The Hip Flexor Mechanism

The hip flexors that get hurt most often are those closest to the surfaces. For example, in athletes we often see the so-called "Hip Pointer" injury. This is really a hip flexor mechanism injury at the proximal insertion of the muscles at the ASIS (the anterior superior iliac spine) - that boney prominence on the front of the hip. Deeper than that are the true hip flexors, Psoas and Iliacus with a common tendon on
the femur Iliopsoas. Because of the proximal insertion of the Psoas on the lumbar spine, people with sway back (a very lordotic standing posture, seem to be more susceptible to hip flexor trouble, especially if active. The reason for this is that a sway back leads to the hip flexor being effectively shortened, and the iliopsoas more susceptible to strain. The anterior pelvic tilt that accompanies a sway back is associated with lower back pain as well.




Manual therapy for shortened iliopsoas includes a myofacial release technique that can be quite painful, and an active/passive manual stretching procedure. For acute injury, I use an extra long ace bandage to support the hip flexors (we call this a spika wrap), and we use ice, occasionally ultrasound and also electrical stimulation to help get us through the acute phase. I also use the Stick to treat the tight muscles of the thigh including the ITB and the Quad mechanism. In the event that you have tightness of the ITB and Quadaceps mechanism, then using a Stick or similar tool at home will help you resolve those restrictions. In any event, the long term key is to first stretching the hip flexors effectively, and then to strengthen them as they gain length.





Three stretches I really like include:
1. Standing: Leg flexed with your foot behind you up on a table, knees aligned to the center, stomach contracted to flatten the back, shoulders upright and then flex the knee of the foot you are standing on. You should feel the stretch in the front of the quad. To increase the stretch, stand further away from the table so you have to reach further back.

2. Half Kneeling: The knee of the hip you want to stretch is on the ground. Your body is upright. Contract the stomach muscles to keep the lower back flat. Bring your weight forward onto the front foot but keep your shoulders upright until you feel the stretch in the groin. Take your same side hand and reach over the top of your head and leaning your body gently over to the side.

3. Prone: Lying face down, arms spread out, bend your knee of the leg you want to stretch. Again, tighten your stomach muscles to keep your back relatively flat. Pick up your knee and try to reach over your body and touch the opposite hand with your foot.

A word about stretching: First of all, stretching SHOULD NOT HURT. Second, you need to hold the stretch for at least 30 seconds. Third, to improve the effectiveness of the stretch, try contracting and relaxing the muscle you want to stretch.

Do muscles get longer when you stretch them? In a word, "no". The length of a muscle is established neurologically. So why stretch? A fair question. What you are doing is helping the dense connective tissue become hydrated and also "resetting" the relationship between the actin and myoisin components of the muscle fiber. This helps the muscle, in either case, be more tolerant of stretching during activity. In other words, you can be active without the hip flexors experiencing failure.

For strengthening, I like these two exercises:
1. Supine: Lie on your back with your foot on top of one of those big Swiss Balls. Loop an elastic cord over the top of your foot, so that it is pulling downwards (along the line of your leg, parallel to the floor). Bend the knee and pull the toes up to keep the rubber band on the foot until your hip flexors get tired.

2. Sprinting up a hill: Like it says, sprint up a really steep hill over and over. Focus on high knees. This makes you flex the hip to prevent catching your toe. This is very a effective exercise. we usually work up to 10 10 second repeats with a 20 second rest break between sprints. If you amke sure to lift your knees, this exercise will make a big difference.

When I Turn My Head I Get Pain in My Arm

In the neck we think of anterior column and posterior column issues. The anterior column is typified by the intervertebral disc, while the posterior column is typified by the facet joints. When you have pain that is not accompanied by weakness, then the pain is not likely to be caused by a bulging disc. Pain associated with weakness or weakness without pain implies that the disc is at fault. This is because in the cervical spine, the spinal nerve roots are distinctly motor nerve or sensory nerve roots. The anterior nerver roots are motor nerves and therefore are more likely to be impacted by a disc bulge or herniation, while the posterior nerve roots are sensory nerves in which case several factors might irritate them.



You can see in this illustration the difference between a disc herniation causing nerve root compression and a normal cervical relationship. Nerve root compression can involve sensory AND motor nerve compression, although it is possible to have pure motor nerve compression. In contrast, posterior column disorders typically produce only sensory changes. These could take the form of increased or decreased sensation as well as pain. Absent sensation implies a nerve root compression, while anything less than that suggests a nerve root irritation.

