6 vertebrae. We decided to fix that, and when she stood up, her foot didn't hurt anymore. One of the coolest things, it was one of my early cases of dealing with dural tension to fix neurological problems.
Now that I am a few years into the cranial treatment world, we see a few more cases of 1+1=3 than we used to. One of my favourites is a lady with a plate in her skull following brain surgery. She was having headaches several years after surgery, her Dr. had cleared her of any internal problems. We found that her cranial bones around the plate had tightened up, once they were mobilized a bit, all the pain was gone. Now we see her every 6-8 months for a tune up, we find that the fascia and suture joints tighten around the plate over that time span. One or two quick treatments and she is right as rain for another 6-8 months.
Sticking with the Cranial treatments, I had another patient with neural pain in her foot, and it was not responding to treatment. So we traced the nerve impingement back to one of her lower incisor teeth, treated that and voila, foot pain gone. That one took some explaining.
So, the moral of this story is I have super interesting people to work with. This is one of the reasons I still find this career challenging. No two injuries are the same, no two people are the same so therefore no two treatment plans are the same.
Why Do I Love to Hate Running?
Lets start this off on the right foot. I do not run. I used to run, although it was often referred to as “plugging along”. I understand there are several cool theories out there that we used to be a running species who would hunt and gather that way. Millions of people run for their physical and mental health. Good for them.
What boils my bunions about running is how many people will suffer though injuries, from the mildest to shockingly severe, all to keep running. I mean, we keep our kids home from school if they barf once. Of course you do. But if you are training for your big race, and your foot is going numb every time you run, do you stop running to get it fixed? Not as often as you would hope. What about Plantar Fasciitis pain? The list of injuries people will run through is longer than it should be.
(Bill Watterson always says it best)
So many people have come to see me with long term “minor” injuries that have grown into bigger problems. If you think about it, there are unique parts in each of us which make us move a certain way. However, within certain parameters we all exhibit the same basic movement patterns. One foot forward at a time, arms swing, hips flex and extend, etc.
The biggest deal for healthy running is a symmetrical gait, meaning the left leg moves the same as the right leg. If that is not happening, then your body will not be absorbing the impact of running equally, which will often lead to things breaking down. If you are someone who has an overuse injury from running but only on one leg, then you probably have a non-symmetrical gait pattern. If your problem was only from training, then both legs would break down at the same rate.
Let me give you an example. Lets say your right hip flexor is tight and irritated. Doesn’t seem too bad, you can handle it. So you run. Of course you do. However, due to the hip being less than perfect, you are unable to extend your hip as far as you normally do. This can cause a multitude of problems, usually affecting how the foot pushes off from the ground. Oh, what a mess this can cause. If we cause the leg to externally rotate on push off more than usual, we increase pressure on the lateral side of the big toe. Long term potential cause of malalingment of toe, bunion formation, sesamoiditis (best name ever), stress fractures, etc.
That is just in the foot. The knee is just waiting to fall apart as well. This change in position places more stress on the patella, causing tracking problems, with will break down the articular cartilage in the joint, tighten the ITB, increase pressure on the medial joint line which can increase the onset of Osteo-Arthritis. Ugh.
Then there is the hip, pelvis and lower back. If movements are not symmetrical, we see compensations throughout this region. Including SI Joint malalignment, compression on various nerve roots such as the femoral and sciatic, lumbar spine rotations and shifts, etc.
Really, it’s a wonder people run at all, what brave fools they are!
Now, this is a worse case scenario, these things do not happen instantly, it takes time to ruin all of these parts of your body, however it does happen. We are usually looking at a gradual downward spiral, as things gradually get worse and keep problems from healing.
Of course, this does not happen to everyone. Many of you are able to run and not spontaneously combust on site. They also have found the Churchill Gene, which means some people do not suffer the depressive side affects of alcohol intake. Some people get all the luck.
