Roberto Varela was always actively involved with chores at home before he started to experience neck, shoulder and leg pain. Due to his symptoms, Mr. Varela had difficulties engaging in regular physical activities, such as driving. However, after being recommended by his wife, he first received chiropractic care with Dr. Alex Jimenez, and Roberto Varela experienced tremendous relief from his neck, shoulder and leg pain, regaining his quality of life. Mr. Varela highly recommends Dr. Alex Jimenez and his staff for their services.
Shoulder Pain Treatment
Shoulder pain or leg pain is common; however, sometimes these problems don’t originate in the location of the symptoms. Shoulder and leg pain may also occur due to health issues in the neck or cervical spine. A variety of injuries and conditions can have their roots in improper posture, sports injuries or automobile accident injuries, causing misalignments, or subluxations, in the cervical spine or neck. Many healthcare professionals will discuss how damage to the cervical spine can be an underlying cause for shoulder pain and leg pain, among other symptoms.
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As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.
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The hips are some of the most flexible structures in the human body, providing the necessary amount of strength and stability needed to support the human body when walking, running or jumping. However, the hip joint can also be vulnerable to damage or injury, resulting in debilitating hip pain. Trochanteric bursitis is hip pain brought on by the inflammation of the fluid-filled sac, or bursa, found on the outer border of the hip.
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Trochanteric Bursitis Overview
There are about 160 bursae located around the entire body. Bursae act as a sort of “cushion” between soft tissues and bones, preventing bones from rubbing against tendons, ligaments, and muscles. Trochanteric bursitis can affect any of the bursae inside the human body. Trochanteric bursitis affects the outer part of the thighbone, or the femur, at the edge of the hip. This bony point is best known as the greater trochanter.
Another bursa, called the iliopsoas bursa, can be found on the inside of the hip. Inflammation of the iliopsoas bursa also triggers pain in the groin. Bursitis is considered to be one of the top causes of hip pain. Repetitive physical activities, such as climbing stairs, or even surgical interventions to the hip may cause inflammation in the bursa. Many doctors commonly refer to trochanteric�bursitis as greater trochanteric pain syndrome.
Signs and Symptoms of Trochanteric Bursitis
The main characteristic of trochanteric bursitis involves pain in the outer area of the hip or pain when laying on the affected side of the hip. The painful signs and symptoms will also generally become worse through certain physical activities, such as walking or climbing stairs. Pain may also�radiate down the�thigh and into the feet, or it may disperse. Pain can be sharp and fade into an ache, accompanied by swelling in the legs.
Causes of Trochanteric Bursitis
Common causes of trochanteric bursitis include�slip-and-fall accidents, strong blows to the hip, or lying on one side of the body for an extended period of time. Sports injuries involving�overuse from repetitive physical activities like running, bicycling, or climbing stairs, a ripped tendon or even standing may cause trochanteric�bursitis. Health issues, such as�bone spurs in the hip or thighbone, may consequently cause trochanteric bursitis.�
A variety of conditions and disorders may also lead to trochanteric bursitis, including spine problems, such as scoliosis or arthritis of the lumbar spine, even rheumatoid arthritis, and gout as well as thyroid disease. Moreover, legs of two different lengths,�hip surgery or prosthetic implants can create problems in the hips. Trochanteric bursitis is most common in middle-aged or elderly people and it is most prevalent in women than men.
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Trochanteric Bursitis Treatment and Chiropractic Care
Avoiding the physical activities which caused trochanteric bursitis will allow time for the body to heal. After seeing a healthcare professional for diagnosis, the doctor may often recommend nonsteroidal anti-inflammatory drugs, or NSAIDs to help control pain and inflammation. The recommended amount should be used to avoid side effects. Some doctors may also use steroid injections to control pain and inflammation.
Many healthcare professionals may also recommend alternative treatment options,�such as chiropractic care and physical therapy to help improve trochanteric bursitis signs and symptoms. A chiropractor may utilize spinal adjustments�and manual manipulations to reduce pressure from the spine while a physical therapist may teach the patient exercises to maintain strength. A cane or crutches can also take the weight off a patient’s hip.