Got all that?

OK so you turn your head to the left and you feel a loss of sensation and pain in your arm and hand. You do not feel weakness, and you do not feel any numbness. When you turn your head away, it feels better. When you backward bend your head, it feels worse, forward bending feels better. Assuming all else is normal, this picture would lead me to believe that you have a posterior column problem with an irritated nerve root.

If I am correct, and again, I assume that you have had your health checked by your doc, you don't feel sick or nauseated and you are otherwise healthy - then you probably have an irritated facet joint at least. In any event, we need to provide a gaping drill to help you unload the structure.

Here is how you unload the RIGHT SIDE posterior column: Start by sitting on your right hand. Then

1. Forward bend your head to a natural stop.

2. Side bend your head to the left side until you encounter a natural stop

3. GENTLY rotate your head to the RIGHT again and again and again PAIN FREE

This should reduce your pain and give you relief by gaping and unloading the right side facet jionts.

Achilles Tendonitis Rupture?

The Achilles Tendon often ruptures somewhere around age 40 - I usually see this injury in men, but as Misty May, the US Beach Vollyball Star learned, women experience this injury as well.

The Achilles tendon, like all tendons, is a dense connective tissue made up of microfibrils of collagen, the most prevalent protein in the animal kingdom. As we age, little by little, the tendon fails microfiber by microfiber, and while this is not a serious issue on a microfiber level, at a certain point, the number of microfibers that have failed starts to interfere with the function of the tendon, usually felt as stiffness in the tendon.

When the tendon reaches a level of weakness that it starts to feel poorly, the tendinitis, there is usually already irreversible damage to the tendon with sufficient microfiber failure that leaves the tendon vulnerable to further damage and eventual rupture.

When the tendon ruptures, it often sounds like a gunshot and feels like you have been kicked on the back of the leg. I often hear stories about the person going down and looking back to see who kicked them, only to find that there is nobody there. The tendon usually ruptures when the foot is placed on the ground while moving backwards, when you plant the foot for example.

The best thing to do to avoid a rupture, and even Achilles tendinitis, is to a. stretch regularly, and b. Strengthen the muscles of the calf, and c. avoid overuse of the tissue if you can help it.



As far as strengthening and stretching are concerned, you need to remember that there are two muscles that could in fact be stretched and also strengthened. The Gastrocs and the Soleus. The Gastrocs cross the knee and the Soleus does not, so in strengthening the Gastrocs for instance, you need to keep the knee straight, while on the other hand, strengthening or stretching the Soleus, you need to keep the knee bent. I believe that most acute strains of the Gastrocs affect eh medial third of the muscle, but most ruptures of the tendon are caused by lack of stretching of the Soleus especially. So give attention to this muscle and I think that a lot of trouble can be avoided.

As for strengthening, my suggestion is that you work up to 40 continuous heel raises off a step so that the heel drops down, with both a bent leg and also a straight leg to ensure strong muscles.

As far as overuse is concerned, this is especially an issue for runners who allow their shoes to deteriorate excessively while putting on the miles, and also for basketball and tennis players, for some reason, who step backwards a lot. I think a good strengthening and stretching program will eliminate most trouble.

One thing to think about is that if you have had a lot of pain and or stiffness in the Achilles tendon over the years, you are at risk for rupture, especially if you can actually feel the tendon get a lot thinner as you palpate along its length. In that case, I suggest you perhaps avoid activities like basketball or tennis, and treat the tendon to reduce inflammation as much as possible.

Holiday Post

This post is more of a free rant. If you will, consider just how fortunate we are. We are in the midst of the worst financial crisis since, some say, the civil war, some say the great depression. And because we live in the Pacific Northwest, we are late to "the party" (some party).

In any event, between the Feds, the stock market, and the media, I see things beginning to turn, so I want to reach out and promote that each of us consider making a contribution to somebody MUCH less fortunate.

In order to stimulate that idea, I have found this website, Kiva.org that is a micro lending site, that in a great way, leverages the power of the internet to connect people who need help with people willing to give help.

If you are reading this post, please make a contribution here.

I am committed to micro lending. It is a truly great way to help again and again and again. The evidence supporting micro lending is overwhelming. This is the very best way to help women in the third world self actualize.

