We know that chiropractic care is more than meets the eye. People often think that a chiropractic doctor is limited to only providing back pain relief and neck pain relief. The total body benefits from chiropractic therapy and back pain treatment. Hands-on care is what you will receive to adjust the imbalances of your spine and entire skeletal system. Your body is composed of a balance of integrated parts and chiropractic medicine is a non-invasive health care system to keep it running smoothly.
Through a series of spinal manipulations, I will return your vertebrae to their proper placement. After manipulation of vertebrae to their correct position, restoration of the nervous system and total healing begins. My goal as your Philadelphia Chiropractor is to return you to perfect health through manipulation of your spine. My way to achieve this is without the use of painkillers or invasive surgery.
Our Chiropractic Services Include:
Walking upright on two feet has advantages, but it also puts intense pressure on the spine, as well as on other muscles and bones. Add to this improper sitting, lifting, or reaching—and the normal wear and tear of working and playing—and you have the perfect recipe for back pain. That’s why back pain is the 2nd most common reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections. In fact, some experts say, as many as 80% of us will experience a back problem at some time in our lives.1
Back injuries are a part of everyday life. They can cause a sharp pain or a dull ache and can be accompanied by a tingling, numbness, or burning sensation. You may also feel weakness, pain, or tingling in your pelvis and upper leg—a condition known as sciatica. The spine is quite good at dealing with back injuries. Minor injuries usually heal within a day or two. Some pain, however, continues. What makes it last longer is not entirely understood, but researchers suspect that stress, mood changes, and the fear of further injury may prevent patients from being active and exacerbate the pain.
Tips for Back Pain Prevention:
- Maintain a healthy diet and weight.
- Remain active—under the supervision of your doctor of chiropractic.
- Avoid prolonged inactivity or bed rest.
- Warm up or stretch before exercising or other physical activities, such as gardening.
- Maintain proper posture.
- Wear comfortable, low-heeled shoes.
- Sleep on a mattress of medium firmness to minimize any curve in your spine.
- Lift with your knees, keep the object close to your body, and do not twist when lifting.
- Quit smoking. Smoking impairs blood flow, resulting in oxygen and nutrient deprivation to spinal tissues.
- Work with your doctor of chiropractic to ensure that your workstation is ergonomically correct.
Chiropractic Treatment for Back Pain
If you experience back pain, consult your doctor of chiropractic. More than 30 million Americans sought chiropractic care last year alone. Past studies have indicated that consumers are very happy with the chiropractic care they receive.
With a thorough knowledge of the structure and functioning of the human body, doctors of chiropractic make diagnoses and take steps to correct problems using spinal adjustments, dietary and lifestyle advice, and other natural tools. Spinal manipulation—the primary form of treatment performed by doctors of chiropractic—is a recommended option for back pain treatment, rated as such by many state and workers’ compensation guidelines.
Research has shown that manipulative therapy and spinal manipulation are not only safe and effective, but can cut costs and get workers back on the job faster than other treatments. A recent medical study has also pointed out that manual manipulation offers better short-term relief of chronic back pain than medication.
Your neck, also called the cervical spine, begins at the base of the skull and contains seven small vertebrae. Incredibly, the cervical spine supports the full weight of your head, which is on average about 12 pounds. While the cervical spine can move your head in nearly every direction, this flexibility makes the neck very susceptible to pain and injury.
The neck’s susceptibility to injury is due in part to biomechanics. Activities and events that affect cervical biomechanics include extended sitting, repetitive movement, accidents, falls and blows to the body or head, normal aging, and everyday wear and tear. Neck pain can be very bothersome, and it can have a variety of causes.
Here are some of the most typical causes of neck pain:
Injury and Accidents: A sudden forced movement of the head or neck in any direction and the resulting “rebound” in the opposite direction is known as whiplash. The sudden “whipping” motion injures the surrounding and supporting tissues of the neck and head. Muscles react by tightening and contracting, creating muscle fatigue, which can result in pain and stiffness. Severe whiplash can also be associated with injury to the intervertebral joints, discs, ligaments, muscles, and nerve roots. Car accidents are the most common cause of whiplash.
Growing Older: Degenerative disorders such as osteoarthritis, spinal stenosis, and degenerative disc disease directly affect the spine.
- Osteoarthritis, a common joint disorder, causes progressive deterioration of cartilage. The body reacts by forming bone spurs that affect joint motion.
- Spinal stenosis causes the small nerve passageways in the vertebrae to narrow, compressing and trapping nerve roots. Stenosis may cause neck, shoulder, and arm pain, as well as numbness, when these nerves are unable to function normally.
- Degenerative disc disease can cause reduction in the elasticity and height of intervertebral discs. Over time, a disc may bulge or herniate, causing tingling, numbness, and pain that runs into the arm.
Daily Life: Poor posture, obesity, and weak abdominal muscles often disrupt spinal balance, causing the neck to bend forward to compensate. Stress and emotional tension can cause muscles to tighten and contract, resulting in pain and stiffness. Postural stress can contribute to chronic neck pain with symptoms extending into the upper back and the arms.
Chiropractic Care of Neck Pain
During your visit, your doctor of chiropractic will perform exams to locate the source of your pain and will ask you questions about your current symptoms and remedies you may have already tried. For example:
- When did the pain start?
- What have you done for your neck pain?
- Does the pain radiate or travel to other parts of your body?
- Does anything reduce the pain or make it worse?
Your doctor of chiropractic will also do physical and neurological exams. In the physical exam, your doctor will observe your posture, range of motion, and physical condition, noting movement that causes pain. Your doctor will feel your spine, note its curvature and alignment, and feel for muscle spasm. A check of your shoulder area is also in order. During the neurological exam, your doctor will test your reflexes, muscle strength, other nerve changes, and pain spread.
In some instances, your chiropractor might order tests to help diagnose your condition. An x-ray can show narrowed disc space, fractures, bone spurs, or arthritis. A computerized axial tomography scan (a CT or CAT scan) or a magnetic resonance imaging test (an MRI) can show bulging discs and herniations. If nerve damage is suspected, your doctor may order a special test called electromyography (an EMG) to measure how quickly your nerves respond.
Chiropractors are conservative care doctors; their scope of practice does not include the use of drugs or surgery. If your chiropractor diagnoses a condition outside of this conservative scope, such as a neck fracture or an indication of an organic disease, he or she will refer you to the appropriate medical physician or specialist. He or she may also ask for permission to inform your family physician of the care you are receiving to ensure that your chiropractic care and medical care are properly coordinated.
A neck adjustment (also known as a cervical manipulation) is a precise procedure applied to the joints of the neck, usually by hand. A neck adjustment works to improve the mobility of the spine and to restore range of motion; it can also increase movement of the adjoining muscles. Patients typically notice an improved ability to turn and tilt the head, and a reduction of pain, soreness, and stiffness.
Of course, your chiropractor will develop a program of care that may combine more than one type of treatment, depending on your personal needs. In addition to manipulation, the treatment plan may include mobilization, massage or rehabilitative exercises, or something else.
