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

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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.

Lower Back Instability

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Much is said about the core. Almost everybody is offering "Core Stability Programs" now. So what gives? First one should understand the etiology of core instability:

1. Tight Hamstrings: In our modern world, we sit all day and our hamstrings are allowed to gradually shorten. If you are a runner, you never really stretch out your legs, so your hamstring is not stretched to its full length then either. Same with cycling. So what? Well tight hamstrings limit the mobility of the pelvis during activities such as bending and lifting, which in turn, requires that the lumbar spine take up the slack. Over time, this shift of motion responsibility to the lumbar spine will have the effect of increasing the mobility in one or two motion segments of the spine. (A motion segment is a disc plus the vertebra attached above and below.) The bottom line is that tight hamstrings are a causative factor to the unstable motion segment of the lower lumbar spine.

2. Weak Abdominals: Our sedentary lifestyle again is responsible for the chronic weakness in our abdominals. There is a "stretch weakness" that exists as well with the abdominals being inhibited by the tight hip flexors and lower back muscles. This is referred to as a "lower cross syndrome". Tightness of hip flexors, coupled with weakness of the abdominals, especially the lower abs reduces the capacity of the trunk to successfully" stabilize" the lower back.

3. Progressive Failure of the Disc: Over time, as we age, it is very common for the disc itself to fail. Failure of the disc over time for several reasons including mechanical wear and tear, leads to excessive "play" in the motion segment making segmental instability a very real problem in many people. Coupled with tight hamstrings, weak abdominals and tight hip flexors, the unstable segment is put under more duress during motion, and as such bears the load of bending and lifting that should rightfully be borne by other structures.

4. Restricted Thoracic Spine: The T-spine is naturally restricted and over time becomes even more restricted resulting in reduced backward bending ROM and reduced ROM into rotation. The loss of this ROM leads to an increased demand for movement in the lower lumbar spine as well as the cervical spine.

When you put all this together with the fact that we have become a sedentary population, over weight and out of shape it is no surprise that the spine breaks down and structures in the spine fail.

Add to that one more fact:

5. Deep Muscle Inhibition: Pain the back is coupled with deep paraspinal muscle guarding, which in turn produces prolonged inhibition of those same muscles through a neurological mechanism. This gradual weakening of the deepest muscles adjacent to the spine are the final "nail in the coffin" of the unstable segment.

OK, so what about core stability exercises, do they work?

In short, the answer is "yes". What core exercises do is stabilize the spinal column by squeezing the organs against the front of the spine and wrap the the trunk in a casement of muscle that is rock hard front and back. The idea is to provide support to the spine through positive pressure that prevents the spine from collapsing or moving excessively under load.

Complementary to the core stability exercises, another key is to strengthen the deep spinal muscles, such as multifidus, in order to provide local stability on a segmental level.

So to summarize, in order to improve athletic performance, reduce segmental back pain, stabilize the lower back and the core, you need to do a good solid core program. I will elaborate on that in a later post.

Long Standing Sacro Iliac Joint Pain

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One of the things I see in people who suffer long standing SI joint dysfunction is the "reluctance" of the Si joint to remain stable once the dysfunction has been reduced. It seems that almost regardless of the subluxation (up slip, down slip, anterior torsion, posterior torsion etc), the joint wants to "return" to the subluxed position.

To help stabilize the joint after reducing a subluxation, I employ two strategies that are muscular and one that is not.

The nature of the SI joint is that there are no muscles that cross the Si joint that are useful for stabilization purposes. The Piriformis originates on the inside of the Sacrum and should be perfect for stabilization purposes, but because it inserts on the Greater Trochanter of the femur, it is useless for stabilizing the SI joint.

