Back Clinic Injury Care Chiropractic and Physical Therapy Team. There are two approaches to injury care. They are active and passive treatment. While both can help get patients on the road toward recovery, only active treatment has a long-term impact and keeps patients moving.
We focus on treating injuries sustained in auto accidents, personal injuries, work injuries, and sports injuries and provide complete interventional pain management services and therapeutic programs. Everything from bumps and bruises to torn ligaments and back pain.
Passive Injury Care
A doctor or a physical therapist usually gives passive injury care. It includes:
Acupuncture
Applying heat/ice to sore muscles
Pain medication
It’s a good starting point to help reduce pain, but passive injury care isn’t the most effective treatment. While it helps an injured person feel better in the moment, the relief doesn’t last. A patient won’t fully recover from injury unless they actively work to return to their normal life.
Active Injury Care
Active treatment also provided by a physician or physical therapist relies on the injured person’s commitment to work. When patients take ownership of their health, the active injury care process becomes more meaningful and productive. A modified activity plan will help an injured person transition to full function and improve their overall physical and emotional wellness.
Spine, neck, and back
Headaches
Knees, shoulders, and wrists
Torn ligaments
Soft tissue injuries (muscle strains and sprains)
What does active injury care involve?
An active treatment plan keeps the body as strong and flexible as possible through a personalized work/transitional plan, which limits long-term impact and helps injured patients work toward a faster recovery. For example, in injury Medical & Chiropractic clinic’s injury care, a clinician will work with the patient to understand the cause of injury, then create a rehabilitation plan that keeps the patient active and brings them back to proper health in no time.
For answers to any questions, you may have, please call Dr. Jimenez at 915-850-0900
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Quadratus Lumborum
Assessment of Shortness in Quadratus Lumborum (Figure 4.21)
Figure 4.21 Palpation assessment for quadratus lumborum overactivity. The muscle is palpated, as is gluteus medius, during abduction of the leg. The correct firing sequence should be gluteus, followed at around 25� elevation by quadratus. If there is an immediate �grabbing� action by quadratus it indicates overactivity, and therefore stress, so shortness can be assumed (see details of similar functional assessments in Ch. 5).
Review Lewit�s functional palpation test described under the heading assessment and treatment of tensor fascia lata.
When the leg of the side-lying patient is abducted, and the practitioner�s palpating hand senses that quadratus becomes involved in this process before the leg has reached at least 25� of elevation, then it is clear that quadratus is overactive. If it has been overactive for any length of time then it is almost certainly hypertonic and short, and a need for MET can be assumed.
Quadratus lumborum test (a) (See also Fig. 5.11A, B.) The patient is side-lying and is asked to take the upper arm over the head to grasp the top edge of the table, �opening out� the lumbar area. The practitioner stands facing the back of the patient, and has easy access for palpation of quadratus lumborum�s lateral border � a major trigger point site (Travell & Simons 1992) � with the cephalad hand.
Activity of quadratus is tested (palpated for) with the cephalad hand as the leg is abducted, while also palpating gluteus medius with the caudad hand. If the muscles act simultaneously, or if quadratus fires first, then it is stressed, probably short, and will benefit from stretching.
Quadratus lumborum test (b) The patient stands, back towards crouching practitioner. Any leg length disparity (based on pelvic crest height) is equalised by using a book or pad under the short leg side heel. With the patient�s feet shoulder-width apart, a pure sidebending is requested, so that the patient runs a hand down the lateral thigh/calf. (Normal level of sidebending excursion allows the fingertips to reach to just below the knee.) (See Fig. 3.2A, B, C.)
The side to which the fingertips travel furthest is assessed. If sidebending to one side is limited then quadratus on the opposite side is probably short. Combined evidence from palpation (test a) and this sidebending test indicate whether or not it is necessary to treat quadratus.
Box 4.8 Notes on Quadratus Lumborum
Norris (2000) describes the divided roles in which quadratus is involved: The quadratus lumborum has been shown to be significant as a stabiliser in lumbar spine movements (McGill et al 1996) while tightening has also been described (Janda 1983). It seems likely that the muscle may act functionally differently in its medial and lateral portions, with the medial portion being more active as a stabiliser of the lumbar spine, and the lateral more active as a mobiliser [see stabiliser/mobiliser discussion Ch. 2]. Such subdivision is seen in a number of other muscles for example the gluteus medius where the posterior fibres are more posturally involved (Jull 1994) the internal oblique where the posterior fibres attaching to the lateral raphe are considered stabilisers (Bergmark 1989) the external oblique where the lateral fibres work during flexion in parallel with the rectus abdominis (Kendall et al 1993).
Janda (1983) observes that, when the patient is sidebending (as in method (b)) �when the lumbar spine appears straight, with compensatory motion occurring only from the thoracolumbar region upwards, tightness of quadratus lumborum may be suspected�. This �whole lumbar spine� involvement differs from a segmental restriction which would probably involve only a part of the lumbar spine.
Quadratus fibres merge with the diaphragm (as do those of psoas), which makes involvement in respiratory dysfunction a possibility since it plays a role in exhalation, both via this merging and by its attachment to the 12th rib.
Shortness of quadratus, or the presence of trigger points, can result in pain in the lower ribs and along the iliac crest if the lateral fibres are affected. Shortness of the medial fibres, or the presence of trigger points, can produce pain in the sacroiliac joint and the buttock.
Bilateral contraction produces extension and unilateral contraction produces extension and sidebending to the same side.
The important transition region, the lumbodorsal junction (LDJ), is the only one in the spine in which two mobile structures meet, and dysfunction results in alteration of the quality of motion between these structures (upper and lower trunk/dorsal and lumbar spines). In dysfunction there is often a degree of spasm or tightness in the muscles which stabilise the region, notably: psoas and erector spinae of the thoracolumbar region, as well as quadratus lumborum and rectus abdominis.
