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.
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 .�
Neuropathy is medically characterized as a form of chronic pain which may commonly result from damage to or pathological changes of the central or peripheral nervous system. Peripheral neuropathic pain has also been previously referred to as painful neuropathy, nerve pain, sensory peripheral neuropathy or peripheral neuritis. Individual�s affected by neuropathy generally describe its symptoms to be unlike any others they�ve ever experienced before. When it comes to neuropathy however, it�s fundamental to understand that chronic pain is not a symptom of injury but rather, the pain is itself the process of the disease. Neuropathy is not associated with the healing process either, instead of a specific injury in the body, the nerves themselves malfunction and are the source of the pain.
Characteristics of Neuropathy
The back pain or other type of painful symptom characteristic of neuropathy can usually be described in several ways. These can be specified as: severe, sharp, electric shock-like, shooting, lightning-like, or lancinating; deep, burning or cold; with persistent numbness, tingling or weakness; and/or trailing along the nerve path into the arms, hands, legs or feet. Furthermore, symptoms of neuropathy can be characterized by pain and discomfort from a light touch or other stimulus which generally shouldn�t cause pain, as well as hypersensitivity to a normally painful stimulus.
Symptoms of neuropathy can manifest as a result of any form of pain which impinges or compresses a nerve. Examples of neuropathic pain which generate from the region of the spine include: chronic pain which trails down the length of the leg, also known as radiculopathy or sciatica; chronic pain that radiates along the arm, also referred to as cervical radiculopathy; and gradual or persistent pain following a back surgical procedure, commonly associated with failed back surgery syndrome. Other well-known causes of neuropathy are: diabetes; phantom limb pain or regional pain syndrome, also referred to as RPS. If an individual�s neuropathy is not treated appropriately, numerous complications such as depression, sleeplessness, feelings of fear and anxiety, limited social interaction and an inability to perform normal daily activities or work have been described as frequent issues affecting those who suffer with chronic pain associated with neuropathy and its other symptoms.
Types of Back Pain
When it comes to neuropathic symptoms, it�s essential to have a general understanding of the major different types of back pain, most importantly because effectively determining these types of symptoms can guide people to receive the best treatment plan.
Nociceptive Pain and Neuropathy
Healthcare providers and professionals in the medical field typically classify pain in one of two general categories: neuropathic pain and nociceptive, or somatic, pain.
Nociceptive pain is felt by the nociceptor sensory fibers after there�s been damage or injury to a structure in the body, such as the muscles, ligaments, tendons, bones, joints or other organs. Nociceptive pain is commonly identified as a deep aching, throbbing, gnawing or sore sensation. Prevalent instances of nociceptive pain associated with back symptoms of pain and discomfort include: pain after direct trauma from an automobile accident or other personal injury case; pain after a back surgical procedure; and arthritis pain. Nociceptive pain is generally localized and can improve with healing treatments. Neuropathic pain, or neuropathy, results when there�s damage or injury to nerve tissue. Neuropathy is often identified as burning, severe shooting pains and/or a persistent numbness or tingling sensation. Prevalent instances of neuropathic pain associated with back symptoms of pain and discomfort include: sciatica, pain that travels from the spine down the arm, pain that persists after back surgery.
It is believed that in several cases, extended nociceptive pain may lead to neuropathy and an individual may subsequently experience both neuropathic pain and nociceptive pain simultaneously. �
Acute Pain and Chronic Pain
It�s also fundamental to recognize the differences between acute pain and chronic pain as these two forms of pain can be very distinct in structure and function.
With acute pain for example, the level of severity can directly correspond with the grade of tissue damage or injury. This provides individuals with a protective reflex, such as the reflex to move a limb immediately after touching a sharp object. Acute pain can be identified as a symptom of damaged or diseased tissue, where if the underlying complication is cured, the pain will subside as well. Acute pain is a form of nociceptive pain. With chronic pain for example, the pain doesn�t have the same structure and function as it does with acute pain. In other words, it does not serve a protective or other biological action. Instead, the nerves continue to send pain signals to the brain regardless if there�s no ongoing tissue damage. Neuropathy is a form of chronic pain.
Anatomy of Nerve Pain
The spinal cord functions as the primary part of the body�s central nervous system which transmits messages directly from the brain and spreads these out to the nerves throughout the body. Nerves can be found traveling to all parts of the body, entering and exiting the spinal cord alongside its entire length.