Instead, we have to look forward to the Adductors which insert onthe inferior pubic ramus and also the Abdominals which insert on the pubis. These muscles are better suited to maintain the stability of the pubic symphesis and indirectly, the SI joint.
Try these two exercises to stabilize the SI joint:

• Sit on the edge of a firm chair, lean over, your knees apart, and put your elbow on the inside of one knee and your hand onthe inside of the other. Squeeze as hard as you can while also at the same time trying to be as relaxed as you can. Repeat this about 8 or 10 times. You are looking or a palpable click to occur in the groin indicating that the pubic symphesis has reduced. this does not always occur though, so if it does not occur, not to worry.

• Lie on your back, both knees flexed up toward your chest. Place a hand on either thigh near the knees and push as hard as you can with both the knees and hands so that you do not let your thighs actually move. You should feel your stomach muscles working hard.

The other stabiliation idea is to use an external fixation, like an SI Stabilization Belt. I like one you can purchase here. It is caled the BOA Sacro-Iliac Belt. Be sure to size it properly, and when you wear it, keep it snug. Also, as an alternative this one is also a good suggestion.

The thing about reducing an SI Jointsubluxation is that after I have sucecssfully reduced the joint, it often wants to return to its former subluxed state, and after each successive reduction, it often takes longer and longer sublux again. My advice is to be very patient. Allow weeks to successfully treat the joint so that it stays reduced. And while you are undergoing treatment, use the belt and do the exercises I suggested for longer lasting relief.

Finally, I think that you should use ice religeously. By that I mean 30 -45 minutes of ice plus water (not those blue ice packs that you throw inthe freezer, not frozen corn or peas, actual ice) right on the skin. Make sure to include water, or risk frost bite.

My Stiff Neck

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People often experiences a stiff neck with or without headache. sometimes this stiffness can last for weeks. There are a few things I suggest that seem to be effective dealing with this problem. But we need to start with the anatomy.

Think of the cervical spine as a mobile column with a bowling ball held on top. remember, your head weighs about 10% of your body weight. The "wires" that hold the head onto the neck are muscles, the Levator Scapula (picture on the left) and the SCM, (picture below). The levator is the muscle most widely thought to be associated with a stiff neck.

In a prefect world, the position of the head over the neck would be in an erect posture with the neck more or less straight up above the shoulder girdle.

Think of a helium balloon, the balloon hovers in the air the string straight up and down. In order for the head to be in a similar position above the shoulder girdle, the guy-wire muscles Levator Scapula and the Sternocleidomastoid will occupy positions in space that give them mechanical leverage.

Gravity works though, and as a result, posture is often poor with a forward head that puts the guy wire muscles of the cervical spine at a mechanical disadvantage. The result is that they have to work harder to hold the head up. Their increased effort leads to increased compression of the joints of the spine. The result is muscles that are over working and accumulating metabolic by products that are irritating to them, joints that are continuously compressed causing irritation of the structures in and around them, and a physical body that is easily fatigued and inefficient in movement patterns and strategies.

The result can be an acquired stiff neck with headaches or without. Sometimes the neck joints can be irritated enough or have accumulated enough destruction to actually irritate the nerves that feed the arm causing pain, numbness, tingling or weakness into the arm or hand as well.

For the purposes of this blog, I am going to focus on only the postural stiff neck with no radicular symptoms.

To reduce your stiff neck, try this:

1. Catch yourself with a forward head position, and bring your head back over your shoulder girdle (think about that balloon floating on top of the string, and make your head do the same on top of you neck).
2. Do 30 minutes of aerobic exercise to get the accessory muscle of respiration (your neck muscles) to actively contract and relax for ong periods of time submaximally so that they can relax.
3. Put a rolled up towel behind the neck, pull it over your shoulders to the front, grab with both hands and pull the towel down toward your feet. Then let your head bend backwards and when all the way back gently rotate left and right. PAIN FREE>
4. If it hurts to turn left, then practice turning into the pain by turning left repeatedly. Do so gently, and just knock on the door of the pain, don't move through the painful range.
5. Remember, the neck joints and structures are very small. You don't need to move too far or work too hard to actually be very helpful to the neck. I like to say about the neck that "Less is More".
   