Symptomatic differential diagnosis of muscle involvement at the LDJ is possible as follows: psoas involvement usually triggers abdominal pain if severe and produces flexion of the hip and the typical antalgesic posture of lumbago; erector spinae involvement produces low back pain at its caudad end of attachment and interscapular pain at its thoracic attachment (as far up as the mid-thoracic level); quadratus lumborum involvement causes lumbar pain and pain at the attachment of the iliac crest and lower ribs; and rectus abdominis contraction may mimic abdominal pain and result in pain at the attachments at the pubic symphysis and the xiphoid process, as well as forwardbending of the trunk and restricted ability to extend the spine.
There is seldom pain at the site of the lesion in LDJ dysfunction. Lewit (1992) points out that even if a number of these muscles are implicated, it is seldom necessary, using PIR methods, to treat them all since, as the muscles most involved (discovered by tests for shortness, overactivity, sensitivity and direct palpation) are stretched and normalised, so will others begin automatically to normalise.
MET for Shortness in Quadratus Lumborum (�banana�)
Quadratus lumborum MET method (a) (Fig. 4.22) The patient lies supine with the feet crossed (the side to be treated crossed under the non-treated side leg) at the ankle. The patient is arranged in a light sidebend, away from the side to be treated, so that the pelvis is towards that side, and the feet and head away from that side (�banana shaped�). As this sidebend is being achieved the affected quadratus can be palpated for bind so that the barrier is correctly identified.
Figure 4.22 MET treatment of quadratus lumborum utilising �banana� position.
The patient�s heels are placed just off the side of the table, anchoring the lower extremities and pelvis. The patient places the arm of the side to be treated behind her neck as the practitioner, standing on the side opposite that to be treated, slides his cephalad hand under the patient�s shoulders to grasp the treated side axilla. The patient grasps the practitioner�s cephalad arm at the elbow, with the treated side hand, making the contact more secure.
The patient�s treated side elbow should, at this stage, be pointing superiorly. The practitioner�s caudad hand is placed firmly but carefully on the anterior superior iliac spine, on the side to be treated. The patient is instructed to very lightly sidebend towards the treated side. This should produce an isometric contraction in quadratus lumborum on the side to be treated.
After 7 seconds the patient is asked to relax completely, and then to sidebend towards the nontreated side, as the practitioner simultaneously transfers his bodyweight from the cephalad leg to the caudad leg and leans backwards slightly, in order to sidebend the patient. This effectively stretches quadratus lumborum. The stretch is held for 15�20 seconds, allowing a lengthening of shortened musculature in the region. Repeat as necessary.
Quadratus lumborum MET method (b) (Fig 4.23) The practitioner stands behind the side-lying patient, at waist level. The patient has the uppermost arm extended over the head to firmly grasp the top end of the table and, on an inhalation, abducts the uppermost leg until the practitioner palpates strong quadratus activity (elevation of around 30� usually).
Figure 4.23 MET treatment of quadratus lumborum. Note that it is important after the isometric contraction (sustained raised/abducted leg) that the muscle be eased into stretch, avoiding any defensive or protective resistance which sudden movement might produce. For this reason, body weight rather than arm strength should be used to apply traction.
The patient holds the leg (and, if appropriate, the breath, see Box 4.2) isometrically in this manner, allowing gravity to provide resistance. After the 10-second (or so) contraction, the patient allows the leg to hang slightly behind him over the back of the table. The practitioner straddles this and, cradling the pelvis with both hands (fingers interlocked over crest of pelvis), leans back to take out all slack and to �ease the pelvis away from the lower ribs� during an exhalation.
The stretch should be held for between 10 and 30 seconds. (The method will only be successful if the patient is grasping the top edge of the table, so providing a fixed point from which the practitioner can induce stretch.)
Contraction followed by stretch is repeated once or twice more with raised leg in front of, and once or twice with raised leg behind the trunk in order to activate different fibres. The direction of stretch should be varied so that it is always in the same direction as the long axis of the abducted leg. This calls for the practitioner changing from the back to the front of the table for the best results. When the leg hangs to the back of the trunk the long fibres of the muscle are mainly affected; and when the leg hangs forward of the body the diagonal fibres are mainly involved.
Quadratus lumborum MET method (c) Gravity-induced postisometric relaxation of quadratus lumborum � self-treatment (See Fig. 3.2A�C and captions) The patient stands, legs apart, bending sideways. The patient inhales and slightly raises the trunk (a few centimetres) at the same time as looking (with the eyes only) away from the side to which side-flexion is taking place. On exhalation, the sidebend is allowed to slowly go further to its elastic limit, while the patient looks towards the floor, in the direction of the side-flexion. (Care is needed that very little, if any, forward or backward bending is taking place at this time.) This sequence is repeated a number of times.
Eye positions influence the tendency to flex and sidebend (eyes look down) and extend (eyes look up) (Lewit 1999). Gravity-induced stretches of this sort require holding the stretch position for at least as long as the contraction, and ideally longer. More repetitions may be needed with a large muscle such as quadratus, and home stretches should be advised several times daily. Quadratus lumborum MET method (d) The side-lying treatment of latissimus dorsi described below also provides an effective quadratus stretch when the stabilising hand rests on the pelvic crest (see Fig. 4.29).
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Piriformis
Assessment of Shortened Piriformis
Test (a) Stretch test. When short, piriformis will cause the affected side leg of the supine patient to appear to be short and externally rotated. With the patient supine, the tested leg is placed into flexion at the hip and knee so that the foot rests on the table lateral to the contralateral knee (the tested leg is crossed over the straight non-tested leg, in other words as shown in Fig. 4.17). The angle of hip flexion should not exceed 60� (see notes on piriformis in Box 4.6).
