Back Clinic Complex Injuries Chiropractic Team. Complex injuries happen when people experience severe or catastrophic injuries, or whose cases are more complex due to multiple trauma, psychological effects, and pre-existing medical histories. Complex injuries can be serial injuries of the upper extremity, severe soft tissue trauma, and concomitant (naturally accompanying or associated), injuries to vessels or nerves. These injuries go beyond the common sprain and strain and require a deeper level of assessment that may not be easily apparent.
El Paso, TX’s Injury specialist, chiropractor, Dr. Alexander Jimenez discusses treatment options, as well as rehabilitation, muscle/strength training, nutrition, and getting back to normal body functions. Our programs are natural and use the body’s ability to achieve specific measured goals, rather than introducing harmful chemicals, controversial hormone replacement, unwanted surgeries, or addictive drugs. We want you to live a functional life that is fulfilled with more energy, a positive attitude, better sleep, and less pain. Our goal is to ultimately empower our patients to maintain the healthiest way of living.
Chiropractor, Dr. Alexander Jimenez gives insight into the relevant anatomy and functional biomechanics of the piriformis muscle, highlights the role it plays in musculoskeletal dysfunction and looks at management options in cases of muscle dysfunction.
The piriformis muscle (PM) is well-known in the fraternity of sports medicine as a significant muscle in the posterior hip. It is a muscle that has a role in controlling hip joint rotation and abduction, and it is also a muscle made famous due to its �inversion of action� in rotation. Furthermore, the PM also grabs attention due to its role in the contentious �piriformis syndrome�, a condition implicated as a potential source of pain and dysfunction, not only in the general population but in athletes as well.
Relevant Anatomy
The name piriformis was first coined by Belgian Anatomist Adrian Spigelius in the early 17th century. Its name is derived from the Latin word �pirum� meaning �pear� and �forma� meaning �shape� � ie a pear shaped muscle (see Figure 1)(1).
The PM originates on the anterior surface of the sacrum and is anchored to it by three fleshy attachments between the first, second, third and fourth anterior sacral foramina(2). Occasionally its origin may be so broad that it joins the capsule of the sacroiliac joint above and with the sacrotuberous and/or sacrospinous�ligament below(3,4).
PM is a thick and bulky muscle, and as it passes out of the pelvis through the greater sciatic foramen, it divides the foramen into the suprapiriform and infra-piriform foramina(5). As it courses antero-laterally through the greater sciatic foramen, it tapers out to form a tendon that is attached to the superior-medial surface of the greater trochanter, commonly blending with the common tendon of the obturator internus and gemelli muscles(6).
The nerves and blood vessels in the suprapiriform foramen are the superior gluteal nerve and vessels, and in the infra- piriforma fossa are the inferior gluteal nerves and vessels and the sciatic nerve (SN)(5). Due to its large volume in the greater sciatic foramen, it has the potential to compress the numerous vessels and nerves that exit the pelvis.
PM is closely associated with the other short hip rotators that lie inferior such as the superior gemellus, obturator internus, inferior gemellus and obturator externus(2). The primary difference between the PM and other short rotators is the relationship to the SN. The PM passes posterior to the�nerve whereas the other otators pass anterior (see figure 2).
Variants
A few anatomical variants have been found with the PM:
1. Additional medial attachments to the first and fifth sacral vertebrae and to the coccyx(7).
2. The tendon may fuse with the gluteus medius or minimus above, or superior gemellus below(7).
3. In less than 20% of cases it is divided into two distinct portions through which part or all of the sciatic nerve may pass(7).
4. It may blend with the posterior hip joint capsule as a conjoined tendon with the obturator internus(8).
5. The distal attachment of the PM has shown to vary in dimensions and position on the supero-medial surface of the greater trochanter. It can span a distance of between 25-64% of the anterior-posterior length on the greater trochanter, with 57% attaching more anterior and 43% more posterior(9).
6. Pine et al (2011) studied the insertion point extensively and found that four types of insertion existed and these were classified based on the relationship to the obturator internus(10). The variability in position and breadth of the distal attachment of the PM muscle may influence the validity of the concept known as �inversion of action� (see below).
The other hotly debated issue is the relationship between the PM and the SN. The conclusion is that there are several anatomical variations of the PM and its SN relationship. The sub-types of this variation include(11-13):
Type 1 (A below). Typical pear shape muscle with the nerve running anteriorly and inferiorly to this (in 70%-85% of cases).
Type 2 (B below). The PM is divided into two parts with the common peroneal nerve running between the two parts and the tibial nerve running anterior and below (found in 10-20% of cases).
Type 3 (C below). The peroneal portion loops over the top of the muscle and the tibial portion is below (found in 2-3% of cases).
Type 4 (D below). Undivided nerve passing through the PM (occurs in about 1% of cases).
It is also believed that two other very uncommon variations occur (see E and F below).
Type A is the most common variation, showing the SN passing below the PM
Functional Considerations
The primary functional roles of the PM are;
1. Hip external rotation(15).
2. Abductor at 90 degrees of hip flexion(15).
3. In weight-bearing, the PM restrains the femoral internal rotation during stance phase of walking and running(2).
4. Assists the short hip rotators in compressing the hip joint and stabilising the joint(6).
5. As it can exert an oblique force on the sacrum, it may produce a strong rotary shearing force on the sacroiliac joint (SIJ). This would displace the ipsilateral base of the sacrum anteriorly (forward) and the apex of the sacrum posteriorly(16).
As the PM is the most posterior of the hip external rotators due to its attachment on the anterior surface of the sacrum, it has the greatest leverage to exert a rotation effect on the hip joint. It is often seen clinically that the PM appears to be tight and hypertonic, while the other short hip�rotators that are closer to the axis of rotation become inhibited and hypotonic.
Inversion Of Action
The most contentious issue related to the function of the PM is its �reversal-of- function role� or �inversion of action� role. Many authors have suggested that as the hip approaches angles of 60-90 degrees and greater, the tendon of the PM shifts superiorly on the greater trochanter. As a result, its line of pull renders it ineffective as a hip external rotator; however it does contribute to internal hip rotation. Therefore it reverses its rotation role at high hip flexion angles(15,17,18).
The function of the PM at varying joint angles is an important consideration for the clinician who is evaluating and treating �piriformis syndrome�. Often it has been advocated to stretch the hip into flexion, adduction and external rotation to stretch the PM over the glutes by utilising the �reversal of function� concept.
However, more recent anatomical dissection studies have shown that the attachment of the PM onto the greater trochanter can be variable and in some instances it may insert in a position whereby it is unable to reverse its function, for example in a more posteriorly placed attachment(19). Therefore, stretching the PM into external rotation when the hip is flexed beyond 90 degrees � based upon reversal of function � would be ineffective as a treatment or misleading as an examination technique(19)
MSK Dysfunction & PM Syndrome
Many decades ago, the role that the PM played in creating sciatic-like symptoms was first suggested by Yeoman (1928) when it was considered that some cases of sciatica may originate outside the spine(20). This was supported soon after when Freiberg and Vinkle (1934) successfully cured sciatica by surgically dividing the PM(21). Based on cadaver dissections Beaton and Anson (1938) gave the hypothesis that the spasm of the PM could be responsible for the irritation of the SN(12).
The term �piriformis syndrome� was first coined by Robinson in 1947(22) and was applied to sciatica thought to be caused by an abnormality in the PM (usually traumatic in origin) with emphasis on ruling out more common causes of sciatica such as nerve root impingement from a disc protrusion. It soon became an accepted clinical entity � but with no consensus about the exact clinical signs and diagnostic tests to differentiate it from other sources of sciatica(23,24).
Piriformis syndrome can be defined as a clinical entity whereby the interaction�between the PM and SN may irritate the SN and produce posterior hip pain with distal referral down the posterior thigh, imitating �true sciatica�. Isolating the dysfunction to this region usually follows exclusion of the more common causes of buttock pain and sciatica.
More specifically, complaints of buttock pain with distal referral of symptoms are not unique to the PM. Similar symptoms are prevalent with the more clinically evident lower back pain syndromes and pelvic dysfunctions. Thus, a thorough evaluation of these regions must be performed to exclude underlying pathology(4). It has been suggested that piriformis syndrome� is responsible for 5-6% of cases of sciatica(25,26). In the majority of cases, it occurs in middle-aged patients (mean age 38 yr)(27) and is more prevalent in women(28).
Pathogenesis Of Piriformis Syndrome (PS)
PS may be caused by or relate to three primary causative factors;
1. Referred pain due to myofascial trigger points (see Figure 4)(2,28-30). Examples include tight and shortened muscle fibres precipitated by muscle overuse such as squat and lunge movements in external rotation, or�direct trauma(16). This increases the girth of the PM during contraction, and this may the source of the compression/entrapment.
2. Entrapment of the nerve against the greater sciatic foramen as it passes through the infrapiriform fossa, or within a variant PM(29,31).
3. SIJ dysfunction causing PM spasm(29,32).
Janvokic (2013) has presented a number of causative factors in PS(29);
1. Gluteal trauma in the sacroiliac or gluteal areas.
2. Anatomical variations.
3. Myofascial trigger points.
4. Hypertrophy of the PM or spasm of the PM.
5. Secondary to spinal surgery such as laminectomy.
6. Space occupying lesions such as neoplasm, bursitis, abscess, myositis. 7. Intragluteal injections.
8. Femoral nailing.
Symptoms
Typical symptoms reported in piriformis syndrome include:
A tight or cramping sensation in the buttock and/or hamstring(33).
Gluteal pain (in 98% of cases)(34).
Calf pain (in 59% of cases)(34).