However, the runners insistent slog towards self destruction is also why they are awesome to work with in the clinic. If clinically you can find the reason things are breaking down for them, and show them a plan of how to get fixed so they can run again, or run better, faster, less pain, etc, then the results can be amazing.
A few simple guidelines for this to work:
I could go on, but I hope you get the general idea. Find the cause and treat the cause of the problem. Work with the patient, involve them in the process and try not to make it seem impossible, because if denial kicks in again, they will go right back to their old patterns again.
Wrap your head around this
As I mentioned before, cranial bones can have a major affect on Dural tension. Before we dive deep into that, lets talk about your skull. Buckle up buttercup, this could be a bit dry.
Your skull is not just one big ball of bone, it is made up of several intricately woven together bones. These include the parietal, frontal, occipital, sphenoid, nasal, zygomatic, ethmoid, temporal, maxilla and the mandible.
Now if you look closely at the picture above, you can see a few squiggly (fancy word, I know) lines across the skull. Those are the suture joints, and they are very closely approximated articulations. Think about interlocking your fingers, that is what we are looking at. Traditionally, people felt that the suture joints fuse when a person is done growing, and thus become solid. However, we see now that they do not fuse, they still have a bit of flex in them. I like to tell people that when you breathe in, your head will expand, and then shrink when you exhale. Not a visible amount, but enough to make a difference when it is no longer there.
So how does this affect your low back pain? Stay with me, I will get there eventually
As I explained last post, all the nerves in the body are connected, and they need to glide. This includes the brain and all of the cranial nerves. Your brain is suspended inside your skull, with various fascial attachments to the inside of the various bones. If the joints between these bones tighten up, then the fascia tightens, and the amount of movement available becomes less. This will pull on the entire nervous system. Several of the cranial nerves can be directly restricted by the suture joints tightening up, providing another source of increased dural tension on the entire system.
What does this mean?
That your calf cramps could be caused by pressure from your sphenoid bone.
Your hip pain caused by femoral nerve entrapment is due to increased dural tension from one of the cranial nerves by your eyeball.
Boy, the looks I get from some people when I hit them with that kind of answer. But think about it. It is a big piece of string, your nervous system, and pulling on one end will affect the other. Don't focus on the location of the symptoms, focus on the cause of the problem.
There is one very important question you need to ask right now. What will cause the symptoms to only occur in certain areas that are not directly related to the skull? For example, if you have a disc pinching on your L2 nerve root, you will have symptoms in the quad and hamstring area. Basic Dermatome and Myotomes. Easy. But if the nerves are getting pulled from higher up the chain, why would only one hip hurt, and not the other?
That is a topic for another day. Thank you for reading, I hope this is as interesting to you as it is to me.
This is why injuries are fascinating
Ok, I have a confession to make. I really like chasing nerve issues around. There is a challenge with this type of injury that I do not find with typical damaged tissue problems. Lets face it, if you come to me with a torn ACL, things are pretty cut and dried from that point on. But if you are having any of the following types of nerve issues: tingling, spasm, weakness, decrease ROM, pain or headaches then finding the cause of the problem is only the beginning.
One of the measuring tools we use in assessing an injury which involves some level of neural problem is a dural tension test. There are a few to pick from depending on what you are testing. To make this very simple, nerves have to glide through the body, like a brake cable on a bike. They do not stretch, at least not happily. You will need to evaluate if that mobility is within “normal” limits. Then you need to determine if the dural tension you are finding is related to the problem your patient is having. Often it is, but not always.
The tricky part is often finding where the restriction is on the neural system. Do not assume it is where the symptoms(pain, tingling, etc) are. I like to describe the neural system as a big piece of string. If one part of it gets stuck, then the ROM it can glide through gets smaller, making every offshoot tighter than it should be. When I said nerves need to glide, I mean the entire system, spinal cord and the brain, all need to have the ability to move around a bit.
