Back Clinic Mobility & Flexibility: The human body retains a natural level to ensure all its structures are functioning properly. The bones, muscles, ligaments, tendons, and other tissues work together to allow a range of movement and maintaining proper fitness and balanced nutrition can help keep the body functioning properly. Great mobility means executing functional movements with no restrictions in the range of motion (ROM).
Remember that flexibility is a mobility component, but extreme flexibility really is not required to perform functional movements. A flexible person can have core strength, balance, or coordination but cannot perform the same functional movements as a person with great mobility. According to Dr. Alex Jimenez’s compilation of articles on mobility and flexibility, individuals who don’t stretch their body often can experience shortened or stiffened muscles, decreasing their ability to move effectively.
Types, location, and stability of tears are v. important during MRI Dx
Vertical/longitudinal tears especially occur in acute ACL tears. Some longitudinal tears found at the periphery or “red zone” may heal
Bucket handle tear: longitudinal tear in the inner edge that is deep and vertical extending through the long axis and may displace into a notch
Oblique/flap/parrot-beak are complex tears
Radial tear at 90-degree to plateau
Axial T2
Axial T2 WI fat-sat and coronal STIR slices of the posterior horn of the medial meniscus.
Note a radial tear of the posterior horn of the medial meniscus near the meniscal root. This is potentially an unstable lesion requiring operative care
The meniscus, in this case, is unable to provide a “hoop-stress mechanism.”
MRI Slices Coronal & Sagittal
Fat-sat coronal and sagittal proton density MRI slices revealing horizontal (cleavage) tear that is more typical in the aged meniscus
In some cases, when this tear does not contain a radial component, it may partially heal obviating the need for operative care
T2 w GRE Sagittal MRI Slice
Complex tear with a horizontal oblique and radial component.
This type of tear is very unstable and in most cases may need operative care
Bucket Handle Tear
Bucket handle tear are m/c in the medial meniscus esp. with acute ACL and MCL tear
MRI signs; double PCL sign on sagittal slices
Absent “bow-tie” sign and others
Most cases require operative care
DDx From Meniscal Degeneration
Occasionally meniscal tears need to be DDx from meniscal degeneration which may also appear bright (high signal) on fluid-sensitive MRI
The simplest rule is that if there is a true meniscal tear aka Grade 3 lesion, it always reaches/extends to the tibial plateau surface
The Role of MSK Ultrasound (US) in Knee Examination
MSK US of the knee permits high resolution and dynamic imaging of primarily superficial anatomy (tendons, bursae, capsular ligaments)
MSK US cannot adequately evaluate cruciate ligaments and the menisci in their entirety
Thus MR imaging remains modality of choice
Potential Pathologies Successfully Evaluated by MSK US
Patellar tendionosis/patellar tendon rupture
Quadriceps tendon tear
Prepatellar bursitis
Infrapatellar bursitis
Pes Anserine bursitis
Popliteal cyst (Baker cyst)
Inflammation/joint effusion with synovial thickening and hyperemia can be imaged with US (e.g., RA) especially with the addition of color power Doppler
Patient Presented With Atraumatic Knee Pain & Swelling
Radiography revealed sizeable soft tissue density within the superficial pre-patella region along with mild-to-moderate OA
MSK US demonstrated large septated heterogeneous fluid collection with mild positive Doppler activity on the periphery indicating inflammation d/t Dx of Superficial pre-patella bursitis
Long Axis US Images
Note normal lateral meniscus and fibers of LCL (above bottom image) compared to
Horizontal degenerative cleavage tear along with protrusion of lateral meniscus and LCL bulging (above top image)
Major limitation: unable to visualize the entire meniscus and the ACL/PCL
MRI referral is suggested
Rupture of Distal Tendon of Quadriceps
Note rupture of distal tendon of the Quadriceps muscle presented as fiber separation and fluid (hypo to anechoic) fluid collection within the substance of the tendon
Advantages of MSK US over MRI to evaluate superficial structures:
Dynamic imaging
Availability
Cost-effective
Patient’s preparation
Disadvantages: limited depth of structures, inability to evaluated bone and cartilage, etc.
