Athletes
Sports Spine Specialist Chiropractic Team: Athletes strive to achieve their body’s maximum performance by participating in numerous training regimens consisting of strenuous exercises and physical activity and ensuring they meet all of their body’s nutritional requirements. Through proper fitness and nutrition, many individuals can condition themselves to excel in their specific sport. Our training programs are designed for athletes that look to gain a competitive edge in their sport.
We provide sport-specific services to help increase an athlete’s performance through mobility, strength, and endurance. Occasionally, however, the excess workouts can lead many to suffer injuries or develop underlying conditions. Dr. Alex Jimenez’s chronicle of articles for athletes displays in detail the many forms of complications affecting these professionals while focusing on the possible solutions and treatments to follow to achieve overall well-being.
by Dr Alex Jimenez | Athletes, Complex Injuries, PUSH-as-Rx
El Paso, TX. science based chiropractor, Dr. Alexander Jimenez looks at this uncommon problem � and how it can be treated.
The true incidence of obturator externus accidents is unknown, as frequently they may be misdiagnosed as hip joint pathology and/ or groin pathology as the website of symptoms as well as also the presenting objective signals may mimic other pathologies such as hip joint labrum pathology, anterior femoral triangle issues and perhaps even gluteal pathology.
Injury for this muscle gifts as a deep obscure groin/hip pain and functionally the muscle may still hide direct involvement as a pain generator since it is primarily a equilibrium muscle rather than a force-producing hip muscle.
This case study presents an unusual case of hip-related pain in a professional baseball player which also shown itself as an injury to the contralateral adductor longus.
The Player
As he was wrestled to the floor, his right hip was compelled at a rapid and loaded flexion/internal turning position. His first sensation was pain deep inside the anterior hip/groin area.
When he presented to the medical team with the accident, he complained of a profound catching sensation inside the hip joint location. It had been difficult to fully bend the hip and to also twist on the stationary limb (because he did whilst kicking a ball). His prior background consisted of a right-sided inguinal hernia repair five seasons before as well as a few gentle on again/off back osteitis pubis-type signs that would normally flare from the first period as his goal-kicking amounts have been increased. He was obviously a left- footed goal kicker.
On examination, he observed that the pain to become worse on passive flexion/internal rotation of the hip (hip walkway test). He was noticeably tight and irritated from the shallow TFL muscle, and also posteriorly across the greater trochanter around the insertion for the gluteals and deep hip rotators. He was also particularly high tone in the right iliopsoas muscle.
He was initially diagnosed clinically because of hip joint sprain due to the mechanism of harm being a pressured flexion/internal rotation type position that would always put pressure on the anterior hip joint capsule/labrum.
He was treated initially with deep iliopoas muscle sparks and hip joint mobilizations using a seat belt to gap the hip joint. He reacted reasonably well with the therapy and immediately felt more comfortable on a hip joint quadrant test. He was rested from coaching for 2 days and ran on the next day and played a match on the fourth day. But during the match, though his right hip did not create any pain, he’d notice pain on his left adductor source that was more pronounced during kicking.
Three days post-game he detected this ongoing left adductor origin pain and it was made worse by kicking again through training. An MRI was performed to Look at the left adductor origin and also the report noted:
- Grade 1 left adductor longus strain deep in the
- Grade 2 right obturator externus strain on its femoral attachment
- Grade 1 right iliopsoas muscle strain in the MTJ.
The surprise finding on the MRI of a grade 2 obturator strain prompted the medical team to more formally assess the participant for ongoing hip joint disorder. The particular features to notice from this medical examination were:
Subjective
? A sensation of weakness and instability in the right hip whilst kicking with the left foot.
? No pain in the right hip with running, even with top-end speed. However, the left adductor longus was symptomatic on running and kicking.
Objective
? Pain on passive right hip internal rotation whilst in 90-degree hip flexion. This pain was deep anteriorly in the hip, almost presented as a groin problem.
? Some discomfort on resisted right hip flexion/external rotation deep inside the iliac fossa.
? Pain and weakness in the left adductor on adductor squeeze tests. These squeeze tests performed at 0/45/90 degrees of knee flexion with a pressure cuff between the knees. Usual pre-season scores measured 260/260/250. On current testing they measured 150/170/180. Pain was felt at the end of the squeeze.
? Discomfort with prone lie hip passive internal rotation. This pain was more focused around the right greater trochanter posteriorly.
Pathomechanics
It had been suspected that this player had endured a secondary injury to the left adductor longus (a muscle used a lot in goal-kicking) due to the inherent failure in bolstering the proper hip throughout the plant phase of the kick due to the inhibition of the right obturator externus, a muscle considered to be an important hip stabilizer and turning control muscle at the hip. With insufficient hip stabilization in kicking, the left hip was required to create more power to compensate for the unstable right hip to gain the length from the kick. Then the left adductor longus failed along with a strain injury led.
Management
The management of the matter initially centered on the two key features being the left-sided adductor strain and the right- sided obturator externus strain.
In the week following the accident, the player was sent to get a series of Actovegin shots to the left adductor longus. This was done according to protocol that was three injections every 48 hours — Monday/ Wednesday/Friday. In this five-day period the adductor longus was handled with deep tissue flush massage and gentle isometric adduction exercises at supine (chunk squeezes) in the three positions of examining — 0/45/90 levels of knee flexion — also as wall squat adductor squeezes in the same positions. The obturator externus was medicated with heavy tissue releases (obtained through the anterior groin region) and direct theraband strengthening of hip external rotation in sitting and in prone. Actovegin shots to the obturator externus are regarded as difficult because of problems with accessing this muscle through the superficial hip musculature.