If pain relievers or alternative treatment options, such as chiropractic care or physical therapy, do not work for the patient, the healthcare professional might recommend surgery to remove the bursa. This procedure can be accomplished through very small incisions with a camera. Other treatment approaches should be considered before following through with surgery.� The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
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Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
If you are considering going upright in your workplace or workspace, you are not alone. Companies large and small are recognizing the benefits of this healthy, spine-friendly way of working and they are incorporating it into their employees� workstations. It places the body in an optimal position, between standing and sitting to provide an ergonomic solution to working at a desk that saves space too. Even home offices are getting in on the movement. These case studies tell the stories of four companies that incorporated upright workspace technology for their organizations.
Shape Up
Rhode Island-based start-up company, ShapeUp, is a health and technology-centered small business with just employees. It manages the design and implementation of socially activated wellness programs in the workplace. They were looking for furniture that was high quality and sturdy enough to withstand a workforce that was very active. At the same time, it needed to promote good health to remain consistent with the company�s health-oriented ideals.
Their first step moving in that direction was to purchase several community upright workstations. This would allow employees to get upright at various points during the day. The feedback from employees was so great that upright workstations were placed in each employee�s work area.� They reported reduced back pain and increased energy, attributing it to the simple act of going upright.
FLUX
FLUX, based in San Francisco, is a small tech company with fewer than 50 employees. The venture-backed start-up created software that �reimagines sustainable building design.�
In 2012, Nicholas Chim, the company�s founder, began searching for body-friendly workstations that would help keep his energy level up and help him maintain his focus. He purchased an upright station for himself to�use in his work area. Many of the employees expressed great interest in this new workstation. Once, Chim came home from a business trip and found that one of the employees had taken over his upright station.
It was then that Chim realized he needed to purchase upright stations for all of his employees if he was going to keep them happy and healthy. He now offers upright workstations to all of his employees; all they have to do is request it.
Katie Rowe Mitchell
Katie Rowe Mitchell has a home office where she runs her start-up, Unfold Yoga + Wellness with her friend and partner Nicole Elipas Doherty. The company brings meditation practices and accessible yoga to organizations as a wellness measure for the companies� employees. She left a�longtime corporate job that left her feeling physically uncomfortable, overstressed, and overworked due, in part, to her sedentary work style.
She recognized the link between yoga and having more energy and better focus so she left her corporate job to start her own company that would bring yoga to be stressed out workers. In her own home office, Katie wanted a more active work style, and an upright workstation was the answer. It keeps her engaged in mind, body, and spirit. She has a newfound sense of freedom that sitting behind a desk for hours every day did not provide. Going upright opened a whole new world for Katie.
Wikimedia Foundation
Tech non-profit Wikimedia Foundation is based in San Francisco and has 200 employees. It powers several collaboratively edited projects including Wikimedia. When the company decided to redesign their office space, they decided that they wanted to create a work environment that empowered and encouraged employees to work together. They chose a dynamic environment with an open floor plan � and they included several upright stations. These workstations were grouped so that all of the employees would have an opportunity to use the stations at different times. The standing desks also proved to be space saving and took up less room in the work area than traditional desks and chairs.
Athletic pubalgia is a debilitating health issue which affects the groin. The injury commonly happens through sports that use sudden changes of direction or intense twisting motions. Also referred to as a sports hernia, athletic pubalgia is characterized as a tear or strain in any soft tissue (muscle, tendon, ligament) of the abdominal or lower abdomen region.
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Physiology of Athletic Pubalgia
The soft tissues most often affected by athletic pubalgia are the oblique muscles found in the lower abdomen, especially in the tendons that attach the oblique muscles to the pubic bone. In many instances, the joints that connect the thigh muscles to the pubic bone,�known as the adductor muscles, are also stretched or torn as a result of athletic pubalgia.
Physical activities which involve planting the feet and twisting with maximum exertion can cause athletic pubalgia. A sports hernia is most prevalent in vigorous sports, such as hockey, soccer, wrestling, and football. Athletic pubalgia�causes pain and discomfort in the groin region which typically gets better with rest but comes back with physical activity.