Lets talk about a case here. We will look at this two different ways. The patient is having pain in their left elbow, but not always, and can be with or without activity. You find that the proximal radio-ulnar joint has slipped anteriorly, nothing drastic but enough to restrict their supination and pronation. You use some type of mobilization technique, joint moves, pain is gone. Give home program and re-evaluate in 7-10 days. Easy. Except when they come back, the joint is restricted the exact same as it was last time, and the symptoms are the same. So you mobilize, stretch, strengthen etc, and repeat the same cycle. Again. Perhaps you could throw some ultrasound on it, to really make it look like you know what you are doing. Because ultrasound fixes everything, or must, since every clinic in the world uses it on every injury all the time. Hey, that could be my next blog topic, “Why I Don’t Use Ultrasound”.
But I digress.
What I look for in an injury like this is the reason the radial head is displaced. Find the cause, treat the cause. How tight is their Bicep Brachii? Constant tension through that muscle can pull the radio-ulnar joint out of place. But why is the Bicep tight? Could be from movement patterns, so dig into the history of what they do, exercise, work, sleep, driving etc that may cause unilateral bicep tension. Check the positioning of the Gleno-Humeral joint, improper positioning here can have a negative affect on the Biceps ability to function properly. But the one spot we have to look at is the Musculocutaneous Nerve, from C5-C7. If we have increased dural tension on a nerve, then its ROM will decrease, and where it attaches, in this case the Bicep, will get pulled along with it, just like a dog on a leash. This tug will cause the affected muscle to be tighter than it normally would be. But, where is the nerve compression coming from? Could be where it passes through the thoracic tunnel in the shoulder, could be at the cervical spine, or it could be in the skull. Yes, the skull. Cranial bone restrictions can have a massive affect on dural tension through the entire system.
And that is where we will start with our next post.
Thanks for reading, and get on your bike, keep the rubber side down.
Things that make you go Hmmmm
When I meet with a patient the first time, we sit down and chat about what problems we have to deal with. Often, I hear the line “I have been told I have __________, and it wont go away.” This is where, in my head, I may groan a bit. Not because of what the patient has done, but because of what someone else has told them and perhaps how they have been treating this persons injury.
The following list includes some of the common injury terms that often are a sign that your treatment provider may be looking in the wrong direction to find the remedy to fix your condition.
Shin Splints. You have all heard of it, many of you have been told you have it. It is what I refer to as a “garbage can” term. Generally, it is used to describe pain in the lower leg, often from activity. But what is actually wrong, what tissue is damaged? Is it bone, muscle, tendon, retinaculum, nerve, or the interosseous membrane that are damaged? As a medical professional, you are doing a disservice to the patient by not giving them an exact picture of what is damaged. As a patient, if you suffered a severe knee injury, and were told that you had some ligament damage, would that be enough information, or would you want to know which ligament it was? Also, there are many instances where this pain is located on one leg only. If this is running caused injury, then both legs should be experiencing the same amount of stress, therefore they should both breakdown at the same time/rate. If that is not the case, then there is a mechanical problem with how the legs are moving, which is placing more stress on the damaged leg. This can include ankle, hip and back issues. If those are not dealt with, then this pain will not go away.
Carpal tunnel syndrome. This is officially referring to a compression of nerve tissue, often the median nerve, as it passes under the fascia band that forms the carpal tunnel in the wrist. It can be very debilitating and difficult to fix. However, there are multiple nerves that run into the hand, and ALL of them come from your neck. What we have gleaned from years in this field is nerve pain is rarely located at the source of the problem. Really, using pain as an assessment tool is potentially misleading, as there are so many factors that determine how, where and when each individual experiences pain that we can’t easily catalogue it. If there is any nerve compression present anywhere along the entire length of the nerve, the patient can experience symptoms mimmicing a variety of issues. So while carpal tunnel does exist, in my experience the vast majority of people with this pain do not have a problem with their wrist, the problem is further up the chain, and until that part of the chain is fixed, nothing will help the pain in their hands.