The adductor exercises progressed into through array adduction with theraband resistance (equally with the left leg being the motion leg as well as the stability leg).
By 12 days post-injury it had been detected that the obturator externus strength had not improved and the player still had deep- seated right back pain pain. It was rationalised that perhaps the direct treatment to this muscle and also the direct open kinetic chain strengthening was possibly making the muscle texture worse. The choice was made to stop any direct hands-on therapy to the muscle and also to prevent any direct open kinetic chain strengthening. Instead the player lasted with bilateral theraband exercises of both hips into flexion and then abduction and expansion in addition to adduction. The avoidance of lead obturator externus soft tissue treatment and exercise appeared to improve the hip function immediately.
The participant started running 20 times post-injury and quickly progressed through running stages over a five-day period of conducting on alternate days. At this point the player’s adductor squeeze scores had improved to steps according to pre- season baselines. However, daily the player ran direct adductor strength operate using a Pilates reformer as a slider drill to immediately load into adduction in addition to hammering theraband adduction exercises in standing and in supine lying.
By 27 days post-injury the player managed to begin kicking, change in direction and rugby training. He played at 30 times post-injury with no ill effects.
Discussion
It arises immediately around the medial side of the obturator foramen, as well as the inferior ramus of the ischium; it also arises in the lateral two-thirds of this outer surface of the obturator membrane, and also in the tendinous arch which completes the canal to the passage of the obturator nerves and vessels.
The action of the muscle is to externally rotate the hip and also helps in hip adduction. It’s postulated to also work as a hip balance muscle in one legged stance along with the obturator internus, quadrutus femoris, piriformis and the gemelli muscles. In a practical activity such as kicking, the muscle acts to stabilize or hold the ball of the femur into the socket (acetabulum).
The incidence of harm to the obturator externus muscle is unknown because there are only a handful of case reports from the medical literature that highlight injuries for this muscle. Additionally, among the vexing issues is the difficulty in creating the correct clinical diagnosis based on the history and physical evaluation. MRI imaging is needed to correctly picture injuries to this muscle.
From the case study introduced, injury for the muscle was a direct result of forceful flexion/internal rotation mechanism to the hip joint. As the muscle primarily functions as a hip stabilizer during jogging, it is possible that a patient can mask symptoms during functioning as the muscle isn’t required to produce any hip skate for locomotion.
Nonetheless, in this event the muscle has a role in stability of the hip during kicking, and for that reason may have produced a poor pelvic/hip complicated during kicking that then led to an accident to the adductor longus on the other hand.
In addition, it seems that direct treatment to the muscle in the form of deep trigger point releases and also direct strengthening may actually delay healing in the muscle in case of injury. This may highlight the value of the muscle as a hip stabilizer instead of a legitimate torque manufacturer in hip rotation.
by Dr Alex Jimenez | Athletes, Chiropractic Examination, Complex Injuries, PUSH-as-Rx
Most of us will experience it at some point — but how does it influence on athletic performance? Chiropractic injury specialist, Dr. Alexander Jimenez investigates.
Research postulates that 80 percent of the populace will undergo an acute onset of back pain at least once in their lifetimes. This adds a considerable financial burden not just on the medical system (physician consultations, prescribed drugs, physiotherapy) but also the financing of the workforce in lost employee hours and loss in productivity.
The types of lower back pain that an individual may experience include (but are not limited to):
1. Lumbar spine disc herniation with/ without sciatica
2. Lumbar spine disc bulges
3. Lumbar spine disc degeneration
4. Lumbar spine disc annular tears
5. Ligament sprains
6. Muscle strains, particularly quadrutus lumborum
7. Osteoarthritis
8. Inflammatory arthritis such as rheumatoid and anklyosing spondylitis
9. Facet joint sprains
10. Bone injuries such as stress fractures, pars defects and spondylolisthesis.
The focus for this paper will be on the previous group — that the bone injuries. This may be simply postural (slow onset repetitive trauma) or related to sports; for instance, gymnastics.
The two demographic groups that tend to endure the most extension-related low back pain are:
1. People who endure all day, for instance, retailers, army, security guards etc.. Prolonged position will obviously force the pelvis to start to migrate to an anterior tilt management. This may begin to place compressive pressure on the facet joints of the spinal column as they also change towards an expansion position since they accompany the pelvic tilt.
2. Extension sports such as gymnastics, tennis, swimming, diving, football codes, volleyball, basketball, track and field, cricket fast bowlers. This is more pronounced in sports that involve extension/rotation.
Pathomechanics
With normal extension of the lumbar spine (or backward bending), the facet joints begin to approximate each other and compress.�The articular processes of this facet above will abut the articular process of the facet below. This is a normal biomechanical movement. However, if the extension ranges are excessive, the procedures will impinge quite aggressively and damage to the cartilage surfaces within the facet joint can result. Sports such as gymnastics, functioning in tennis, and handling in American Soccer may all involve uncontrolled and excessive extension.
It would be unlikely that a bone stress response or even a stress fracture could be brought on by an isolated expansion injury. It would be more likely that a sudden forced extension injury may damage an already pre-existing bone strain reaction.
Similarly, if an individual stands daily and the pelvis migrates into lateral tilt, then the aspects will be placed under low load compression but for extensive intervals.