Aggravation through sitting and squatting(35), especially if the trunk is inclined forward or the leg is crossed over the unaffected leg(36).
Possible peripheral nerve signs such as pain and paraesthesia in the back, groin, buttocks, perineum, back of the thigh (in 82% of cases)(34).
Physical Findings & Examinations
Palpable spasm in and around the PM and obturator internus and external tenderness over the greater sciatic notch (in 59-92% of cases)(34,35). The patient is placed in the Sims position. The piriformis line overlies the superior border of the PM and extends from immediately above the greater trochanter to the cephalic border of the greater sciatic foramen at the sacrum. The line is divided into equal thirds. The fully rendered thumb presses on the point of maximum trigger-point tenderness, which is usually found just lateral to the junction of the middle and last thirds of the line.
Hip flexion with active external rotation or passive internal rotation may exacerbate the symptoms(36).
Positive SLR that is less than 15 degrees the normal side(37).
Positive Freiberg�s sign (in 32-63% of cases)(34,35). This test involves reproducing pain on passive forced internal rotation of the hip in the supine position � thought to result from passive stretching of the PM and pressure on the sciatic nerve at the sacrospinous ligament.
Pacers sign (in 30-74% of cases)(34,35). This test involves reproducing pain and weakness on resisted abduction and external rotation of the thigh in a sitting position.
Pain in a FAIR position(34). This involves the reproduction of pain when the leg is held in flexion, adduction and internal rotation.
An accentuated lumbar lordosis and hip flexor tightness predisposes one to increased compression of the sciatic nerve against the sciatic notch by a shortened piriformis(38).
Electro-diagnostic tests may prove useful (see below).
Investigations
Conventional imaging such as X-ray, CT scan and MRI tend to be ineffective in diagnosing piriformis syndrome.
However, some value may exist in electro- diagnostic testing.
It is beyond the scope of this paper to discuss in detail the process of electro- diagnostic testing; the reader is directed to references for more a more detailed description of how these tests are administered(35,36,39). However the purpose of these tests is to find conduction faults in the SN. Findings such as long-latency potentials (for example the H reflex of the tibial nerve and/or peroneal nerve) may be normal at rest but become delayed in positions where the hip external rotators are tightened(27,36,39).
It is accepted that the tibial division of the SN is usually spared, the inferior gluteal nerve that supplies the gluteus maximus may be affected and the muscle becomes atrophied(40). However testing of the peroneal nerve may provide more conclusive results as is more likely to be the�impinged portion of the SN. The H-wave may become extinct during the painful position of forced adduction-internal rotation of the affected leg(36).
The �Myth� Of Piriformis Syndrome
Stewart 2003 argues that piriformis syndrome is an often over-used term to describe any non-specific gluteal tenderness with radiating leg pain(41). He argues that only in rare cases is the PM implicated in nerve compression of the SN to truly qualify as a piriformis syndrome. He cites only limited evidence and cases where the diagnosis of piriformis syndrome can be made.
1. Compressive damage to the SN by the PM. Stewart cites studies whereby in few isolated studies, the SN was seen to be compressed by the PM in instances such as hypertrophy of the muscle,�usual anatomical anomalies such as a bifid PM, and due to compression by fibrous bands.
2. Trauma and scarring to the PM leading to SN involvement; it is possible that rare cases of true Piriformis Syndrome have been caused by direct heavy trauma to the PM due to a blunt trauma to the muscle. This is termed �post- traumatic PS�.
McCory (2001) supports this argument by stating that it is more likely that (given the anatomical relationship of the PM to the various nerves in the deep gluteal region) the buttock pain represents entrapment of the gluteal nerves, and the hamstring pain entrapment of the posterior cutaneous nerve of the thigh, rather than the SN alone(33). This would explain the clinically observed phenomenon in the absence of distal sciatic neurological signs. Whether the PM is the cause of the compression has not been clearly established. It is possible that the obturator internus/gemelli complex is an alternative cause of neural compression. He suggests using the term �deep gluteal syndrome� rather than piriformis syndrome.
Treatment
When it is believed that a piriformis syndrome exists and the clinician feels that a diagnosis has been made, the treatment will usually depend on the suspected cause. If the PM is tight and in spasm then initially conservative treatment will focus on stretching and massaging the tight muscle to remove the PM as being the source of the pain. If this fails, then the following have been suggested and may be attempted(23,36):
Local anaesthetic block � usually performed by anaesthesiologists who have expertise in pain management and in performing nerve blocks.
Steroid injections into the PM.
Botulinum toxin injections into the PM.
Surgical Neurolysis.
Here, we will focus on therapist-directed interventions such as stretching of the PM and direct trigger point massage. It has always been advocated that PM stretches are done in positions of hip flexion greater than 90 degrees, adduction and external rotation to utilize the �inversion of action� effect of the PM to isolate the stretch to this muscle independent of the other hip external rotators.
However, recent evidence from Waldner (2015) using ultrasound investigation discovered that there was no interaction between hip flexion angle and the thickness of the PM tendon in both internal and lateral hip rotation stretching � suggesting that the PM does not invert its action(19). Furthermore, Pine et al (2011)(9) and Fabrizio et al (2011)(10) in their cadaveric studies found that the PM insertion is a lot more complex and varied than first thought. It is possible that the PM may invert its action only in some subjects but not others.
Therefore, due to the disagreements and confusions over the �inversion of action� concept, it is recommended that the clinician �covers all bases� and performs two variations of a PM stretch � stretches in flexion, adduction and external rotation and stretches in flexion, adduction and internal rotation. Examples of these stretches are given in figures 5-7 below.
Trigger Points & Massage
(see Figure 8)
The best approach to palpate the PM trigger points is in the position suggested by Travel and Simons(2) and this is shown below. In this position, the clinician can feel for the deep PM trigger points and apply a sustained pressure to alleviate the trigger�points � and also apply a flush massage to the muscle in this position.�In this position the large gluteus maximus is relaxed and it is easier to feel the deeper PM.
Summary
The PM is a deep posterior hip muscle that is closely related anatomically to both the sacroiliac joint and the sciatic nerve. It is a hip external rotator at hip flexion angles of neutral to 60 degrees of hip flexion, an abductor when in flexion and also contributes to hip extension.
It has been previously accepted that the PM will �invert its action� or �reverse its function� after 60 degrees of flexion to become a hip internal rotator. However, recent ultrasound and cadaveric studies has found conflicting evidence that this �inversion of action� may in fact not exist.
PM is a muscle that is a dominant hip rotator and stabiliser, and thus has a tendency to shorten and become hypertonic. Therefore, stretching and massage techniques are best utilised to reduce the tone through the muscle. Furthermore, it has also been implicated in compression and irritation of the sciatic nerve � often referred to as piriformis syndrome�.
References
1. Contemp Orthop 6:92-96, 1983.
2. Simons et al (1999) Travell and Simons� Myofascial Pain and Dysfunction. Volume 1 Upper Half of the Body (2nd edition). Williams and Wilkins. Baltimore.
3. Anesthesiology; 98: 1442-8, 2003.
4. Joumal of Athletic Training 27(2); 102-110, 1996.
5. Journal of Clinical and Diagnostic Research. Mar, Vol-8(3): 96-97, 2014.
6. Clemente CD: Gray�s Anatomy of the Human Body, American Ed. 30. Lea & Febiger, Philadelphia, 1985 (pp. 568-571).
7. Med J Malaysia 36:227-229, 1981.
8. J Bone Joint Surg;92-B(9):1317-1324, 2010.
9. J Ortho Sports Phys Ther. 2011;41(1):A84, 2011.
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11. Med Sci Monit, 2015; 21: 3760-3768, 2015.
12. J Bone Joint Surg Am 1938, 20:686-688,1938.
13. Journal of Clinical and Diagnostic Research. 2014 Aug, Vol-8(8): 7-9, 2014.
14. Peng PH. Piriformis syndrome. In: Peng PH, editor. Ultrasound for Pain Medicine Intervention: A Practical Guide. Volume 2. Pelvic Pain. Philip Peng Educational Series. 1st ed. iBook, CA: Apple Inc.; 2013 .
15. Kapandji IA. The Physiology of Joints. 2nd ed. London: Churchill Livingstone; 1970: 68.
16. J Am Osteopath Assoc 73:799-80 7,1974.
17. J Biomechanics. 1999;32:493-50, 1999.
18. Phys Therap. 66(3):351-361, 1986.
19. Journal of Student Physical Therapy Research. 8(4), Article 2 110-122, 2015.
20. Lancet. 212: 1119-23, 1928.
21. J Bone Joint Surg Am 16:126�136, 1934.
22. Am J Surg 1947, 73:356-358, 1947.
23. J Neurol Sci; 39: 577�83, 2012.
24. Orthop Clin North Am; 35: 65-71, 2004
25. Arch Phys Med Rehabil; 83: 295-301,2002.
26. Arch Neurol. 63: 1469�72, 2006.
27. J Bone Joint Surg Am; 81: 941-9,1999.
28. Postgrad Med 58:107-113, 1975.
29. Can J Anesth/J Can Anesth;60:1003�1012, 2013.
30. Arch Phys Med Rehabil 69:784, 1988.
31. Muscle Nerve; 40: 10-8, 2009.
32. J Orthop Sports Phys Ther;40(2):103-111, 2010.
33. Br J Sports Med;35:209�211, 2001.
34. Man Ther 2006; 10: 159-69, 2006.
35. Eur Spine J. 19:2095�2109, 2010.
36. Journal of Orthopaedic Surgery and Research, 5:3, 2010.
37. Muscle & Nerve. November. 646-649, 2003.
38. Kopell H, Thomnpson W. Peripheral Entrapment Neuropathies. Huntington, NY: Krieger, 1975:66.
39. Arch Phys Med Rehabil;73:359�64, 1992.
40. J Bone and Joint Surg, 74-A:1553-1559, 1992.
41. Muscle & Nerve. November. 644-646, 2003
Corticosteroid injections are widely used to aid injury rehabilitation but we still understand very little about their mechanism. Chiropractor, Dr. Alexander Jimenez examines the current thinking and discusses how this potentially impacts treatment options…
Corticosteroids are used for their anti- inflammatory and pain reducing effects. They can also reduce muscle spasms and influence local tissue metabolism for faster healing. Injection therapy is now widely available from specially trained general practitioners, physiotherapists and consultants, and can be offered for a wide range of clinical conditions. Because of this wide availability and the growing desire for injury �quick fixes�, it is important that they are used correctly and the full consequences are understood prior to injection.