Tennis elbow or Golfers elbow. This is another beauty. Golfers elbow is an inflammation of the common flexor tendon on the medial side of the elbow, and was named such because of the force placed on that tissue when swinging a golf club. When contact is made with the ball and/or turf, the elbow on your bottom hand, for most people your right, takes all this stress and eventually breaks down. Tennis elbow is on the opposite side of the elbow, the common extensor tendon which breaks down from hitting backhand shots in tennis, among other things. There are a couple of issues here. One, these tendons often do break down and get injured. The key to fixing them is why. There often will be a mechanical problem with how they are moving the elbow during their activity. What is causing that? Posture, mobility or positioning of the head, neck, shoulder and hand are all possible issues. The equipment they are using may be too big, too heavy, etc. They may be executing their movement improperly which places more pressure on their tissue than it can handle. A final thing to consider, there is a major nerve passing through each side of the elbow, in close proximity to the tendons. If the nerve is affected, it can mirror tendon pain when there is nothing wrong with the tendon.
Bursitis. To deal with this, we must first look at what the bursa does. It is a fluid sac located around every tendon in the body, meant to protect the tendon from pressure around the joint they cross. There are hundreds of them in the body. When they get inflamed, there will be swelling, sometimes massive amounts, pain and restricted activity. They are usually damaged in two ways. One is a direct trauma to the area, such as falling on your elbow, banging the bursa on the back of the elbow and it will swell, sometimes to the size of a grapefruit. This is easy, treat the swelling and they recover and go back to their daily lives. The more common problem, and more difficult to treat, is when the bursa gets inflamed from activity, not from direct trauma. An example of this would be a bursa inflammation in your shoulder from throwing a ball repeatedly. Movements that are done properly should not cause abnormal stress on the bursa. To fix this type of problem, you need to find and fix the cause of the irregular movement pattern, otherwise the bursa will just keep getting irritated and never really go away.
The moral of the story is, unless the cause of your injury is found and treated, no amount of treatment will help you. Too often treatment is focused solely on the lesion site, using various treatment styles and modalities. You can stop the activity, and the pain may go away. However, when you start the activity again, if the underlying cause is still there, it will just keep coming back. If you have been stuck in a treatment loop for longer than you think is appropriate, ask why the injury occurred in the first place, and what steps are being taken to ensure it doesn't happen again.
Awesome injury names
Back in my teaching days, I used to love making up bonus questions for the exams. Some nights, my wife would find me working late to finish making up a mid-term exam. I would have the content questions finished long before this, but I would be giggling and switching things around for the bonus questions. I always gave them a choice of two questions, one would be an obscure anatomy question, like name one ligament that has both attachments to the same bone.
The other would be a bit more silly. Movie questions like what kind of car did they destroy in Ferris Bueller’s Day Off? Who was the lead actor in The Man With One Red Shoe? What fast food mogul did the father hate in So I Married An Axe Murderer? You know, important stuff.
Sometimes I would mix it up and pull out some archaic sounding names of injuries or conditions that you could think were made up in a Monty Python skit. Then I would see if they could come close to naming what was actually wrong with the poor diseased peasant diagnosed with this condition. I will give you some examples, because I still chuckle at some of these names.
Weavers Bottom: irritation of the ischial bursa from sitting on the hard narrow seat of a loom (still my favourite name)
Mallet Finger: a rupture of the tendon that extends the end joint in the finger, so the joint cannot be straightened without external support. This one is quite common, I just enjoy the name
Dead Butt Syndrome: chronic weakening of pelvic stabilizing muscles during long term exercise, causing pain on the outside of the hip
Housemaids Knee: irritation of the bursa sac around the patella from kneeling on a hard surface for an extended period of time, like scrubbing floors by hand
White Finger Disease: compression of the nerves and blood vessels in the finger(s) from repeated trauma and squeezing, such as using large hammers, chainsaws
Bakers Cyst: bursa inflammation in the back of the knee, limiting ROM in the knee
Dowagers Hump: a gradual breakdown of the upper thoracic vertebrae, often due to osteoporosis, causing a prominent hump to form at the base of the neck
Trigger finger: a condition in which one of your fingers gets stuck in a bent position. Your finger may straighten with a snap — like a trigger being pulled and released.