With ongoing uncontrolled loading, stress is then transferred from the facet joint to the bone below (pars interarticularis). This originally will manifest as a pressure reaction on the bone. This bone strain may advance to a stress fracture throughout the pars if uncorrected. This fracture is also referred to as a “pars flaw”, or spondylolysis.
It was initially considered that stress fractures of the pars was a congenital defect that introduced itself at the teenage years. However, it is now agreed that it is probably obtained through years of overuse into extension positions, especially in young sportspeople involved with expansion sports. What’s more, one-sided pars defects often occur more commonly in sport which also included a rotational component such as tennis serving or fast bowling in cricket.
The stress fracture can then advance to impact the opposite side, causing a bilateral strain fracture, with anxiety subsequently being transferred to the disk in between both levels.
Spondylolisthesis features bilateral pars defects which could possibly be a result of repetitive stress into the bilateral pars in extension athletics, but more likely it is an independent pathology that manifests in the early growing stages (9-14) as this pathology is often viewed in this age category. If they become symptomatic in later years because of involvement in expansion sports, it is exceedingly likely that the defects were there by a young age but presented asymptomatically. As a result of rapid growth spurts in teenage years and the high-volume training experienced by teenaged athletes, it is possible that these dormant spondylolisthesis then pose as ‘acute onset’ back pain in teenage years.
In summary, the progression of this bone stress reactions tends to follow the following continuum:
1. Facet joint irritation
2. Pars interarticularis stress response
3. Stress fracture to the pars
4. Pars defect (or spondylolysis)
5. Spondylolisthesis due to activity or more likely congenital and found later in teenage years due to participation in�extension sports.
The landmark publication related to spondylolysis and spondylolisthesis was presented by Wiltse et al (1976) and they classified these injuries as follows:
1. Type I: dysplastic � congenital abnormalities of L5 or the upper sacrum allow anterior displacement of L5 on the sacrum.
2. Type II: isthmic � a lesion in the pars interarticularis occurs. This is subclassified as
a. lytic, representing a fatigue fracture of the pars,
b. elongated but intact pars, and c. acute fracture.
3. Type III: degenerative � secondary to long-standing intersegmental instability with associated remodeling of the articular processes.
4. Type IV: traumatic � acute fractures in vertebral arch other than the pars.
5. Type V: pathological � due to generalized or focal bone disease affecting the vertebral arch.
The vast majority of spondylolysis and sponylolisthesis accidents are Type II — the isthmic variety.
For the purposes of this paper, we will refer to the above stages as the posterior arch bone stress injuries (PABSI).
Epidemiology
It is a lot more widespread at the L5 level (85-90 percent). It’s a high asymptomatic prevalence in the general population and is often found unintentionally on x ray imaging. Nonetheless, in athletes, particularly young athletes, it is a common reason for persistent low back pain. From the young athlete, the problem is often referred to as ‘active spondylolysis’.
Active spondylolysis is normal in virtually every gamenevertheless, sports such as gymnastics and diving and cricket pose a much greater danger due to the extension and turning character of the sport. The progression from an active spondylolysis into a non-union type spondylolisthesis has been associated with a greater prevalence of spinal disk degeneration.
Early detection through screening and imaging, therefore, will highlight those early at the bone stress phase and if caught early enough and managed, the progression to the larger and more complicated pathologies are avoided as a result of therapeutic capacity of the pars interarticularis in the early stages.
It is more common to find teens and young adults afflicted by PABSI. This will highlight the rapid growth of the spine through growth spurts that is also characterized by a delay in the motor control of the muscle system during this period. Furthermore, it’s thought that the neural arch actually gets stronger in the fourth decade hence possibly explaining the low incidence of bone stress reactions in mid ages.
The incidence of spondylolysis has been reported to be around 4-6% in the Caucasian population (Friedrikson et al 1984). The rates seem to be lower in females and also in African-American males. It has also been suggested that a link exists between pars defects and spina bifida occulta.
The incidence of spondylolysis seems to be higher in the young athletic population than in the general population. Studies in gymnasts, tennis, weightlifting, divers and wrestlers all show disproportionately high incidence of spondylolysis compared with the general population of age-matched subjects.
Tennis
The tennis serve generates excessive extension and rotation force. In addition, the forehand shot may also produce elevated levels of spinning/ extension. The more traditional forehand shot demanded a great deal of weight shift through the legs to the torso and arms. However, a more favorite forehand shot is to currently face the ball and also generate the force of this shot utilizing hip rotation and lumbar spine extension. This action does increase ball speed but also puts more extension and compressive loads on the spine potentially resulting in a greater degree of stress on the bone components.
Golf
The most likely skill component involved in golf that may cause a PABSI are the tee shot with a 1 wood when forcing for distance. The follow-through of this shot entails a significant quantity of spine rotation with maybe a level of spine expansion.
Cricket
Fast bowlers in cricket are the most susceptible to PABSI. This will occur on the opposite side to the bowling arm. As the front foot engages on plant stage, the pelvis abruptly stops moving but the spine and chest continue to proceed. With the wind-up of this bowling action (rotation), when coupled with expansion this can place large forces on the anterior arch of the thoracic. More than 50% of fast bowlers will create a pars stress fracture. Young players (up to 25) are most vulnerable. Cricket governments have implemented training and competition guidelines to avoid such injuries by restricting the number of meals in training/games.
Field Events
The more common field events to cause a PABSI would be high leap followed by javelin. Both these sports create enormous ranges of backbone extension and under significant load.