   Try these techniques to resolve your local neck pain without any radicular symptoms of pain or numbness or weakness.

To Stretch or Not to Stretch?

There is a lot of mythology in circulation regarding stretching.

The resting tone of a muscle is established neurologically. What that means is that organelles in the muscle called the muscle spindle, which controls the quick stretch mechanism of the muscle, determines the sensitivity to stretch of the muscle, and it also seems to be involved in establishing the resting tension in the muscle. So in a nutshell, that means that stretching does not seem to impact the resting length of the muscle.

So why stretch?

Well, I can think of a few reasons to stretch. First of all, when it comes to competing, a little pre-competition stretching has been shown to improve performance. The reason for this is surmised to be that the actin and myosin relationships in the muscle are optimized allowing the muscle to work more efficiently. And clearly you see top athletes stretching before and after competing for sure. What is current practice in competitive athletes today is what is known as an "active warm up", which is made up of little movement patterns that are part of the full motion package that the athlete will engage in. I also know, though, that top teams spend a lot of time stretching to prevent injury in professional soccer players for instance. So there is still uncertainty.

I also believe that when one stretches, one is taking the joints through a more complete range of motion, which will have a positive impact on the articular cartilage. Cartilage requires intermittent compression plus gliding to be properly nourished, and stretching might get you to take your joints through a full ROM without overloading them.

Additionally, the same idea is true for your dense connective tissues - the ligaments and capsules get maximally stretched when the joint achieves maximum congruence, which occurs at the end of the range of motion of a joint. So at the end of the joints ROM, the cartilage is maximally compressed and the ligaments and capsules are maximally stretched, all of which helps prepare the tissue for activity. I imagine that the dense connective tissues imbibe water as they relax after being maximally stretched for a few seconds, and it is that process that "protects" them from overuse injury during activity.

Stretching also activates both joint receptors and muscle receptors in areas being stretched that are inhibitory to the muscle and relax it for the moment. Does this relaxed muscle stay relaxed? I don't believe so. I believe that muscles get longer if you "play them longer". What I mean by this is that if you use a muscle in a longer range, say by following through while kicking a football for example, then your muscle will gradually tolerate a longer resting length. Muscles are very elastic. If I cut your biceps tendon at the elbow, I could take the end of the muscle and walk across the room with it, more or less, and if I let go of the end I was holding, the muscle would recover its resting length.

"What about yoga?" I hear you asking...Well in yoga, you don't just stretch, you activate the muscles in longer ranges which is why people who practice yoga actually become more flexible. But they also increase the flexibility of their joints, and their muscles are encouraged to be active through longer ranges, hence appear to be longer because of stretching.

Whats the bottom line, to stretch or not to stretch?


I think that stretching is a valuable practice to engage in for injury prevention purposes in active people. Stretching helps prepare the muscles,tendons, and the joint dense connective tissues including the cartilage be prepared for loading. I do not think that stretching makes you more flexible in your muscles per se though. So yes, before and after exercise, stretch. In Anderson and Anderson's classic book, Stretching, there is a great 10 minute daily total body stretching routine. In my mind, that's all one really needs to do as a routine stretching practice.

Beyond that, it is really up to you, and if you do more and feel better for it, by all means go ahead.

If you intend to stretch, it pays to warm up a bit before you do so. I suggest a 5 to 10 minute warm up before you stop and stretch, then you will be ready to compete, you joints and other dense connective tissues lubricated and hydrated, your muscles prepped for activity, and your brain in the mindset for competition.

Managing Acute Back Pain

I wrote an article for the Journal Orthopedic Clinics of North America a few years ago with my colleague Mike Kane, PT a physio in Yakima, WA. The premise was Functional Rehabilitation Strategies of the Lower Back. In that article I laid out the full picture, and also talked about acute lower back pain (LBP). Since 80% of people suffer lower back pain, and a third of them in the last 24 hours, I thought that I would share my successful strategy for dealing with acute back pain in greater detail.