Next post will be about a few common medical conditions that sound proper, but are often used in such a vague way they are practically as silly as those mentioned above.
By the way, the answers to the above questions are coraco-acromial ligament (one of a few), Ferrari 250 Californian, Tom Hanks & Colonel Sanders.
When is a door not a door? When its ajar
An extremely large number of chronic pain scenarios involve some type of restricted mobility in a joint above or below the pain site. If I had a nickel for every time we have fixed anterior hip pain by stabilizing their SI joint and Lumbar spine I would have a very large pile of nickels. This goes back to a mantra that my professors drove into us in school. Find the cause of the problem, treat the cause, not the symptoms. Pain is almost always a symptom, and while we do not want our patients in pain, you have to look past that to really help them.
An impingement of the Supraspinatus Tendon is very common with overhead athletes. Allowing yourself to focus on the irritated tendon and ignore the bio-mechanical breakdown that allows the tissue to get impinged in the first place is leading down a very long and slow rehabilitation process. Not to say you can ignore the damaged tissue, but you have to find what is causing it and fix that as well. Now your patient may think you are nuts, why are you looking at my neck when my shoulder hurts? Educate them, make it clear what the chain of injury is, and set out your plan of attack.
One thing I do with all my patients, especially the younger ones, is have them explain to me what the nature of their injury is before they leave. It is their body, their pain, we have to make sure that they understand what exactly is wrong, and what we are going to do about it. Sometimes we are not able to tell them exactly what is wrong, so we have to be honest with them and give them what we feel the problem is, and tell them why we are unable to give them a solid answer at this time.
And a final thing, make sure you use terminology appropriate for the patient. I had a former assistant who would make a point of using the biggest fanciest words possible to describe an injury to students with no idea what he was talking about. This does not make you look smart to them, they are asking you for help because they already think you are smart. It makes you look like an arrogant ass. The world has lots of those, don't add to the total.
Athletes getting hurt (part 2)
Previously I was mentioning a few things that we can try to do to lessen our chances of having a catastrophic injury occur to us. We discussed personal fitness levels, competition levels and being careful when combining fatigue and risky complex movements.
Lastly, and this is the one that applies to my profession, getting injuries assessed and treated properly can ensure that they do not build into a larger problem. With any injury to a joint, we will lose some of our proprioception ability, ROM, and strength. If these are not dealt with, you may be prone to having the injury re-occur, or they can lead to problems in other parts of the body.
Lets use a minor ankle sprain as an example. Our most common problem is an inversion ankle sprain, with damage to the outside ligaments of the joint. With minor injuries, if you are patient, your strength and ROM will come back just fine. What does not come back on its own is your proprioception, aka balance, aka co-ordination. I am talking about quick reactionary muscle responses to your bodies positioning in relation to another object, often the ground. If this is not retrained, then you are putting yourself at risk to repeat injuring this ankle when you jump, run, etc in the future. This is often the case when we see someone sprain their ankle over and over after the initial injury.
How can an ankle sprain affect the rest of the body? If your ankle is lacking in dorsiflexion, then simply walking will increase the rotation stress on the knee, potentially causing patellar tracking issues, compression forces in the SI joint and lateral pressure on the big toe, leading to bunion formation. Since the legs and pelvis are the base for the spine to sit on, any imbalances here will translate up into your back, neck and shoulders. Running and jumping will obviously make all of these problems magnify greatly. This will occur in various ways in all parts of the body, remember that everything is connected, the body will compensate for shockingly major problems to allow the end result to occur. The long term affects of those compensations should make you question if it was worth it to go back to activity a little sooner than you should have.