Osteochondral Knee Injuries (OI)
osteochondral knee injuries can occur in children 10-15 y.o presented as Osteochondritis Dissecance (OCD) and in mature skeleton m/c following hyperextension and rotation trauma, particularly in ACL tear.
OCD-typically develops from repeated forces in immature bone and affects m/c postero-lateral portion of the medial femoral condyle.
OI in mature bone occurs m/c during ACL tears mainly affecting so-called terminal sulcus of the lateral femoral condyle at the junction of the weight-bearing portion opposed to tibial plateau and the part articulating with the patella
Osteochondral injuries may potentially damage the articular cartilage causing secondary OA. Thus need to be evaluated surgically
Imaging plays an important role and should begin with radiography often followed by MR imaging and orthopedic referral.
OCD Knee
95% associated with some trauma. Other etiology: ischemic bone necrosis especially in adults
Other common location for osteochondral injuries: elbow (capitellum), talus
1st step: radiography may detect osteochondral fragment potentially attached or detached
Location: a posterior-lateral aspect of the medial femoral condyle. Tunnel (intercondylar notch) view is crucial
MRI: modality of choice >90% specificity and sensitivity. Crucial for further management. T1-low signal demarcating line with T2 high signal demarcating line that signifies detachment and unlikely healing. Refer to orthopedic surgeon
Management: stable lesion esp. in younger children>off weight-bearing-heals in 50-75%
Unstable lesion and older child or impending physeal closure>operative fixation.
Result from valgus or varus stress with or w/o axial loading
Associated with periarticular soft tissues injury
High-stress injury m/c due to jumps falls and axial loading, often with the splitting of the tibial plateau. Men>women. Patients are in their 30s
Low impact or no trauma in patients with osteoporosis d/t insufficiency fractures
Impaction injury is more common with depression of tibial plateau. Women>men. Patients are in their 70s
Lateral Tibial Plateau Fractures More Common
Functional anatomy plays a significant role
60% of weight bearing is by the medial plateau
The medial plateau is more concave
Lateral plateau is slightly higher and more convex. Valgus stress impacts lateral plateau.
Tibial plateau fractures considered intra-articular and prone to delayed healing, non-union, meniscal injury (m/c lateral) ACL tear, secondary OA. Other complications: compartment syndrome, vascular injury.
Management: operative in many cases especially if >3-mm step-off at the plateau
If medial plateau or bicondylar Fxs present, ORIF will be required.
Imaging Plays A Crucial Role
Begins with x-radiography. X-radiography may not reveal the complexity and extent of this injury.
CT scanning w/o contrast will further delineate fracture complexity and pre-operative planning
MR imaging may be considered to evaluate for internal derangement: meniscal, ACL injuries.
Shatzke classification may help to evaluate the complexity of this injury
Key Diagnostic Sign
AP and lateral horizontal beam (cross table) left knee radiograph. Note subtle depression of the lateral plateau manifested by the lateral plateau appearing at the same level or lower as the medial. A critical diagnostic sign is the presence of fat-blood-interphase or FBI sign on cross-table lateral (above arrow) indicating intra-articular knee fracture
Lipohemarthorosis aka FBI Sign
Can be detected by radiography, CT or MR imaging
FBI sign is a reliable secondary radiographic sign of intra-articular knee fractures, regardless of how small they are
Mechanism: fracture results with acute hemarthrosis
Hemarthrosis will also occur w/o Fx. However, Fx will result with a fatty marrow being released into the joint cavity. Fat is a less dense medium (lighter) and will appear on the top of the hemorrhage if the patient is held in the supine position for 5-10-minutes before the cross-table radiograph is taken
FBI sign confirms the intra-articular Fx.