A sports�hernia does not result in a visible bulge in the groin, such as the well-known inguinal hernia does. As time passes, athletic pubalgia can lead to an inguinal hernia, and abdominal organs can push against the diminished cells to form a visible bulge. Without treatment, this sports injury could lead to chronic, disabling pain and other symptoms.
Healthcare Professional Diagnosis
During the first consultation, a doctor will discuss the individual’s symptoms and how the injury happened. To�diagnose athletic pubalgia, the healthcare professional will look for tenderness in the groin or above the pubis. Although a sports hernia may be related to an inguinal hernia, the doctor may not find any hernias during a physical examination.
Furthermore, to help determine the presence of athletic pubalgia, the healthcare professional will probably ask the patient to perform a sit-up or to�bend the trunk against resistance. If you have a sports hernia, these tests will be painful. The doctor may also require�x-rays or magnetic resonance imaging (MRI) to help determine whether you have athletic pubalgia.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
The vast majority of clinically suspected bone Mets are found in the axial skeleton and proximal femurs/humeri
Radiography is the most cost-effective and readily available initial imaging tool to investigate bone Mets but often fails early metastatic detection
Tc99 bone scintigraphy is the most sensitive and cost-effective imaging modality to demonstrate metastatic foci
MR imaging may help� regional identification of bone Mets especially if x-radiography is unrewarding
Significant limitations of MRI: inability to perform a whole-body MRI scan
Cost and other contraindications such as cardiac pacemakers and cochlear implants may be another limiting factor
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Marrow Based Neoplasms
Malignancy originating from the marrow cells are often referred to as “round-cell tumors.”
Multiple Myeloma (MM)
Lymphoma
Ewing’s sarcoma
The last two are less frequent than MM
Red marrow in adults is in the axial skeleton and proximal femurs/humeri d/t gradual marrow “retraction” following the childhood
Note bone marrow biopsy histopathology specimen of MM with abnormal plasma cells replacing regular marrow residents (above image)
Multiple Myeloma (MM) is the most common primary bone neoplasm in adults>40s. Etiology is unknown, but many theories exist (e.g., genetic, environmental, radiation, chronic inflammation, MGUS)
MM: malignant proliferation of plasma cells >10% of red marrow, with subsequent replacement of normal marrow cells by myeloma cells and overproduction of monoclonal antibodies paraproteins (M protein) with heavy chains IgG (52%), IgA (21%), IgM (12%) and light chains kappa or lambda aka Bence-Jones proteins
Clinical Presentation of MM
MM is occasionally detected as unexplained anemia on routine blood studies for unrelated complaints
Common MSK symptoms: Bone pain/Pathologic fractures
Diagnostic imaging plays an essential role during the Dx of MM
Bone marrow aspiration biopsy, blood tests, and serum protein electrophoresis may be used
Imaging approach: bone pain is investigated with initial x-radiographs if radiographs are unrewarding MR imaging may help to reveal bone marrow abnormality. MRI is recommended as myeloma survey
Currently, MRI protocol known as “whole body myeloma scan” consisting of T1, T2-fat suppressed, and T1+C coronal sequences can detect MM in the skull, spine, pelvis, ribs and femurs/humeri. This technique is much more superior to radiographic “skeletal myeloma survey.”
Tc99 bone scintigraphy is not typically used for MM because over 30% of MM lesions are “cold” or photopenic on radionuclide bone scan d/t highly lytic nature of MM with osteoclasts outpacing osteoblasts.