Merry Christmas to you - Happy Hanukkah too. Whatever you celebrate this holiday season, I hope that you will be safe, healthy, and find yourself prosperous next year!

Happy New Year.

Neil

My Foot Still Hurts After Months, What Gives??

Plantar Fasciitis causes really painful feet, especially in the bottom of the foot near the heel. I agree that it can be difficult to treat, and so I am going to share my "secrets".

First of all, lets establish that you actually have plantar fasciitis:
- You experience persistent pain under the foot that is worse in the morning, worse with every step.
- If you press near the heel under the foot, it HURTS
- You do better with heavy boots, or at least with stiff soled shoes
- You have had only marginal relief with NSAID's

OK, so this is how I treat this injury:
1. Ice massage every day.
2. Night Splint every night
3. Small steps in the morning
4. Low Dye tape protection
5. Ultrasound in physical therapy
6 Discontinue activity temporarily
7. After the injury calms down (about three weeks) then start stretching and strengthening
8. Custom orthotic therapy
9. Gradual return to loaded activities.


This is an example of a Plantar Fascia night splint. Some are more elaborate than others, but this one is a good one.

Lets say you try the above and it STILL does not seem better, then I have my ace in the hole....Crutches. Yep, you have to go non-weight bearing for 6 weeks, and also do all the items above as well. Honestly, I have helped hundreds of people recover from persistent Plantar Fascia inflammation using this strategy.

Rotator Cuff Tear or Tendonitis

The rotator cuff tendons, especially Supraspinatus, is one of those spots in the body that is set up to fail. Why you ask? Well the tendon is located in a "watershed" area between two bones, the head of the Humerus below and the Acromion above with not great blood supply. Every time the arm is elevated, the blood supply is further impacted by the Humerus pinching against the Acromian. In people who have a "down sloping" Acromion, the pressure arrives on the tendon earlier than usual, and over time the tendon weakens in the area with poor blood supply, and the tendon can tear when loaded. I have seen so many people with surprising stories about how they ended up tearing the Supraspinatis tendon, from being pulled behind a boat while water skiing on one hand to playing basketball and catching an arm while shooting on the other.

A tear in the RC Cuff can be full thickness or partial thickness. A partial thickness tear can produce some shoulder pain, usually out on the lateral side of the shoulder, and it can "hide" being mostly pain free, or produce an achy shoulder from time to time. I had a partial thickness tear in my left shoulder from an gymnastics injury in high school when I was 17 years old, and it came and went for years until I tore it again playing basketball when I was 38 years old. At that point the tear was deep enough to bother me all the time, and especially at night. Night time shoulder pain is one of those "red flags" that implies that further testing is appropriate. If you are having hard time lifting things, opening your car door, and coping with unexpected movements, its time to see you doctor!

The good news is that an accromioplasty (shaving the underside of the acromion) and a rotator cuff repair (shaving off the torn part) is a quick recovery, but the full thickness tear is more work. Here is a good full thickness surgery repair blog

Even after the full thickness repair, a full recovery is completely possible...you can read more about recovering from injuries on my website here.

The Wacky SacroIliac Joint

The Sacro Iliac joint is complex for sure. Besides having to axis of motion and a weird shaped joint surface, there are two of them, all the muscles that cross it have more than one joint that they control, the symmetry or lack of symmetry between the joints add a degree of complexity as well, and the entire weight of the upper body is transfered through the SI joints to the lower extremities.


This is an x-ray of the SI joints looking down on the middle of the joints from the top:



I will say this: We see many more problems with women than men with respect to the SI joint. The reasons for this are first, the wide pelvis and the shallower SI joint angles, second, the impact of hormones on ligament laxity, and third, the consequence of pregnancy (change in weight bearing loads and angles combined with ligament laxity). We usually see SI joint problems in people who were not recently pregnant after trauma of some sort. For example, runners who land in a hole or shallow spot unexpectedly, or people involved in a sudden breaking event or head on impact in a car for example. My point is that absent pregnancy it is rare to see a true SI joint instability. On the other hand, we do see restrictions of SI joint mobility that do have consequences at the hips and lower back for example.

How do you know if your SI joint is irritated? Well, if there is a true hypermobile SI joint that is symptomatic, you will most likely have unilateral pain in your buttock. In the event that the joints are simply hypomobile, then it is harder to determine on your own, and a good evaluation will reveal the restriction. Unfortunately, the symptoms that the irritated SI joint usually cause are also symptoms of other typical issues like lower back pain of discogenic origin, and a good physical evaluation is key to sorting out your symptoms.