The main indications for corticosteroid injection use are(1):
Acute and chronic bursitis
Acute capsulitis (tight joint capsule)
Chronic tendinopathy
Inflammatory arthritis
Chronic ligament sprains
Steroid injections of hydrocortisone are a synthetic form of a naturally produced hormone within the body called cortisol. Cortisol is important for regulating carbohydrate, protein and fat metabolism. It is also involved in metabolic responses in times of stress such as emotional problems, trauma, and infection, where levels of inflammation are elevated. Steroid injections work on the immune system by blocking the production of chemicals that activate the inflammatory reactions, therefore reducing inflammation and pain within injury locations.
Steroid injections can be directed into a joint, muscle, tendon, bursa, or a space around these structures. Figure one shows an injection aiming for the bursa within the shoulder joint. This is often a source of irritation and causes impingement when the shoulder moves. The location will depend on what tissue is causing the symptoms. When injected locally to the specific structure, the effects are primarily only produced there and widespread detrimental effects are minimal(2).
When To Use
Identifying the correct time to issue a steroid injection following injury requires careful consideration. The mechanical status of the tissue is important because this will vary depending on the stage of healing and therefore the effectiveness of the injection will also vary.
Figure 2 shows the different stages that a tendon can progress through following trauma. This is equally applicable to muscles, fascia, and other tissues too. A reactive tendinopathy (tendon degeneration/damage) will present shortly after injury/trauma/stress/ excessive loading, and will display acute swelling and inflammation. The initial care should be 2-3 weeks of rest, analgesia, ice application and gentle physiotherapy. If symptoms have not significantly improved after this period, then the introduction of a corticosteroid injection is appropriate for providing symptomatic relief by reducing inflammation and eliminating the occurrence of further damage because mechanical normality will be quickly restored(3).
If the tendon continues to be placed under excessive load, swelling and inflammation will remain or escalate, and continuous loading will eventually cause micro trauma and further tendon degeneration. If this is prolonged for long enough then the tendon will fail structurally(4).
The use of corticosteroids here is questionable because there is unlikely to be inflammation present to combat, and the injection alone will not repair this physical damage. Injection treatment at this stage may only be indicated if the athlete is in too much pain to participate in any significant rehabilitation. The symptomatic relief the injection may bring at this point could allow exercises to be performed, which can help accelerate the repair of physical damage. Ultimately, physical exercise is a key component in recovery following corticosteroid injections.
Impact On Treatment & Performance
For the best outcome, post-injection care � particularly with respect to timing � is important. Relative rest is recommended for the first two weeks post-injection. During this first two weeks the tissues are weakened and their failing strengths are reduced by up to 35%; this means the strength at which they would fail (tear) is much lower and more susceptible to rupturing(8).
By six weeks the bio-mechanical integrity is reestablished and the tissues are deemed �normal� again, with increased strength and function(8). Benefits are optimal within this 6-week period and often short-lived; therefore the athlete must comply strictly to a rehabilitation program to gradually load the tissues and ensure the correct load is applied during this period(9). Research has also shown that at twelve weeks post-injection�there is little significance in the difference between those who received a steroid injection and those who focused on exercise therapy alone, suggesting this early symptom relief should be used to enhance rehabilitation(10). If loading is accelerated in the early stages the athlete risks re-aggravation of the injury, delayed healing, further weakening and thus rupture.
If this rehabilitation protocol is followed, the athlete will likely maximise their outcome. They can return to training, and with the severity of their symptoms reduced, this can allow progression to the next stage of training. If the injury is severe enough that surgery may be considered within three months, a steroid injection should not be performed as this can affect the success of the surgery.
Evidence For Sports Injuries
Here we will consider some of the more common sports injuries and summarize what the current evidence regarding steroid injection suggests.
Shoulders
Injection therapy is indicated in subacromial impingement or bursitis (as in Figure 3 below) to allow the inflammation reduction and restoration of normal movement. It is also indicated in rotator cuff pathology where the tendons are again inflamed, but also damaged and unable to undergo exercise therapy. Shoulder injections are shown to produce early improvements in pain and function with a high level of patient satisfaction(10). Symptoms are similar to those without injection at 12 weeks however, suggesting physical therapy is also important(10). Injection is not appropriate for shoulder instability as it can make the joint more unstable. Exercise therapy alone is recommended for this condition.
Hip Pain
Two soft tissue conditions that benefit the most from injection are piriformis syndrome (muscle tightness running deep to the buttock muscles), and greater trochanter pain syndrome (affecting the bursa surrounding the hip joint, or the gluteal tendons that are all in close proximity to the lateral hip)(11). Injection success is reported to be approximately 60-100% if the diagnosis is accurate and the correct protocols are adhered to(12). Other regions such as the adductor and hamstring tendons can also be treated for tendinitis or groin pains. However, injections into these�regions are deep and painful, and require extensive rest afterwards.
Knee Pain
Knee joint injections for arthritic conditions are most commonly used, with injection to the soft tissues much less common due to the complex diagnosis, and risk of detrimental side effects. The various bursa around the knee, the iliotibial band, and quadriceps and patellar tendons have all been shown to significantly benefit in the short-term; however accurate location is essential to ensure the tendon itself is not penetrated � only the surrounding regions(13).
Plantar Fasciitis
This is a painful injection to receive, and pain can last for well over one week post- injection (see figure 4). There is an approximate 2-4% risk that the fascia can rupture. In addition, there�s a risk of local nerve damage and wasting of the fat pad within the heel. Studies have demonstrated that at 4 weeks post-injection pain and thickness of the injured plantar fascia are reduced and these benefits remain three months later, suggesting a good outcome if the risks are avoided(14).
The majority of clients that present to the clinic with anterior knee pain over the coming year will more often than not have a patellofemoral (PF) problem.
It may be a slight bit of biomechanical mal-alignment that has stirred up the knee cap – this is the good, or they may have started to wear the cartilage behind the knee cap and as a result it has softened – chondromalacia � this is the bad. They may even have worn a hole into the knee cap cartilage and they now have a chondral defect, or worse still an osteochondral defect – the downright ugly.
These problems affect runners, cross fitters, group exercise enthusiasts (PUMP classes) and simple recreational walkers who spend a lot of time on hills and stairs.
How These Extremes Are Managed Will Differ
The biomechanical irritations and the chondromalacia versions can be managed conservatively with a combination of local treatment modalities and correcting the biomechanical faults. The more serious chondral/osteochondral defects often need some surgical intervention as often the pathology is too advanced to respond to conservative treatment alone.
Understanding the exact mechanical contributions of the knee cap in relation to the femur is critical for the therapist to effectively manage these problems.
At the local PF level, the fault is usually a malposition of the patella in the femoral trochlear groove. Often the knee cap is being pulled too far laterally and superiorly in the groove, creating an uneven contact situation between the knee cap and the femur. The PF compression force during loaded knee flexion (squats, lunges etc.) is no longer optimal and usually a smaller portion of the patella cartilage is taking all the load. This wears the cartilage down and creates pain and pathology. This is most noticeable as the knee flexes to 30 degrees and onwards as it is this knee flexion angle where the knee cap enters the femoral trochlear groove.
The more distant (but often dominant) faults lie at the hip/pelvis and at the feet. Below is a breakdown of common biomechanical faults that may contribute to PF pain syndromes.
1. Overpronation
If the foot pronates (rolls in) for too long or too much, the pronated midfoot forces the tibia to remain internally rotated. The femur follows the tibia and also internally rotates. This creates a mal-alignment at the knee whereby the PF arrangement is altered and the knee cap shifts laterally. We are all familiar with the Q angle of the knee and how this affects the PF alignment.
Common causes of overpronation may be structural flatfoot problems that can be corrected with orthotics and shoe selection. However, tight soleus (that limits dorsiflexion) or a tight and overactive peroneal system that everts the foot and flattens the foot can also be a cause.
Stretching and loosening the soleus and peroneals along with strengthening the anti-pronation muscles such as tibialis posterior, flexor hallucis longus and flexor digitorum longus may help fix this problem.
FADDIR represents a flexed, adducted and internally rotated hip joint at foot strike. This is often caused by tight and overactive hip flexors such as TFL and the adductors and weakness in the abductors (gluteus medius) and external hip rotators (gemellus, obturator muscles). This hip posture forces the femur to roll inwards and as a result the knee is deviated medially and away from the vertical line drawn up from the foot. This also increases the Q angle and PF misalignment results and perpetuates the local knee imbalance of tight and overactive lateral quadriceps and lateral hamstrings along with ITB tightness. As a result the VMO weakens.
Loosening the overactive TFL, adductors, lateral quad, ITB and lateral hamstring whilst strengthening the gluteus medius, hip external rotators and VMO may help this biomechanical mal-alignment.