Sciatica describes persistent pain felt along the sciatic nerve, which runs from the lower back, down through the buttock, and into the lower leg. The sciatic nerve is the longest and widest nerve in the body, running from the lower back through the buttocks and down the back of each leg. It controls the muscles of the lower leg and provides sensation to the thighs, legs, and the soles of the feet.
Although sciatica is a relatively common form of low-back and leg pain, the true meaning of the term is often misunderstood. Sciatica is actually a set of symptoms—not a diagnosis for what is irritating the nerve root and causing the pain.
Sciatica occurs most frequently in people between the ages of 30 and 50 years old. Most often, it tends to develop as a result of general wear and tear on the structures of the lower spine, not as a result of injury.
What are the symptoms of sciatica?
The most common symptom associated with sciatica is pain that radiates along the path of the sciatic nerve, from the lower back and down one leg; however, symptoms can vary widely depending on where the sciatic nerve is affected. Some may experience a mild tingling, a dull ache, or even a burning sensation, typically on one side of the body.
Some patients also report:
• A pins-and-needles sensation, most often in the toes or foot
• Numbness or muscle weakness in the affected leg or foot
Pain from sciatica often begins slowly, gradually intensifying over time. In addition, the pain can worsen after prolonged sitting, sneezing, coughing, bending, or other sudden movements.
How is sciatica diagnosed?
Your doctor of chiropractic will begin by taking a complete patient history. You’ll be asked to describe your pain and to explain when the pain began, and what activities lessen or intensify the pain. Forming a diagnosis will also require a physical and neurological exam, in which the doctor will pay special attention to your spine and legs. You may be asked to perform some basic activities that will test your sensory and muscle strength, as well as your reflexes. For example, you may be asked to lie on an examination table and lift your legs straight in the air, one at a time.
In some cases, your doctor of chiropractic may recommend diagnostic imaging, such as x-ray, MRI, or CT scan. Diagnostic imaging may be used to rule out a more serious condition, such as a tumor or infection, and can be used when patients with severe symptoms fail to respond to six to eight weeks of conservative treatment.
What are my treatment options?
For most people, sciatica responds very well to conservative care, including chiropractic. Keeping in mind that sciatica is a symptom and not a stand-alone medical condition, treatment plans will often vary depending on the underlying cause of the problem.
Chiropractic offers a non-invasive (non-surgical), drug-free treatment option. The goal of chiropractic care is to restore spinal movement, thereby improving function while decreasing pain and inflammation. Depending on the cause of the sciatica, a chiropractic treatment plan may cover several different treatment methods, including but not limited to spinal adjustments, ice/heat therapy, ultrasound, TENS, and rehabilitative exercises.
An Ounce of Prevention Is Worth a Pound of Cure
While it’s not always possible to prevent sciatica, consider these suggestions to help protect your back and improve your spinal health.
• Maintain a healthy diet and weight
• Exercise regularly
• Maintain proper posture
• Avoid prolonged inactivity or bed rest
• If you smoke, seek help to quit
•Use good body mechanics when lifting
If you spend a large amount of time in one fixed position, such as in front of a computer, on a sewing machine, typing or reading, take a break and stretch every 30 minutes to one hour. The stretches should take your head and neck through a comfortable range of motion.
Low-impact exercise may help relieve the pain associated with primary headaches. However, if you are prone to dull, throbbing headaches, avoid heavy exercise. Engage in such activities as walking and low-impact aerobics.
Avoid teeth clenching. The upper teeth should never touch the lowers, except when swallowing. This results in stress at the temporomandibular joints (TMJ) – the two joints that connect your jaw to your skull – leading to TMJ irritation and a form of tension headaches.
Drink at least eight 8-ounce glasses of water a day to help avoid dehydration, which can lead to headaches.
Perform spinal manipulation or chiropractic adjustments to improve spinal function and alleviate the stress on your system.
Provide nutritional advice, recommending a change in diet and perhaps the addition of B complex vitamins.
Offer advice on posture, ergonomics (work postures), exercises and relaxation techniques. This advice should help to relieve the recurring joint irritation and tension in the muscles of the neck and upper back.
Whiplash is a generic term applied to injuries of the neck caused when the neck is suddenly and/or violently jolted in one direction and then another, creating a whip-like movement. Whiplash is most commonly seen in people involved in motor vehicle accidents, but it can also occur from falls, sports injuries, work injuries, and other incidents.
What structures are injured in a whiplash?
Whiplash injuries most often result in sprain-strain of the neck. The ligaments that help support, protect, and restrict excessive movement of the vertebrae are torn, which is called a sprain. The joints in the back of the spine, called the facet joints, are covered by ligaments called facet capsules, which seem to be particularly susceptible to whiplash injury.
In addition, the muscles and tendons are strained—stretched beyond their normal limits. The discs between the vertebrae, which are essentially ligaments, can be torn, potentially causing a disc herniation. The nerve roots between the vertebrae may also be stretched and become inflamed. Even though it is very rare, vertebrae can be fractured and/or dislocated in a whiplash injury.
What are the common signs and symptoms of whiplash?
The most common symptoms of whiplash are pain and stiffness in the neck. These symptoms are generally found in the areas that are “whiplashed.” For example, during a whiplash, first the head is lifted up from the upper-cervical spine. This creates a sprain/strain in the region just below the skull, where symptoms usually occur. Symptoms may also commonly be seen in the front and back of the neck. Turning the head often makes the pain and discomfort worse.
Headache, especially at the base of the skull, is also a common symptom, seen in more than two thirds of patients. These headaches may be one-sided (unilateral) or experienced on both sides (bilateral). In addition, the pain and stiffness may extend down into the shoulders and arms, upper back, and even the upper chest.
In addition to the musculoskeletal symptoms, some patients also experience dizziness, difficulty swallowing, nausea, and even blurred vision after a whiplash injury. While these symptoms are disconcerting, in most cases, they disappear within a relatively short time. If they persist, it is very important to inform your doctor that they are not resolving. Vertigo (the sensation of the room spinning) and ringing in the ears may also be seen. In addition, some patients may feel pain in the jaw. Others will even complain of irritability, fatigue, and difficulty concentrating. These symptoms also resolve quickly in most cases. In rare cases, symptoms can persist for weeks, months, or even years.
Another important and interesting aspect of whiplash is that the signs and symptoms often do not develop until 2 to 48 hours after the injury. This scenario is relatively common but not completely understood. Some speculate that it may be due to delayed muscle soreness, a condition seen in other circumstances.
How is whiplash treated?
One of the most important aspects of whiplash management is for the patient to stay active, unless there is some serious injury that requires immobilization. Patients should not be afraid to move and be active, within reason. In addition, your doctor will often prescribe an exercise or stretching program. It is particularly important to follow this program as prescribed, so that you can achieve the best long-term benefits.