The real challenge in treating the SI joint is not so much the hypomobile structure, because it is relatively easy to get a stuck joint moving again, but rather, the challenge is to stabilize the hypermobile joint. The reason for this, I alluded to earlier, and that is that every muscle that crosses the SI joint also crosses or controls another joint. For example, the Piriformis muscle is the major muscle that crosses the joint close to the joint line. But while the Piriformis muscle inserts on the inside of the Sacrum, it also inserts on the femur crossing the hip once it exits the pelvis crossing the SI joint.

You can see how intimately the Piriformis muscle relates to both the SI joint and the hip and the adjacent hip muscles as well as the Sciatic Nerve.

So what do you need to do if you think you have an SI joint problem? First of all, use ice over the gluteal muscles. It seems to make a big difference. Second, get a good evaluation because the maneuvers that you need to make to figure this out need someone specialized to test and observe. Third, (and this depends on the evaluation) you will either need stabilizing exercises or mobilizing exercises. Finally, footwear might play a roll (Excessive pronation or supination will lead to stress across the SI Joint.) If you need stabilization though, an SI joint belt might be of service. This is often hit or miss though, but definitely worth a try.

My best advice is to get a good mechanical evaluation by a physiatrist, a physical therapist or a chiropractor, because that will determine the specific treatment strategy you need.

That Crazy Pain in My Shoulder!!

Today, a 45 year old baseball pitcher described a pain in his shoulder that only hurt when he crossed his arms and pressed his fist into the back of his arm, pushing his arm forward causing local pain in the front of the shoulder more or less. He also described getting grossly fatigued while pitching, losing both velocity and staying power. The pain came on originally after he pitched through an illness.

Physical exam was insignificant. Rotator cuff screens were negative as was the AC joint screen. Palpation unable to reproduce symptoms. Muscle test negative. Neuro negative. Joint play negative. The only positive symptom occurred with him reproducing the anterior glide of the humeral head on the glenoid using his other hand behind the involved right arm.

My conclusion is that he tore his Glenoid Labrum. We will find out for sure after he has an MRI or surgery if the surgeon decides to go that way.




The Labrum seats around the Gelnoid Fossa to make it effectively deeper for the Humerous to seat properly. When the Labrum tears, it can tear on the top (a SLAP lesion) or on the bottom (a Bankart lesion). You can see the proximity of the biceps lesion to the superior tear in the Labrum, and for this reason, many SLAP lesions actually also involve the Biceps Tendon.



In the event that you actually have a torn Glenoid Labrum in either form, the SLAP lesion or the Bankart tear, I am afraid that the best option is surgical. The good news is that recovery is excellent. The last patient I treated who had surgery for this condition, had both the SLAP and the Bankart lesion, and he went on to a full recovery after surgery by playing college football just a few months later.

Rehab for the post surgical course is not very complex, it just takes hard work. Starting with immobilization, then self mobilization activities, to full ARROM to strengthening to dynamic strengthening and throwing ultimately.

Its a long road back for sure, but the route back to full participation is certain. "Bulletproof" shoulders are possible after surgical repair.

Lets talk about Core Stability

"Why should I do core exercise?" is the most common question I field for people suffering lower back pain.

First, the anatomy - segmental instability occurs because a motion segment (vertebra - disc - vertebra) allows a component motion of sheer which is not anatomic. In other words the vertebra above should never sheer against the vertebra below. This abnormal motion would occur when a disc has lost its volume and therefore its height. we see this as a narrowing of the disc space on x-ray. Once sheer is allowed, it is safe to assume that the static stability of the spine is lost.

In this image you can see the loss of disc height.






Muscularly, there is an opportunity to stabilize the spine dynamically using the muscles that surround the core. In front and on the sides are the Rectus Abdominus, the Internal and External Oblique muscles and the Transverse Abdominus as well. In addition there is the strong lateral stabilizer - the Quadratus Llumborum and the posterior structures including the deep paraspinal muscles Multifidus and Rotatores and others. Further, there is the large back muscle Latisimus Dorsi that inserts into the thoraco-lumbar dorsal fascia and the Gluteal muscles that also do so and provide additional tension to the structures. Finally, there is the diaphragm above and the pelvic floor below that both play a significant role in providing true core stability.