How Nerve Pain Works
There are 31 pairs of spinal nerves which can be found exiting the spinal cord between openings separating each vertebrae. The nerve root, or the point where the nerve exits the spinal cord, branches out into many smaller nerves which control distinct regions of the body, best referred to as the peripheral nerves. For instance, a nerve that exits the lower back will have peripheral branches that travel all the way down to the toes. Peripheral nerves make up the peripheral nervous system. The peripheral nerves are comprised of both motor nerves and sensory nerves. Sensory nerves receive sensory stimuli, such as how something physically feels and whether it is painful or not. These consist of nerve fibers known as sensory fibers. Additionally, mechanoreceptor fibers sense body movement and pressure placed against the body while nociceptor fibers sense tissue injury. Motor nerves travel throughout the muscles and stimulate their movements. These consist of nerve fibers known as motor fibers.
Nerve Injury and Neuropathy Pain
Although there is no sufficient research or evidence to support the following theory, it is believed that damage or injury to any of the above types of nerve tissues may be a possible reason which could lead to the development of neuropathic pain or neuropathy. Generally, the area of the nerve cell that is damaged by neuropathy is medically defined as the axon, which is the inner information pathway of the nerve cell, and/or its myelin covering, which is identified as the fatty outer sheath which protects the nerve cell and helps transfer information throughout the nervous system. When neuropathy pain occurs due to damage or injury to the above mentioned structures, neuropathy is sustained by abnormal processing of sensory input by the central nervous system and the peripheral nervous system.
Trending Topic: Vaxxed�From Coverup To Catastrophe
In 2013, biologist Dr. Brian Hooker received a call from a Senior Scientist at the U.S. Centers for Disease Control and Prevention (CDC) who led the agency�s 2004 study on the Measles-Mumps-Rubella (MMR) vaccine and its link to autism.
The scientist, Dr. William Thompson, confessed that the CDC had omitted crucial data in their final report that revealed a causal relationship between the MMR vaccine and autism. Over several months, Dr. Hooker records the phone calls made to him by Dr. Thompson who provides the confidential data destroyed by his colleagues at the CDC.
Dr. Hooker enlists the help of Dr. Andrew Wakefield, the British gastroenterologist falsely accused of starting the anti-vax movement when he first reported in 1998 that the MMR vaccine may cause autism. In his ongoing effort to advocate for children�s health, Wakefield directs this documentary examining the evidence behind an appalling cover-up committed by the government agency charged with protecting the health of American citizens.
Interviews with pharmaceutical insiders, doctors, politicians, and parents of vaccine-injured children reveal an alarming deception that has contributed to the skyrocketing increase of autism and potentially the most catastrophic epidemic of our lifetime.
Americans deserve real solutions for the economic, social and environmental crises we face. But the broken political system is only making things worse.
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For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
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.
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.
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.
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 the interaction between the piriformis muscle and the sciatic nerve, where these may irritate the nerves and develop posterior hip pain with distal referral down the posterior thigh, resembling symptoms of true sciatica. Differentiating�the damage to this region typically follows exceptions of the more well-known 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
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.
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.
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 confirmed that the tibial division of the sciatic nerve is usually spared, the inferior gluteal nerve that supplies the gluteus maximus may be affected and the muscle can become 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 discussed that piriformis syndrome is a commonly over-used term used to describe any non-specific gluteal tenderness with radiating leg pain. It was argued that only in rare cases is the piriformis muscle involved in nerve compression of the sciatic nerve which may then accurately 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, foremostly, 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�may be caused by an entrapment of the gluteal nerves and the hamstring pain may be due to an entrapment of the posterior cutaneous nerve of the thigh, rather than an entrapment of 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 one of the several causes of piriformis syndrome is discovered and a healthcare specialist feels that an appropriate diagnosis has been made, the treatment will generally 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 clear the piriformis muscle from 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 determined that there was no connection between hip flexion angle and the thickness of the piriformis muscle tendon in both internal and lateral hip rotation stretching, which implies that the piriformis muscle does not invert its action. Furthermore, researchers who performed cadaveric studies concluded that the piriformis muscle insertion is different and a lot more complex than it was first believed to be. It is possible that the piriformis muscle may invert its action only in some individuals but not in others.