Chiropractic manipulation and physical therapy
Ice and/or heat are often used to help control pain and reduce the muscle spasm that results from whiplash injuries. Other physical therapy modalities, such as electrical stimulation and/or ultrasound, may provide some short-term relief. They should not, however, replace an active-care program of exercise and stretching. Spinal manipulation and/or mobilization provided by a chiropractor can also give relief in many cases of neck pain.
Can whiplash be prevented?
Generally speaking, whiplash cannot be “prevented,” but there are some things that you can do while in a motor vehicle that may reduce the chances of a more severe injury. Always wear restraints (lap or shoulder belt), and ensure that the headrest in your vehicle is adjusted to the appropriate height.
Widespread pain in all 4 quadrants of the body for a minimum of 3 months; and
Tenderness or pain in at least 11 tender points when pressure is applied. These tender points cluster around the neck, shoulder, chest, hip, knee, and elbow regions.
Dizziness or lightheadedness
Cognitive or memory impairment
Malaise and muscle pain after exertion
Numbness and tingling sensations
Skin and chemical sensitivities
Other rheumatic diseases
Allergies and nutritional deficiencies
Disorders that cause pain, fatigue, and other fibromyalgia-like symptoms.
Studies have shown that a combination of 300 to 600 mg of magnesium per day, along with malic acid, may significantly reduce may significantly reduce the number of tender points and the pain felt at those that remain. B vitamins may also be helpful.
Eating more omega-3 fatty acids and fewer saturated fats has shown promise in fibromyalgia patients. Limit red meat and saturated fats and increase the amounts of omega-3 fatty acids by including fish, flax, and walnut oils in your diet. Fatty acid deficiencies can interfere with the nervous system and brain function, resulting in depression and poor memory and concentration.
Improving the quality of sleep can help reduce fatigue. Watch your caffeine intake, especially before going to bed. Reduce TV and computer time. If you watch TV in the evening, choose relaxing, funny programs instead of programs with violent or disturbing content. Ask your doctor of chiropractic for other natural ways to help you sleep better.
Stress-managing strategies can also help address anxiety or depression issues. Cognitive therapy has been shown helpful in relieving fibromyalgia patients’ negative emotions and depression by changing their perception of themselves and attitudes toward others.
A traditional gym-based or aerobic exercise program may exacerbate fibromyalgia symptoms and is not recommended. Instead, yoga, Pilates, or tai chi—which offer mild stretching, relaxation, and breathing techniques—may work better than vigorous exercise.
Studies have shown that acupuncture is another effective, conservative approach to treating fibromyalgia symptoms and many doctors of chiropractic offer this service right in their offices.
Chiropractic care has consistently ranked as one of the therapeutic approaches that offer the most relief for the fibromyalgia patient. Your doctor of chiropractic can also include massage therapy, ultrasound and electrical stimulation in the treatment program, which may help relieve stress, pain, and other symptoms.
Years ago, doctors hardly ever told rheumatoid arthritis patients to “go take a hike” or “go for a swim.” Arthritis was considered an inherent part of the aging process and a signal to a patient that it’s time to slow down. But not so anymore. Recent research and clinical findings show that there is much more to life for arthritis patients than the traditional recommendation of bed rest and drug therapy.
What Is Rheumatoid Arthritis?
The word “arthritis” means “joint inflammation” and is often used in reference to rheumatic diseases. Rheumatic diseases include more than 100 conditions, including gout, fibromyalgia, osteoarthritis, psoriatic arthritis, and many more. Rheumatoid arthritis is also a rheumatic diseases, affecting about 1 percent of the U.S. population (about 2.1 million people.)1 Although rheumatoid arthritis often begins in middle age and is more frequent in the older generation, it can also start at a young age.
Rheumatoid arthritis causes pain, swelling, stiffness, and loss of function in the joints. Several features distinguish it from other kinds of arthritis:
- Tender, warm, and swollen joints.
- Fatigue, sometimes fever, and a general sense of not feeling well.
- Pain and stiffness lasts for more than 30 minutes after a long rest.
- The condition is symmetrical. If one hand is affected, the other one is, too.
- The wrist and finger joints closest to the hand are most frequently affected. Neck, shoulder, elbow, hip, knee, ankle, and feet joints can also be affected.
- The disease can last for years and can affect other parts of the body, not only the joints.2
Rheumatoid arthritis is highly individual. Some people suffer from mild arthritis that lasts from a few months to a few years and then goes away. Mild or moderate arthritis have periods of worsening symptoms (flares) and periods of remissions, when the patient feels better. People with severe arthritis feel pain most of the time. The pain lasts for many years and can cause serious joint damage and disability.
Should Arthritis Patients Exercise?
Exercise is critical in successful arthritis management. It helps maintain healthy and strong muscles, joint mobility, flexibility, endurance, and helps control weight. Rest, on the other hand, helps to decrease active joint inflammation, pain, and fatigue. For best results, arthritis patients need a good balance between the two: more rest during the active phase of arthritis, and more exercise during remission.2 During acute systematic flares or local joint flares, patients should put joints gently through their full range of motion once a day, with periods of rest. To see how much rest is best during flares, patients should talk to their health care providers.3
The following exercises are most frequently recommended for patients with arthritis:*
Range-of-motion exercises, e.g. stretching and dance Help maintain normal joint movement and increase joint flexibility. Can be done daily and should be done at least every other day. Strengthening exercises, e.g. weight lifting Help improve muscle strength, which is important to support and protect joints affected by arthritis. Should be done every other day, unless pain and swelling are severe. Aerobic or endurance exercises, e.g. walking, bicycle riding, and swimming Help improve the cardiovascular system and muscle tone and control weight. Swimming is especially valuable because of its minimal risk of stress injuries and low impact on the body. Should be done for 20 to 30 minutes three times a week unless pain and swelling are severe.
* Adapted from Questions and Answers about Arthritis and Exercise.3
If patients experience
- Unusual or persistent fatigue,
- Increased weakness,
- Decreased range of motion,
- Increased joint swelling, or
- Pain that lasts more than one hour after exercising,
they need to talk to their health care provider.3 Doctors of chiropractic will help arthritis patients develop or adjust their exercise programs to achieve maximum health benefits with minimal discomfort and will identify the activities that are off limits for this particular arthritis patient.
Nutrition for the Rheumatoid Arthritis Patient
Arthritis medications help suppress the immune system and slow the progression of the disease. But for those who prefer an alternative approach, nutrition may provide complementary support. Some evidence shows that nutrition can play a role in controlling the inflammation, and possibly also in slowing the progression of rheumatoid arthritis.
Some foods and nutritional supplements can be helpful in managing arthritis:
- Fatty-acid supplements: eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and gamma linolenic acid (GLA). Several studies point to the effectiveness of these fatty acid supplements in reducing joint pain and swelling, and lessening reliance on corticosteroids.4,5
- Deep-sea fish, such as salmon, tuna, herring, and halibut, are sources of EPA and DHA. GLA is found in very few food sources, such as black currants and borage seed.