Figure 4.17 MET treatment of piriformis muscle with patient supine. The pelvis must be maintained in a stable position as the knee (right in this example) is adducted to stretch piriformis following an isometric contraction.
The non-tested side ASIS is stabilised to prevent pelvic motion during the test and the knee of the tested side is pushed into adduction to place a stretch on piriformis. If there is a short piriformis the degree of adduction will be limited and the patient will report discomfort behind the trochanter.
Test (b) Palpation test (Fig. 4.18) The patient is side-lying, tested side uppermost. The practitioner stands at the level of the pelvis in front of and facing the patient, and, in order to contact the insertion of piriformis, draws imaginary lines between:
ASIS and ischial tuberosity, and
PSIS and the most prominent point of trochanter.
Where these reference lines cross, just posterior to the trochanter, is the insertion of the muscle, and pressure here will produce marked discomfort if the structure is short or irritated.
Figure 4.18 Using bony landmarks as coordinates the commonest tender areas are located in piriformis, in the belly and at the attachment of the muscle.
If the most common trigger point site in the belly of the muscle is sought, then the line from the ASIS should be taken to the tip of the coccyx rather than to the ischial tuberosity. Pressure where this line crosses the other will access the mid-point of the belly of piriformis where triggers are common. Light compression here which produces a painful response is indicative of a stressed muscle and possibly an active myofascial trigger point.
Piriformis Strength Test
The patient lies prone, both knees flexed to 90�, with practitioner at foot of table grasping lower legs at the limit of their separation (which internally rotates the hip and therefore allows comparison of range of movement permitted by shortened external rotators such as the piriformis).
The patient attempts to bring the ankles together as the practitioner assesses the relative strength of the two legs. Mitchell et al (1979) suggest that if there is relative shortness (as evidenced by the lower leg not being able to travel as far from the mid-line as its pair in this position), and if that same side also tests strong, then MET is called for. If there is shortness but also weakness then the reasons for the weakness need to be dealt with prior to stretching using MET.
Box 4.6 Notes on Piriformis
Piriformis paradox. The performance of external rotation of the hip by piriformis occurs when the angle of hip flexion is 60� or less. Once the angle of hip flexion is greater than 60� piriformis function changes, so that it becomes an internal rotator of the hip (Gluck & Liebenson 1997, Lehmkuhl & Smith 1983). The implications of this are illustrated in Figures 4.17 and 4.19.
This postural muscle, like all others which have a predominence of type l fibres, will shorten if stressed. In the case of piriformis, the effect of shortening is to increase its diameter and because of its location this allows for direct pressure to be exerted on the sciatic nerve, which passes under it in 80% of people. In the other 20% the nerve passes through the muscle so that contraction will produce veritable strangulation of the sciatic nerve.
In addition, the pudendal nerve and the blood vessels of the internal iliac artery, as well as common perineal nerves, posterior femoral cutaneous nerve and nerves of the hip rotators, can all be affected.
If there is sciatic pain associated with piriformis shortness, then on straight leg raising, which reproduces the pain, external rotation of the hip should relieve it, since this slackens piriformis. (This clue may, however, only apply to any degree if the individual is one of those in whom the nerve actually passes through the muscle.)
The effects can be circulatory, neurological and functional, inducing pain and paraesthesia of the affected limb as well as alterations to pelvic and lumbar function. Diagnosis usually hinges on the absence of spinal causative factors and the distributions of symptoms from the sacrum to the hip joint, over the gluteal region and down to the popliteal space. Palpation of the affected piriformis tendon, near the head of the trochanter, will elicit pain and the affected leg will probably be externally rotated.
The piriformis muscle syndrome is frequently characterised by such bizarre symptoms that they may seem unrelated. One characteristic complaint is a persistent, severe, radiating low back pain extending from the sacrum to the hip joint, over the gluteal region and the posterior portion of the upper leg, to the popliteal space. In the most severe cases the patient will be unable to lie or stand comfortably, and changes in position will not relieve the pain. Intense pain will occur when the patient sits or squats since this type of movement requires external rotation of the upper leg and flexion at the knee.
Compression of the pudendal nerve and blood vessels which pass through the greater sciatic foramen and re-enter the pelvis via the lesser sciatic foramen is possible because of piriformis contracture. Any compression would result in impaired circulation to the genitalia in both sexes. Since external rotation of the hips is required for coitus by women, pain noted during this act could relate to impaired circulation induced by piriformis dysfunction. This could also be a basis for impotency in men. (See also Box 4.7.)
Piriformis involvement often relates to a pattern of pain which includes: pain near the trochanter; pain in the inguinal area; local tenderness over the insertion behind trochanter; SI joint pain on the opposite side; externally rotated foot on the same side; pain unrelieved by most positions with standing and walking being the easiest; limitation of internal rotation of the leg which produces pain near the hip; and a short leg on the affected side.
The pain itself will be persistent and radiating, covering anywhere from the sacrum to the buttock, hip and leg including inguinal and perineal areas.
Bourdillon (1982) suggests that piriformis syndrome and SI joint dysfunction are intimately connected and that recurrent SI problems will not stabilise until hypertonic piriformis is corrected.
Janda (1996) points to the vast amount of pelvic organ dysfunction to which piriformis can contribute due to its relationship with circulation to the area.
Mitchell et al (1979) suggest that (as in psoas example above) piriformis shortness should only be treated if it is tested to be short and stronger than its pair. If it is short and weak (see p. 110 for strength test), then whatever is hypertonic and influencing it should be released and stretched first (Mitchell et al 1979). When it tests strong and short, piriformis should receive MET treatment.