Accordingly�due to the disagreements and confusions over the concept of inversion of action, it is suggested that healthcare professionals should perform 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 anatomically similar to both the sacroiliac joint and the sciatic nerve. It is a muscle that functions as a dominant hip rotator and stabilizer, with a propensity to shorten and become hypertonic. For that reason, stretching and massage techniques are best utilized and often recommended to reduce the tone through the muscle. In conclusion, it has also been implied in compression and irritation of the sciatic nerve, most frequently referred to as piriformis syndrome.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Medial tibial stress syndrome, commonly referred to as shin splints, is not considered to be a medically serious condition, however, it can challenge an athlete�s performance. Approximately 5 percent of all sports injuries are diagnosed as medial tibial stress syndrome, or MTSS for short.
MTSS, or shin splints, occurs most commonly in specific groups of athletes, accounting for 13-20 percent of injuries in runners and up to 35 percent in military service members. Medial tibial stress syndrome is identified as pain along the posterior-medial border of the lower half of the tibia, which is active during exercise and typically inactive during rest. Athletes report feeling discomfort along the lower front half of the leg or shin. Palpation along the medial tibia can usually recreate the pain.
Causes of Medial Tibial Stress Syndrome
There are two main suspected causes for medial tibial stress syndrome. The first is that contracting leg muscles place a repeated strain upon the medial portion of the tibia, producing inflammation of the periosteal outer layer of bone, commonly known as periostitis. While the pain of a shin splint is felt along the anterior leg, the muscles located around this region are the posterior calf muscles. The tibialis posterior, flexor digitorum longus, and the soleus all emerge from the posterior-medial section of the proximal half of the tibia. As a result, the traction force from these muscles on the tibia probably aren�t the cause of the pain generally experienced on the distal portion of the leg.
Another theory of this tension is that the deep crural fascia, or the DCF, the tough, connective tissue which surrounds the deep posterior muscles of the leg, may pull excessively on the tibia, causing trauma to the bone. Researchers at the University of Honolulu examined a single leg from 5 male and 11 female adult cadavers. Through the study, they concluded that in these specimens, the muscles of the posterior section of muscles were introduced above the portion of the leg that is usually painful in medial tibial stress syndrome and the deep crural fascia did indeed attach on the entire length of the medial tibia. Doctors at the Swedish Medical Centre in Seattle, Washington hypothesized that, given the anatomy, the tension from the posterior calf muscles could produce a similar strain on the tibia at the insertion of the DCF, causing injury. In a laboratory study conducted using three fresh cadaver specimens, researchers determined that strain at the insertion site of the DCF along the medial tibia advanced linearly as tension increased in the posterior leg muscles. The study confirmed that an injury caused by tension at the medial tibia was possible. However, studies of bone periosteum on individuals with MTSS have yet to find inflammatory indicators to confirm the periostitis theory. The second theory believed to cause medial tibial stress syndrome is that repetitive or excessive loading may cause a bone-stress reaction in the tibia. When the tibia cannot properly bear the load being applied against it, it will bend during weight bearing. The overload results in micro damage within the bone, not just along the outer layer. If the repetitive loading exceeds the bone�s ability to repair, localized osteopenia can occur. Because of this, some researchers consider a tibial stress fracture to be the result of a continuum of bone stress reactions that include MTSS. Utilizing magnetic resonance imaging, or MRI, on the affected leg can often show bone marrow edema, periosteal lifting, and areas of increased bony resorption in athletes with medial tibial stress syndrome. This supports the bone-stress reaction theory. An MRI of an athlete with a diagnosis of MTSS can also help rule out other causes of lower leg pain, such as a tibial stress fracture, deep posterior compartment syndrome, and popliteal artery entrapment syndrome.
Risk factors for MTSS
While the cause, set of causes or manner of causation of MTSS is still only a hypothesis, the risk factors for athletes developing it are well identified. As determined by the navicular drop test, or NDT, a large navicular drop considerably corresponds with a diagnosis of medial tibial stress syndrome. The NDT measures the difference in height position of the navicular bone, from a neutral subtalar joint position in supported non-weight bearing, to full weight bearing. The NDT explains the degree of arch collapse during weight bearing. Results of more than 10 mm is considered excessive and can be a considerable risk factor for the development of MTSS.