- Turmeric, a spice that’s used to make curry dishes, may also be helpful. A 95 percent curcuminoid extract has been shown to significantly inhibit the inflammatory cascade and provide relief of joint inflammation and pain.
- Ginger extract has been shown to be beneficial in terms of inflammation.
- Nettle leaf extract may inhibit some inflammatory pathways.
- A vegetarian or low-allergen diet can help with the management of rheumatoid arthritis as well.
The benefits and risks of most of these agents are being researched. Before taking any dietary supplement, especially if you are using medication to control your condition, consult with your health care provider.
What Can Your Doctor of Chiropractic Do?
If you suffer from rheumatoid arthritis, your doctor of chiropractic can help you plan an individualized exercise program that will:
- Help you restore the lost range of motion to your joints.
- Improve your flexibility and endurance.
- Increase your muscle tone and strength.
Doctors of chiropractic can also give you nutrition and supplementation advice that can be helpful in controlling and reducing joint inflammation.
Carpal tunnel syndrome (CTS)
Carpal tunnel syndrome (CTS) is the most expensive of all work-related injuries. Over his or her lifetime, a carpal tunnel patient loses about $30,000 in medical bills and time absent from work.
CTS typically occurs in adults, with women 3 times more likely to develop it than men. The dominant hand is usually affected first, and the pain is typically severe. CTS is especially common in assembly-line workers in manufacturing, sewing, finishing, cleaning, meatpacking, and similar industries. Contrary to the conventional wisdom, according to recent research, people who perform data entry at a computer (up to 7 hours a day) are not at increased risk of developing CTS.
What Is CTS?
CTS is a problem of the median nerve, which runs from the forearm into the hand. CTS occurs when the median nerve gets compressed in the carpal tunnel—a narrow tunnel at the wrist—made up of bones and soft tissues, such as nerves, tendons, ligaments, and blood vessels. The compression may result in pain, weakness, and/or numbness in the hand and wrist, which radiates up into the forearm. CTS is the most common of the “entrapment neuropathies”—compression or trauma of the body’s nerves in the hands or feet.
What Are the Symptoms?
Burning, tingling, itching, and/or numbness in the palm of the hand and thumb, index, and middle fingers are most common. Some people with CTS say that their fingers feel useless and swollen, even though little or no swelling is apparent. Since many people sleep with flexed wrists, the symptoms often first appear while sleeping. As symptoms worsen, they may feel tingling during the day. In addition, weakened grip strength may make it difficult to form a fist or grasp small objects. Some people develop wasting of the muscles at the base of the thumb. Some are unable to distinguish hot from cold by touch.
Why Does CTS Develop?
Some people have smaller carpal tunnels than others, which makes the median nerve compression more likely. In others, CTS can develop because of an injury to the wrist that causes swelling, over-activity of the pituitary gland, hypothyroidism, diabetes, inflammatory arthritis, mechanical problems in the wrist joint, poor work ergonomics, repeated use of vibrating hand tools, and fluid retention during pregnancy or menopause.
How Is It Diagnosed?
CTS should be diagnosed and treated early. A standard physical examination of the hands, arms, shoulders, and neck can help determine if your symptoms are related to daily activities or to an underlying disorder.
Your doctor of chiropractic can use other specific tests to try to produce the symptoms of carpal tunnel syndrome. The most common are:
- Pressure-provocative test. A cuff placed at the front of the carpal tunnel is inflated, followed by direct pressure on the median nerve.
- Carpal compression test. Moderate pressure is applied with both thumbs directly on the carpal tunnel and underlying median nerve at the transverse carpal ligament. The test is relatively new.
Laboratory tests and x-rays can reveal diabetes, arthritis, fractures, and other common causes of wrist and hand pain. Sometimes electrodiagnostic tests, such as nerveconduction velocity testing, are used to help confirm the diagnosis. With these tests, small electrodes, placed on your skin, measure the speed at which electrical impulses travel across your wrist. CTS will slow the speed of the impulses and will point your doctor of chiropractic to this diagnosis.
What Is the CTS Treatment?
Initial therapy includes:
- Resting the affected hand and wrist
- Avoiding activities that may worsen symptoms
- Immobilizing the wrist in a splint to avoid further damage from twisting or bending
- Applying cool packs to help reduce swelling from inflammations
Some medications can help with pain control and inflammation. Studies have shown that vitamin B6 supplements may relieve CTS symptoms.
Chiropractic joint manipulation and mobilization of the wrist and hand, stretching and strengthening exercises, soft-tissue mobilization techniques, and even yoga can be helpful. Scientists are also investigating other therapies, such as acupuncture, that may help prevent and treat this disorder.
Occasionally, patients whose symptoms fail to respond to conservative care may require surgery. The surgeon releases the ligament covering the carpal tunnel. The majority of patients recover completely after treatment, and the recurrence rate is low. Proper posture and movement as instructed by your doctor of chiropractic can help prevent CTS recurrences.
How Can CTS Be Prevented?
The American Chiropractic Association recommends the following tips:
- Perform on-the-job conditioning, such as stretching and light exercises.
- Take frequent rest breaks.
- Wear splints to help keep the wrists straight.
- Use fingerless gloves to help keep the hands warm and flexible.
- Use correct posture and wrist position.
- To minimize workplace injuries, jobs can be rotated among workers. Employers can also develop programs in ergonomics—the process of adapting workplace conditions and job demands to workers’ physical capabilities.
A muscle cramp can bring a jogger to his knees or elicit the fear of drowning in a swimmer; however, athletes are not the only individuals to experience a muscle cramp or spasm. According to one estimate, approximately 95 percent of people will at some time in life experience the sudden, sharp pain associated with a muscle cramp.
A muscle spasm is an involuntary contraction of a muscle, part of a muscle, or several muscles that usually act together. If the spasm is forceful and sustained, it becomes a cramp. Most people describe a muscle cramp as a feeling of tightness in the muscle; it’s not unusual to feel a lump of hard muscle tissue underneath the skin in the vicinity of the cramp. During a spasm or cramp, it may be painful, or even difficult, to use the affected muscle or muscle group.
Cramps and spasms can affect any muscle, even those affiliated with the body’s various organs; however, they are most common in the calves, hamstrings, and quadriceps. Cramps in the feet, hands, arms, and lower back occur frequently, as well.
Many possible causes
Common as they are and painful as they can be, a shroud of mystery surrounds the cause of muscle spasms and cramps. Some researchers believe that inadequate stretching and muscle fatigue lead to cramps. According to the University of Michigan, other possible factors include a low level of fitness, overexertion (especially in intense heat), stress, and depletion of electrolytes through excess sweating or dehydration. Certain diuretic medications can also cause cramping due to a loss of sodium, potassium, and magnesium.
Treatment of muscle spasms
Typically, muscle cramps require no treatment other than patience and stretching; medicines are not generally needed to treat an ordinary muscle cramp. Gentle and gradual stretching, along with massage, may ease the pain and hasten recovery.