ACL/PCL, meniscal tears will not result in FBI sign
Lateral Tibial Plateau Fx
Lateral tibial plateau Fx that was managed operatively
Most common complication: premature secondary OA
More complex injuries may result in more extensive operative care
Knee Internal Derangement
Acute or chronic injuries of meniscal fibrocartilages and ligamentous restraints
Tears of the ACL and posterior horn of the medial meniscus are the most common
Acute ACL tears, however, often result with a lateral meniscus tear
Acute ACL tear may occur as a combined injury of the ACL, MCL, and medial meniscus
Functional anatomy: ACL prevents anterior displacement of the tibia and secondary varus stress
MCL functions together with ACL in resisting external rotation of the tibia especially when the foot is planted (closed chain position)
MCL is firmly attached to the medial meniscus, explaining the classic triad of ACL, MCL and medial meniscal tear (O’Donahue terrible triad)
Cruciate ligaments (ACL/PCL) are intra-articular but extra-synovial. Less likely to be torn in closed pack position (full extension). When all articular facets of tibia and femur are in full contact, the ACL/PCL are at least tension and stable
When the knee is flexed 20-30-degrees or more ACL is taut and remains unstable
ACL is a significant mechanoreceptor that feeds the info to CNS about the joint position. Thus the majority of previous ACL tears will lead to some degree of knee instability
Functional Anatomy of ACL
Diagnosis of ACL Tear
Diagnosis of ACL tear requires MR imaging
Concerns exist of not only ligamentous injuries but injuries to the articular cartilage and menisci.
Most vendors will perform at least: one T1 WI in coronal or sagittal planes. Sagittal and coronal Proton-density slices to evaluate cartilaginous structures. Fast spin-echo sagittal, axial and coronal T2 fat-saturated or sagittal and coronal STIR images are crucial to demonstrate edema within the substance of knee ligaments
ACL is aligned along the Blumensaat line or oblique line corresponding the intercondylar roof of Femoral condyles. Lack of such alignment by the ACL is significant for ACL tear
Imaging Dx of Internal Derangement
MRI shows 78-100% sensitivity and 78-100% specificity
Primary signs of ACL tear: non-visualization of ACL (above green arrow), loss of its axis along the Blumensaat line (above triangle heads), wavy appearance and substance tear (above white arrow) or edema and cloud-like indistinctness (above yellow arrow)
Reliable Secondary Signs of ACL Tear
May be observed on the radiographs and MRI
Segond avulsion fracture (80% specificity for ACL tear) (next slide)
Deep femoral notch sign indicating osteochondral fracture (above bottom images) and
Pivot -shift bone marrow edema in the posterolateral tibial condyle d/t external rotation and often valgus impact by the lateral femoral condyles (above top image)
Segond Fracture (Avulsion by ITB)
Segond fracture at Gerdy’s tubercle. A vital sign of the ACL tear seen on both radiographs and MRI
Management of ACL Tears
In acute cases, usually operative using cadaveric or autograft (patella ligament or hamstring) ACL reconstruction
Complications: graft tear, instability and premature DJD, joint stiffness d/t lack of postoperative rehab or gaft shortening. More rare, infection, a formation of intraosseous synovial cysts, etc.
Yoga has long been touted as a healing activity that extends beyond its known fitness benefits. It can help alleviate depression, relieve stress, and decrease anxiety as well as tighten and tone the body.
A 2016 study by Yoga Alliance and Yoga Journal shows that the more than 20 million people who practice yoga spend more than $10 billion on related classes and products. Chiropractors have picked up on the benefits of yoga and are recommending it to their patients. Why, because it helps to improve flexibility as well as spinal health.
Chiropractic and the spine�s role in the body.
Chiropractic is primarily intended to align the spine and balance the body. The spine is the primary support for the body. It houses most of the central nervous system and provides pathways for neural impulses to move throughout the body.
When the spine is out of alignment, it can affect how the central nervous system functions. It can also affect flexibility and even overall mobility as well as cause pain and stiffness.
Chiropractic treatment brings the spine back into alignment. It helps to balance the body and treat injuries as well as help with the changes the aging body experiences.
One of the best-known uses for chiropractic is to treat pain. It is a medication free, non-invasive treatment for chronic pain, sports-related injuries, and even automobile accidents. Many patients had reported finding relief with chiropractic when nothing else worked.
Combining yoga with chiropractic increases the effectiveness of the treatment while strengthening the body and making it better able to respond to it. It is the perfect complement to chiropractic care, and many patients are discovering tremendous health benefits from this winning, healthy combination.
What is Yoga?
In its purest form, it is an ascetic and spiritual discipline that comes from Hindu culture. It involves simple meditation, conscious breathing or breath control, and performing certain body postures.