Since piriformis is an external rotator of the hip it can be inhibited (made to test weak) if an internal rotator such as TFL is hypertonic or if its pair is hypertonic, since one piriformis will inhibit the other.
Box 4.7 Notes on Working and Resting Muscles
Richard (1978) reminds us that a working muscle will mobilise up to 10 times the quantity of blood mobilised by a resting muscle. He points out the link between pelvic circulation and lumbar, ischiatic and gluteal arteries and the chance this allows to engineer the involvement of 2400 square metres of capillaries by using repetitive pumping of these muscles (including piriformis).
The therapeutic use of this knowledge involves the patient being asked to repetitively contract both piriformis muscles against resistance. The patient is supine, knees bent, feet on the table; the practitioner resists their effort to abduct their flexed knees, using pulsed muscle energy approach (Ruddy�s method) in which two isometrically resisted pulsation/contractions per second are introduced for as long as possible (a minute seems a long time doing this).
Figure 4.19 MET treatment of piriformis with hip fully flexed and externally rotated (see Box 4.6, first bullet point).
Figure 4.20 A combined ischaemic compression (elbow pressure) and MET side-lying treatment of piriformis. The pressure is alternated with isometric contractions/stretching of the muscle until no further gain is achieved.
MET Treatment of Piriformis
Piriformis method (a) Side-lying The patient is side-lying, close to the edge of the table, affected side uppermost, both legs flexed at hip and knee. The practitioner stands facing the patient at hip level.
The practitioner places his cephalad elbow tip gently over the point behind trochanter, where piriformis inserts. The patient should be close enough to the edge of the table for the practitioner to stabilise the pelvis against his trunk (Fig. 4.20). At the same time, the practitioner�s caudad hand grasps the ankle and uses this to bring the upper leg/hip into internal rotation, taking out all the slack in piriformis.
A degree of inhibitory pressure (sufficient to cause discomfort but not pain) is applied via the elbow for 5�7 seconds while the muscle is kept at a reasonable but not excessive degree of stretch. The practitioner maintains contact on the point, but eases pressure, and asks the patient to introduce an isometric contraction (25% of strength for 5�7 seconds) to piriformis by bringing the lower leg towards the table against resistance. (The same acute and chronic rules as discussed previously are employed, together with cooperative breathing if appropriate, see Box 4.2.)
After the contraction ceases and the patient relaxes, the lower limb is taken to its new resistance barrier and elbow pressure is reapplied. This process is repeated until no further gain is achieved.
Piriformis method (b)1 This method is a variation on the method advocated by TePoorten (1960) which calls for longer and heavier compression, and no intermediate isometric contractions.
In the first stage of TePoorten�s method the patient lies on the non-affected side with knees flexed and hip joints flexed to 90�.The practitioner places his elbow on the piriformis musculotendinous junction and a steady pressure of 20�30 lb (9�13 kg) is applied. With his other hand he abducts the foot so that it will force an internal rotation of the upper leg.
The leg is held in this rotated position for periods of up to 2 minutes. This procedure is repeated two or three times. The patient is then placed in the supine position and the affected leg is tested for freedom of both external and internal rotation.
Piriformis method (b)2 The second stage of TePoorten�s treatment is performed with the patient supine with both legs extended. The foot of the affected leg is grasped and the leg is flexed at both the knee and the hip. As knee and hip flexion is performed the practitioner turns the foot inward, so inducing an external rotation of the upper leg. The practitioner then extends the knee, and simultaneously turns the foot outward, resulting in an internal rotation of the upper leg.
During these procedures the patient is instructed to partially resist the movements introduced by the practitioner (i.e. the procedure becomes an isokinetic activity). This treatment method, repeated two or three times, serves to relieve the contracture of the muscles of external and internal hip rotation.
Piriformis method (c) A series of MET isometric contractions and stretches can be applied with the patient prone and the affected side knee flexed. The hip is rotated internally by the practitioner using the foot as a lever to ease it laterally, so putting piriformis at stretch. Acute and chronic guidelines described earlier are used to determine the appropriate starting point for the contraction (at the barrier for acute and short of it for chronic).
The patient attempts to lightly bring the heel back towards the midline against resistance (avoiding strong contractions to avoid knee strain in this position) and this is held for 7�10 seconds. After release of the contraction the hip is rotated further to move piriformis to or through the barrier, as appropriate. Application of inhibitory pressure to the attachment or belly of piriformis is possible via thumb, if deemed necessary.
Piriformis method (d) A general approach which balances muscles of the region, as well as the pelvic diaphragm, is achieved by having the patient squat while the practitioner stands and stabilises both shoulders, preventing the patient from rising as this is attempted, while the breath is held. After 7�10 seconds the effort is released; a deeper squat is performed, and the procedure is repeated several times.
Piriformis method (e) This method is based on the test position (see Fig. 4.17) and is described by Lewit (1992). With the patient supine, the treated leg is placed into flexion at the hip and knee, so that the foot rests on the table lateral to the contralateral knee (the leg on the side to be treated is crossed over the other, straight, leg). The angle of hip flexion should not exceed 60� (see notes on piriformis, Box 4.6, for explanation).
The practitioner places one hand on the contralateral ASIS to prevent pelvic motion, while the other hand is placed against the lateral flexed knee as this is pushed into resisted abduction to contract piriformis for 7�10 seconds. Following the contraction the practitioner eases the treated side leg into adduction until a sense of resistance is noted; this is held for 10�30 seconds.
Piriformis method (f) Since contraction of one piriformis inhibits its pair, it is possible to self-treat an affected short piriformis by having the patient lie up against a wall with the non-affected side touching it, both knees flexed (modified from Retzlaff 1974). The patient monitors the affected side by palpating behind the trochanter, ensuring that no contraction takes place on that side.