When a muscle spasm or cramp is the result of an injury, applying ice packs for the first two to three days may help alleviate the pain. Spasms that last a long time may be treated with moist heat for 20 minutes several times a day.
If you tend to get muscle cramps during exercise, make sure you drink enough fluids, and, after your workout, consider a warm Epsom salt bath followed by stretching of the affected muscles. Generally speaking, water is sufficient for rehydration; however, some may find a sports drink or juice beneficial as a means to restore their body’s electrolyte balance.
If your muscle cramps are associated with a specific medical condition, keep in mind that you need to address the underlying health problem for the cramps to subside.
Tips for Prevention
As with any health condition, it is always best to prevent muscle cramps or spasms—especially if you tend to develop them. Consider altering your diet and lifestyle by incorporating the following suggestions:
- Take steps to improve your diet. Eliminate sugar and caffeine from the diet, and increase consumption of fiber and protein. In addition, remember to eat plenty of calcium- and magnesium- rich foods, such as green leafy vegetables, yogurt, legumes, whole grains, tofu, and Brazil nuts. High-potassium foods, including bananas, avocados, lima beans, and fish, may also be helpful.
- Before and after you exercise, stretch muscle groups that tend to cramp.
- Incorporate strengthening exercises into your fitness routine.
- Avoid dehydration. To prevent dehydration, consume plenty of fluids and foods high in water such as fruits and vegetables.
- Avoid excess sodium and soda (high in phosphoric acid), as they can leach calcium.
- Avoid chocolate, caffeine, and alcohol, which can interfere with magnesium absorption.
- Improve your posture. For example, you may have mid-back spasms after sitting at a computer desk for too long in an awkward position.
Vitamin E has been said to help minimize cramp occurrence. Although scientific studies documenting this effect are lacking, anecdotal reports are common and fairly enthusiastic. Since vitamin E is thought to have other beneficial health effects and is not toxic in usual doses, taking 400 units of vitamin E daily could be considered.
Discuss with your doctor of chiropractic if your cramps are severe, happen frequently, respond poorly to simple treatments, or are not related to obvious causes like strenuous exercise. These could indicate a possible problem with circulation, nerves, metabolism, hormones, medications, and/or nutrition.
Participation in sports or exercise is an important step in maintaining your health. Exercise strengthens your heart, bones, and joints and reduces stress, among many other benefits. Unfortunately, injuries during participation in sports are all too common. Often, these injuries occur in someone who is just taking up sports as a form of activity, doesn’t use proper safety equipment, or becomes overzealous about the exercise regimen.
The more commonly injured areas of the body are the ankles, knees, shoulders, elbows, and spine. Remember that you should discuss any exercise program with your doctor of chiropractic before undertaking such activities.
Strains and Sprains
Although bones can sometimes be fractured with acute sports injuries, the most commonly injured structures are the muscles, tendons, and ligaments. Tendons attach muscles to bones, and ligaments attach one bone to another.
An acute twisting or overextension of a joint can lead to tears of muscles and tendons, called “strains,” and tears of ligaments result in “sprains.” These tears range from mild to severe. In mild injuries, just a few fibers are torn or stretched. Severe injuries, where there is a tear through the full thickness of the structure, are most often considered unstable injuries and frequently require surgical intervention. The intervertebral disc, a ligament between the vertebrae of the spine that works as a shock absorber, can also be torn, resulting in a disc bulge and/or herniation.
Ankle sprains most often involve tears of one or more of the ligaments along the outside of the ankle. Knee ligaments, including the larger external supportive ligaments and the smaller internal stabilizing ligaments, can also be torn. The cartilage on the back of the patella (knee-cap) can also become eroded from overuse, leading to a condition termed chondromalacia patella.
In those who are training too much, overuse of a particular joint or joints in the body can result in pain and dysfunction. These injuries are called “overuse syndromes.” A common overuse injury is tendinosis, also called tendinitis. In this condition, the tendon becomes inflamed from repetitive use. In the shoulder, the rotator cuff (a complex of muscles that stabilizes and moves the shoulder) becomes inflamed, resulting in rotator cuff tendinitis. Tennis elbow is another form of tendinitis that occurs along the outside of the elbow, most commonly in tennis players. In golfer’s elbow, the tendons on the inside of the elbow are affected.
Some athletes may experience a stress fracture, also called a fatigue fracture. This type of fracture occurs when an abnormal amount of stress is placed on a normal bone. This might occur in a runner who rapidly increases the amount of mileage while training for a race. Stress fractures also occur in people who begin running as a form of exercise but overdo it from the start, rather than gradually progress to longer distances.
One final common injury is worth mentioning, and that is shin splints. This overuse injury is caused by microfractures on the front surface of the tibia (shin bone). This is most often seen in runners, although other athletes can also be affected.
Diagnosis and Treatment
Sports injuries are most often diagnosed from the history of the activity that brought on the pain, along with a physical examination. In some cases, x-rays are necessary to rule out a fracture. Magnetic resonance imaging (MRI) and diagnostic ultrasound are also used in finding soft-tissue injuries, like tendinitis and sprains.
Fractures require the application of some stabilizing device, such as a cast, after the bone is put back into position. Rarely, surgical intervention is required. There is a relatively standard treatment protocol for most of the other overuse types of injuries. This protocol involves the following:
Generally no more than 48 hours of rest and/or immobilization is needed, depending on the severity of the injury. In most cases, the sooner the person becomes active after an injury, the more rapid is the recovery. In fact, long-term immobilization can sometimes be harmful to recovery. Your doctor of chiropractic will guide this process, as too early a return to activity, choosing the wrong type of activity, or excessive activity can be detrimental.
Ice or heat
Ice or heat can be helpful with pain reduction and tissue healing.
Compression of the area may reduce the amount of swelling from the injury. Your doctor of chiropractic will determine if this will be beneficial in your case.
Elevation of the injured arm or leg above the level of the heart is thought to be helpful in reducing swelling.
Recent research has demonstrated that some nonsteroidal anti-inflammatory drugs may actually slow the healing process by restricting the body’s natural healing mechanisms, so they should be used sparingly.
Recent research has shown us that, in some cases, joint manipulation can be helpful with pain reduction and more rapid recovery. Your doctor of chiropractic will determine if this procedure will be helpful in your case.
A Word about Prevention
In many cases, sports injuries can be prevented. Proper conditioning and warm-up and cool-down procedures, as well as appropriate safety equipment, can substantially reduce injuries. Understanding proper techniques can also go a long way toward preventing injuries.
Sufficient water intake is also an important preventive measure.
When a patient comes into a chiropractic office complaining of non-incapacitating, non-traumatic neck pain, there are three things the doctor of chiropractic (DC) should always remember:
1) Chances are good this isn’t the first time the patient has experienced this pain.
2) Chances are even better it won’t be the last.
3) If it’s just a stiff neck, and not seriously incapacitating or due to recent severe trauma, it’s likely to get better on its own in about three days. With treatment, however, it’s likely to get better in about … 72 hours.