3. Pelvic Trendelenburg
Defined as lateral pelvic shift whereby at stance phase the opposite side of the pelvis drops down below the height of the pelvis on the stance side. This is usually caused by a weak gluteus medius complex that is unable to hold the pelvis stable during stance phase. The implications again are that this causes the knee to roll in and increase the Q angle. The solution is to muscle up the gluteus medius.
This often forgotten about imbalance creates a situation whereby the individual finds it difficult to attain hip extension at the end of stance phase. The hip remains locked in a degree of flexion.
The knock on effect is that the knee also stays locked in some flexion. With the knee in flexion, the knee cap is now compressed against the femur, compression on the underside of the kneecap may result. To fix this the therapist needs to stretch/loosen the hip flexors and strengthen the gluteus maximus to promote more hip extension.
Sciatica is generally described as a set of symptoms, primarily characterized by pain and discomfort, along with tingling sensations and numbness. Athletes frequently report experiencing symptoms of sciatica, however, there are many factors as well as a variety of injuries and conditions which can manifest these well-known symptoms. Piriformis syndrome is a disorder that is frequently confused with symptoms of sciatica.
The piriformis muscle is commonly known among athletes and healthcare professionals as a significant muscle in the posterior hip. This muscle functions to control hip joint rotation and abduction and it is also a distinguishable muscle due to its inversion of action in rotation. The piriformis muscle also raises awareness as the various causes of piriformis syndrome, a condition suspected to be a potential source of pain and dysfunction, not only in athletes, but in the general population as well.
Anatomy of the Piriformis Muscle
The piriformis muscle originates on the anterior surface of the sacrum and it is securely held to it by three tissue attachments found between the first, second, third and fourth anterior sacral foramina. Occasionally, its origin may be so broad that it joins the capsule of the sacroiliac joint with the sacrotuberous and/or sacrospinous ligament. The piriformis muscle is a thick and strong muscle that travels out of the pelvis through the greater sciatic foramen, dividing the foramen into the suprapiriform and infra-piriform foramina. As it courses through the greater sciatic foramen, the muscle decreases to a point where it forms a tendon that attaches to the superior-medial surface of the greater trochanter, frequently integrating with the tendon of the obturator internus and gemelli muscles.
The nerves and blood vessels found within the suprapiriform foramen are known as the superior gluteal nerves and vessels, and those found in the infra-piriforma fossa are known as the inferior gluteal nerves and vessels, including the sciatic nerve. Because of its broad size in the greater sciatic foramen, there�s a risk the numerous vessels and nerves that exit the pelvis may become compressed.
The piriformis muscle is closely associated with other short hip rotators as well, such as the superior gemellus, obturator internus, inferior gemellus and obturator externus. The primary difference between this muscle and other short rotators is its connection to the sciatic nerve. The piriformis muscle passes behind the nerve while the other rotators pass before it.
Anatomical Variants
Several anatomical variations have been previously diagnosed among the piriformis muscle. First, there may be additional medial attachments to the first and fifth sacral vertebrae and to the coccyx. Second, the tendon may merge with the gluteus medius or minimus or with the gemellus. Also, in approximately less than 20 percent of cases, the piriformis muscle may be divided into two different segments, through which part or all of the sciatic nerve may travel. Then, the muscle may blend with the posterior hip joint capsule as a conjoined tendon with the obturator internus. Additionally, the distal attachment of the piriformis muscle has been demonstrated to vary in proportion and position on the supero-medial surface of the greater trochanter. It can stretch across 25 to 64 percent of the anterior-posterior length along the greater trochanter, with 57 percent of it attaching more anteriorly and 43 percent more posteriorly. Last but not least, researchers studied its insertion point broadly and discovered that four types of insertions existed and these were characterized based on the relationship to the obturator internus. The variation of placement and width of the distal attachment of the piriformis muscle may influence the effectiveness of the concept known as the inversion of action.
Furthermore, the connection between the piriformis muscle and the sciatic nerve has been a highly debated complication. It�s been previously concluded that there are several anatomical variations among the piriformis muscle and its connection to the sciatic nerve. The sub-types of this variation include: type 1-A, where the muscle is pear shaped with the nerve running anteriorly and inferiorly to this, found in 70 to 85 percent of cases; type 2-B, where the piriformis muscle is divided into two sections with the common peroneal nerve running between the two parts and the tibial nerve travels anteriorly and below, found in 10 to 20 percent of cases; type 3-C, where the peroneal portion loops over the top of the muscle and the tibial portion is found below, found in 2 to 3 percent of cases; and type 4-D, where the undivided nerve passes through the piriformis muscle, found in approximately 2 percent of cases.
Moreover, it is also speculated that two other, very rare variations may occur, demonstrated by letters E and F in the diagram. Type 1-A is the most common variation, displaying the sciatic nerve as it passes below the piriformis muscle.
Function of the Piriformis Muscle
The fundamental functions of the piriformis muscle are to provide hip external rotation and allow abduction at 90 degrees of hip flexion. During weight-bearing, the piriformis muscle restricts femoral internal rotation in the stance phase of walking and running. Also, it assists the short hip rotators in compressing the hip joint and stabilizing it. Because it can exert an oblique force on the sacrum, it may produce a strong rotary shearing force on the sacroiliac joint. Otherwise, this would dislocate the ipsilateral base of the sacrum forward and the apex of the sacrum backwards.
Since the piriformis muscle is the furthest behind of the hip external rotators because of its attachment on the anterior surface of the sacrum, it has the greatest influence to apply a rotation effect on the hip joint. Occasionally, healthcare specialists have found issues with the piriformis muscle where it appears to be tight and hypertonic, while the other short hip rotators which are found closer to the axis of rotation become inhibited and hypotonic.
Inversion of action
The most argumentative complication relating to the function of the piriformis muscle is its reversal-of-function role, best referred to as the inversion of action role. Researchers have suggested that as the hip approaches angles of 60 to 90 degrees and greater, the tendon of the piriformis muscle shifts on the greater trochanter. As a result, its line of pull becomes ineffective as a hip external rotator, however, it does contribute to internal hip rotation. Consequently, it reverses its rotation function at high hip flexion angles.
The role of the piriformis muscle at several joint angles is an essential consideration for healthcare professionals who evaluate and treat the causes of piriformis syndrome. Frequently, it�s recommended to stretch the hip into flexion, adduction and external rotation to stretch the piriformis muscle over the glutes by utilizing the reversal of function concept.
Nonetheless, more recent studies conducted through anatomical dissection have demonstrated that the attachment of the piriformis muscle onto the greater trochanter can change and, in some instances, it may insert in a position by which it may be unable to reverse its function, for example, in a more posteriorly placed attachment. Thus, stretching the piriformis muscle into external rotation when the hip is flexed beyond 90 degrees, based on the inversion of action role, would be ineffective as a treatment or misleading as an examination technique.
MSK Dysfunction and Causes of Piriformis Syndrome
Many decades ago, it was suggested that in some cases, sciatica symptoms may originate outside the spine as a result of the piriformis muscles. This hypothesis was supported soon after when specialists successfully improved an individual�s symptoms of sciatica by surgically dividing the piriformis muscle. Based on cadaver anatomical dissections, the researchers believed that the spasm of the piriformis muscle could be responsible for the irritation of the sciatic nerve.
The medical term piriformis syndrome then became associated to sciatica symptoms, believed to be caused by a usually traumatic abnormality in the piriformis muscle with a focus on ruling out more common causes of sciatica, such as nerve root impingement caused by a disc herniation. It soon became an accepted interpretation but with no consensus about the exact clinical signs and diagnostic tests to differentiate it from other sources of sciatica.
Understanding the Causes of Piriformis Syndrome
Piriformis syndrome can be defined as a clinical entity whereby the interaction between the piriformis muscle and the sciatic nerve may irritate the nerves and develop posterior hip pain with distal referral down the posterior thigh, resembling symptoms of true sciatica. Distinguishing the damage to this region typically follows exceptions of the more common causes of sciatica and buttock pain.
More specifically, reports of buttock pain with distal referral of symptoms are not unique to the causes of piriformis syndrome. Similar symptoms are prevalent with the more medically evident lower back pain syndromes and pelvic dysfunctions. Therefore, a complete evaluation of these areas must be performed to rule out any underlying pathology. It has been suggested that the causes of piriformis syndrome can be held responsible for approximately 5 to 6 percent of sciatica cases. In the majority of instances, it develops in middle-aged individuals, an average or 38 years and it�s more common among women.
Pathogenesis of Piriformis Syndrome
The causes of Piriformis syndrome can be associated to three primary causing factors: First, the referred pain may be the result of myofascial trigger points. Second, the entrapment of the nerve against the greater sciatic foramen as it passes through the infrapiriform fossa or within a variating piriformis muscle. And third, sacroiliac joint dysfunction causing piriformis muscle spasms.
Other researchers presented an additional number of factors behind the causes of piriformis syndrome as follows: gluteal trauma in the sacroiliac or gluteal regions, anatomical variations, myofascial trigger points, hypertrophy of the piriformis muscle or spasms of the piriformis muscle, secondary to spinal surgery such as laminectomy, space occupying lesions such as neoplasm, bursitis, abscess and myositis, intragluteal injections and femoral nailing.
Symptoms
The general symptoms described with the causes of piriformis syndrome include: a tight or cramping sensation in the buttock and/or hamstring, gluteal pain in up to 98 percent of cases, �calf pain in up to 59 percent of cases, aggravation through sitting and squatting if the trunk is inclined forward or the leg is crossed over the unaffected leg and possible peripheral nerve signs such as pain and paresthesia in the back, groin, buttocks, perineum and back of the thigh in up to 82 percent of cases.