Now, I am not advocating getting every bump and bruise assessed by someone, that is a bit too extreme. However, you need to be aware that injuries that have affected your ability to move/function for an extended period of time will have a potential negative affect on the rest of the body. When in doubt, have a qualified professional take a look at your condition to help ensure that your first injury does not lead you into another one down the road.
blog post #2
Why are all the Pro Athletes Getting Hurt?
I have been asked multiple times about the rash of injuries that seem to occur to pro athletes, from NFL quarterbacks to the local Oilers. How can these guys get hurt all the time, are they not in shape with awesome medical teams helping them? Well, yes they are, and yes they do.
What we do not know is what kind of injuries that athlete has built up over their career. For example, how can a quarterback shred his knee while planting and pivoting in what seems like a “normal” pattern? Well, if they have a history of minor injuries to the various ligaments and meniscus in that knee, then perhaps this “normal” move was the straw that broke the camels back. If ligaments become lax after repeated trauma, then they can be at a greater risk of a catastrophic injury.
Also, there is a basic rule in physics, if you exceed the tensile strength of a structure, be it steel, wood or collagen, it will break. Sometimes, a seemingly simple movement pattern will be done at the precise speed and position to tear even the healthiest and strongest tissue.
So if this kind of injury can occur to the elite athletes in the world, what hope do the other 99.9% of us have of not getting seriously hurt?
There are a wide array of things we mere mortals can do to improve our odds of not suffering a catastrophic injury. The most obvious is to be in the best physical shape you can be, specific to your sport needs. If you are an offensive lineman in football, where size and power are needed, do not undertake a marathon running program.
Secondly, try to ensure that your competition and training program are appropriate for your age, fitness and skill levels. Getting pushed too far, hit too hard or being beaten all the time will make maximum performance harder to achieve. Often, when you are dictating the pace, you are not as physically at risk of getting hurt.
Thirdly, as fatigue levels go up, our co-ordination, reaction time and strength all get worse. This will make us more prone to poor mechanics, increasing our potential for injury. We see a large number of injuries occur at the end of practice, when people are tired and not totally paying attention to how they perform a dynamic movement. As a coach or athlete, keep an eye on peoples ability to do the work in a safe, effective manner. Perhaps ensure that your high risk exercises and drills are done earlier in practice or training, and at the end when people are exhausted they are doing safer activities.
In my next post, I will tell you the final part of my look at major injury prevention
blog post 1
Helping what you can’t see
When it comes right down to it, my job as an Athletic Therapist can be summed up in one sentence. I need to ensure that people are able to return to their chosen activity safely, regardless of the injury.
There are a multiple things to keep in mind, including symptom management, strength, proprioception and joint mobility to name just a few. Potentially the most important one is the one people tend to miss or ignore. There is often a significant emotional component as well. This can show as a fear of repeating the accident, concern over fitness or skill loss, unknown long term issues, denial, fear & anger. All of these will have to be dealt with if the patient is to fully recover and return to their previous lifestyle.
So what can we do for someone who has emotional side-affects from their injury?
If you are not trained as a professional counsellor, psychologist, etc, then you should not act as one. If they need professional help with these matters, do your best to ensure they get to talk to a professional.
This does not allow you to be a cold fish to their emotional needs. You need to empathize with them, listen to their problems, but you may not be able to solve them. That is ok, often just having a person listen to their concerns will make a difference to them. You need to be professional in your responses, do not make inappropriate remarks or comments, let them know that you hear them. Also, you may want to try to normalize their responses and concerns, so they do not think they are “strange” for feeling this way.
As Athletic Therapists, we can help all patients by tailoring a return to activity program to cover their needs. This will include multiple steps to go from injured and non-active to 100% intensity. By making sure that they pass each level of your program, it will greatly alleviate concerns they may have about getting back into their sport. Knowing that they have passed each step symptom free will help both the patient and the therapist know that they are ready to play.
So often we only look at the physical and measurable results with patients, but we have to make sure we keep track of the inside pain and problems that all patients will have.
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