Chronic Neck Pain Revisited

Earlier, I wrote a blog about chronic neck pain after an accident. I want to make a few more points about managing chronic neck pain that I think are worthwhile.

• Less is more: The structures of the cervical spine are small. Look at your little fingernail. That is the size, more or less, of the facet joints in the cervical spine. Imagine how much force you put your shoulder through and compare the size of the joints! So the "less is more" idea speaks to doing only a few exercises at a time. I like to limit the reps to 6 (yep, six), and also suggest 6 times a day.
• Move into the pain: Unlike the lower back, it makes a lot of sense in the neck to move into the direction of the pain. If it hurts on the right and you avoid right rotation for example, you will quickly find that you cannot turn right.
  
• Heat or Ice? I mostly say that ice is the ticket, but for some reason, heat around the neck will help the muscles relax more. Remember this: Heat only helps WHILE it is on, take it off and the muscles tighten right up.
  
• Posture, posture, posture: Try to get your head over your shoulder girdle. It makes all the difference.
• Fit or fat? It turns out that aerobic exercise stimulates the accessory muscles of respiration. This will help your neck settle down. 30 minutes a day every day.

Hope this helps,

Neil

Femoral Stress Fracture

I have had several patients over the past couple of years that have sustained femoral stress fractures while running. The presentation is not always the same because the fractures happen in different places along the femur. In each case, the patient was referred to me by another medical practitioner for physical therapy to treat their non-specific leg pain. In each case, the pain mimicked muscle pain and only a careful history teased out the possibility that a stress fracture was hiding under the radar.

• First of all, I can say that almost without fail, the fracture occurred as the running intensity was elevated. The patient did not notice the pain immediately, but noticed it soon after, in each case by the next day.

• Second, the pain was exacerbated with running, and specifically elevated with impact (landing on the injured leg).

• Third, no matter what stretches the patient employed, if they used ice or not, the pain did not diminish.

• Fourth, taking meds, like NSAIDs, did not resolve the pain.

• Fifth, a complete orthopedic evaluation ruled out all the muscles as a source of the pain.

A suspicion of a stress fracture needs to be further investigated by a bone scan which shows a 2% change in bone density rather than an x-ray which illustrates a fracture when there is a 50% change in bone density. Some physicians prefer an MRI to rule it out, but most opt for a bone scan.

The treatment for a stress fracture is the same as for any fracture. Non-weight bearing for 6 weeks, followed by 6 weeks of rehab before returning to previous mileages.

My Love Affair with the Concept 2 ERG continued!

Coming off a long layoff after a rough motor vehicle accident 3 and a half years ago, I started to work on increasing my fitness on the Concept 2 Erg...see the earlier post. Well the first 2K I rowed, my VO2Max was recorded at 14 ml O2/kg/m....this is really low fitness for sure since the scale is 15-70! What V02Max determines is ones level of aerobic capacity measuring how much oxygen can me transported to and used in the working muscles during exercise.

10 weeks later, my VO2Max is recorded to be 41 ml O2/kg/m, which is above average...the concept 2 website has a great calculator that considers your age and weight and best 2K time to calculate the number.

So in 10 weeks I have gone from horribly low off the scale fitness to above average fitness on about 33,000 m of hard rowing per week (5 days a week).

I am excited about this beyond that as well since I am losing weight and firming up. I have lost inches from my waistline and I am on the road back to my fighting weight!

That's it for now!

Neil

The Way Back From Runners Knee

Turn your volume up and click "Play":




One of the most common injuries I see is often referred to as "Runners Knee". This is really anterior knee pain that commonly afflicts runners, but could be caused by several different tissues. Most commonly, the condition reflects lateral tracking patella and patella femoral pain. In point of fact, most people I see are also suffering patella tendinitis in addition the pain caused by the loading of the patella against the femur. I consider the combination of these two to be a more accurate reflection of the diagnosis "runners knee".

Runners develop these complaints largely because of their biomechanics. Not to put too fine a point on it, but structure governs function. What this means is that the architecture of the knee is ultimately determined by the architecture of the foot on one hand and the hip on the other.

Since our feet sprout from the trunk sole up in utero, and later in development rotate to assume the position that allows us to ambulate in a bipedal fashion, we end up with a foot that is either partially rotated (supinated) or one that has simply rotated too far (pronated).

So in the end, since the knee, which is a simple joint, follows the tibia in space and since the tibia follows the talus, and since the talus follows the calcaneus, the position of the calcaneus at the time the foot hits the ground and its subsequent motion ultimately determines where the knee ends up in space.

This is important because the foot has two jobs in life: It is either a mobile adapter (as it swings through space during the swing phase of the gait cycle) or it is a rigid lever (as it prepares to propel us forward off the ground). It is the transition between these two end points that is interesting to me.

It turns out that if the foot is pronated or supinated, the knee will probably end up too medially, which will put pressure on the patella to located itself more laterally and this will indeed lead to excessive patella femoral contact and possibly pain. The stress on the patella tendon here will also likely cause irritation in the tendon as well.

The shape of the pelvis and the location of the femoral neck on the femor will also play a roll, with the wider hips of women being to blame for the more severe "Q-angle" at the knee in women, again a factor in lateral tracking patella.

OK, so you have runners knee and want to know the way back.

First, you need to use ice. I advocate ice plus water in a plastic bag on the knee for 30 minutes,
either that, or an ice popsicle (freeze a paper cup filled with water) and rub that over the knee for 10-15 minutes. It is sometimes easier to use the ice popsicle, and sometimes easier to use the plastic bag. If your pain is largely in the tendon, then the ice massage technique works better. To get the cold to penetrate so that the patella femoral irritation is reduced, then the ice bacg seems to be a better strategy.

You also need to stretch the quad and ITB if they are tight, and you need to use the stick or foam roller to massage and elongate those tissues.

For patella tendinitis, you need to do the following: Take a dinner spoon or fork, and place the long neck of the implement against the tendon. Press firmly into the tendon and rub back and forth to resolve any irritation in the tendon. It is often quite painful at first, but over a few days this technique seems to reduce the irritation significantly.

Don't forget that this is really a biomechanical problem at its root, and so you need a biomechanical solution - i.e. Custom Orthotic Therapy. You need to get fit with custom made orthotics, especially if you find yourself wanting to walk or stand on the outside of your feet (implying an uncompensated forefoot varus). You can read more about orthotics in an earlier post.

From a long term intervention perspective, you need to take a joint supplement if you don't already. I also posted about joint supplements earlier.

And of course, there is no substitute for common sense. You can do things like avoid down hill running, avoid hard surfaces (concrete, pavement and blacktop), moderate your distances and of course make sure your shoes are in good repair.Make sure to return to running on a gradient...ie do not run too fast, too far or too early.