Contact Sports
Sports like NFL, rugby and AFL all require skill components that need backbone expansion under load.
Gymnastics/Dancers
It goes without saying that gymnastics and dancing involves a substantial amount of repetitive spine expansion, particularly backflips and arabesques. It has been suggested that nearly all Olympic degree gymnasts could have suffered from a pars defect. Many organizing bodies now put limits on the number of hours young gymnasts can instruct to prevent the repetitive loading on the spine.
Diving
Spine extension injuries occur mostly off the spring board and on water entrance.
Diagnosis Of PABSI In Athletes
Clinical investigation
These can pose as preventable injuries. Research shows that the incidence was emphasized from the general population that have nil indicators of back pain. But, individuals will typically complain of back ache that is deep and generally unilateral (one side). This may radiate into the buttock area. The most offending movements tend to be described as expansion moves or backward bending movements. This may be a slow progression of pain or might be initiated by one acute episode of back pain in a competitive extension motion.
On clinical examination:
1. Pain may be elicited with a one-leg extension/rotation test (standing on the leg on the affected side) � stork test.
2. Tenderness over the site of the fracture.
3. Postural faults such as excessive anterior tilt and/or pelvic asymmetry.
The one-legged hyperextension test (stork test) was suggested to be pathognomonic for busy spondylolysis. A negative evaluation was stated to effectively exclude the diagnosis of a bone stress-type injury, thus creating radiological investigations unnecessary.
But, Masci et al (2006) examined the connection between the one-legged hyperextension test and gold standard bone scintigraphy and MRI. They discovered that the one-legged hyperextension test was neither sensitive nor specific for active spondylolysis. Moreover, its negative predictive value was so poor. Thus, a negative test can’t exclude energetic spondylolysis as a possible cause.
Masci et al (2006) go on to indicate that the bad relationship between imaging and the one-legged test may be because of a number of factors. The extension test would be expected to move a significant extension force on to the lower back spine. In addition to putting substantial strain on the pars interarticularis, it might also stress different regions of the spinal column like facet joints as well as posterior lumbar disks, and this may subsequently induce pain in the existence of other pathology such as facet joint arthropathy and spinal disc disease. This will explain the poor specificity of the test. Conversely, the inadequate sensitivity of the test may be related to the subjective reporting of pain by issues performing the maneuvre, which may vary based on individual pain tolerance. Additionally, this evaluation can preferentially load the fifth cervical vertebra, and so bone stress located in the upper lumbar spine may not test positive.
Grade 1 spondylolisthesis are normally asymptomatic; nonetheless, grade 2+ lesions often present with leg pain, either with or without leg pain. On examination, a palpable slip could be evident.
Imaging
Clinical assessment of active spondylolysis and the more severe pars defects and spondylolisthesis can be notoriously non-specific; this is, not all patients suffering PABSI will present with favorable abstract features or positive signs on analyzing. Thus, radiological visualization is important for diagnosis. The imaging methods available in the diagnosis of bone stress injury are:
1. Conventional radiology. This test is not very sensitive but is highly unique. Its limits are partially because of the cognitive orientation of the pars defect. The oblique 45-degree films may show the timeless ‘Scotty Dog’ appearance. Spondylolisthesis can be looked at simply on a lateral movie x-ray.
2. Planar bone scintigraphy (PBS) and single photon emission computed tomography (SPECT). SPECT enhances sensitivity in addition to specificity of PBS than straightforward radiographic study. Comparative research between PBS and conventional radiology have shown that scintigraphy is more sensitive. Patients with positive SPECT scan must then undergo a reverse gantry CT scan to assess whether the lesion is active or old.
3. Computed tomography (CT). The CT scan is considered to be more sensitive than conventional radiology and with higher specificity than SPECT. Regardless of the type of cross-sectional image utilized, the CT scan provides information on the state of the flaw (intense fracture, unconsolidated flaw with geodes and sclerosis, pars in procedure for consolidation or repair). The “inverse gantry” perspective can evaluate this condition better. Repeat CT scan can be used to track progress and recovery of the pars defect.
4. Magnetic resonance imaging (MRI). This technique shows pronounced changes in the signal in the amount of the pars. This is recognized as “stress response” and can be classified into five different degrees of action. MRI can be helpful for evaluating elements that stabilize isthmic lesions, for example intervertebral disc, common anterior ligament, and related lesions. The MRI isn’t as specific or sensitive as SPECT and CT combination.
Therefore, the current gold standards of investigation for athletes with low back pain are:
1. bone scintigraphy with single photon emission computed tomography (SPECT); if positive then
2. limited reverse-gantry axial computed tomography .
MRI has many advantages over bone scintigraphy, for instance, noninvasive nature of the imaging along with the absence of ionizing radiation. MRI changes in active spondylolysis include bone marrow edema, visualized as increased signal in the pars interarticularis on edema-sensitive sequences, and fracture, visualized as reduced signal in the pars interarticularis on T1 and T2 weighted sequences.
However, there is greater difficulty in detecting the changes of busy spondylolysis from MRI. Detecting pathology from MRI relies on the interpretation of distinct contrasts of signals compared with normal tissue. Unlike stress fractures in different parts of the body, the little region of the pars interarticularis may make detection of those changes harder.