Key core exercises tackle all these muscles. Front, back, sides, top and bottom. The secret is that it is not possible to compress water, and so by having a dynamic compression of the contents of the core, stability is created whereby the segmental instability described above is restricted from movement by the compression of the abdominal contents. Make sense?

There are other considerations such as muscle tightness and joint restriction above and blow the spine that contributes to the load at the unstable segment, perhaps perpetuating the instability and the consequence of that instability


on the pain one experiences. For example, the Hamstrings insert on the Ischeal Tuberosity and it is easy to imagine how the tight hamstrings would limit the ability of the pelvis to tilt forward during forward bending, which means that as one bends forward, the unstable segment in the spine would carry the load INSTEAD of the hamstrings. And because it is moving under load more than it should, and because the motion takes it past normal ranges due to sheering, an unstable segment is more likely to become even more unstable causing yet more pain and dysfunction as time passes.

What this means is that core stability needs to be a priority, but normalizing hip and thoracic spine mobility also need to be addressed for the core exercises to matter and for their effect to last.

Why does Aerobic Exercise Help My Neck Feel Better?

The case for aerobic exercise in management of neck pain is an interesting one. At first blush, it does not seem to make much sense, but lets look a little closer.



Besides the obvious short term benefits of aerobic activity, including improved circulation and muscular relaxation as well as pain inhibition. Aerobic exercise causes one to breathe deeply by expanding the rib cage, which is obvious lower down in
the rib cage. That process is really designed to get oxygen deeper into the lungs during exercise when more oxygen is needed in the working muscles. One thing often overlooked is that the rib cage is also expanded in the region of the upper rib case with the upper ribs expanding upwards to further expand the lungs. This upper rib cage action is controlled by the accessory muscles of respiration which are mostly neck muscles.


The cervical spine, the rib cage and shoulder share many muscles, muscles that originate in the cervical spine, for example and insert into the first two ribs like the Scalene muscles, or muscles that originate on the Scapula and insert into the cervical spine like the Levator Scapula.









The Levator Scapula, because of this relationship is the muscle primarily responsible for the experience of a stiff neck.

Aerobic exercise raises the body temperature, relaxes the neck muscles, improves circulation, and calms the mind through the manufacture of endorphines, natural opiates, even as it really helps to reduce neck pain.

I routinely advise people suffering cervical spine dysfunction to perform aerobic exercise as a critical component of their rehab program. It helps tremendously.

What is a Forefoot Varus?

This topic is the source of a great deal of misunderstanding. First, lets define some terms:
- "Supinated" and "pronated" are POSITIONS
- "Supination" and "Pronation" are MOTIONS

The whole body supinates and pronates during normal everyday activity. Gravity is trying to squish us into the ground (pronate us) and we resist that force (by supinating). Every step we take causes us to go through pronation and supination at every joint in the body.

The foot is said to be pronated or supinated. This is in reference to the subtalar joint, and specifically to a position called subtalar neutral (where the rear foot is neither pronated nor supinated).

When the forefoot is supinated relative to the rear foot, the condition is referred to as a forefoot varus.




So in other words, when a forefoot is supinated it can appear to be pronated because the body will get the forefoot onto the ground by pronating somewhere. The thing of it is that the pronation that gets the foot on the ground actually occurs higher up the chain as in at the rear foot, the ankle, the knee,the hip or the pelvis and lower back. When this occurs at the subtalar joint, for example,it is not uncommon to see the knees achieve a valgus position (knock kneed).




When a foot APPEARS pronated, one first has to determine if the foot ITSELF is pronated or if it just APPEARS to be pronated. It is easy to confuse the appearance of pronation in the case of a forefoot varus where the forefoot is effectively supinated. The nature of the condition causes failure in teh foot, at the ankle, at the knee and at the hip.

The incidence of this condition is 8% of 116 female subjects (McPoil et al, 1988) and 86% of 120 male and female subjects (Garbalosa et al, 1994).

There are three patterns of compensation:
- uncompensated
- fully compensated
- partially compensated

Forefoot Varus deformities produce numerous associated pathologies, including:

- shin splints
- plantar fasciitis
- tibialis posterior tendonitis
- patello-femoral syndrome
- lesser digital deformity
- hallux abducto valgus
- lower back pain
- sciatica
- metatarsal stress fracture (see Hughes, 1983)

Varus problems are easily treated through the application of Custom Orthotic Therapy.