A radiographic skeletal survey is considered more sensitive than bone scintigraphy in MM
PET-CT scanning of MM is gaining popularity due to the high level of detection of multiple sites of MM
Radiographic Dx of MM: consists of identification of characteristically localized focal osteolytic “punched out” or “moth-eaten” lesions of variable sizes following the distribution of adults red marrow
Note rad abnormality is known as “raindrop skull” is characteristic of MM
Radiographic appearance of MM may vary from “punched out” round radiolucencies to “moth-eaten” or permeating osteolytic lesion producing endosteal scalloping (yellow arrow)
Pelvis and femurs are commonly affected by MM and present radiographically as round lytic punched out or moth-eaten lesions
N.B. Occasionally MM may pose radiographic dilemma by presenting as generalized osteopenia in the spine that can be difficult to differentiate from age-related osteoporosis
MR imaging of MM reveals� marrow changes with low signal on T1, a high signal on fluid-sensitive sequences and bright contrast enhancement on T1+C gad d/t increased vasculature and high activity of� MM cells
Example of full-body MRI of “whole body myeloma scan” with T2-fat suppressed (A), T1 (B) and T1+C (C) pulse sequences produced in coronal slices
Note multiple foci of bone marrow changes in the spine pelvis and femurs
Miscellaneous Neoplasms of the Spinal Column
Chordoma: is relatively uncommon but considered the m/c primary malignant neoplasm that only affects the spine. D/t slow growth is often misdiagnosed for a considerable length of time as LBP
Pathology: derives from malignant transformation of notochordal cells presented as mucoid, gelatinous mass containing physaliphorous cells
Demo:�M: F 3:1 (30-70S). 50%-sacrococcygeal, 35% spheno-occipital 15%-spine
Clinically: asymptomatic for a long time until non-specific LBP, changes in bladder & bowel, neurological signs are less common d/t midline “outward” growth & inferior to S1. Local invasion worsens prognosis. 60%-survive 5-years, 40%-10-years, Mets are delayed, poor prognosis d/t local invasion. >50% can be id. on DRE.
Imaging:�x-rays often tricky d/t overlying gas/feces. CT is >sensitive to id the bone mass and internal calcifications. MRI: T2 bight signal, T1 heterogeneously low and high d/t mucus/blood decomposition, MRI best detects local invasion and essential for care planning. Rx:� complete excision is often impossible d/t local vascular invasion.
Giant cell tumor (GCT):�2nd most common primary sacral tumor. It is a histolgically benign neoplasm containing multinucleated Giant cells of Monocyte-Osteoclast origin
Imaging Dx:�x-radiography is the 1st step usually in response to complaints of LBP. Often challenging to id on x-rays d/t bowel gas/feces
Key rad feature: osteolytic expansile lesion noted by destruction of sacral arcuate lines. CT may id the lesion better. MRI is the modality of choice following x-rays. MRI: T1 low to intermediate signal. Heterogeneously high d/t edema with areas of low signal on T2 d/t blood degradation and fibrosis. Characteristic fluid-fluid levels may be noted especially if ABC develops within a GCT. Rx: operative. Prognosis is less favorable than GCT in long bones d/t lung Mets (deposits) in 13.7%
Aneurysmal Bone Cysts (ABC) are benign expansile tumor-like bone lesions (not a true neoplasm) composed and filled with numerous blood-filled channels. Thus the term “blood sponge.” ABC is m/c id in children and adolescents
Unknown etiology: trauma and pre-existing bone neoplasm (e.g., GCT) often reported. Clinically: pain that may be progressive d/t rapid nature of ABC expansion. In the spine, ABC m/c affects posterior elements and presented as expansile, soap-bubbly or lytic lesion.
DDx: can be broad, but Osteoblastoma and GCT are the top DDxs.
Imaging: x-rays demo expansile mass in posterior elements, CT is more sensitive than x-rays, MRI will demo characteristic fluid-fluid levels and mixed high and low signal d/t edema and blood decomposition/aging with some septations.
N.B. MRI fluid-fluid levels are not exclusive to ABC, and DDx includes GCT, osteoblastoma, telangiectatic osteosarcoma.
Rx: operative curettage and bone grafting, fibrosing agents. Recurrence 10-30%.
Athletic pubalgia, also known as a hockey hernia,�hockey groin, Gilmore’s Groin,�sports hernia, or groin disruption, is a health issue of the pubic joint. It is a condition characterized by chronic groin pain in athletes and identified by a dilated ring of the inguinal canal. Soccer and ice hockey players are the athletes most commonly affected by athletic pubalgia, and both recreational and professional athletes can be impacted.
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Athletic Pubalgia Symptoms
Symptoms of athletic pubalgia�generally manifest as pain following physical activity, most frequently through hip extension, and twisting and turning movements. The painful symptoms usually radiate into the adductor muscle region and the testicles, although it is often difficult for the individual to pinpoint the exact location of the�symptoms. Athletes with athletic pubalgia�experience soreness and stiffness after physical activity.