However, unlike MRI, computed tomography has the capability to differentiate between acute and chronic fractures, and this differentiation might be an important determinant of fracture healing. Accordingly, in areas using pars interarticularis fractures discovered by MRI, it might nonetheless be necessary to execute thin computed tomography slices to determine whether or not a fracture is severe or chronic — an important factor in fracture resolution.
by Dr Alex Jimenez | Athletes, Complex Injuries, PUSH-as-Rx
Chiropractor, Dr. Alexander Jimenez summarizes some fascinating injury stories in the combat game…
I was recently on a holiday in Koh Lanta in Thailand and throughout my holiday I visited a Muay Thai training gym for two reasons. Firstly, as I’ve had a fascination with the sport for some time having formerly handled some injuries in some fighters in Australia it was to have a private Muay Thai training session with a few of the boxers. I was that I could use as material. I clarified the purpose of my visit and approached the head coach and discover a few of the interesting injury stories they’d out and he was pleased for me to talk to a few fighters. The following are just two case studies from this fact-finding mission.
The Biker’s Elbow
The initial fighter was a seeing K1 fighter out of Holland who spends six weeks a year in Thailand. He had been a fit and healthy 25-year-old man with a history of prior knee and back injuries; nonetheless, his complaint at this stage was pain on the inside of the right elbow that made grappling through fighting and also lifting weights at the gym hard.
The pain had started only a few days to his recent trip to Thailand and had been present for about five days. It had been focused around the medial epicondyle of the elbow. Any powerful gripping moves whilst flexing the elbow was shown to be debilitating. It had been affecting his coaching as some other work that was grappling was too painful and he was unable to perform any type gym movements such as chin ups and rowing motions. All pushing type movements were asymptomatic.
He whined no preceding elbow pain and refused any trauma to the elbow such as a arm lock-type situation or a hyperextension type injury during training or fighting.
He had been tender to palpate the source of the wrist flexor muscles which start on the elbow along, as well as any forceful wrist extension was uneasy. His elbow felt secure and using a stress test. Strong grip of the hands was painless until he was put to a position of wrist extension that is complete.
With no history of injury and without any changes to his coaching regimen I quizzed him. We exercised that whilst in Thailand he traveled on a scooter — a pastime for thieves to tackle when. He’d spent plenty of time around the sightseeing on the bicycle when he came.
The type of scooter he used was a automatic without equipment shifting the accelerator is on the right side of the bars. The reasoning was because of the continuous wrist extension used to accelerate the scooter at a pronated position, the wrist flexor muscles were put in a position of stretch with constant tension due to the co-contraction of this wrist flexor/extensor group required to do this particular movement. Coupled with this was that the vibration that is constant on the bicycle caused by the movement of the scooter in addition to the frequent pot holes and undulating road typical of Thai roads. The diagnosis was an inflammatory response in the wrist flexor origin.
I made the following suggestions:
1. Regularly extend by putting the hand flat on a table with the wrist turned to supination, the wrist flexors. He was to hold this for 30-second efforts.
2. Soft tissue massage to the wrist flexor muscle group, something he could do in Thailand using the massages on offer.
3. Moderate outrageous wrist flexor exercise working with a 5kg dumbbell using the forearm put on a desk (palm upward) and also to slowly lower the weight into wrist extension and use the flip side to help the concentric lifting. He was to do this
4. Change the hand place on the accelerator. It was suggested he can do three distinct things to achieve this. Primarily he can flare the elbow out broad whilst riding to decrease the amount. He up to this point kept the elbow close in to the body to perform this. Secondly he could occasionally hold the accelerator handle on the end so that he could keep his forearm supination position as this requires radial deviation to quicken the bike. Finally, on stretches of street I invited him undo the grip so he utilized wrist flexion to accelerate the bicycle and to actually supinate his forearm.
5. Rub some topical gel.
Two weeks later, I saw him and he maintained that the elbow pain had entirely subsided.
The Buzzing Thigh
A 30-year-old Thai local fighter had whined a six- month history of a ‘buzzing’ kind pain on the outside of the thigh and in the calf that was ideal region. It’d started after he obtained a hard kick to the back of his right hip. The kick was so strong that he lost function of his right leg at the time and needed a sensation down the thigh into the foot and calf. As this occurred in training, he rested on the leg and stopped and used the Thai concoction of heat and ointments to manage this harm. He returned to coaching a couple of days later and had been involved in a couple of fights after. He felt he had been still practical, but still felt a buzzing sensation every time. He claimed that he managed to perform everything and even blows to the thigh and hip were no longer painful than normal.
On examination he had movement in both hips his internal rotation when lying prone was decreased compared to another side. He was able to squat and perform a single leg pain free. All knee motions and ligament testing demonstrated unremarkable.
What was painful was a slump test on the ideal side and this reproduced the proper- sided throat sensations he experienced with kicking. The pain was made worse with dorsiflexion of the ankle whilst at a slump position.
It was concluded that when he had sustained the blow to the posterior hip, he had bruised the subsequent hematoma and the right piriformis muscle had created fibrosis around the sciatic nerve. Each time he had to stretch into full hip flexion with the knee extended and the foot dorsiflexed to complete a roundhouse kick, he had been effectively stretching the nerve against the port made by the scarring and fibrosis around the guts by the preceding injury to the soft tissues. This would be sufficient to give him a neuropathic-type pain down the leg across the course of the nerve and in the superficial peroneal nerve.
I explained that the way to remove this was to frequently ‘extend’ or move the guts from the vents to try to release the nerve out of any fibrosis. I showed him how to run his own gentle nerve mobilizations as a slide and slide method (neurological wracking) and also how to hold the place on stretch to make a sustained elongation.