“It’s often a self-limiting problem,” says Pete Fernandez DC, a Seminole, Fla., doctor of chiropractic, practice consultant, and the author of 20 books, including Neck Pain, Neck Pain, You Don’t Want It, You Don’t Need It. “I’m sure this will cause a stir, but I’ve found that a much easier way of treating this problem (torticollis)—a way that makes the patients happy and doesn’t hurt them—is, don’t treat it.”
Neck pain remains one of the most widely suffered maladies of modern life. Depending on the definition of just what constitutes “neck pain,” up to an estimated 71.5 percent of the general population will experience the problem in a given year. For most, it will not seriously affect their normal routines.
A New Model
“You’re not helpless,” assures Dr. Scott Haldeman, clinical professor in the Department of Neurology at the University of California at Irvine and adjunct professor in the Department of Epidemiology at the University of California at Los Angeles. “You just have to realize that you have limitations, and then treat patients with neck pain according to the most current clinical guidelines and teach them how to reduce their pain through proper lifestyle steps. There’s a lot you can do. But you have to change the classically-taught decision-making paradigm on how to manage neck pain.”
Dr. Haldeman is uniquely qualified to speak to this issue. He is both a medical doctor and a doctor of chiropractic. He suggests the best first step for any health care provider who sees patients with neck pain is to spend time reading the results of the Neck Pain Task Force. “This is where every spine-care clinician should start his or her search on what to do,” says Dr. Haldeman, who chaired the task force.
The task force, a multinational, multimilliondollar venture sponsored by the United Nations/ World Health Organization Decade of the Bone and Joint Initiative, met for eight years, 2002-2010, reviewed more than 1,200 scientific articles and conducted original research projects. The results were published in three peer-reviewed journals: European Spine Journal, Journal of Manipulative and Physiological Therapeutics and Spine.
“It’s the most widely published task force on any spinal condition, ever,” Dr. Haldeman says. “Wherever you go after that, the first thing you realize is that we’re dealing with a new model of neck pain. Much of what all of us learned about neck pain, we can throw out the window. We must realize that it’s not a curable disease. It’s a chronic recurring condition.”
Once a patient presents with neck pain, it’s crucial to screen for serious pathology, Dr. Haldeman says. He agrees with Dr. Fernandez that for minor neck pain—a simple stiff neck, such as seen in torticollis— most people get better in a few days without treatment, though manipulation, anti-inflammatories and possibly acupuncture can bring some pain relief. But screening is critical.
“If I’m dealing with neck pain that is just intermittent, that’s just starting, it gets treated one way. If it’s severe or incapacitating, it gets treated another,” he says. Neck pain that is only slightly incapacitating, but that raises no red flags for serious pathology or nerve injury and is confined solely to the neck, can often be successfully treated in the short term. But, Dr. Haldeman warns, there are no guarantees, and some sufferers never obtain complete relief.
Dr. Haldeman cites three common mistakes practitioners often make: not screening properly, ordering too many tests and then interpreting them incorrectly, and prolonging treatments that aren’t working.
“It a patient doesn’t respond within two to four weeks, then the current treatment that is being offered isn’t working and shouldn’t be continued,” he says.
Dr. Fernandez says once a doctor has identified the cause of the problem, and knows that it is a condition that can be managed by a DC—not a disease or a broken bone—that is causing the pain, the first objective is pain relief, reduction of swelling if there is any and reduction of spasms the patient may be experiencing.
“Knock out the pain, knock out the swelling, knock out the spasm. Then the patient is ready to go into any kind of corrective or rehabilitative care,” he says.
Dr. Fernandez likes to prescribe exercises to patients with simple stiff necks and torticollis to relieve spastic muscles. He suggests the patient turn his or her head as far as possible to the nonpainful side, then place a finger on the jaw and help turn it another half-inch. Then slowly bring the chin around to the painful side. Do this about three times, each time slowly increasing the range of motion to the painful side.
“Then you let an hour go by and you do it again,” he says.
Finally, he prescribes manganese phytate to relax the tissues, Vitamin E to increase circulation and bromelain to reduce inflammation, each taken four times a day.
“Then I put them in a soft cervical collar, and the patient will sigh a large sigh of relief,” he says. “I tell them to call me in three days and tell me if they have any pain. If they do, they come back and proceed to a more extensive treatment. But 99 percent don’t need to.”
Almost as important as treating the patient’s pain is simultaneously lowering the patient’s expectations, Dr. Fernandez says. “They expect to get well immediately,” he says. “While a chiropractor is extremely well trained, the body has to have a chance to heal, and a doctor has to have a chance to correct the problem. Every now and then a doctor gets lucky and treats a patient once or twice and it’s all gone. But that’s not the norm.”
The most efficient neck therapy is preventive, doctors say. By talking to patients about risk factors, and activities that can increase or decrease neck-pain symptoms, doctors can help many patients avoid neck problems before they ever develop.
“Most of us simply don’t spend enough time talking to patients about risk factors,” Dr. Haldeman says.
Dr. Fernandez advises offering regular neck-pain prevention and relief classes to patients. “If a patient comes in with pain, and I fix their neck, then they go home and sleep on their stomach for eight hours, they’ll wring their neck back out of place. They need to know what kind of pillow to sleep on, what kind of mattress to buy. They need to know what they should and shouldn’t do, like using rearview mirrors instead of turning their head around and looking at traffic behind them. They need to think about how they can change their activities of daily living to take better care of themselves.”
Arm and Shoulder
HIP PAIN CAN MAKE IT DIFFICULT TO FUNCTION. It hurts to walk and to sit. The conservative care offered by doctors of chiropractic (DCs) is a great first option for patients to consider when suffering from hip problems. Many benefits flow to the patient who seeks chiropractic first.
Larry Wyatt, DC, DACBR, FICC, professor/ senior faculty, division of clinical sciences at Texas Chiropractic College, notes that many causes of hip pain are biomechanical. “Given the manual medicine approach that chiropractors take, manual therapies such as mobilization, manipulation and therapeutic exercise, along with ergonomic training, can be quite helpful in managing these patients,” he says.
Leo Bronston, DC, MAppSc, vice president of ACA’s Council of Delegates and owner of six chiropractic clinics in Wisconsin, points out that because technology is changing so fast, leading to many advancements in hip surgery, the longer a patient can put off an inevitable hip replacement, the better the outcome.
Dr. Bronston sees patients generally presenting with pain that occurs during an activity or functional event. He explains that when the DC identifies the hip pathology and related structures involved, he or she can create a treatment plan, such as loosening up the soft tissues, creating traction with the hip to gain more space and breaking up adhesions or restrictions. “It prolongs the use of the body so the patient can plan out when to have a hip replacement,” he says.
Another benefit is to have immediate relief without resorting to pharmacology. That should be a last resort, because it’s not hip specific and can affect other functions. “Chiropractic can prolong a patient’s expectancy to be pain-free and the ability to function without resorting to drugs or surgery for a longer period,” Dr. Bronston says.
The Hip or the Spine?
