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.

Can I run with Hardware On board?

I got a great question from Vitor about his hardware, the message is:

"Hello,

I had ankle surgery about a year ago following a motorcycle accident, and got a metal plate and some screws (don't know how many exactly). I used to run before the accident and surgery, but I only ran twice recently and stopped because I was afraid I might be doing something that might damage the bone because of screws and plate being there, although I didn't actually feel any pain while running. I've just imagined the screws damaging the bones with the running impact and stopped running. In a month I will have surgery to remove these metal plate and screws. Do you think I should wait until after the plate removal surgery to run?

Thank you very much!"

I responded:

Vitor, this is a really great question. When you have open reduction internal fixation (ORIF) the metal plates and screws serve as "stress risers" in the bone, which means that the bone is having to attenuate more force around the screws than they otherwise would have to if the screws were not there. Ultimately, these stress risers lead to local fractures. Additionally, the plates prevent the bones from flexing, bending and twisting. These are natural actions of the skeleton during the gait cycle especially during running activities which increases the impact loading over walking quite dramatically. The consequence of this is that other stress risers will also develop as the bone responds to the new stresses in new locations, and the result, you guessed it, fractures.

So the long and short of it is this, get the hardware removed, and then allow at least 6 if not 12 weeks to pass before you run again in order the bone to fill the screw holes. ORIF is unfriendly to runners!

Hope this helps,

Neil

The Science of Weight Loss

I have spent a lot of my time thinking about weight loss. My research began several years ago when I found a piece of technology that let us measure metabolic function in the clinic. This tool allows us to identify peak fat metabolism by heart rate, and forms the baseline tool of our in-clinic weight loss program.

The question I asked myself was this: Why do people seem to be unable to lose weight AND keep it off?

The data supported this question with harsh realities such as 8 of 10 people gain 110% of the weight they lose within a year for example.

In reality, it is very simple arithmetic - Eat less and exercise more. But the real questions are how much less? And how much more?

The premise of my research argues for simplicity in weight loss. We know that you can lose weight by going on a diet, and we know that you need to exercise to keep it off (the national weight loss registry supports this assertion even though the number of people who have lost more than 50# and kept it off for more than 5 years is very few.)

But I felt that there was something missing, and in my research, I believe I found the answer!

Ready? Type II muscle selectively atrophies.

This fact is made even more important because Type II muscle is preferential in fat metabolism.

Type II muscle is only produced when MAXIMAL effort is expended. I'll rephrase that, in order to build Type II muscle, you have to exercise at maximal effort because if you do not, you only build Type I muscle. On the other hand, if you do exercise at maximal effort, then you actually build both Type I and Type II muscle.

So my conclusion is that in order to lose weight you need to go on a diet (I believe that a Paleo Diet makes the most sense - i.e. fresh fruit and vegetables along with lean sources of animal protein), AND in order to keep it off, you need to exercise at maximal intensity to stimulate production of Type II muscle.

But in the middle, while eating well (nourishing foods), there is value to sub-maximal exercise that takes advantage of the peak fat metabolism HR data we gather by measuring metabolic output.

For example, I have measured in myself that if I exercise at 140 b/m, I burn 8 Kcal of fat per minute, compared to 130 b/m where I only burn 3 Kcal of fat per minute. So if I row (on the ERG) for an hour at 140 b/m, I have burned 480 Kcal of FAT! And because I sprint for 30 seconds every 10 minutes and for the last minute of my training time, I make Type II muscle, which leads to ongoing fat loss at rest while my body first replenishes the used muscle glycogen, and then runs at a higher RPM (more muscle on board means a higher resting metabolism).

One other consideration is muscle based glycogen. A good hard workout burns up muscle based glycogen as well as liver and heart based glycogen. Post exercise recovery involves replenishing this resource. Regular exercise means that you deplete and replenish in an ongoing manner leading to a revved up metabolism. Since you can only replenish at a defined rate between 5% and 10% an hour depending on your fitness, daily submaximal exercise with intervals to stimulate Type II muscle metabolism leads to this cycle in the most efficient manner.

Weight loss occurs intramuscularly first, then intra-abdominally second and finally sub-cutaneously last. When it does start to occur sub-cutaneously, then it starts at the top of your head and works its way down...so be patient, persistent, disciplined, and consistent.

Eat less and exercise more..now you know!

Neil

Ramping Up Training

This time of year, I see my triathlon patients showing up in the clinic with overuse injuries.

Because it is early season and the weather is getting nicer, there is a tendency to ramp up training too fast. My suggestion is pretty simple really, instead of increasing miles in your run, say, try to double up sports, do a bike ride before your run. That way you increase your aerobic training, but reduce the pounding . As the season progresses, you can increase your mileage output in your run, bike or swim, but to avoid injury, try doubling up sports.

Remember, the best way to deal with a sports injury is to avoid one altogether!

High Ankle Sprain

Typical ankle sprains are sprains of the anterior talo fibular ligament. The high ankle sprain also involves the syndesmosis between the tibia and fibula as well. The big difference is that while the ATF ligament sprain does well with early mobilization, the high ankle sprain needs to be stabilized in a cast boot for three to six weeks. Failure to do so almost ensures arthritis long term. Once out of the boot, the rehab is about the same as for any ankle sprain.

You should progress from balance to balance challenges to loading (lunging and elevation changes) , to impact loading (jumping and hopping) to running with cutting, stop/start and turning.

Acutely, RICE therapy is appropriate, but weight bearing should be in a cast boot for the best outcome. Its best to wear the cast boot for at least 6 weeks to allow the tissue to heal to a sufficiently strong repair.

Remember at 3 weeks, the scar will be present, but weak, only 15% of its final integrity. At 6 weeks, the scar will be 42% of its final integrity. At six weeks, 42% strong, the scar can tolerate much more loading than at any time earlier.

Better safe than sorry. A high ankle sprain in a cast boot means back on the field with little or no residual long term effects. To early back to the field of competition, and you are risking a chronically irritated ankle with arthritis developing over time.