While an ancient practice long used for spiritual and emotional healing as well as physical wellness, yoga has been adopted in western culture and widely accepted as a form of fitness as well as a therapeutic practice used for relaxation and overall good health. It focuses on inward healing for outward results.
People who regularly practice find they are more centered, handle stress better, and aren�t as likely to experience depression and anxiety. They also are more flexible, have better mobility, and have stronger leaner bodies.
What happens when you combine yoga and chiropractic care?
Because yoga helps to lower blood pressure, decrease stress, and strengthen the body�s core, it is perfect therapy for the chiropractic patient. While chiropractic care is working to align the spine and balance the body, yoga is helping to strengthen the muscles surrounding the spine, providing better support. The numerous health benefits, particularly regarding blood flow and relaxation help to increase chiropractic�s effectiveness as a pain management tool.
Patients who combine yoga and chiropractic will also often find that they see the effects of both treatments much faster than they would if they were only doing one or the other. Both chiropractic and yoga help with balance, flexibility, and mobility, but they come at it from somewhat different approaches. The benefit of this is that it provides a more balanced, well-rounded treatment in these areas as one supports the other.
Yoga also tones and tightens the body, preparing it for much more profound levels of healing, cleansing and releasing the body of tensions that may have been held�in for years. It also works to stretch muscles that have been restricted for years, or even for the patient�s entire life. It prepares the body to accept the full benefits of chiropractic and respond faster and more thoroughly.
Everyone knows that exercise is great for overall wellness, better health, and a healthy body. Many chiropractors will often recommend regular exercise to their patients who need to lose weight, want better mobility, or are seeking relief from depression. Some chiropractors are turning to Pilates to help their patients get stronger, more flexible, and more mobile.
What is Pilates?
In the early 20th century Joseph Pilates developed the exercise program to help World War I soldiers improve their physical fitness. It was used to rehabilitate patients who had been injured. By incorporating resistance, stretching, and target strengthening exercise, Pilates uses resistance bands, individual machines, and floor work to reshape and rehabilitate the body. Dancers, gymnasts, athletes, and celebrities use Pilates to stay in shape. However, anyone can do it for a healthier, more supple spine.
Care of the spine is at the core of Pilates. By keeping it in a neutral, or natural, position, this exercise can prevent back pain as well as help ease it. When done correctly, Pilates can:
Improve muscle control and movement efficiency through mental focus.
Make you more mindful of your body�s position, specifically, remaining aware of the spine�s position and keeping it neutral
Improve centering and mental focus through special, breathing techniques
Support and improve posture by strengthening the abdominal and back muscles.
Benefits of Pilates for Chiropractic Patients
The benefits of Pilates tremendous, but for chiropractic patients, it is even more so. By regularly incorporating Pilates into your exercise routine, you can enjoy these incredible benefits.
You can adapt Pilates to your fitness level and needs. Whether you are just starting a fitness program or you�ve been working out for years, Pilates can be tailored to your fitness needs and level.
It helps you strengthen your core. The deep muscles of your abdomen, back, and pelvic floor make up the core muscles of your body. Many of the movements focus on these muscles, making a body that is strong and the frame is supported.
Allows you to strengthen your muscles without bulking up. With Pilates your muscles get strong, but it also stretches the muscles so that they are lean and long. You will look toned and tight but not bulky and muscular.
It focuses on whole body fitness. Many types of exercise only work certain parts of the body, but this focuses on entire body fitness. It works every part of the body so that the muscle development is balanced.
It helps to improve your posture. It strengthens your body and helps to keep your spine in proper alignment due to a strong core. As a result, your posture naturally improves. By incorporating it into your exercise routine, you will find yourself standing taller, stronger, and more graceful.
You can become more connected through your mind and body by increased awareness. Pilates engages your mind and increases body awareness. It unites the mind, body, and spirit for complete coordination. Each movement is done with full attention.
It improves your flexibility. Pilates is a gentle but powerful exercise that works to safely stretch the muscles, making them longer, and increasing the range of motion in the joints.
It can protect you from injuries. By strengthening your body, Pilates can help protect you against injury. It conditions your whole body so that your muscles and strength are balanced. This reduces your risk of injury.
You get a natural energy boost. Just like with any exercise, it will give you an energy boost. However, it is increased even more thanks to the focused breathing and increase in circulation stimulating the muscles and spine.