Physical findings and examinations
When palpable spasm within the surrounding piriformis muscle occur and there is obturator internus pain and external tenderness over the greater sciatic notch, found in approximately 59 to 92 percent of cases, the individual must perform the Sims position to follow up an evaluation. The piriformis line should overlie the superior border of the piriformis muscle and extend immediately from above the greater trochanter to the cephalic border of the greater sciatic foramen at the sacrum. The examination will continue where the line is divided into equal thirds. The fully rendered thumb presses on the point of maximum trigger-point tenderness, which is usually found just lateral to the junction of the middle and last thirds of the line.
It�s important to keep in mind that hip flexion with active external rotation or passive internal rotation may aggravate the symptoms of dysfunction. Additional findings for the evaluated causes of piriformis syndrome have demonstrated a positive SLR that is less than 15 degrees on the normal side. Other tests used to evaluate the causes of piriformis syndrome include, positive Freiberg�s sign, used in 32 to 63 percent of cases, involves the reproduction of pain on a passively forced internal rotation of the hip in the supine position, believed to result from passive stretching of the piriformis muscle and pressure of the sciatic nerve at the sacrospinous ligament. Pacers sign, used in 30 to 74 percent of cases, involves reproducing pain and weakness on resisted abduction and external rotation of the thigh in a sitting position. Pain in a FAIR position used to evaluate dysfunction, involves the reproduction of pain when the leg is held in flexion, adduction and internal rotation. Furthermore, an accentuated lumbar lordosis and hip flexor tightness predisposes an individual to increased compression of the sciatic nerve against the sciatic notch by a shortened piriformis. Electro-diagnostic tests may also prove useful to diagnose piriformis muscle complications.
Investigations
Conventional imaging, such as X-ray, CT scan and MRI, tend to be ineffective in diagnosing the presence and causes of piriformis syndrome. However, some value may exist in electro-diagnostic testing. The purpose of these tests is to find conduction faults in the sciatic nerve. Findings such as long-latency potentials, for instance the H reflex of the tibial nerve and/or peroneal nerve, may be normal at rest but become delayed in positions where the hip external rotators are tightened.
It�s been established that the tibial division of the sciatic nerve is typically spared, the inferior gluteal nerve that supplies the gluteus maximus may be affected and the muscle becomes atrophied. However, testing of the peroneal nerve may provide more conclusive results as they�re more likely to be the impinged portion of the sciatic nerve. The H-wave may become inactive during the painful position of forced adduction-internal rotation of the affected leg.
Piriformis Syndrome Myths
Researchers argued that piriformis syndrome is a frequently over-used term to describe any non-specific gluteal tenderness with radiating leg pain. It was discussed that only in rare cases is the piriformis muscle involved in nerve compression of the sciatic nerve to legitimately qualify as one of the causes of piriformis syndrome. It was cited that there is only limited evidence and cases where the diagnosis of the causes of piriformis syndrome can be made. First, where there is compressive damage to the sciatic nerve by the piriformis muscle. In several isolated studies, the sciatic nerve was seen to be compressed by the piriformis muscle in instances such as hypertrophy of the muscle, general anatomical abnormalities such as a bifid piriformis muscle and due to compression by fibrous bands.
Also, trauma and scarring to the piriformis muscle can involve the sciatic nerve. It is possible that rare cases of true piriformis syndrome have been caused by direct heavy trauma to the piriformis muscle due to a blunt trauma to the muscle. This is termed as post- traumatic piriformis syndrome.
Researchers supported this argument by stating that it is more likely that, given the anatomical relationship of the piriformis muscle to the various nerves in the deep gluteal region, the buttock pain represents entrapment of the gluteal nerves and the hamstring pain entrapment of the posterior cutaneous nerve of the thigh, rather than the sciatic nerve alone. This demonstrates the medically analyzed circumstance in the absence of distal sciatic neurological signs. Whether the piriformis muscle is the cause of the compression has not been clearly established. It is possible that the obturator internus/gemelli complex is an alternative cause of neural compression. The researchers have suggested utilizing the term deep gluteal syndrome rather than piriformis syndrome.
Treatment
When it is believed that a factor which is considered one of the several causes of piriformis syndrome exists and a healthcare professional feels that a proper diagnosis has been made, the treatment will usually depend on the cause behind the dysfunction. If the piriformis muscle is tight and it spasms, then initially conservative treatment will focus on stretching and massaging the tight muscle to remove the piriformis muscle as being the source of the pain. If this fails, then the following have been suggested and may be attempted: local anesthetic block, typically performed by an anesthesiologist who has expertise in pain management and in performing nerve blocks; steroid injections into the piriformis muscle; botulinum toxin injections in the piriformis muscle; and surgical neurolysis.
Therapist-directed interventions, such as stretching of the piriformis muscle and direct trigger point massage, can also be used as treatment. It�s been encouraged that piriformis muscle stretches are done in positions of hip flexion greater than 90 degrees, adduction and external rotation to utilize the inversion of action effect of the piriformis muscle to isolate the stretch to this muscle independent of the other hip external rotators.
However, recent evidence utilizing ultrasound investigation demonstrated that there was no interaction between hip flexion angle and the thickness of the piriformis muscle tendon in both internal and lateral hip rotation stretching, which suggests that the piriformis muscle does not invert its action. Furthermore, researchers who performed cadaveric studies found that the piriformis muscle insertion is a lot more complex and varied than initially believed. It is possible that the piriformis muscle may invert its action only in some subjects but not in others.
As a result, due to the disagreements and confusions over the inversion of action concept, it is recommended that healthcare professionals should performs two variations of a piriformis muscle stretch: stretches in flexion, adduction and external rotation and stretches in flexion, adduction and internal rotation.
Pigeon Stretch for left piriformis muscle: hip flexion, neutral adduction and maximal hip external rotation.
Stretch for left piriformis muscle: hip is in flexion, neutral adduction and maximal external rotation.
Short leg posterior chain stretch for right piriformis muscle: hip is in 90 degree flexion, adduction and neutral rotation.
Trigger Points and Massage
The most appropriate suggestion to palpate the piriformis muscle trigger points is in the following recommended position. In this posture, the healthcare professional can feel for the deep piriformis muscle trigger points and apply a constant pressure to relieve the trigger points as well as apply a flush massage to the muscle in this position. In this position, the large gluteus maximus is relaxed and it is easier to feel the deeper piriformis muscle.
The piriformis muscle is a deep posterior hip muscle that is closely related anatomically to both the sacroiliac joint and the sciatic nerve. It is a muscle that is a dominant hip rotator and stabilizer, with a tendency to shorten and become hypertonic. Therefore, stretching and massage techniques are best recommended and utilized to reduce the tone through the muscle. In conclusion, it has also been suggested in compression and irritation of the sciatic nerve, most commonly referred to as piriformis syndrome.
In athletes, piriformis syndrome is a common disorder identified by the irritation and inflammation of the piriformis muscle which can generally result in the compression of the sciatic nerve. This impingement of the nerves and its surrounding tissues can cause the symptoms of sciatica to manifest, characterized by pain and discomfort, along with tingling sensations and numbness, affecting an athlete’s performance.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Headache After Auto Injury
After being involved in an automobile accident, the sheer force of the impact can cause damage or injury to the body, primarily to the structures surrounding the spine. Whiplash is a common result of an auto collision, affecting the bones, muscles, tendons, ligaments and other tissues around it, causing symptoms such as head pain. Headaches are a common symptom after an automobile accident, which may require immediate medical attention to determine its source and follow through with treatment.
Athletes regularly participate in rigorous training and competition. While they routinely stretch and exercise accordingly to prevent experiencing injuries while performing their specific sport of physical activity, they constant and repetitive movements of the body can often cause damage or injury, even developing an aggravating condition regardless of the process they follow to avoid harm. Hamstring injuries are recognized as frequent injuries among athletes, particularly due to the use of the legs in a majority of sports or physical activities.
Hamstring injuries are significantly common in athletes and the risk of re-injury is reasonably frequent. Researchers found that in elite-level Australian football, hamstring injuries were the most prevalent type of sports injury which required time away from competition. Researchers also determined that low-grade muscle strains occur most frequently, followed by more significant myotendinous junction tears. Fortunately, these have shown a positive response to conservative rehabilitation. Hamstring avulsions are considerably rare, same as complete ruptures originating at the hamstring. Such type of sports injuries can be debilitating.
Muscle ruptures in the form of hamstring avulsions have been reported more frequently in the younger population due to an immature epiphyseal growth plate found on the ischial tuberosity in older children and adolescents. Hamstring avulsions in adults with fully fused ischial tuberosities are contributed to be ruptures of the proximal hamstring tendon or complete avulsion fractures of the ischial tuberosity.
An immediate diagnosis following proper treatment methods for ischial tuberosity avulsions or tendon ruptures is essential at this point because several individuals whom were treated non-operatively for hamstring ruptures experienced residual loss of power. Further complications for hamstring avulsions include pain, weakness, cramping during locomotion and pain while sitting. As with the majority of tendon avulsions, treating the injury as soon as possible can present better outcomes than delaying treatment. According to research, receiving treatment within four weeks of injury resulted in better recovery outcomes as compared to those which received treatment after four weeks of injury.
Anatomy of the Hamstring & its Function
The hamstring muscles consist of the biceps femoris, both the long head and the short head, the semitendinosus and the semimembranosus. All of these muscles, excluding the biceps short head, attach onto the ischial tuberosity. The short head biceps begin along the femur simultaneously with the linea aspera.