He did so sitting on the conclusion of the fighting ring at a full slump position (neck flexed, spine arched into flexion) and he had been to straighten the ideal knee with the foot dorsiflexed until he felt a gentle uncomfortable tug onto the guts (felt like a buzzing down the ideal leg). This was to be achieved to this point of discomfort but not pain. I explained that if he overdid motion and this stretch he could make the issue worse, so I invited him to underdo this and not over do this. He had been to spend five minutes after a warm-up finishing a string of knee extension and release the stretch. After a pause continue this on/off movement for five minutes per day and he was to stretch again.
I didn’t figure out how this solved as this movement would take a few weeks to make a noticeable shiftI can expect that he would have discovered a relief from his signs at some stage in the future.
by Dr Alex Jimenez | Athletes, Complex Injuries, Physical Rehabilitation, PUSH-as-Rx
Chiropractor, Dr. Alexander Jimenez looks at the way this common injury shows itself.
Introduction
Iliotibial band syndrome (ITBS) between the knee is frequently diagnosed in sport injury clinics. ITBS presents having an incidence rate of around 22% in most lower extremity running-related injuries (1) also has been said to be the second most common complaint amongst distance runners (2). ITBS has been given the expression ‘runner’s knee’.
Trainers like endurance runners who perform flexion and extension combined with loading are subjected to this illness. ITBS presents during the first two or three miles in running with no mechanism of injury, which can make identifying the cause more interesting. With plenty of factors having been considered within the literature, changes are often purported to be a cause of ITBS. But some biomechanical factors have been researched and have been found to have little or no effect in the start of ITBS. Therefore this text’s point would be to examine the biomechanical changes which may induce an individual to the beginning of ITBS. The research published reviewed is largely based on a current systematic review that was published in Physical Therapy in Sport in 2014 (3).
Anatomy & Function
The iliotibial band (ITB) encapsulates the tensor fascia latae (TFL) presenting with both deep and superficial fibre attachments at the pelvis (4). In addition to attaching to the TFL, approximately three-quarters of the gluteus maximus tendon also conjoins with the ITB (4). The ITB courses along the lateral aspect of the hip and passes the greater trochanter. The ITB maintains an attachment on the posterior ridge of the femur whilst attaching itself to the fascia. The ITB has a fixed attachment at the lateral femoral condyle where it then divides into three segments with the first being the lateral patella (3). The remaining two segments cross the knee joint to insert at the head of fibula and most distally at the infrapatellar tubercle also known as Gerdy’s tubercle on the tibia (3). Figure 1 illustrates the location of the ITB.
The ITB passively functions to resist hip adduction, hip internal rotation and internal rotation of the knee in accordance with its attachments at the pelvis, femur and tibia(3). The gluteus maximus functions, through its attachment, to increase stability through the hip and knee complex by increasing the tension of the ITB(4). It is possible to see, based on its attachments at both the knee and hip, how changes could bring about the onset of ITBS.
Studies have proposed that as the knee flexes and extends the ITB ‘slides or flicks’ over the lateral femoral condyle of the knee causing an irritation beneath. This notion was debated by Falvey and colleagues (5), who stated that it was highly unlikely that the ITB would flick or slide over the bone during knee flexion due to it not being a loose structure. But the authors did agree that the impact of compression on the richly innervated fat pad was pain’s cause but by strain of the ITB where pain presents crossing the lateral femoral condyle. Strain rate and strain magnitude were measured in a prospective study involving female runners (6). The results indicated that frequency of strain of the ITB at the lateral femoral condyle was greater that the strain magnitude. This implies that a runner might have the ability to run for a short period but then incur lateral knee pain because of the strain to the ITB.
MRI scans have ascertained the knee flexion angle of 30� elicited the greatest compression of the ITB at the point of heel strike, whereas others have said that maximal compression occurs between 20-30�(2,6). A knee flexion angle at the point of heel strike has been found to be significantly different with 20.6� in ITBS patients compared to 15.3� in the control(7). Downhill running produces a greater knee flexion angle at the point of heel strike eliciting a larger strain load to the ITB and therefore this is often a main precursor to ITBS (6). Although an elevated knee flexion angle at the point of heel strike has been considered to contribute to ITBS, it is essential to examine the lower extremity from the frontal and transverse planes too and not solely from the sagittal plane (2).
Rearfoot Eversion
It’s possible to envisage how rear foot eversion could contribute to ITBS causing internal rotation of the tibia resulting at the distal attachment in greater strain of the ITB. In contrast Ferber and colleagues (2) indicated that there was no significant difference in the peak eversion angle of the female subjects, who were previously diagnosed with ITBS but were now symptom free, compared to controls. In a similar study non-significant differences were found between the currently symptomatic ITBS patients and controls for rear foot eversion (8).
Louw & Deary(3) found that ITBS patients sometimes demonstrated decreased eversion angles, accompanied by decreased internal rotation of the knee, at the point of heel strike. Ferber and colleagues (2) noted an increased inversion moment in the ITBS group which was suggested to control and limit the eversion moment. By comparison, currently symptomatic ITBS patients demonstrated a substantial difference compared to a control group with twice the rear foot motion during running (9).
Knee Internal Rotation
Peak internal rotation angle of the knee was found to be significantly greater in the ITBS patients when compared with controls at the point of heel strike (2). This research was supported by other studies who also found a significant effect for increased internal rotation of the knee following a run of moderate intensity to physical exhaustion(7). With excessive rotation comes compression due to increased strain of the ITB at the attachment.