Any exertion which increases intra-abdominal pressure, such as sneezing or�coughing, as well as physical activity, can lead to pain. While pain in the stomach and pelvis can occur due to a variety of health issues, including injuries to the low back, or lumbar spine, the hip joint, the sacroiliac joint, and the abdomen, along with the genito-urinary system, diagnosis of athletic pubalgia demands skillful differentiation and evaluation.
Clinical Presentation of Athletic Pubalgia
The diagnosis of athletic pubalgia is based on the patient’s history, where healthcare professionals may also depend on the use�of magnetic resonance imaging,�or MRI. Symptoms can frequently be reproduced by certain movements, such as performing crunches or sit-ups. Pain associated with athletic pubalgia may also be elicited with the patient in a “frog posture,” in which the individual is supine with knees bent and heels together.
Many athletes experience concomitant fatigue or tearing of the�adductor muscles or labral tears of the hip. If there is stiffness in the adductor muscles post-injury, painful symptoms can manifest. Alternative treatment options should be to restore normal movement after the adductor has begun to heal, normally 6 to 8 weeks post-injury. Moreover, sleeping in a prone position with the hip on the affected side flexed and externally rotated can offer relief to some athletes with athletic pubalgia.
The precise prevalence of this health issue is unknown. Conservative therapies,�such as gentle stretching, may temporarily alleviate painful symptoms, however, definitive treatment options should be considered for long-term relief.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Sleeping. New parents chase it, Type A personalities fight it, but everyone needs it. The thing is, most people don�t get enough of it. According to the National Sleep Foundation, 45 percent of adults in the United States report that in a seven day period lack of sleep affected their daily activities.
Sleep quantity is not as much of a problem as sleep quality. Around 35 percent of people who said they slept for 7 or 8 hours a night still reported that their sleep quality was �only fair� or �poor� and 20 percent said that they did not feel refreshed upon waking. When a person is dealing with pain, such as lower back pain, it can make it even more difficult to get a good night�s sleep.
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The Importance of Sleeping
Sleep is vital for good health. The Centers for Disease Control (CDC) cites insufficient sleep as a contributing factor to a variety of conditions including obesity, diabetes, depression, and cardiovascular disease. It is also a significant contributing factor in many machine related crashed, worksite accidents, and automobile accidents, leading to injury, disability, and even death.
Sleep allows your body to heal and the spine to rejuvenate. It helps you handle stress better and manage pain more effectively. It is an essential part of good health so making sure that you get good quality sleep should be a priority � and it is possible. These are the best sleep positions to get your best sleep when you have lower back pain.
Stomach Position
Sleeping on your stomach is usually the least back friendly sleep position, but some people can�t sleep any other way. Take the strain off of your back by supporting it with a pillow under your lower abdomen and pelvis. Using a pillow may put too much stress on your back, so you might need to try to sleep without one. Another alternative is to use a flatter, less fluffy pillow. Try different positions, such as drawing one leg up or splaying your legs more until you find on that is right for you.
Back Position
If you sleep on your back, you likely won�t be comfortable just lying flat. Try different positions such as placing a rolled towel under your knees or the small of your back to provide added support. Use a good pillow to support your neck. Some pillows are made specifically for people who sleep on their backs; you may want to give it a try.
Side Position
Many people with lower back pain find sleeping on their side to be the most comfortable sleep position. If you sleep on your side, pull your knees up slightly so that they are almost perpendicular from your body. You may have to make some adjustments to how bent your legs are before you find a position that takes the pressure off of your back. Place a pillow between your thighs and knees. You may want to use a body pillow to provide even more support all along your legs.
A Word about Your Pillow and Your Bed
The position that you sleep in can help relieve your back pain, but getting good quality sleep will help you manage your pain much better so it should be your goal to get a�good, restful sleep every night. You should change out your pillow on a regular basis.
Pillows can get worn and no longer deliver the support they once did. If you are waking up with neck or back pain or headaches, it could be your pillow. Additionally, studies show that making your bed every day improves your quality of sleep. Make sure that the temperature is comfortable and avoid electronic devices for about an hour before bedtime. Be kind to your body; make sleep a priority.