At the proximal origin, the long head of the biceps and the semitendinosus form a combine to create the tendon which attaches to the ischial tuberosity and the semimembranosus.
When an individual undergoes puberty, a secondary ossification center at the ischial tuberosity develops without fusing until the individual�s late teens or early twenties. Within the period of time between the fusion of the apophysis, an increased force traction may cause a hamstring avulsion along the apophysis as a result of a weakened connection between the bone and the muscle. After the bones begin to mature, injuries at the myotendinous junction become more common.
The structures of the hamstring greatly associate with the passage of the sciatic nerve along the upper posterior thigh. A severe injury to the muscle that causes a large hematoma may develop adhesions in and around the sciatic nerve which may create complications towards an athlete�s overall performance after the rehabilitation process. Also, the nerve may become damaged or injured as a result of a traction neuritis when the muscle belly retracts away from the nerve. Furthermore, compression or impingement due to a tight fibrotic band distal to the ischial tuberosity may also cause complications for many athletes. Managing hamstring avulsions and other types of injuries relating to the proper function and mobility associated with the sciatic nerve is an important factor towards overall recovery.
It is not uncommon for hamstring avulsions to involve only two heads of the hamstring and not all three. These are identified as partial avulsions. It is more common if the hamstring avulsions are partial to where it involves the combined tendon of the biceps femoris and the semitendinosus.
Mechanism of Injury
Due to the anatomical structure of the hamstrings, these can be highly vulnerable to suffer trauma or injury in the regions where the muscles and other tissues cross both the hip and knee, primarily because of its large leverage to function with the hip during movements.
The most common mechanism of injury involves forced knee extensions in a position of hip flexion while the muscle is placed under a large and rapid eccentric load. The force is conducted to the myotendinous junction. This often results due to a sudden and forceful landing from a jump where the knee was locked in extension, during foot contact in sprinting or in excessive and uncontrolled hip flexion, such as when the leg slips out from underneath the body and moves into hip flexion with the knee extended during sports or physical activities like forward splits, water skiing and bull riding.
Nonetheless, it�s been considered that in order for tendons to rupture, some level of degenerative alterations must have developed in the tendon before the rupture occurred. This hypothesis has been identified in athletes where the Achilles tendons rupture and the supraspinatus tendons rupture. Researchers have associated these findings with why myotendinous ruptures in the hamstrings of young athletes almost never occur, how they fail at the growth plate as well as explaining its increasing frequency in middle aged, recreational athletes.
The degeneration of the tendon occurs throughout the anatomical and biochemical change in the tissue of the tendon. The collagen fibers become disorganized, the intracellular matrix changes, cystic foci develop in the tendon and hypervascularity within the tendon becomes present. Tension and compression forces being applied against the body can often create these degenerative effects. The forces of tension occur as a result of a rapid, eccentric loading against the hamstring tendon as the hip is rapidly flexed. The forces of compression occur when the singular anatomy of the ischial tuberosity bone presses against the tendon and creates a zone of impingement. Repetitive and constant tension and compression forces then progressively degenerate, eventually becoming weaker and rupturing.
Furthermore, because of the proximity of the hamstring muscles to the sciatic nerve which runs down each leg from the lower back, a hamstring rupture could also affect this crucial nerve. As a result, the inflammation and swelling caused by an injury to the hamstring muscles and other surrounding tissues may compress the sciatic nerve, leading to symptoms of sciatica. Sciatica is commonly referred to as a series of symptoms rather than a single injury and condition. Therefore, athletes with hamstring avulsions may additionally experience symptoms of sciatica.
The affected athlete must seek immediate medical attention not only to effectively treat hamstring injuries but also to determine the presence of sciatica and properly diagnose whether another type of injury or underlying condition may be causing the sciatic nerve pain besides the hamstring rupture.
Hamstring Injury Symptoms
Athletes with hamstring avulsions commonly describe experiencing severe and debilitating symptoms after the injury. Many athletes report the pain as a sudden shot along with an audible pop. A majority of individuals faced with hamstring avulsions are guarded on the affected limb and are reluctant to bear full weight on a loaded limb. Hamstring ruptures causing sciatica may experience pain along with numbness and tingling sensations, radiating along the lower back, buttocks and thighs. Also, in some cases of injury, an athlete may develop myofascial pain syndrome, a disorder causing muscle pain in seemingly unrelated areas of the body.
When the affected athlete visits a healthcare professional, such as a chiropractor, physical therapist or other specialist, on examination, a palpable defect may be felt below the ischial tuberosity and a loss of the contour of the hamstring can often be observed. These, however, generally depend on the size of the gluteals and any intervening adipose tissue which could make direct palpation and visualization difficult. Healthcare specialists usually describe a significant discoloration throughout the hamstring muscle a few days after the injury occurred.
Further evaluation of athletes with hamstring avulsions show weakness in both isolated knee flexion and isolated hip extension along with reported pain. The individual�s range of motion is greatly restricted due to the symptoms and walking with a limp may be common as they may be unable to bear weight through the injured muscle.
If proper medical attention is delayed because the injury appears to be muscle related and the athlete believes it could heal on its own, the individual may experience hamstring muscle atrophy due to disuse.
Imaging
Basic X-rays and CT scans won�t provide beneficial results unless the hamstring avulsions occurred from the ischial tuberosity.
Ultrasound imaging may be useful, however, further research regarding its sensitivity and specificity requires more research.
MRI is the preferred method when the presence of a hamstring rupture is suspected because the details of the soft tissues are well displayed on an MRI, highlighting the level of tendon retraction as well as any interference with the sciatic nerve. Furthermore, MRI can be utilized throughout all stages of rehabilitation to evaluate the healing capacities of the tendon.
Hamstring Injury: Common Sports Injuries
Hamstring Lesion Treatment & Care
The treatment procedures for hamstring injuries have long been considered controversial, whether they effectively repair or don�t repair the damage or injury. A large number of criteria has been suggested to help healthcare professionals, such as chiropractors and physical therapists, among others, to help determine if athletes faced with hamstring avulsions may require surgery.
First, the osseous avulsion must have more than a 2 cm retraction. Second, there must be complete tears in all 3 tendons with or without retraction, and last, partial tears reporting painful and symptomatic despite prolonged conservative treatment, are some of the criteria an individual must meet to signal the need for surgery.
However, some partial or complete ruptures of the hamstring generally requires some form of operative treatment among the vast majority of athletes, primarily due to concerns regarding residual loss of strength and power.
Instances where partial hamstring ruptures may require operative treatment still remain fully unclear. In some cases, partial ruptures may rehabilitate properly through conservative procedures but if pain and other symptoms continue after a prolonged period of rehabilitation, then repairing a partial rupture through operative measures may lead to positive outcomes.
Surgical Intervention for Hamstring Ruptures
The surgical procedure for repairing hamstring avulsions is as follows: First, the hamstring muscle is contacted with a posterior incision beginning at the gluteal fold. The incision may extend over a 10 cm distance in order for the specialist to be able to fully access the retracted hamstring tendon. The placement of the posterior cutaneous nerve and the sciatic nerve in relation to the individual will be visualized and any adhesions at this point can be carefully resected, a process known as neurolysis. Neurolysis is almost always essential if surgery has been delayed due to misdiagnosis or following unsuccessful conservative treatment procedures. If a hematoma is detected, then this will be cleared.
The end piece of the proximal tendon on the ischial tuberosity is then located, as is the retracted tendon, and these will be closely located with the knee in flexion to reduce the hamstring stretch. Then, they will be repaired with Ethibond sutures and Merselene tapes. If the tendon has avulsed, then this will be anchored with a titanium self-tapping screw.
The stability of the surgical repair is evaluated by passively flexing the knee 45 degrees to create tension in the muscle and tendon. This allows the specialist to analyze the safety of the individuals range of motion throughout the course of surgery so that rehabilitation exercises and stretches can being early within safe ranges. Furthermore, this will avoid prolonged immobilization which have been shown to lead to considerable amounts of atrophy as well as loss of strength and range in post-operative hamstring repairs.
If hamstring injuries are effectively treated early, the need for a post-operative knee flexion brace is generally not necessary but, if the surgery was delayed, then a post-operative knee flexion brace may be required.
Several researches have attempted endoscopic repairs of hamstring avulsions, stating that this procedure can offer more benefits, such as minimizing scar tissue, superior visualization of the hamstring tendon, decreasing the amount of bleeding and better protection of the neurovascular bundle.
Post-Surgical Results
A majority of studies regarding the outcomes of hamstring tendon repairs through surgery providing the return of the individual�s strength and function have demonstrated that it may be unreasonable to expect an athlete to return to full strength in the hamstring following a surgically repaired hamstring tendon. Although the strength and function of the hamstring may be reduced, the athlete can successfully return to a pre-injury level of competition in most cases.
Researchers found that among individuals with repaired hamstring tendons through surgical procedures, 80 percent of them returned to participate in pre-injury levels of sports or physical activities. Moreover, the individual�s hamstring isotonic strength returned to an average of 84 percent while hamstring endurance returned to an average of 89 percent. Additionally, the researchers found that 90 percent of the hamstring injuries they followed had returned to pre-injury levels of sport or physical activity. All of these reported excellent outcomes in function and isokinetic tests demonstrated that the strength of the hamstring returned to 83 percent at six months as compared to 56 percent at the pre-surgery level. Finally, the researchers reported the evaluated results of seven individuals who underwent operative repair and concluded that the average time they experienced a restoration of function was 8.5 months. By six months of port-operative procedures, six of the seven individuals had returned to pre-operative levels of function.