After a contraction lasting 10 seconds or so of the non-affected side (the patient presses the knee against the wall), the patient moves away from the wall and the position described for piriformis test (see Fig. 4.17) above is adopted, and the patient pushes the affected side knee into adduction, stretching piriformis on that side. This is repeated several times.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Tensor Fascia Lata
�Assessment of shortness in tensor fascia lata (TFL)
The test recommended is a modified form of Ober�s test (see Fig. 4.14).
Figure 4.14 Assessment for shortness of TFL � modified Ober�s test. When the hand supporting the flexed knee is removed the thigh should fall to the table if TFL is not short.
Patient is side-lying with back close to the edge of the table. The practitioner stands behind the patient, whose lower leg is flexed at hip and knee and held in this position, by the patient, for stability. The tested leg is supported by the practitioner, who must ensure that there is no hip flexion, which would nullify the test.
The leg is extended only to the point where the iliotibial band lies over the greater trochanter. The tested leg is held by the practitioner at ankle and knee, with the whole leg in its anatomical position, neither abducted nor adducted and not forward or backward of the body.
Box 4.5 Notes on TFL
Mennell (1964) and Liebenson (1996) say that TFL shortness can produce all the symptoms of acute and chronic sacroiliac problems.
Pain from TFL shortness can be localised to the posterior superior iliac spine (PSIS), radiating to the groin or down any aspect of the thigh to the knee.
Although the pain may arise in the sacroiliac (SI) joint, dysfunction in the joint may be caused and maintained by taut TFL structures.
Pain from the band itself can be felt in the lateral thigh, with referral to hip or knee.
TFL can be �riddled� with sensitive fibrotic deposits and trigger point activity.
There is commonly a posteriority of the ilium associated with short TFL.
TFL�s prime phasic activity (all postural structures also have some phasic function) is to assist the gluteals in abduction of the thigh.
If TFL and psoas are short they may, according to Janda, �dominate� the gluteals on abduction of the thigh, so that a degree of lateral rotation and flexion of the hip will be produced, rotating the pelvis backwards.
Rolf (1977) points out that persistent exercise such as cycling will shorten and toughen the fascial iliotibial band �until it becomes reminiscent of a steel cable�. This band crosses both hip and knee, and spatial compression allows it to squeeze and compress cartilaginous elements such as the menisci. Ultimately, it will no longer be able to compress, and rotational displacement at knee and hip will take place.
The practitioner carefully introduces flexion at the knee to 90�, without allowing the hip to flex, and then, holding just the ankle, allows the knee to fall towards the table. If TFL is normal, the thigh and knee will fall easily, with the knee contacting the table surface (unless unusual hip width, or thigh length prevent this).
If the upper leg remains aloft, with little sign of �falling� towards the table, then either the patient is not letting go or the TFL is short and does not allow it to fall. As a rule the band will palpate as tender under such conditions.
Lewit�s TFL Palpation
(Lewit 1999; see also functional assessment method in Ch. 5)
Patient is side-lying and practitioner stands facing the patient�s front, at hip level. The practitioner�s cephalad hand rests over the anterior superior iliac spine (ASIS) so that it can also palpate over the trochanter. It should be placed so that the fingers rest on the TFL and trochanter with the thumb on gluteus medius. The caudad hand rests on the mid-thigh to apply slight resistance to the patient�s effort to abduct the leg.
The patient�s table-side leg is slightly flexed to provide stability, and there should be a vertical line to the table between one ASIS and the other (i.e. no forwards or backwards �roll� of the pelvis). The patient abducts the upper leg (which should be extended at the knee and slightly hyperextended at the hip) and the practitioner should feel the trochanter �slip away� as this is done.
If, however, the whole pelvis is felt to move rather than just the trochanter, there is inappropriate muscular imbalance. (In balanced abduction gluteus comes into action at the beginning of the movement, with TFL operating later in the pure abduction of the leg. If there is an overactivity (and therefore shortness) of TFL, then there will be pelvic movement on the abduction, and TFL will be felt to come into play before gluteus.)
The abduction of the thigh movement will then be modified to include external rotation and flexion of the thigh (Janda 1996). This confirms a stressed postural structure (TFL), which implies shortness.
It is possible to increase the number of palpation elements involved by having the cephalad hand also palpate (with an extended small finger) quadratus lumborum during leg abduction. In a balanced muscular effort to lift the leg sideways, quadratus should not become active until the leg has been abducted to around 25�30�. When quadratus is overactive it will often start the abduction along with TFL, thus producing a pelvic tilt.�(See also Fig. 5.11A and B)
Method (a) Supine MET treatment of shortened TFL (Fig. 4.15) The patient lies supine with the unaffected leg flexed at hip and knee. The affected side leg is adducted to its barrier which necessitates it being brought under the opposite leg/foot.
Figure 4.15 MET treatment of TFL (see Fig. 1.4 for description of isolytic variation). If a standard MET method is being used, the stretch will follow the isometric contraction in which the patient will attempt to move the right leg to the right against sustained resistance. It is important for the practitioner to maintain stability of the pelvis during the procedure. Note: the hand positions in this figure are a variation of those described in the text.
Using guidelines for acute and chronic problems, the structure will either be treated at, or short of, the barrier of resistance, using light or fairly strong isometric contractions for short (7 second) or long (up to 20 seconds) durations, using appropriate breathing patterns as described earlier in this chapter (Box 4.2).
The practitioner uses his trunk to stabilise the patient�s pelvis by leaning against the flexed (nonaffected side) knee. The practitioner�s caudad arm supports the affected leg so that the knee is stabilised by the hand. The other hand maintains a stabilising contact on the affected side ASIS.