First of all, realize that most episodes of lower back pain are self limiting. Very often, the pain will resolve within a few days, and 8 out of 10 times, within a month, 9 out of 10 times within 2 months.

Because we are not very good at diagnosing LBP (something like 15% of the time is a diagnosis determined to be accurate), the underlying cause is not really important in dealing with acute LBP.

The literature strongly suggests that a person suffering LBP should not curtail their activities. If you are a runner, keep running, a walker, keep walking, a swimmer, keep swimming.

But lets say you experience a severe episode of LBP with or without pain into the leg, you should know this: It is a medical emergency if you actually lose control of your bladder. If that happens, go to the ER immediately. You only have a limited amount of time to address this problem or you face the permanent loss of bladder control.

In the alternative, here is my fail safe almost 100% successful acute LBP treatment strategy:



1. Start out lying on your back on the floor in the 90/90 position with your legs up on a chair. Stay in this position for about a minute focusing on your breathing. Try to relax as you do so. The reason that this position is useful is that in this posture, the intra-discal pressure is the lowest it can be, and that usually means less pain.


2. In this position, start by dragging your right foot along the chair as you bring your knee toward your chest. Use your hip flexors and abdominal muscles to bring your knee up to your chest as far as you can. Try to move as quickly as you can PAIN FREE. When you achieve the maximum ROM, then push your foot back along the chair and repeat the move with your left leg. Repeat this activity back and forth 30 times with each leg. Remember, move as quickly as you can as far as you can, but drag rather than lift your leg.

3. The next exercise involves you bringing both legs up at the same time. Make sure to spread your knees apart as you do so in order to clear your pelvis. Again try to really curl up by engaging the lower abdominal muscles. Repeat 30 times. Be sure to drag your feet rather than lift them, and make sure the movement is as rapid as possible, but again, PAIN FREE.

4. The next exercise is desigend to engage the trunk in a rotational movement pattern. Wrap both arms around your chest and pick your head up. Keeping your butt on the ground, roll onto your right shoulder, then onto the left shoulder. Repeat 30 times in each direction as quickly as possible, PAIN FREE.

5. OPTIONAL. This exercise I make optional for people. The activity is in sidelying, but you have to roll up a blanket and put it under your ribs. Push it up to the arm pit to reduce the ROM, or further down to increase the ROM. Place the up arm on top of the body, and grab the top shoulder with the bottom arm. Perform 10 reps of side lifts PAIN FREE. Roll over, reposition the blanket and repeat on the other side.

Perform all these exercises 3 times through - it will take about 20 minutes.

The final exerise is key. You need to do this exericse at the conclusion of your previous exericses and again every hour throughout the day, or whenever you LBP irritates you.

6. Half sit on a table with your feet firmly planted on the floor shoulder width apart, your arms wrapped tightly around your chest, one arm above the other. Maintain an erect spine posture, but lean slightly forward at the waist. The exercise is a 5 minute drill of left and right rotation only. The key, as you might already guess, is to move as quickly as possible, PAIN FREE. Gradually increase the ROM as you do the exercise and can tolerate more motion.

Franky, this last exercise is almost magical. Almost everybody with very few exections will benefit from the exercise.

Finally, you need to use ice to inhibit the muscle guarding. In our clinic we have found that crushed ice plus a little water in a plastic bag right on the skin for 30 -40 minutes is the best solution. The reason this is important is that it takes 10 minutes for the ice to penetrate 1cm (about a half inch), and the muscles that are guarding live about 3 cm deep. So prolonged ice inhibits the pain, decreases muscle guarding and reduces edema that might be present.

Add to that 30 minutes of walking and you have a very very very effective acute LBP management program. We call this program Phase 1 LBP Managment.

Good luck

Return to Running after a Lateral Ankle Injury

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