Hamstring injuries are common complications which occur among a variety of athletes. While the symptoms of the injury can vary depending on the severity of the issue, it’s often reported that hamstring injuries can develop symptoms of sciatica. The sciatic nerve extends from the lower back, down the buttocks and thighs, which is why damage or injury to the legs can generally affect the nerves and tissues surrounding them.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Sciatica is a frequent diagnosis among the general population of individuals who report low back pain as well as pain and discomfort along their buttocks, thighs, and legs. While these set of symptoms are the most prevalent cause for painful symptoms in the thighs of athletes and others alike, thigh pain can also be attributed to other factors and causes. As a matter of fact, injury or complications affecting the tensor fascia latae muscle found within the thigh has been known to cause issues among the population.
The tensor fascia latae, or TFL, is a well-known hip muscle among healthcare professionals and rehabilitation specialists. Because of its function, this muscle may be responsible for pain and dysfunction in the lower extremities, pelvis and spine. Research studies conclude however, that this muscle is poorly understood and needs further examination. Furthermore, the majority of research which has been already conducted have in fact simplified the accurate anatomy of, not only the TFL, but also its anatomical relationship to the iliotibial band, or ITB.
The TFL, or tensor fascia latae, is a complex muscle which is intricately arrangement anatomically with the ITB, or iliotibial band, and it performs various essential functions, such as allowing hip mobility as well as transmitting fascial tension through the fascia latae located in the thigh and the iliotibial band. The TFL also provides postural support during one-legged stance and limits the tensile stress on the femur caused by the combination of bodyweight, ground reaction force and how these create individual bending forces against the femur.
Anatomy of the Tensor Fascia Latae and the ITB
When one discusses the anatomy of the TFL, the anatomy of the ITB should also be discussed as these serve a conjoined role in order to function. A study conducted to compare the TFL and ITB in humans to other primates and mammals determined that human beings are the only mammals to have a defined ITB. The study also further regarded the anatomy and function of both the tensor fascia latae and the iliotibial band. Additional studies via cadaveric and biomechanical modelling research added a substantial amount of knowledge about this often misunderstood muscle, the TFL, and its relationship to the ITB.
The general agreement is that the tensor fascia latae begins on the iliac crest which starts just lateral to the origin of the sartorious, or ASIS, and extends posteriorly along the iliac crest to combine several types of tissue into the iliac crest and onto the gluteal fascia. It�s been highlighted that the muscle provides multiple functions and contains anatomically distinct heads: the anteromedial, or AM, and the posterolateral, or PM, head.
Available research describes that the muscle has both a bony insertion onto the femur and a fascial insertion onto the iliotibial band, or more specifically, onto the region of the middle longitudinal layer of the fascia latae of the thigh, the iliotibial band.
Early studies perceived the ITB to be a ligament that connected the ilium with the knee in order to help maintain the balance of the body while in motion or when standing. Later studies demonstrated that human beings are the only mammals to own a distinct fascial lateral band down the thigh, indicating that the ITB may play a role in bipedal balance and stance.
Other studies demonstrated that the fascia latae of the thigh contains a multifaceted array of layers which all attach. The middle longitudinal layer, or MLL, of the fascia latae is a thick, connective tissue that originates on the iliac crest and extends downwards into various insertions. A large part of the MLL blends with the inner transverse layer of the fascia latae and is introduced directly onto the femur. The middle longitudinal layer also has superficial fibres that extend all the way down and insert into the knee.
Anteriorly at the hip, the MLL surrounds the TFL to ensure the muscle is effectively joined between the superficial and deep middle longitudinal layer. It also contains fibres which directly combines the superficial fibres of the gluteus maximus The MLL is joined in part to the gluteus maximus and in part to the TFL. As well as being enveloped by the middle longitudinal layer, some of the distal fibres of both heads of the TFL then insert into the MLL. The anteromedial fibres of the TFL fuse with the MLL and course down the thigh to introduce onto the lateral patella retinaculum. This is believed to influence the position of the patella in relation to the femoral trochlear groove.
Nevertheless, none of these tissues cross the knee joint, therefore they have no effect on motion at the tibia. According to research, the primary function of the muscles and tissues appears to be at the hip. Some of the fibres of the posterolateral tensor fascia latae together with the tissues of the gluteus maximus, contribute function for the MLL and attach all the way down onto the lateral tubercle of the tibia. These do cross the knee joint and may ultimately help stabilize the pelvis and the lower extremities.
Essentially, the MLL travels down the thigh and heavily combines with the inner transverse layer of the fascia latae as it is largely developed and dense within the upper third of the thigh. These transverse fibres run obliquely to anchor strongly to the femur, making up the deep and thick intermuscular septum of the femur. The septum effectively forms an osteo-fascial wall between the anterior quadriceps muscle group and the posterior hamstring muscle group.
Fibres from the inner transverse layer also allow the superior fibres of the gluteus maximus to develop an ascending tendon. The part of the tensor fascia latae that did not combine with the middle longitudinal layer of the tissue also combines with this rising tendon to insert directly onto the intermuscular septum and the femur. In other words, the majority of the TFL indirectly inserts onto the femur via the ascending gluteal tendon and indirectly via the blending of the MLL to the thick transverse layer.
Further down the thigh, the iliotibial band continues as a thickened section of the fascia latae, creating the fascial barrier between the anterior quadriceps and the posterior hamstrings. It then completely envelops the thigh, holding to the distal lateral femoral shaft through strong obliquely directed fibrous strands and follows the patellar retinaculum. Because these fibrous tissues divide the ITB into a proximal tendinous portion and a distal ligamentous portion, it�s been concluded that the tensor fascia latae has very little involvement in the mobility of the tibia and knee and its primary function is directed at the hip.
Function of the Tensor Fascia Latae
Anteromedial fibres (AM)
The main function of the anteromedial fibres is to flex the hip during open kinetic chain movements, such as hip flexion over the swing phase of gait, as confirmed through EMG and electrical stimulation experiments. The muscle is restricted upon heel strike which suggests that the muscle is required to be inactive to allow hip extension to occur during stance phase. The muscle is most active during the acceleration phase of running which also demonstrates its main role as a powerful hip flexor.
During pure open kinetic-chain movement, the AM fibres are most active in hip flexion movements as well as in abduction movements. It becomes restricted though, if the hip is externally rotated whilst abducting. This should be an important consideration when a healthcare professional is recommending specific hip rehabilitation exercises for the gluteal muscles and other hip external rotators.
Posterolateral fibres (PL)
The posterolateral fibres are most active during the stance phase of gait. This suggests that the muscle acts as a major hip stabilizer during single leg stance as it activates its role as a hip abductor. In this process, the superior portion of the gluteus maximus is also active during walking phase. Considering that the PL head has fibres that join the tendon from the superior gluteus maximus, this proposes that the posterolateral fibres and superior gluteus maximus cooperate to control the stability of the pelvis during stance phase.
Both the tensor fascia latae and gluteus maximus apply their role as a hip muscle through the contribution they have with the MLL, the deep transverse layer of the fascia latae and the intermuscular septum. They effectively insert onto the femur through this complex system of fascia and are considered muscles which begin at the pelvis which are introduced onto the femur. In pure open kinetic chain movements, the PL, or posterolateral fibres, are active in all hip internal rotation movements and in abduction movements. Similar to the AM fibres, the PL fibres remain restricted if the hip is abducting whilst in external rotation.
Function of the TFL at the Knee
A majority of the comprehensive studies examining the role of TFL in relation to the movements of the knee and the stability of the patella find it challenging to identify a direct function for the TFL in knee function. It almost certainly does not contribute to knee extension, flexion or rotation. As a result, all previous descriptions of the TFL being a synergistic knee extender with the quadriceps or an externally rotator of the tibia can almost certainly be rejected. It�s also been concluded that the TFL does not play an active role in pulling the patella laterally. The most likely role the TFL has in knee patella stability is indirectly, through maintaining the tension in the fascia latae and the distal portion of the ITB that combines with the patella retinaculum.
The TFL as a Fascial Tensioner
Several studies have demonstrated that the tensor fascia latae also functions to maintain fascia tension during movement. This is primarily due to a complex arrangement of fascial planes of various thicknesses which have development over the thigh. It has a loose anterior and posterior layer which cover the quadriceps and hamstrings. The loose anterior superficial layer of the TFL would gather during knee extension movements if there did not exist some manner of tensioning system for the fascia to maintain the fascial envelope. In the same manner, the posterior fascia latae would most likely gather during knee flexion movements.
Based on their anatomical arrangement with the fascia latae, the muscles which can maintain this fascial tension during knee movements include the TFL anteriorly and the superior gluteus maximus posteriorly. The TFL must then become slightly active during knee extensions to progressively shorten the fascia upwards whilst the knee is extended, to prevent the anterior fascia from creasing and twisting. Similarly, the gluteus maximus can maintain fascial tension during knee flexion movements.
The Tensile Force of the Femur
One of the most extraordinary roles assigned to the ITB is the role it has in reducing the bending and tensile force on the lateral femur. Humans walk on two feet, which means that during a section of the gait cycle, they are in a one-leg stance. This can create large lateral femur tensile forces and medial femur compression forces which, if not properly monitored, could develop a varus effect of the femur and essentially bend the femur.
During a study, researchers investigated the function of the ITB and concluded that the varus bending forces on the femur could be partially relieved by tensioning the iliotibial band. Other studies analyzed the stresses on the femur caused by the varus force on the bone and also found that by increasing the tension in the ITB, the lateral tension force and the medial compression force on the femur would both ultimately limited. The study also suggests that the TFL and gluteus maximus may add further tension to the ITB and lessen this lateral tension force on the femur.