The rectus femoris muscle attaches to the pelvis and just below the knee as it is one of four muscles found at the front part of the thigh. It functions by extending the knee and flexing the hip. The rectus femoris muscle is made up of�fibers which adapt to quick action. Rectus femoris muscle strain is caused by forceful movements, such as kicking a ball or when beginning to sprint, and it is particularly vulnerable to stress and pressure.
Painful symptoms generally manifest at the top of the thigh after the rectus femoris muscle suffers a strain or tear. In severe cases, the health issue may even become noticeable if the tissue is completely ruptured. Fortunately, complete tears are rare. Healthcare professionals will commonly use an MRI scan to diagnose the extent of the sports injury. Proper diagnosis and treatment�are�essential. A rectus femoris muscle strain should not be rushed, as individuals who return-to-sport too soon may suffer re-injury.
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Treatment for Rectus Femoris Strain
According to many healthcare professionals, when it comes to sports injuries to the rectus femoris muscle, it’s crucial to immediately apply the RICE principle (Rest, Ice, Compression, and Elevation) to the affected thigh. This treatment aims to decrease bleeding and inflammation to the muscle. Also, it will help reduce painful symptoms after the injury. Based on how much pain has been experienced, simple painkillers might be utilized, although it’s best to attempt to prevent the use of these.
Once movement is restored enough to allow the individual to walk using their regular range of motion, and once the swelling has gone down, then you will have recovered from the acute phase of the injury. It would then be an excellent time to engage in physical activity, without inflicting damage or stress to the quadriceps muscles. This can be performed on an exercise bicycle or through swimming, where the weight is kept�off the limb. Stretches and gentle resistance exercises are crucial, as this will help to align the scar tissue that has formed during the healing process.
Recovery must be monitored so that improvements can be noted and the treatment shifted to help the rehabilitation process. It is hard to measure the length of time to complete recovery. It can take from six to eight weeks or even longer, although some people will commonly recover within one to four weeks.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Metastatic Bone Disease (aka Mets) or “Secondaries.” Are the most common malignant bone neoplasms affecting the spine, aka spinal neoplasms (>70%) and the rest of the skeleton in adults.
5-Primaries are m/c involved:
Breast (16-37%)
Lung (12-15%)
Thyroid (4%)
Renal (3-6%)
Prostate (9-15%)
Spine, pelvis, proximal femurs & proximal humeri are m/c affected in that particular order of frequency
Thoracic & upper Lumbar spine considered the m/c site of spinal Mets
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Pathophysiology & Etiology of Metastasis
Malignant cells a very good at evading immune detection and elimination
They gain�access to circulation expressing Vascular Endothelial Adhesion Molecules (e.g., integrines & selectins)
Once reaching their target organs, malignant cells stimulate the production of various vasogenic growth factors and by exiting blood vessels invade their target tissues
Lung, Liver, and Bone are particularly at risk due to the character of their blood supply
Baston venous plexus-is a network of valveless freely communicating� veins connecting axial skeleton/meninges and proximal femurs/humeri with abdomino-pelvic and thoracic cavities
The risk of Mets is increased during daily variations in the intra-abdominal and intra-thoracic pressure
In adults, the axial skeleton is involved in hematopoiesis, and it is particularly vulnerable to metastatic deposits via an abundant network of sinusoids within a spongy bone
The vast majority of bone Mets will be detected in the axial skeleton
Clinical Presentation
Back pain often mimicking “mechanical back pain” is the m/c and often misleading symptom
Chiropractors and other manipulators should be particularly aware of this dangerous pitfall.