It can help you lose weight and attain a lean, long, healthy body. It tones and strengthens the body, and if you do it regularly, it will reshape you. The body is more muscular and more balanced. It also helps you move with more grace and ease.
If you sit behind a desk all day with little or no activity, you could be compromising your physical health, mental health, and brain health which could impact your productivity at work. From a physical standpoint, it isn�t healthy to remain in one position for too long. It can lead to various health conditions including diabetes, heart disease, and even cancer. Experts advise movement. By getting up and walking around every hour or so or do exercises at your desk.
Healthy brain function can�be impacted by inactivity if you sit at work without moving for long periods of time your brain could suffer. The lack of activity could cause it to enter into a state of slumber which can lead to a decrease in brain processing speed and short-term memory loss.
It can also impact a person�s ability to learn or retain new information. It is so important to create an organizational culture that encourages moving around as part of their workday.
Create written policies that encourage and advocate movement during work hours. Incorporate moving workstations, moving meetings, flexible scheduling, more breaks when meetings run long, and a movement-friendly dress code.
Provide information and training to all employees and leadership underlining the importance of the policies and explaining the importance of movement as well as what they can do to support the initiative.
Places
Create workspaces that are conducive to movement, adjusting workstations so that they encourage active movement and incorporating dynamic change into current processes and workflows while minimizing the time employees spend sitting.
Seek out software and applications that encourage users to stretch or get up and move while they are working. Make stairwells more accessible and appealing, improve common areas, and promote collaboration that requires moving to various workstations or common areas.
People
Identify employees who are good role models for movement and train them for leadership roles so that they can encourage other employees to move a part of their workday. Train them in the policies regarding movement and task them with helping to create a culture of health and mobility within the organization.
Organize groups to walk during breaks or meet in common areas for light stretching and other types of movement. Sponsor contests and competitions with prizes for employees who achieve set goals.
Permission
Educate all employees and all levels of management or leadership on the benefits of movement and how it can positively impact personal production and performance as well as organizational outcomes. Stress that moving during the work day should become a regular activity and must be welcomed and allowed. Emphasize that it is the task of all employees to make a culture of movement the norm as opposed to the exception.
The benefits of moving around in the workplace extend far beyond healthier employees and increased production. Employees perceive themselves as valuable to the organization and morale is increased. Employee engagement�improves�on the job, and they invest more in their work as opposed to just doing a job. They are happier, empowered, and more productive at work and take more of an active role in business outcomes as well as their health.
Of course, employees will also enjoy individual benefits such as increased blood flow, as well as improved problem solving, better alertness, and enhanced creativity. A workplace that incorporates movement into its culture is a healthier, happier place to work with more robust, and more satisfied employees. You can�t afford to not implement this simple, effective strategy into your own organizational culture.
Dealing with joint or muscle pain can be a daunting experience. It’s important to work on maintaining mobility and flexibility. The more flexible, the less likely to be injured. One of the best ways to improve flexibility is through stretching.
First and foremost is the need to warm up your muscles before stretching. Stretching first can actually cause injury by pushing the joints too far. Spend a few minutes doing some light activity before stretching. This can be a quick walk or some basic calisthenics.
A chiropractor can recommend stretches, or you can use some of these basic techniques. There are two basic forms of stretching, static and dynamic.
Static Stretching & Dynamic Stretching
Static stretching involves holding a position for a certain period of time in order to loosen up the muscles. This is what most people think of when they think about stretching. However, dynamic stretching involves moving specific parts of the body to work on flexibility.
Effective Back Pain Stretches Can Be Done At Home. For example:
Lie on your back with your knees bent
Grasp one knee in both hands and pull it up towards your chest. Hold this position for 30 seconds
Lower the knee to the starting pose
Repeat with the other knee.
Both knees can be done at the same time.
A Similar Stretch Begins In The Same Position As The Previous Stretch Except:
Instead of lifting your knee to your chest
Roll both legs to one side so that your knees are as close to the floor as possible
Hold this position for 10 seconds, and then roll to the other side
Another Stretch Recommended By Chiropractors Comes From Yoga, Known As The “Cat Pose.”
On the floor hands and knees, with your hands directly under your shoulders.