TFL Complications
For all the TFL issues that affect many individuals, almost nothing exists in the literature that highlights the role this muscle has in dysfunction. All theories and ideas are based on clinical reasoning and assumptions. The most interesting observation regarding TFL complications is the role it has in causing hip internal rotation/flexion during the stance phase of gait.
Frequently, many individuals who report lower limb injuries caused by overuse or low back and sacroiliac joint pain are commonly diagnosed with an exaggerated hip flexion/internal rotation position during the functional movements of a single extremity. The stance suggests an internally rotated and flexed position.
This complication then develops what is known as a valgus collapse at the joint of the knee, directly affecting the Q angle of the knee. With an increase in the Q angle, the patella often tends to drag laterally and compress against the lateral femoral condyle. This may then lead to patellofemoral pain at the knee. This is believed to occur because the TFL maintains the stability of the pelvis during one-leg stance by beginning its abduction role. The tensor fascia latae may also display its hip flexion/internal rotation role. The gluteus maximus, and other hip external rotators, should provide and equal opposite external rotation/extension role.
The gluteus medius and minimus primarily function on the hip joint by contributing a compressive and stabilizing role. These work little to assist in maintaining a stable pelvic position. Instead, this role is assigned to the tensor fascial latae and gluteus maximus.
The TFL is a significant muscle in pelvic dysfunction because it has the greatest mechanical advantage to influence the pelvis and hip joint. It is the most anterior muscle at the front of the hip, as a result, it�s believed to have the greatest leverage advantage to encourage a flexion posture or an anterior tilt of the ilium. Observing the hip from the front, the tensor fascia latae is also the most lateral muscle on the hip. Therefore, it has the greatest leverage to affect abduction of the hip. This explains how such a small muscle can have such a large influence.
Furthermore, because the complex structures surrounding the lower back, buttocks, hip/pelvis and leg can become directly affected causing pain, irritation and inflammation as a result of TFL complications, other structures of the body can be greatly affected as well. The sciatic nerve is the largest single nerve found in the body and it runs through, the lower back, buttocks and leg. The nerve is tightly surrounded by muscles and other tissues. When these surrounding tissues are altered, the sciatic nerve can be easily compressed, causing symptoms of sciatica. Sciatica is described as a set of symptoms rather than a single condition. The most common symptoms of sciatica include: lower back/buttock/hip/leg pain, burning and tingling sensations, and numbness.
While the following tests can be used to determine the presence of TFL complications, a proper diagnosis can help differentiate whether the individual is experiencing sciatica as a result of tensor fascia latae dysfunction or due to another serious complication. Chiropractors are healthcare professionals who specialize in musculoskeletal and nervous system injuries and conditions. Chiropractic care offers a form of alternative treatment which uses spinal adjustments and manual manipulations to carefully diagnose a variety of injuries or conditions and decrease or eliminate the symptoms of sciatica which may also be associated with TFL. In addition, an individual may follow through with chiropractic treatment to also find relief from their tensor fascia latae dysfunction after determining its presence with the next set of tests.
Chiropractic for Sciatica Symptoms
Assessing TFL Issues
To properly assess the tightness in the TFL, utilizing an Ober Test or a Thomas test can help.
Ober test
Start position
The individual must be positioned on their side with the unaffected side facing down. The pelvis and spine should be in neutral alignment with the bottom leg flexed for support. The uppermost leg is extended above the horizontal. The hip is then laterally rotated and extended, as long as no lumbar extension occurs.
Movement
The individual must actively flatten their waist towards the floor and hold their leg in slight abduction and lateral rotation. The individual will then be instructed to slowly and carefully lower their leg towards the floor until the tensor fascia latae and the iliotibial band hangs on the greater trochanter and cannot lower any further. The key to an accurate test is to not allow the pelvis to move, either into a lateral tilt, anterior tilt or rotation. As the leg lowers, the hip should not flex or medially rotate. It�s essential for the individual to maintain the laterally rotated position of the hip. Ideally, the leg should lower into at least 10 to 15-degree adduction without losing the proximal control of the pelvis or hip. The tensor fascia latae and iliotibial band may lack elasticity if the leg does not adduct sufficiently.
Thomas test
On a plinth, the individual should lie supine with the untested leg held in hip flexion. The tested leg is then forced into extension and adduction. If the tested leg is unable to attain a horizontal alignment and is held in flexion and/or abduction, this is indicative of tightness in the tensor fascia latae.
Managing TFL Issues
To manage the overactive or tight tensor fascia latae, 2 important criteria must be met. First, it must be stretched and then, it must be massaged and manipulated. The most effective stretch for the TFL is the knee-down hip flexor stretch.
To stretch the left TFL, first, the individual should kneel on the left knee with the right leg at 90-degrees hip flexion and knee flexion. Second, the individual must push their left hip forward until the slack is taken up. Third, by placing the hands on the right thigh, the individual will follow by twisting the trunk around to the right whilst the pelvis remains facing forward, inducing an external rotation of the hip to add to the rotation component of the stretch. Then, if the individual has any slack left, they must push their left leg outwards. Finally, the individual must isometrically contract the right hamstring by attempting to drag the left heel backwards. To stretch the right TFL, the same procedures should be followed but using the opposite leg.
To self-massage or trigger the TFL, the individual should lie on their side and place a trigger ball/Muscle Mate/Posture Pro under the tensor fascia latae in order to apply gentle pressure. The hip, knee and ankle should remain in a straight line with the body. This can be performed as a rolling type movement or as sustained pressure to relieve the trigger points within the muscle, ultimately helping to reduce the painful symptoms associated with TFL dysfunction, among other serious complications which may need medical attention as soon as possible.
Treating Sciatica
They symptoms of sciatica can greatly restrict an individual’s ability to function properly throughout their everyday lives and, as for athletes who participate in rigorous training and competitions, healing the symptoms can be utterly important in order for them to perform effectively in their specific sport or physical activity. There are numerous ways to treat sciatica, however, chiropractic care is among one of the most popular and effective forms of alternative treatment to help individuals recover from their specific injuries and/or conditions.�
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Back pain is a common symptom which affects a majority of the population, although for most individuals, the prevalent discomfort is often mild and temporary. Unfortunately, back pain can become a constant issue for some people. In several instances, these symptoms may even need immediate medical attention.
If you�ve experienced back pain sometime throughout your lifetime, especially if it�s new, recurring discomfort, causing the individual to lose control of their bowel or bladder, seeking a proper diagnosis as soon as possible is fundamental to determine the source of the symptoms and begin treatment. Listen to your body.
Seeking Help from a Healthcare Professional
Back pain, soreness and stiffness are generally frequent and can resolve on their own without the need of a medical evaluation. But, other symptoms could signal the development of a much more serious complication. The following symptoms may need further diagnosis as these could an indication of a spinal condition: pain which lasts for longer than six weeks; pain, weakness or numbness in the legs; difficulty sleeping due to back or neck pain; and/or a sudden onset of back pain without an obvious cause. If you�ve experienced any of the above mentioned symptoms, it�s essential to seek a proper diagnosis from a qualified healthcare professional.
Chiropractic care is a common alternative treatment option that is utilized to correct numerous spinal complications. Chiropractic primarily focuses on the musculoskeletal system and the nervous system. When visiting a doctor of chiropractic, or chiropractor, the healthcare professional will first conduct an evaluation of the spine to diagnose whether a spinal misalignment, also referred to as a subluxation, or any other type of injury or condition is the cause of the symptoms.
Together with a review of the individual�s medical history, including any previous test results from prior appointments with other physicians, if any. To complete the spinal assessment, aside from a physical exam, the chiropractor may also need additional studies, such as an X-ray or MRI scan. This will help pinpoint the source of the symptoms. Whether the individual is diagnosed with a common injury or condition, such as sciatica, or a more complex and severe complication, the doctor of chiropractic will follow up with an up to date description of the individual�s cause of their symptoms before developing an appropriate treatment plan.
The healthcare professional should provide an overview of treatment options, including a detailed discussion of the benefits and possible risks of each. The most common chiropractic care techniques and therapy procedures include spinal adjustments and manual manipulations. Through the use of chiropractic adjustments and manipulations, a chiropractor will carefully realign the spine, helping to reduce the stress and pressure being placed against the structures surrounding the spine in order to improve function. By restoring the individual�s natural spinal alignment, any pain, inflammation and numbness, as well as other symptoms of back pain and discomfort, will be decreased, providing the individual with their original strength, mobility and flexibility, promoting their overall health and wellness.
Furthermore, a chiropractor may also recommend a series of stretches and exercises, as well as several lifestyle changes, to further improve an individual�s injury or condition and promote a faster recovery time. Physical therapy and spinal surgery are also possible treatment options for various types of back complications, However, spinal surgery is only recommended if conservative treatment options have failed before. Although back pain is a common complication among the population, seeking diagnosis and following through with treatment is important to ensure the individual lives with the proper health and wellness.
Back pain symptoms can affect a wide number of individuals and, while a majority of cases resolve on their own, it’s important to seek medical attention as soon as possible to determine the cause of the symptoms, especially with chronic pain. Chiropractic treatment can help restore the original health of the spine.
Trending Topic: Vaccines Revealed Episode 6
Dr. Gentempo and others are bringing great awareness to our community regarding vaccinations and their dangers.
Vaccines Revealed and Exposed on Episode #6
As a healthcare provider, Dr. Patrick Gentempo has been searching for the truth behind the effects of vaccines on the general population. When making critical decisions about you and your children�s health, it�s essential to have the correct knowledge of all medical procedures you�re being involved in, including the administration of mandatory vaccines, among others.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
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