www.srcpt.com/blog

Friends, I appreciate the interest this blog continues to get, but I have moved the blog to my company website and you can find what you are looking for at www.srcpt.com/blog - comments and queries are open there.

Please visit the current blog to get your comments posted and your questions answered. Thanks

Neil

The Blog Has Moved

Friends,

I have relocated my blog to my website. It can now be found here

Please visit my blog there to post questions and search topics.

Thanks

Neil

Postural Headaches

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

My torn Mensicus Two and a Half Weeks Out

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.

Cervical Nerve Root Compression

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.

Costochondritis/Rib Cage Pain

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.

Peroneal Tendon Subluxation

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.

SI Joint Related Pain in a 60 yo Male

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.

Post Meniscus Recovery - one week out

Well, two weeks ago I inured my knee, tearing my meniscus while working out at the track. A week ago I had a minor surgery to repair the torn medial meniscus. All that was needed was a trim of the tor material. With that I should be able to get back to my usual level of activity fairly quickly. I was prompted to have the surgery rather than wait because my knee was unable to straighten and weight bearing was very painful.

The surgery went great, in and out, and at first, while the nerve block was still active, I had very little pain. I went home and put my leg up, my knee on ice. I pretty much had a good day and went to bed thinking all was well.

Then the nerve block wore off! Oh My God..that was painful!!! So with pain meds on board I spent the next 12 hours sleeping.

But I continued to keep off my leg for the next 3 days and treated my knee with ice and electrical stimulation until I went back to work on Tuesday. Even though I iced and stimmed twice during the day, by the end of the day I was tired and sore. By Wednesday though the pain in my quads was quite severe, and my knee was not very happy. This time I used UltraSound on the scars and The Stick on my muscles, and I made it to Friday.

By Friday, one week out, I was no longer limping, but my ROM still had not returned (swelling) and I still have to remind myself to take NSAID's and take it easy.

Today, I will walk a bit, try a bit of rowing, and generally take it easy with my knee on ice.

The most interesting thing that I learned about this post surgical time is that by day 5, the muscles around the knee are really, really tight and sore and really do well with the Ultrasound.

On Thursday, I found myself at the foot of three flights of stairs in a building that has no elevator. That was the most work my knee had done since surgery and I painlessly managed by climbing slowly, although I was muscularly fatigued my knee swelled up a bit after that. I can see how easy it is to over do things. The leg feels like it can do more and I have to consciously restrain myself from moving too quickly, or stepping up or down with my surgical leg.

I am just happy that I was able to get my knee surgically repaired so quickly after I injured it. I am also lucky that the meniscus trimming is a relatively minor procedure because there is very little bleeding, if any, during the procedure, so the recovery is abbreviated.

My torn Medial Meniscus

So I was in training for life, and engaging in a drill where I did various plyometric drills down the track and sprinted back up the track at about 80%.

I did this after a long warm up - a 3 mile jog to the track.

On my 6th repetition, during the plyometric portion of the drill, I was skipping using big arms and gaining a lot of air each skip. After about 30 meters I felt my left knee complain a bit... not too much, but complain nevertheless.

I walked it off and sprinted back making a mental note that I was tired and still had a 3 mile jog ahead of me, so I put it all out there during my last sprint.

25 meters in, my knee went "crunch" and I pulled up with a gimpy left knee. I could not easily bear weight and at first I could not tell what I had done. It felt like my medial meniscus was damaged.

After a few minutes of standing there rubbing my knee, the pain along the medial joint line set in and I limped off home.

On Sunday I had an MRI confirming my suspicions, and tomorrow I go see the surgeon! Ouch. More to follow.