Let your abdomen drop down towards the floor
Then, reverse this movement by arching your back
Repeat this cycle three to five times
Other Dynamic Stretches Can Also Be Good For Muscle Pain. Try doing:
Hand walks to stretch your shoulders and abdominal muscles.
Stand up straight and slowly lower your hands towards the floor.
Walk your hands out in front of you until you are as far down as you can go.
Then walk your hands back to the starting position.
A Final Stretch That Can Help Sore Back Muscles Known As The “Scorpion.”
Lie face-down and stretch your arms out to the sides
First, slowly move your right foot towards your left arm
Then, move your left foot towards your right arm
Make sure to move in a slow and controlled fashion
When you are suffering from muscle or joint pain, it is a good idea to stretch both in the morning and the evening. By incorporating these exercises into your daily routine, you can avoid common injuries.
If you need further instruction regarding stretches, please give us a call so that you can schedule an appointment.
Unfortunately, there are no stretches for� Root canals or Kidney stones. But there are stretches for Piriformis syndrome.
These ailments are painful and no fun! Piriformis syndrome�is especially a pain, in the butt, no pun intended.
Seriously, people suffering from Piriformis syndrome have frequent and sometimes severe pain and numbness through the buttocks and down their legs. This occurs when the Piriformis muscle spasms. When this happens, it�can end up also aggravating the sciatic nerve, which compounds the pain with tingling and numbness.
The Piriformis�is a short, small�muscle deep inside our hips, and helps rotate our legs both outward and inward. Because of its proximity to the sciatic nerve, this little body part can cause big problems, and hinder our ability to run, or even walk, through our daily activities with ease.
Fortunately, there are a variety of exercises that help stretch and relax the Piriformis muscle, giving sufferers much-needed relief from the pain and numbness it causes. If you are dealing with Piriformis syndrome, try these stretches to get yourself back on your feet and moving, pain-free.
Stretches
The “Knee Up” Stretch
Lie on the floor, use a mat or thick rug for comfort, on your back. Stretch both legs out, with your arms to your sides.�Bend one of your legs at the knee and use your hand to pull it toward the opposite shoulder Hold for ten to thirty seconds.�Straighten out that leg, and then do the same motion with the opposite leg and shoulder.
The “Cross Arm” Stretch
Arrange yourself in a sitting position. The bottoms of your feet should be touching each other, with your arms crossed and your hands resting on the opposite leg. Push both knees down toward the floor until you feel the stretch inside your thighs. Hold the position for a count of 30, then relax for a few seconds and repeat up to five more times.
The “Standing” Stretch
This is a handy exercise you can do in the bathroom at work, in a hotel, or anywhere that you would rather not lie on the floor.
Begin in a standing position with both feet flat on the floor, with your feet a shoulder-length apart.��Don’t lock your knees, and keep your back straight.�Lift one knee up and grasp it with both hands. Make sure you keep the knee parallel to the corresponding hip. Use your hands to pull your knee toward the opposite shoulder until you feel a pull along the side of your buttocks. Hold up to one minute, or as long as you can balance. Repeat the action with the other leg. Try to do it three times for each leg.
The “Sit and Bend” Stretch
This is another convenient�exercise that doesn’t require getting on the floor. Choose a solid, straight-backed chair that doesn’t roll,�sit, and bring one leg across the other, resting your ankle on your other leg. Slowly lean forward until you feel a pull along the crossed leg. Hold for up to 30 seconds. Repeat with the other leg, stretching each side 3 times.
Remember that consistency is key. Perform these exercises at least once a day, every day, until your pain and numbness is gone.
These four simple exercises�help you make great strides in recovering from Piriformis syndrome. However, if you perform these for several days and still have pain, or experience pain while attempting the stretches, it is a good idea to make an appointment with a professional chiropractor. He or she will be able to evaluate your condition and offer a comprehensive treatment plan to treat the Piriformis so it doesn’t get worse, or cause additional issues with your sciatic nerve.
IFM's Find A Practitioner tool is the largest referral network in Functional Medicine, created to help patients locate Functional Medicine practitioners anywhere in the world. IFM Certified Practitioners are listed first in the search results, given their extensive education in Functional Medicine