Both DCs agree that from their perspective, the general treatment options for the spine and hip are similar, given that you will be managing biomechanical problems in the hip. But Dr. Bronston points out that the hip takes him longer to care for in a clinical session than an uncomplicated lowerback problem.
He explains why. “A lot of uncomplicated lower back and spinal conditions are requiring the DC to address the specific area of complaint, so for example you take care of just the spinal segment and maybe look at some pelvic alignment as well. But when you examine the hip, you have a complex muscular system that is a pivot point between your spine and your foot.”
Dr. Wyatt also points out that management of a hip condition does afford the clinician the use of appliances such as walkers and canes, which are typically not useful for spine disease. His experience is that long axis traction maneuvers and circumduction exercises, both passive and active, are helpful with hip pathology but not particularly helpful for spine disease.
Testing and Diagnosis
The primary way a DC knows the patient is dealing with a hip problem is via testing. Hip issues can make for a difficult differential diagnosis, so the DC has to use several tools to determine the source of the pain.
“There are some well-designed physical exam procedures and orthopedic tests that can diagnose hip disease with a high degree of certainty,” says Dr. Wyatt. Dr. Bronston uses orthopedic tests, including the range-of-motion test.
“The challenge is that these tests and procedures are not as accurate at defining the exact nature of the pathology,” says Dr. Wyatt.
Dr. Bronston says that when the hip has mechanical pathology, it may throw off the patient’s gait, which can affect the lower back as well as the pelvis and the knee. Dr. Wyatt notes that the distinctive gait pattern is called a lurch and is an attempt by the patient to shift his or her weight to avoid causing hip pain.
The location of the pain is also helpful. “Patients with hip joint pathology often point to the area of maximum pain intensity in the groin approximately halfway between the ASIS and the symphysis pubis,” says Dr. Wyatt. “While other areas of discomfort might be present, this anterior region tends to be most painful in patients with true hip joint pathology.”
“A clinical history of difficulty bringing the foot up to put on socks or shoes, activities involve twisting the hip, difficulty with stairs and sitting and rising from a seated position all suggest hip pathology,” Dr. Wyatt adds.
Sometimes, patients can have lumbar spine and hip pathology at the same time. This adds to the confusion, but testing and imaging are usually successful at telling between them.
Dr. Bronston believes the most important takeaway is when examining even the lower back, the DC needs to look at the hip because often, especially in an aging population, the hip has degenerative changes or may have labral tears that can be identified by an orthopedic examination and/ or imaging depending on whether it’s soft tissue or bony degenerative changes. “It’s a multitude of tests that have to be utilized and then try to narrow down to where the source of the pain and dysfunction is emanating from. But it is not always decisively related to one area,” he says.
Common Hip Injuries
“The most likely hip pathology seen in adults by DCs is degenerative joint disease,” says Dr. Wyatt. It produces hip stiffness and substantial alterations in a patient’s normal activities of daily living.
While he does treat a lot of degenerative hips, Dr. Bronston is presented with more cases of hip impingement syndromes and is now seeing surgical procedures used for its treatment, which was not the case five or ten years ago. He usually relieves impingement with chiropractic techniques, such as extremity mobilization to the hip and other soft-tissue and ancillary modalities. “I question, from a clinical perspective, whether more people are getting impingement surgically repaired when they should try something more conservative,” he says. “I think anyone needs to look at the evidence and the long-term effect of having that surgery as opposed to trying conservative intervention.”
Dr. Wyatt says, “Other common pathologies of the hip include muscle strains, capsular sprains and bursitis. In addition, hypertonicity/spasm of the tensor fascia lata muscle may lead to biomechanical alterations in the hip and may contribute to reduced performance and pain in athletes.” One other problem to be considered in patients with hip/anterior thigh pain is meralgia paresthetica (MP). Dr. Wyatt explains that in MP, “there is entrapment of the lateral femoral cutaneous nerve, often in obese patients. Manual therapies, along with weight loss, can be helpful in some of these cases.”
Dr. Bronston recently took part in a multidisciplinary intervention, when a patient came in with what appeared to be sciatica disguised as leg, back, lower-back and buttock pain. What complicated this patient’s condition was stage 2 hypertension producing swelling in his lower limbs. Dr. Bronston treated his hip with mechanical intervention traction and mobilization, while addressing some of the gluteus musculature to free up that sciatic nerve, and the patient experienced improvement immediately. But Dr. Bronston knew he needed to get his blood pressure under control and made a referral so the patient could go on a diuretic. The improvement was even more significant, as lower extremity edema was relieved.
“The lesson is that there are so many people who are not getting the right care,” says Dr. Bronston. “One of the biggest issues I see with accountable care is many people don’t know about preventive care or what is being paid – the deductibles are too high, and they are not seeking providers.” He believes this is an opportunity for DCs, who are known as being cost-effective and can perform preventive screening of patients.
Hip Considerations in Young and Old
In pediatric patients, be on the lookout for Legg-Calve-Perthes (LCP) disease, says Dr. Wyatt. This is a form of avascular necrosis of the femoral capital epiphysis that can be asymptomatic and in some cases, refer pain or only cause knee pain. Residual deformities of the femoral head can lead to precocious degenerative joint disease where a patient may seek care during adulthood. The adult analogue of LCP is spontaneous osteonecrosis of the hip, seen in alcoholics, patients with hip injuries, long-term corticosteroid use and other diseases, such as sickle cell and systemic lupus erythematosus.
Slipped femoral capital epiphysis, a Salter-Harris Type I fracture, should also be considered in pediatric patients with hip pain, especially those who are active.
In the geriatric population, be cognizant of two conditions in particular: hip fractures and malignancy. Hip fractures are a common cause of morbidity and mortality, and a small percentage of those fractures can be occult. In some cases, normal activities of daily living may result in an insufficiency fracture of the hip that is difficult to visualize on conventional radiography. If the index of suspicion for a hip fracture is high, but conventional AP and frog leg views of the hip are normal, advanced imaging of the hip with MRI, CT scanning or radionuclide bone scanning can confirm such suspicions. Of the three, MRI is considered the gold standard.
Malignancy, especially metastases to the hip, is a potential diagnosis in the elderly with an insidious onset of pain. Conventional radiography will often identify these lesions. But if plain films are normal, the same three imaging modalities may be used. Radionuclide bone scanning has the advantage, in a search for metastases, to identify lesions throughout the skeleton at a relatively low cost.
Hip Osteoarthritis and Manual Therapy
The American College of Rheumatology (ACR) has accepted evidence from many randomized placebo controlled trials that there is no difference between real arthroscopy, with actual surgical debridement or lavage, and sham arthroscopy, with only a real surgical cut but no debridement. The evidence from these trials is so strong that ACR’s 2012 guidelines now strongly recommend against common or routine arthroscopic surgery for hip or knee osteoarthritis.