Nocturnal pain or pain unresponsive to NSAID may be reported in more advanced cases
Advanced cases may also present with a neurological deficit due to pathologic vertebral fractures and spinal cord/nerves compression
Metastatic hypercalcemia may occasionally develop in severe cases and considered a medical emergency that potentially presents with confusion, muscle weakness, and renal signs
Imaging plays a significant role in the Dx and management of bone metastasis
Lab tests are of limited value, but hypercalcemia and alkaline phosphatase (Alk Phos) may be elevated
In some cases, a bone biopsy may be used to confirm bone Mets
When Bone Mets are Detected, Patients Prognosis is Significantly Worsened
Median survival:
Thyroid – 48 – months
Prostate – 40 – months
Breast – 24 – months
Renal Cell – may vary, can be as low as 6 – months
Lung – 6 – months
Imaging Diagnosis
Begins with radiography investigating a clinical complaint of back/bone pain
If radiographs are unrewarding or equivocal, unique imaging modalities are required
MRI may help to show marrow replacement by Mets foci but limited to specific regions
Tc99 radionuclide bone scan (scintigraphy) is considered one of the most sensitive and reliable imaging steps in evaluating bone Mets
Bone scintigraphy is good at detecting both lytic and blastic Mets
However, very aggressive/vascular osteolytic Mets and Multiple Myeloma often appear “cold” or photopenic on bone scan due to greater stimulation/activation of osteoclasts which “outpace” osteoblasts ability to uptake the radiopharmaceutical
CT scanning is an excellent modality to show bone destruction, but it is not widely used during bone Mets Dx especially if radiography, bone scintigraphy, and MRI provide adequate information about the process
CT scanning may be particularly helpful with delineation of pathological fractures
General Radiographic Features of Bone Mets
Osteolytic (lytic), osteoblastic (blastic) aka sclerotic Mets or misec Mets can be identified radiographically
However, it takes between 30-50% of lamella (cortical) bone and 50-75% of trabecular (cancellous) or spongy bone to be destroyed before it can be detected on plain film radiographs
This can make early radiographic detection of bone Mets very difficult, requiring particular imaging modalities (e.g., MRI)
Also, bowel gas/fecal matter and numerous soft tissue densities in the abdomino-pelvic and thoracic cavities may pose challenges of bone Mets detection
Different tumors often manifest with different metastatic appearance, depending on tumor activity and release of cytokines (IL6, IL11), endothelin 1 or other growth factors that will be responsible for either osteolytic, osteoblastic or mixed Mets
For example: purely lytic bone Mets are noted in Lung, Thyroid, and Renal cell CA (very vascular)
Breast CA may present with 60% of blastic Mets
Prostate CA presents with 90% of blastic Mets
Other blastic Mets may derive from urinary bladder, melanoma and GI adenocarcinomas
Sclerotic foci may also represent as previously treated primaries
Very vascular� Mets like Renal cell and Thyroid may present with markedly� lytic and expansile foci often called “blow out Mets.”
Mets found distal to elbows and knees (acro-metastasis) are commonly associated with Lung CA
PA chest view of a routinely screened patient with a known Hx of Prostatic adenocarcinoma
Note sclerotic lesion identified in the left posterior Rib 5
What imaging modality is required next?
Radionuclide bone scan should be suggested
Multiple foci of high uptake of the Tc99 radiopharmaceutical
This is due to Mets and increased osteoblastic activity in the thoracic and lumbar spine, ribs and other sites of the skeleton
Comparison of purely lytic (a and b) versus blastic (d) and mixed (c) Mets
What primaries to consider?