The patient is asked to abduct the leg against resistance using minimal force. After the contraction ceases and the patient has relaxed using appropriate breathing patterns, the leg is taken to or through the new restriction barrier (into adduction past the barrier) to stretch the muscular fibres of TFL (the upper third of the structure).
Care should be taken to ensure that the pelvis is not tilted during the stretch. Stability is achieved by the practitioner increasing pressure against the flexed knee/thigh. This whole process is repeated until no further gain is possible.
Method (b) Alternative supine MET treatment of shortened TFL (Fig. 4.16) The patient adopts the same position as for psoas assessment, lying at the end of the table with non-tested side leg in full hip flexion and held by the patient, with the tested leg hanging freely, knee flexed.
Figure 4.16 MET treatment of psoas using Grieve�s method, in which there is placement of the patient�s foot, inverted, against the operator�s thigh. This allows a more precise focus of contraction into psoas when the hip is flexed against resistance.
The practitioner stands at the end of the table facing the patient so that his left lower leg (for a right-sided TFL treatment) can contact the patient�s foot. The practitioner�s left hand is placed on the patient�s distal femur and with this he introduces internal rotation of the thigh, and external rotation of the tibia (by means of light pressure on the distal foot from his lower leg).
During this process the practitioner senses for resistance (the movement should have an easy �springy� feel, not wooden or harsh) and observes for a characteristic depression or groove on the lateral thigh, indicating shortness of TFL.
This resistance barrier is identified and the leg held just short of it for a chronic problem, as the patient is asked to externally rotate the tibia, and to adduct the femur, against resistance, for 7�10 seconds. Following this the practitioner eases the leg into a greater degree of internal hip rotation and external tibial rotation, and holds this stretch for 10�30 seconds.
Method (c) Isolytic variation If an isolytic contraction is introduced in order to stretch actively the interface between elastic and non-elastic tissues, then there is a need to stabilise the pelvis more efficiently, either by use of wide straps or another pair of hands holding the ASIS downwards towards the table during the stretch.
The procedure consists of the patient attempting to abduct the leg as the practitioner overcomes the muscular effort, forcing the leg into adduction. The contraction/stretch should be rapid (2�3 seconds at most to complete). Repeat several times.
Method (d) Side-lying MET treatment of TFL The patient lies on the affected TFL side with the upper leg flexed at hip and knee and resting forward of the affected leg. The practitioner stands behind patient and uses caudad hand and arm to raise the affected leg (which is on the table) while stabilising the pelvis with the cephalad hand, or uses both hands to raise the affected leg into slight adduction (appropriate if strapping used to hold pelvis to table).
The patient contracts the muscle against resistance by trying to take the leg into abduction (towards the table) using breathing assistance as appropriate (see notes on breathing, Box 4.2). After the effort, on an exhalation, the practitioner lifts the leg into adduction beyond the barrier to stretch the interface between elastic and non-elastic tissues. Repeat as appropriate or modify to use as an isolytic contraction by stretching the structure past the barrier during the contraction.
Additional TFL Methods
Mennell has described superb soft tissue stretching techniques for releasing TFL. These involve a series of snapping actions applied by thumbs to the anterior fibres with patient side-lying, followed by a series of heel of hand thrusts across the long axis of the posterior TFL fibres.
Additional release of TFL contractions is possible by use of elbow or heel of hand �stripping� of the structure, neuromuscular deep tissue approaches (using thumb or a rubber-tipped T-bar) applied to the upper fibres and those around the knee, and specific deep tissue release methods. Most of these are distinctly uncomfortable and all require expert tuition.
Self-Treatment and Maintenance
The patient lies on her side, on a bed or table, with the affected leg uppermost and hanging over the edge (lower leg comfortably flexed). The patient may then introduce an isometric contraction by slightly lifting the hanging leg a few centimeters, and holding this position for 10 seconds, before slowly releasing and allowing gravity to take the leg towards the floor, so introducing a greater degree of stretch.
This is held for up to 30 seconds and the process is then repeated several times in order to achieve the maximum available stretch in the tight soft tissues. The counterforce in this isometric exercise is gravity.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
Relieve: A small muscle located deep in the buttocks, the piriformis muscle performs the essential function of rotating the leg outwards. Piriformis Syndrome is a painful condition that occurs when the piriformis muscle is tight and intrudes upon the sciatic nerve in the buttocks. Causing pain and tenderness and sometimes numbness in the buttocks, piriformis syndrome pain may also radiate down the sufferer’s leg, and in some cases, even into the calf.
There are two commonly identifiable potential causes for piriformis syndrome. One is sitting for prolonged periods of time, which can cause tightening of the muscle. The second cause is an injury to the buttocks, either by a fall, an accident, or a sports injury. Trauma causes the piriformis muscle to swell and irritate the sciatic nerve.
Spasms can also cause piriformis syndrome, however, the underlying cause of the spasms frequently remains unknown.
Unfortunately, once an individual has suffered from piriformis syndrome, the condition can recur periodically, usually brought on by too much exercise or sitting for a long time without stretching.
Whatever the initial cause, piriformis syndrome treatment options are vital in relieving the painful symptoms and healing the condition.
Relieve:
These Four Treatment Options Are Frequently Used To Treat Piriformis Syndrome.
Medication. Over-the-counter or prescribed pain medicines, anti-inflammatory drugs, or muscle relaxers frequently serve to reduce the pain from piriformis syndrome. A doctor may also inject medicine directly into the piriformis muscle to improve the condition.
Heat. A common way to relax tight muscles is to apply heat. Piriformis syndrome sufferers may find relief from painful symptoms by periodically applying heat directly to the tender area.