For the first time in history, the ACR has recommended that manual therapy, if added to exercise or rehabilitation, may further benefit hip or knee osteoarthritis. The foremost recommended manipulation is HVLA Grade V thrust manipulation to the hip joint, and lesser grades in some cases. For more on the subject, go to the ACA Rehab Council website at www.ccptr.org/news/new-ebook-out-by-james-brantingham-dc-phd/
The rotator cuff, as all doctors of chiropractic know, is actually composed of four separate muscles: the supraspinatus, the infraspinatus, the teres minor and the subscapularis. Most of the approximately 2 million people who seek care for rotator cuff injuries in the United States every year have injured the supraspinatus, but the involvement of at least one of the other muscles is more common than was previously thought, says Dale Huntington, DC, owner of the Huntington Chiropractic Clinic in Springdale, Ark. “We used to think these tears were just in the super-spinatus 90 percent of the time. Now we’re realizing that, in the converging of these tendons, the infraspinatus is often being torn as well.”
And many people, especially athletes, may be walking around with small rotator cuff tears (a full tear usually requires surgery) without realizing it, because they’ve become so used to working or playing through the pain. “If you’re the DC for your local high school or college team, or even a pro team, you want to screen all of your athletes with functional movement screening to determine if there’s anything wrong with their shoulders,” says Dr. Petruska.
In addition to the FMS and the SFMA, Dr. Petruska relies on what noted sports chiropractor Craig Liebenson, DC, director of L.A. Sports and Spine, calls “the Magnificent 7”—a series of functional tests that appear in his popular Rehabilitation of the Spine manual.
“With functional testing, you can isolate the underlying problem, whether it’s regional interdependence, muscle imbalance, red light reflex, upper crossed syndrome—because there’s a reason why that person got injured to begin with,” Dr. Petruska says. “The rotator cuff didn’t just magically tear. A series of events led to that happening. Once you’ve identified that, from there you can design a functional treatment plan to handle the situation.”
Some patients, as Dr. Petruska points out, may not even realize that they’ve injured their shoulder. But many others will walk into your office complaining of a pain that could be bursitis or tendinitis, could be impingement syndrome (a precursor to a rotator cuff tear), or could be a microscopic or more severe tear.
With these patients, functional testing goes hand in hand with the diagnostic exam and patient history. Key questions to ask your patient include:
• How long have you had this pain?
• Was there a specific event that precipitated it? Were you doing something around then that you don’t usually do?
• Are you taking any medications (i.e., some might cause weakness in the muscle)?
• Have you had any injections into the site previously?
• Have you injured the site previously? If so, what sort of therapy did you seek? Was it successful?
• Have you had any prior imaging studies?
“You have to be very specific,” says Dr. Huntington. “Sometimes patients aren’t very forthcoming, and if you aren’t well versed in the examination process for the rotator cuff, you won’t get very far.”
If the exam and functional testing point to a rotator- cuff tear, imaging may be needed to determine the degree of injury.
When doing an X-ray, the two most important views to get for a shoulder injury are the neutral arm view and the “baby arm,” or abduction/external rotation shoulder view, as well as internal rotation, says Dr. Huntington.
“For these soft-tissue injuries, we are going more and more to diagnostic ultrasounds,” says prominent sports chiropractor, Thomas Hyde, DC, who recently retired from active practice in Asheville, N.C. “They’re noninvasive and readily available in most areas, and can give you a great deal of information about nonbony injuries.”
First-degree, or “microscopic,” tears and second-degree tears (a nebulous category defined as “greater than microscopic”) can usually be rehabilitated with conservative management.
Third-degree tears are thought to virtually always require surgery, but Dr. Hyde says that is not necessarily the case. “However, if you have an elite athlete, of course that athlete is probably going to be evaluated by an orthopedic surgeon,” he says. “I had a 78-year-old man who was still an excellent tennis player with a third-degree tear of his supraspinatus. I gave him the option of going to an orthopedic surgeon or doing rehab with me, explaining that he might lose mobility and need other muscles to compensate. That’s what we did; he couldn’t do an overhand serve, but he served underhand and went back to playing great tennis without surgery.”
That might be controversial, but Dr. Hyde points out that surgery can pose risks for a 78-year-old, no matter how healthy. Some, like his patient, may see conservative management as preferable to those risks. “You just have to be careful that you understand what you’re doing from a rehab point of view, so you don’t disrupt the surrounding structures.”
To rehabilitate a rotator cuff tear, says Dr. Petruska, it’s important to start with the patient’s mobility. “You cannot build stability over poor mobility. You’ll fail every time. It’s a common mistake a lot of practitioners make, and then their treatment fails and they wonder why. The patient comes back with a reinjury or more pain, it’s determined that ‘conservative care failed,’ and now it’s necessary to do surgery.”
To avoid that outcome, Dr. Petruska recommends adhering faithfully to a careful rehabilitation pattern:
1. Perform initial passive care. Options during this stage include manipulation, Graston, neuromobilization, flexion/distraction, laser, anodyne therapy and many others.
2. Fix the mobility. Physical therapist Gray Cook and sports medicine expert Lee Burton, PhD, developers of Functional Movement Systems, offer a series of simple exercises to improve shoulder mobility on their website, functionalmovement.com.
3. Strengthen the inner core, then the outer core. Standard tools for this stage include thera pads, rocker boards and Bosu balls.
4. Work next on postural stabilizers such as the glutes and knees. “Always look for imbalances,” Dr. Petruska says.
5. Next, work on endurance, and assess the patient’s overall condition with tests such as the Harvard Step Test or an EKG. “Faulty breathing patterns can lead to functional deficits,” says Dr. Petruska.
6. For deconditioned patients, work them up to a higher level through high-intensity interval training. Dr. Petruska suggests a regimen such as 7 minutes on the treadmill, 7 minutes on the elliptical, 7 minutes on the recumbent bike and 7 minutes on the upright stationary bike. “You want to rotate and cross train.”
7. The next step involves functional integrated training (FIT). In this stage, the patient should be challenged using options such as Otis rings on a gym ball, Bodyblade on a rocker board or playing catch with medicine balls on a Bosu ball.
8. Now, finally you are ready to strength train. “It’s the very last thing you do, and honestly it’s only about 5 percent of the importance. Whether you’re using kettle bells, therabands, free weights, whatever, that’s less important than going through the right steps of rehab progression,” Dr. Petruska advises.
“Throughout this process, you want to turn short-term corrections into long-term gains,” he says. “You’re trying to make certain actions automatic, and you never want to train a bad or deficient motor pattern. If your patient is doing an exercise incorrectly, stop and let him or her rest.”
Although the rehab progression should be consistent, things such as specific exercises and time spent in each phase will differ patient by patient. “You have to consider the individual in front of you: age, lifestyle, overall condition, symptoms and the severity of the injury. It’s not cookie cutter,” says Dr. Hyde. “And these things take time. Rotator cuff injuries are not a quick adjustment and out the door.”
To avoid the resulting chronic weakness, doctors may wish to encourage at-risk patients to begin a lumbar stabilization program to strengthen those muscles and build flexibility within a pain-free range.
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