An explanation of increased internal rotation of the knee was attributed to excessive external rotation of the femur perhaps due to shortening of the piriformis, gemellus inferior and superior and the obutrator externus (8). The authors added that excessive rotation at the hip might result from muscular activity of the rotators that were hip being the medius, minimus and the tensor fascia latae. These studies(2,7) were retrospective in design in that they tested healthy runners with a history of ITB pain, whereas(8) was a prospective study of patients with ITBS at the point of testing.
Hip Adduction Angle & Hip Abductor Strength
The hip adduction angle during the stance phase has been suggested to be greater. Ferber and colleagues(2) found that the peak hip adduction angle was significantly greater in the ITBS cohort and stated that with 95% confidence. Increased angle results in increased stress to the ITB and consequently increased compression at the lateral femoral condyle when combined with increased internal rotation of the tibia.
Figure 2 illustrates, when peak hip adduction and internal rotation combine, how this may result in increased the compression of the ITB at the lateral femoral condyle. Louw and Deary(3), however, stated that it remained inconclusive whether the peak hip adduction angle was a substantial element. Additional research is therefore required to support Ferber and colleagues'(2) initial findings as this study was a retrospective study carried out on healthy female runners with a history of ITBS.
Hip Abductor Strength
It’s been proposed that an increased peak hip adduction angle may coincide with hip abductor activity involving the gluteus medius in this group. During the stance phase of gait the gluteus medius functions to keep stability. Research has indicated that during stance the adduction forces can exceed three times an individual’s body weight(3). What’s more, it was stated that these forces were beyond the metabolic capacity of the gluteus medius to main pelvic stability during the stance phase using just this muscle alone(3).
Louw and Deary (3) were not able to identify a heightened hip abductor moment in the ITBS patients with increased peak hip adductor angles and suggested that it was more of an issue of timing as opposed to the size of the hip abductors. Louw and Deary (3) stated that the research is yet to examine trunk and pelvic movements in ITBS patients and it is plausible to suggest that biomechanical changes from higher up the kinetic chain has the potential to be a contributing element in ITBS etiology.
A research study of 24 (14 female, 10 male) patients with ITBS undertook a six-week rehabilitation programme to increase the strength of the hip abductors(10). Following six weeks of hip abductor strengthening to running 22 patients reported being pain-free and had returned. The female patients reported an average hip abductor torque increase of 34.9% and the male patients found 51.4% increase. However this study used a hand held dynamometer to measure isometric strength and therefore Fedricson (10) findings should be viewed with caution.
A more recent study assessed the hip abductor strength of currently symptomatic patients with healthy controls in a fixed position(11). The results indicated that no substantial differences occurred for static and dynamic hip abductor strength between the groups. Further research should look into the EMG and strength of the hip abductors in the role of managing ITBS. Table 1 shows of significance in the some of the variables of the studies used in this text.
Rehabilitation programs, following periods of immobilization and during, should include gluteal exercises to provide stability to the leg that is involved. If active exercises for the gluteal muscles are provided in a manner that is secure and effective then this can influence the period of transition from non weight. It’s prudent based on the research provided to date to develop function although research is lacking in terms of quality and volume as to the biomechanical influences on the etiology of ITBS. This guarantees that once load bearing commences that the leg that is involved has the stability and control that is active to keep the beginning of load of the ITB.
Summary
The recent review published by Louw and Deary(3) indicates that much of the research published within the literature depending on the etiology of ITBS is inconclusive. The level of research is relatively low and is based on retrospective trials. The research does indicate that knee biomechanics and abnormal hip is involved in the occurrence of ITBS. The authors ascertain that muscle strength is involved as is foot biomechanics that are abnormal. It is recommended that future research should measure kinematic movements of the hip and knee during downhill running as this is a complaint of ITBS onset.
References
1.Clini J of Sports Med, May 2006,16, (3), 261-268
2.J of Sports Phys Therap, Feb, 2010, 40, 2, 52-58.
3.Phys Therap in Sport, 2014, 15, 64 e75.
4.Surgic and Radiologic Anatomy (Dec) 2004; 26, (6), 433 – 446
5.Scand J of Med & Sci in Sports, Aug 2010, 20 (4), 580-587.
6.Clini Biomech, 2008, 23, 1018-1025.
7.Gait Posture. 2007 Sep, 26 (3), 407-13
8.Clini Biomech, Nov 2007, 22 (9), 951-956.
9.Med Sci in Sport & Ex, 1995, 27, 951-960.
10.Clini J of Sports Med, 2000, 10:169�175.
11. Int J of Sports Med, Jul, 2008, 29 (7), 579-583.
by Dr Alex Jimenez | Diets, Fitness
Macaroni and cheese mixes made with powdered cheese contain high levels of potentially harmful chemicals called phthalates, according to a new study.
Phthalates, which can get into food from packaging and equipment used in manufacturing, have been linked to genital birth defects in infant boys and learning and behavior problems in older children, The New York Times reported.
Researchers tested different cheese products and found that all 10 varieties of macaroni and cheese included in the study had high levels of phthalates, even those labeled as organic.
“The phthalate concentrations in powder from mac and cheese mixes were more than four times higher than in block cheese and other natural cheeses like shredded cheese, string cheese and cottage cheese,” said Mike Belliveau, executive director of the Environmental Health Strategy Center, one of four advocacy groups that funded the report, according to The Times.