Heat therapy may relieve the tightness of the muscle and promote healing of the entire area. However, it’s important to avoid treating the muscle with heat if there is a chance the muscle may be torn.
Exercise. The overall cause of the condition is a tight piriformis muscle, so it stands to reason a proper exercise regimen will loosen the muscle and alleviate the symptoms associated with piriformis syndrome. A doctor can prescribe the correct exercises to stretch and subsequently strengthen the muscles and the body’s other muscles. A strong body will reduce the chances of the issue recurring down the road.
Hands on therapy. Used with other types of treatment or on their own, these types of therapies are popular because of their effectiveness, as well as the fact they are drug-free ways to gain relief from the pain. Massage is a commonly used therapy for piriformis syndrome, as it helps increase blood flow to the area. The massage therapist can manipulate the area to relieve the tightness of the muscle.
Another hands on therapy that produces positive results is chiropractic care.
Chiropractors view the body in its entirety, and will often treat other parts of the body, such as a foot or leg, in order to improve the condition of the piriformis muscle. They may also utilize a regimen of pelvic and spinal adjustments along with joint manipulation and stretching to loosen up the muscle and help heal the afflicted area.
As stated earlier, once the condition has been controlled and the area has healed, it’s vital to take precautions to avoid re-aggravating the area. Proper stretching before exercise, periodic breaks when sitting, and maintaining spinal and pelvic alignment will increase an individual’s chances of living free of the pain of piriformis syndrome in the future.
Treating Sciatica
If you have a question about how chiropractic care can help with the symptoms of piriformis syndrome, or other health conditions, contact us today.
This article is copyrighted by Blogging Chiros LLC for its Doctor of Chiropractic members and may not be copied or duplicated in any manner including printed or electronic media, regardless of whether for a fee or gratis without the prior written permission of Blogging Chiros, LLC.
Even if you have never stepped foot onto a court before, you may end up with tennis elbow. Occurring along the muscle that allows extension of the wrist, it is a painful condition that can linger for weeks or months.
Previously, tennis elbow primarily showed up in athletes. Due to the increased interest in physical fitness, tennis elbow is being found in everyday exercisers, as well as people who perform work-related repetitive motion.
Tennis elbow presents several symptoms. Pain will occur on the outside of the elbow an inch or so down from the bony part.
There may also be pain when the individual tries to extend the hand and fingers against resistance. Extreme weakness in the wrist is another symptom.
I Have Been Diagnosed With Tennis Elbow. Now What?
Tennis elbow is often difficult to diagnose, which can delay treatment. A correct diagnosis of tennis elbow is the first step towards being able to treat the condition and rehab the afflicted area. From there, a variety of treatments for tennis elbow are available.
Passive remedies like rest, ice, and arm braces are critical components to healing tennis elbow. Take measures to reduce the movements that aggravate the pain, and use ice at regular intervals to help minimize pain and inflammation.
An arm brace supports and stabilizes the area to promote healing. These remedies assist greatly in treating the condition, especially in the beginning.
Active remedies consist of stretching and strengthening exercises, and are vital aspects of improving the condition. Individuals suffering from tennis elbow should begin an exercise regimen as soon as the pain allows.
An individual dealing with tennis elbow may utilize a variety of medicinal remedies to manage pain and inflammation. Over-the-counter pain relievers and steroid injections are commonly used to treat the condition. Following doctor’s orders when taking medications is strongly recommended.
Untraditional remedies also provide vast improvements in tennis elbow, and these treatments have gained favor in the last few years due to their effectiveness. Regimens of massage therapy and acupuncture work on small areas contributing to the condition, and make significant strides in pain reduction and promote the body’s restorative healing process.
Another remedy that offers strong benefits to treating tennis elbow is chiropractic care. A chiropractor assesses the condition, then lays out a plan to promote healing.
Treatment often includes working to align the bones and treating the surrounding joints so they function at maximum capacity, and can “take up the slack” of the injured area while it heals. Chiropractic care serves the dual purpose of treating the condition directly, and healing the areas around the injury so that the body continues to strengthen and renew.
In a very small number of cases, the only remedy for tennis elbow is surgery. This is considered as the last straw, once all other forms of treatment have been exhausted.
The best way to treat tennis elbow is to avoid it in the first place. Be sure to stretch before exercising, consistently perform strengthening exercises, employ correct techniques and proper equipment during physical activity, and don’t overexert your arms (this goes for your entire body, by the way) during physical activity.
If you are diagnosed with tennis elbow, it’s essential to understand the variety of treatment options available. The best course is often a blend of more than one remedy. Chiropractic care should be part of your healing process, as it helps decrease pain, reduce healing time, and offers a non-medicinal approach to treating the body as a whole.
The Risks Of College Sports
This article is copyrighted by Blogging Chiros LLC for its Doctor of Chiropractic members and may not be copied or duplicated in any manner including printed or electronic media, regardless of whether for a fee or gratis without the prior written permission of Blogging Chiros, LLC.
As experienced chiropractors, we like answering the questions we receive from our patients. A common inquiry is “what is the difference between a sprain and a strain?” Sprains and strains are injuries to the musculoskeletal system that are commonly diagnosed conditions, and are two separate issues people frequently mix up. We will attempt to explain away some of the confusion today.
Let’s look at three ways sprains and strains differ from each other.
1. Sprains & Strains Afflict Different Parts Of The Body.
2. Sprains & Strains Are Most Often Caused From Different Actions.
Falling or twisting the wrong way typically causes a sprain, because the movement forces a joint into an awkward position and ends up stretching or tearing the ligament. Twisting an ankle, falling down the stairs, or trying to catch yourself on an icy walkway are all ways to end up with a sprain.