Research studies have suggested that athletes with MTSS are most frequently female, have a higher BMI, less running experience, and a previous history of MTSS. Running kinematics for females can be different from that of males and has often been demonstrated to leave individuals vulnerable to experience anterior cruciate ligament tears and patellofemoral pain syndrome. This same biomechanical pattern may also incline females to develop medial tibial stress syndrome. Hormonal considerations and low bone density are believed to be contributing factors, increasing the risk of MTSS in the female athlete as well.
A higher BMI in an athlete demonstrates that they have more muscle mass rather than being overweight. The end result, however, is the same in that the legs bear a considerably heavy load. It�s been hypothesized that in these cases, the bone growth accelerated by the tibial bowing may not advance quickly enough and injury to the bone may occur. Therefore, those with a higher BMI may need to continue their training programs gradually in order to allow the body to adapt accordingly. Athletes with less running experience are more likely to make training errors, which may be a common cause for medial tibial stress syndrome. These include but are not limited to: increasing distance too quickly, changing terrain, overtraining, poor equipment or footwear, etc. Inexperience may also lead the athlete to return to activity before the recommended time, accounting for the higher prevalence of MTSS in those who had previously experienced MTSS. A complete recovery from MTSS can take from six months up to ten months, and if the original injury does not properly heal or the athlete returns to training too soon, chances are, their pain and symptoms may return promptly.
Biomechanical Analysis
The NDT is used as a measurable indication of foot pronation. Pronation is described as a tri-planar movement consisting of eversion at the hindfoot, abduction of the forefoot and dorsiflexion of the ankle. Pronation is a normal movement of the body and it is absolutely essential in walking and running. When the foot impacts the ground at the initial contact phase of running, the foot begins to pronate and the joints of the foot acquire a loose-packed position. This flexibility helps the foot absorb ground reaction forces.
During the loading response phase, the foot further pronates, reaching peak pronation by approximately 40 percent during stance phase. In mid stance, the foot moves out of pronation and back to a neutral position. During terminal stance, the foot supinates, moving the joints into a fastened position, creating a rigid lever arm from which to generate the forces for toe off. Starting with the loading response phase and throughout the rest of the single leg stance phase of running, the hip is stabilized and supported as it is extended, abducted and externally rotated by the concentric contraction of the hip muscles of the stance leg, including the gluteals, piriformis, obturator internus, superior gemellus and inferior gemellus. Weakness or fatigue in any of these muscles can develop an internal rotation of the femur, adduction of the knee, internal rotation of the tibia, and over-pronation. Overpronation therefore, can be a result of muscle weakness or fatigue. If this is the case, the athlete may have a completely normal NDT and yet, when the hip muscles don�t function as needed, these can overpronate.
In a runner who has considerable overpronation, the foot may continue to pronate into mid stance, resulting in a delayed supination response, causing for there to be less power generation at toe off. The athlete can make the effort to apply two biomechanical fixes here that could contribute to the development of MTSS. First of all, the tibialis posterior will strain to prevent the overpronation. This can add tension to the DCF and strain the medial tibia. Second, the gastroc-soleus complex will contract more forcefully at toe off to improve the generation of power. However, it�s hypothesized that the increased force within these muscle groups can add further tension to the medial tibia through the DCF and possibly irritate the periosteum.
Evaluating Injury in Athletes
Once understood that overpronation is one of the leading risk factors for medial tibial stress syndrome, the athlete should begin their evaluation slowly and gradually progress through the procedure. Foremost, the NDT must be performed, making sure if the difference is more than 10mm. Then, it�s essential to analyze the athlete�s running gait on a treadmill, preferably when the muscles are fatigued, such as at the end of a training run. Even with a normal NDT, there may be evidence of overpronation in running. � Next, the athlete�s knee should be diagnosed accordingly. The specialist performing an evaluation should note whether the knee is adducted, whether the hip is leveled or if either hip is more than 5 degrees from level. These can be clear indications that there is probably weakness at the hip. Traditional muscle testing may not reveal the weakness; therefore, functional muscle testing may be required. Additionally, it should be observed whether the athlete can perform a one-legged squat with arms in and arms overhead. The specialist must also note if the hip drops, the knee adducts and the foot pronates. Furthermore, the strength of the hip abductors should be tested in side lying, with the hip in a neutral, extended, and flexed position, making sure the knee is straight. All three positions with the hip rotated in a neutral position and at end ranges of external and internal rotation should also be tested. Hip extensions in prone with the knee straight and bent, in all three positions of hip rotation: external, neutral and internal can also be analyzed and observed to determine the presence of medial tibial stress syndrome, or MTSS. The position where a medical specialist finds weakness after the evaluation is where the athlete should begin strengthening activities.