The other groups were the Ecology Center, Healthy Babies Bright Futures and Safer States.
“Our belief is that (phthalates are) in every mac ‘n’ cheese product – you can’t shop your way out of the problem,” Belliveau said.
He encouraged consumers to contact manufacturers and ask them to determine how phthalates are getting into their products and take action to prevent it. Nine of the cheese products tested were made by Kraft. Company officials did not respond to requests for comment on the study findings, The Times reported.
The U.S. government phthalates from children’s teething rings and rubber duck toys a decade ago.
by Dr Alex Jimenez | Diets, Fitness, Pregnancy
Pregnant women who drink non-diet sodas during pregnancy are more likely to have kids who carry extra body fat by age 7, researchers say.
In the study of more than 1,000 mother-child pairs, each additional serving of sugary soda per day consumed in pregnancy was associated with higher increments of waist size and body mass in kids years later.
“Sugary beverages have been linked to obesity in children and adults,” said study author Sheryl Rifas-Shiman of Harvard Medical School in Boston.
Although past research has tied sodas and some fruit drinks to excess weight gain, obesity, metabolic syndrome and type 2 diabetes, few have looked at beverage intake during pregnancy, she and her colleagues write in Pediatrics.
“Childhood obesity is widespread and hard to treat,” Rifas-Shiman told Reuters Health by email. “So it’s important to identify modifiable factors that occur prenatally and during infancy so prevention can start early.”
The researchers recruited 1,078 women from among patients at eight obstetric offices affiliated with Atrius Harvard Vanguard Medical Associates in eastern Massachusetts.
The study team had in-person meetings with each woman at the end of her first and second trimesters, as well as during the first few months after her baby was born. In addition, kids were assessed in early childhood, around age 3, and in mid-childhood, around age 8. Mothers also completed mailed questionnaires every year for the child’s first six birthdays.
At all visits, researchers collected information about both parents and details of the household. During pregnancy, women answered questionnaires about what they typically ate and drank, including how much regular and sugar-free soda, fruit juice, fruit drinks and water they consumed each day.
At the mid-childhood visit, when kids were between ages 6 and 11 years, the research team measured each child’s height, weight, waist circumference and skinfold thickness. With these measurements, they calculated body fat percentage and body mass index (BMI), a measure of weight relative to height.
When researchers looked at data gathered during pregnancy, they found that more than half of mothers had consumed more than half a serving a day of non-diet soda during pregnancy, and nearly 10 percent had consumed two or more servings a day.
Mothers who drank more sugary drinks during pregnancy tended to be younger, had higher prepregnancy BMI, lower education, lower income, shorter breastfeeding times and were more likely to have smoked during pregnancy.
About one quarter of the children were overweight or obese by mid-childhood, and BMI, waist circumference and skinfold thickness were highest among kids whose mothers drank at least two servings of sugary drinks per day.
Only regular sodas were associated with this difference. Juice, diet soda and water consumed during pregnancy weren’t linked to a higher BMI score in kids. The research team also didn’t see differences based on the mother’s weight, race or ethnicity, the child’s gender or the amount of soda children themselves drank.
“I was surprised that maternal intake seemed to be more important than child intake,” Rifas-Shiman noted.
In the future, she and colleagues plan to study the long-term effects of efforts to reduce sugary beverage intake during pregnancy. They’re now using new methods to analyze when children’s intake of sugary beverages matters the most for their weight and health.
“I was struck that the differences in children’s body composition were seen in relation to intake levels that appear unremarkable, even less than one serving per day,” said Sian Robinson of the University of Southampton in the UK, who wasn’t involved in the study.
“We need to know more about the long-term effects of maternal nutrition on offspring health,” she told Reuters Health by email. “Few intervention studies in pregnancy have longer-term follow-up data to describe the effects on children’s body composition.”
Several of these intervention studies have been completed recently, Robinson added, and that follow-up data will be available soon.
“The links between sugar-sweetened beverages and obesity are well-established,” she said. “But this new data suggests mothers’ consumption is important and has public health relevance.”
by Dr Alex Jimenez | Diets, Fitness
It’s hard to eat right all the time, but making small improvements by choosing healthier foods now and then may significantly boost one’s chances of living longer, said a US study Wednesday.
The report in the New England Journal of Medicine is the first to show that improving diet quality over at least a dozen years is associated with lower total and cardiovascular mortality.
Researchers at Harvard University tracked dietary changes in a population of nearly 74,000 health professionals who logged their eating habits every four years.
Researchers used a system of diet-quality scores to assess how much diets had improved.
For instance, a 20-percentile increase in scores could “be achieved by swapping out just one serving of red or processed meat for one daily serving of nuts or legumes,” said a summary of the research.
Over the 12-year span, those who ate a little better than they did at the start — primarily by consuming more whole grains, fruits, vegetables, and fatty fish — saw an eight to 17 percent lower risk of dying prematurely in the next 12 years.
Those whose diets got worse over time saw a higher risk of dying in the next 12 years of follow-up, on the order of a six to 12 percent increase.
“Our results highlight the long-term health benefits of improving diet quality with an emphasis on overall dietary patterns rather than on individual foods or nutrients,” said senior author Frank Hu, professor and chair of the Harvard Chan School Department of Nutrition.
“A healthy eating pattern can be adopted according to individuals’ food and cultural preferences and health conditions,” he added.
“There is no one-size-fits-all diet.”