Frog leg view of the hip
Clinical Dx: Prostatic adenocarcinoma
Note diffuse blastic Mets in the proximal femur
Hx: severe shoulder and arm pain unrelieved by rest
Rad DDx: Mets, Myeloma or less frequently Lymphoma
This classic DDx is used by the majority of Radiologists when aggressive osteolytic bone lesions are noted
The patient had a known Hx of Breast CA
A 51-year-old female with Breast CA
Large lytic destructive lesion in the distal femoral metaphysis characteristic of aggressive osteolytic Mets
Sudden onset of severe leg pain and inability to stand in a 53-year-old female with Breast CA
Dx: Pathological fracture through the distal femoral shaft
Pathological Mets fractures in the spine and extremities are dreaded by most Oncologists due to higher association with severe complications and poor clinical prognosis
Radiographic Dx of vertebral Mets should be suspected if a “missing pedicle sign” aka “winking owl sign” is noted
DDx: pedicle agenesis (above left) shows hypertrophy and sclerosis of a contralateral pedicle d/t increased mechanical stress
Pedicle Mets are often thought of as the m/c initial site of spinal Mets
Vertebral Body Pathologic Fracture (VERTEBRA PLANA)
Isolated compression fracture at the T8 segment noted (above arrow)
The loss of the posterior and anterior height suggest an underlying pathologic condition for which the differential diagnosis includes:
Differentiating Pathological Fx of the vertebral body from an osteoporotic insufficiency Fx can be a significant challenge
Close inspection of the posterior body height is helpful but often not reliable
In metastasis, the posterior body is collapsed
In OSP, the posterior body may be maintained appearing more as anteriorly wedge fracture
MR imaging and/or radionuclide bone scan need to be performed
A skeletal radiographic survey may be used occasionally for the evaluation of bone Mets especially in well-established cases
It includes bilateral AP & lateral Thoracic and Lumbar views, AP pelvis, humeri, femurs, and the skull
Availability of special imaging has supplanted the use of skeletal radiographic survey
However, in a clinical practice skeletal radiographic study of Multiple Myeloma may still be used primarily if the diagnosis was previously established
Technetium-99 (99mTc) bone scintigraphy is very sensitive and cost-effective study:
For the detection/localization of Mets and often an assessment of their biologic activity and response to treatment
This modality is a well-established part of the workup for known as well as unknown primaries
It may also help with determination of lesions that will be most accessible and easy to biopsy
When the burden of Mets is significantly high as shown in the case above
The radiotracer uptake is being almost entirely taken in by metastatic lesions
No material is left for the kidneys to excrete
This is known as a “super scan”
Sagittal Lumbar and Lower Thoracic MRI. Multiple metastasis are noted on T1 (above right) and T2 (above left)� WI as hypointense foci of marrow replacement of the vertebral bodies in a patient with Hx of Prostate CA
MR imaging protocol with T1, T2, and T1+C gad can be used in many cases if x-radiography is unrewarding or questionable
�MRI can reveal bone marrow changes due to bone marrow replacement by Mets and surrounding edema
Typically blastic Mets appear as abnormally decreased signal intensity (hypointense) lesions on T1 and T2 pulse sequences
Purely lytic Mets often appear as hypo-intense on T1 and hype-intense on T2
Increased gadolinium uptake may also be evident on T1+C fat suppressed sequence d/t increased vascularity of malignant foci especially in very aggressive vascular neoplasms
The hip is commonly described as a “ball-and-socket” type joint. In a healthy hip, the ball at the top end of the thighbone, or femur, should fit firmly into the socket, which is part of the large pelvis bone. In babies and children with developmental dysplasia, or dislocation, of the hip, abbreviated as DDH, the hip joint may not have formed normally. As a result, the ball of the femur might easily dislocate and become loose from the socket.
Although DDH is often present from birth, it could also develop during a child’s first year of life. Recent research studies have demonstrated that infants whose thighs are swaddled closely with the hips and knees straight are at a higher risk for developing DDH. Because swaddling has become�increasingly popular, it is essential for parents to understand how to swaddle their babies safely, and they should realize that when done improperly, swaddling may cause health issues such as DDH.
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Diagnosis for�Developmental Dysplasia of the Hip
In addition to visual cues, when�diagnosing for DDH, the healthcare professional will perform a careful evaluation, such as listening and feeling for “clunks” which indicates that the hip is placed in different positions. The doctor will also utilize other methods and techniques to determine if the hip is dislocated. Newborns recognized to be at higher risk for DDH are often tested using ultrasound. For babies and children, x-rays of the hip might be taken to provide further detailed images of the hip joint.
Treatment for�Developmental Dysplasia of the Hip
If DDH is discovered at birth, it can usually be treated with the use of a harness or brace. If the hip isn’t dislocated at birth, the condition might not be diagnosed until the child starts walking. At that point, treatment for DDH is much more complex, with less predictable results. If diagnosed and treated accordingly, children ought to have no restriction in function and develop the standard hip joint. DDH may result in atherosclerosis and other problems. It may produce a difference in agility or leg length.
In spite of proper treatment, hip deformity and osteoarthritis may develop later in life. This is particularly true when treatment starts after the age of 2 years. Therefore, diagnosis and treatment are essential in newborns and children with DDH. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
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Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
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