A strain often results from overexertion or trauma, and repetitive movement. Lifting an item that is too heavy, jumping into an exercise routine that is too strenuous, or performing repetitive movements in either a sport or work are ways an individual can end up suffering from a strain.
3. Sprains & Strains Generally Affect Different Areas Of The Body.
Sprains occur at parts of the body that are injured when falling or suddenly twisting. According to the U.S. National Library of Medicine, ankle sprains alone number around 2 million each year.
Ankles, wrists, knees, and fingers are all areas that are frequently sprained. Strains, on the other hand, commonly occur in the back, shoulder, or hamstring, as both of these areas are affected by overexertion or repetitive movement.
Although sprains and strains are different injuries, they do have some similarities. This is most likely why people get them mixed up.
Let’s discuss a few commonalities of sprains and strains.
Both share common symptoms.� Both injuries can bring on pain, swelling, and limited movement at the injury site. The pain can be moderate or intense, depending on the severity of the injury. Sprains and strains both benefit from ice packs, rest, and elevation.
They can require surgery.� Most diagnosed strains and sprains heal on their own with time, but a serious tear can require surgery to repair. With both injuries, it’s important to visit a doctor if an individual experiences severe pain and swelling, and decreased mobility.
Both can benefit from chiropractic care.� Chiropractors can work wonders on the neck and back, but chiropractic care can assist in lessening the impact of a strain or sprain injury, too.
The benefits of seeing a chiropractor for both sprains and sprains are twofold. Chiropractic treatments promote healing of the injured area as well as help strengthen the areas around the injury to decrease the chance of future injuries.
These types of injuries can sideline individuals from their activities, no matter if they are athletes or regular guys doing yard work. It’s vital to take steps to avoid sprains and strains in the first place.
Always properly stretch and avoid overexertion to prevent strains. Take pains to clear walkways and stairways to avoid falls or sudden twisting movements to decrease the risk of sprains.
Washington Cheerleader Talks Chiropractic
If you end up with a strain or sprain, contact us for a consultation. We have extensive experience in working with patients suffering from sprains and strains.
This article is copyrighted by Blogging Chiros LLC for its Doctor of Chiropractic members and may not be copied or duplicated in any manner including printed or electronic media, regardless of whether for a fee or gratis without the prior written permission of Blogging Chiros, LLC.
Carpal tunnel syndrome (CTS) is a serious, painful nerve injury that affects many people in the United States. CTS occurs when the median nerve, which runs down a person’s forearm to his or her hand, gets compressed in the eight bones in the wrist called the carpal tunnel. This injury is frequently caused over time by repetitive motion such as assembly line work, and is the most expensive work-related injury. Symptoms of CTS include pain and numbness of the hand and wrist. While there are a variety of treatment options available to those who are afflicted with carpal tunnel syndrome up to and including surgery, chiropractic care has become a popular and effective option.
Here are four ways patients with carpal tunnel syndrome benefit from chiropractic care.
Chiropractic Care Is Documented To Work On Carpal Tunnel Syndrome.
While there are no guarantees that any one mode of treatment will work on every person, two studies have shown strong results that back the effectiveness of chiropractic treatment on CTS.
In both cases, the majority of participants showed significant improvement in several measures such as range of motion, finger sensation, and pain reduction. These studies provide evidence to people suffering from carpal tunnel syndrome. Patients can feel confident in improving their symptoms when choosing to pursue a chiropractor’s care.
Chiropractors Provide A Less Invasive Treatment Option.
Carpal tunnel syndrome, particularly cases that have gone undiagnosed or treated for an extended period of time, that ends up being too painful and advanced to be handled with medicine may face surgery. However, chiropractic care often helps minimize that option as a last resort. Regular visits to a chiropractor can show positive results in the controlling and healing of many of the CTS symptoms.
Chiropractic Care Offers An Alternative To Drugs To Manage Pain
As with surgery, daily doses of medicine may be a less than ideal plan when managing carpal tunnel syndrome. Certain patients may suffer from issues with the medicine, CTS medicines may conflict with other medication, or they may simply not want to take daily medications.
If medicinal treatment is not an attractive option, a chiropractor appointment is the next logical step. Chiropractic care often helps CTS by adjusting the patient’s elbow and spine.
Another common treatment is bracing. This technique limits the hand’s movements with the goal of allowing the wrist and tendons to heal and recover.
A chiropractor who is experienced with carpal tunnel syndrome is able to review each case individually and make solid treatment recommendations that can alleviate the patient’s dependence on managing the pain with drugs.
Allows Patients To Learn How To Manage Carpal Tunnel Syndrome.
Unfortunately, health problems that produce chronic pain can take a toll on the patient not only physically, but psychologically. Dealing with CTS can make a person feel powerless over their own body. Working with a chiropractor to relieve, control, and heal the symptoms of carpal tunnel syndrome empowers the patient to be able to feel ownership of managing and improving his or her health.
Workers who perform repetitive tasks daily as part of their job need to be especially aware of the symptoms of carpal tunnel syndrome. Feeling pain, numbness, tingling, or burning in their palms or fingers may be the first symptoms of CTS. The earlier it’s diagnosed, the more effective less-invasive treatment will be.
Of all the carpal tunnel syndrome treatment choices, chiropractic care offers the dual benefits of being a highly effective treatment while still employing tactics that are not as invasive as other options. If you or a loved one are suffering from this condition, give us a call. We�re here to help!
This article is copyrighted by Blogging Chiros LLC for its Doctor of Chiropractic members and may not be copied or duplicated in any manner including printed or electronic media, regardless of whether for a fee or gratis without the prior written permission of Blogging Chiros, LLC.
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3. Sprains & Strains Generally Affect Different Areas Of The Body.