Treating the Kinetic Chain
In the presence of hip weakness, the athlete should begin the strengthening process by performing isometric exercises in the position of weakness. For example, if there is weakness during hip abduction with extension, then the athlete should begin isolated isometrics in this position. Until the muscles consistently activate isometrically in this position for 3 to 5 sets of 10 to 20 seconds should the individual progress to adding movement. Once the athlete achieves this level, begin concentric contractions, in that same position, against gravity. Some instances are unilateral bridging and side lying abduction. Eccentric contractions should follow, and then sport specific drills. In the case that other biomechanical compensations occur, these must also be addressed accordingly. If the tibialis posterior is also displaying weakness, the athlete should begin strengthening exercises in that area. If the calf muscles are tight, a stretching program must be initiated. Utilizing any modalities possible might be helpful towards the rehabilitation process. Last but not least, if the ligaments in the foot are over stretches, the athlete should consider stabilizing footwear. Using a supported shoe for a temporary period of time during rehabilitation can be helpful to notify the athlete to embrace new movement patterns.
MTSS and Sciatica
Medial tibial stress syndrome, best referred to as as shin splints, is a painful condition that can tremendously restrict an athlete�s ability to walk or run. As mentioned above, several studies can be performed by a healthcare professional to determine the presence of MTSS in an athlete, however, other conditions aside from shin splints may be causing the individuals leg pain and hip weakness. That is why it�s important to also seek the expertise of additional specialists to ensure the athlete has received the correct diagnosis for their injuries or conditions. Sciatica is described as a set of symptoms that begin from the lower back, generally caused by an irritation of the sciatic nerve. The sciatic nerve is the single, largest nerve in the human body, communicating with many different areas of the upper and lower leg. Because leg pain can occur without the presence of low back pain, an athlete�s medial tibial stress syndrome could really be sciatica originating from the back. Most commonly, MTSS can be identified by pain that is generally worse when walking or running while sciatica is generally worse when sitting with an improper posture. Regardless of the symptoms, it�s essential for an athlete to seek proper diagnosis to determine the cause of their pain and discomfort. Chiropractic care is a popular form of alternative treatment which focuses on musculoskeletal injuries and conditions as well as nervous system dysfunctions. A chiropractor can help diagnose an athlete�s MTSS as well as conclude the presence of sciatica as a cause of the symptoms. Additionally, chiropractic care can help restore and improve an athlete�s performance. By utilizing careful spinal adjustments and manual manipulations, a chiropractor can help strengthen the structures of the body and increase the individual�s mobility and flexibility. After suffering an injury, an athlete should receive the proper care and treatment they need and require to return to their specific sport activity as soon as possible.
Chiropractic and Athletic Performance
In conclusion, the best way to prevent pain from MTSS is to decrease the athlete�s risk factors. An athlete should have a basic running gait analysis and proper shoe fitting as well as include hip strengthening in functional positions as part of the strengthening program. Furthermore, one must ensure the athletes fully rehabilitate before returning to play because the chances of recurrence of medial tibial stress syndrome can be high.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
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Next, the athlete�s knee should be diagnosed accordingly. The specialist performing an evaluation should note whether the knee is adducted, whether the hip is leveled or if either hip is more than 5 degrees from level. These can be clear indications that there is probably weakness at the hip. Traditional muscle testing may not reveal the weakness; therefore, functional muscle testing may be required. Additionally, it should be observed whether the athlete can perform a one-legged squat with arms in and arms overhead. The specialist must also note if the hip drops, the knee adducts and the foot pronates. Furthermore, the strength of the hip abductors should be tested in side lying, with the hip in a neutral, extended, and flexed position, making sure the knee is straight. All three positions with the hip rotated in a neutral position and at end ranges of external and internal rotation should also be tested. Hip extensions in prone with the knee straight and bent, in all three positions of hip rotation: external, neutral and internal can also be analyzed and observed to determine the presence of medial tibial stress syndrome, or MTSS. The position where a medical specialist finds weakness after the evaluation is where the athlete should begin strengthening activities. 
