Back Clinic Sports Injuries Chiropractic and Physical Therapy Team. Athletes from all sports can benefit from chiropractic treatment. Adjustments can help treat injuries from high-impact sports i.e. wrestling, football, and hockey. Athletes that get routine adjustments may notice improved athletic performance, improved range of motion along with flexibility, and increased blood flow. Because spinal adjustments will reduce the irritation of the nerve roots between the vertebrae, the healing time from minor injuries can be shortened, which improves performance. Both high-impact and low-impact athletes can benefit from routine spinal adjustments.
For high-impact athletes, it increases performance and flexibility and lowers the risk for injury for low-impact athletes i.e. tennis players, bowlers, and golfers. Chiropractic is a natural way to treat and prevent different injuries and conditions that impact athletes. According to Dr. Jimenez, excessive training or improper gear, among other factors, are common causes of injury. Dr. Jimenez summarizes the various causes and effects of sports injuries on the athlete as well as explaining the types of treatments and rehabilitation methods that can help improve an athlete’s condition. For more information, please feel free to contact us at (915) 850-0900 or text to call Dr. Jimenez personally at (915) 540-8444.
Athletes are at higher risk of experiencing injuries or aggravating a previously existing condition due to the constant exposure to rigorous training and competitions. Although the lower extremities most frequently result in damage or injury, lower back complications have only been increasingly reported among the wide majority of athletes alike.
Among the young college athletes and professional athletes alike, low back pain is considered to be one of the most common complaints, estimated to affect more than 30 percent of athletes at least once in their career. A wide number of back injuries can affect the athlete, including muscle spasms and stress fractures, spondylosis, spondylolisthesis, disc degeneration, facet joint arthropathy and disc issues, such as lumbar disc herniation.
Lumbar disc herniation is a well-known type of injury which often causes impairing low back pain, however, it can also compress the nerve roots in the area and generate radicular pain and other symptoms along the lower extremities, such as altered sensations and muscle weakness. Furthermore, this type of injury will not only affect the athlete�s ability to perform during their specific sport or physical activity, it may also become chronic and affect the athlete in the future.
Conservative treatments are frequently utilized when managing lumbar disc herniation in athletes, although surgical options may be considered if the injury is too severe. Many elite athletes often request faster recovery methods for their type of injuries and symptoms in order to minimize their time spent away from training and competition. As a result, a wide number of athletes will seek surgical alternatives earlier than recommended, provided they meet the criteria for lumbar spine surgery. The most popular surgical procedure for athletes with a low back disc herniation is the lumbar disc microdiscectomy.
Anatomy & Biomechanics of the Lumbar Spine
The intervertebral discs of the lumbar spine perform an essential biomechanical role within the spine. These function to provide mobility between the segments of the spine while distributing compressive, shear and torsional forces. These discs are made up of a thick, outer ring of fibrous cartilage, known as the annulus fibrosis, which surround the gelatinous core of the disc, known as the nucleus pulposus, which is contained within the cartilage end plates.
Each intervertebral disc consists of cells and substances, such as collagen, proteoglycans and scattered fibrochondrocytic cells, which function to absorb and conduct increased forces from body weight and muscle activity. In order to effectively perform its function, the disc depends immensely on the structural condition of the annulus fibrosis, nucleus pulposus and the vertebral end plate. If the disc is healthy, it will evenly spread the forces being applied against the spine. However, disc degeneration caused by cell degradation, loss of hydration or disc collapse, can decrease the disc�s ability to withstand external forces and these will no longer be absorbed and conducted evenly across the spinal structures.
Tears in the annulus fibrosis of the disc along with extrinsic loads may ultimately cause the disc to herniate. Alternatively, applying a large, biomechanical force against a normal disc, such as a heavy compression on the spine due to a fall on the tailbone or strong muscle contraction from heavy weight lifting, can also damage the healthy structures of the disc and cause a rupture.
Disc herniation is characterized when the nucleus pulposus, the soft, jelly-like material in the center of a disc, pushes through a tear in the annulus fibrosis, the fibrous exterior of the disc. If the protrusion does not compress the nerve roots that travel along the spine, the individual may only experience back pain. But, if the herniated disc pushes against the lumbar nerve roots or other structures within the lower back, the individual may experience radicular pain along with neurological symptoms, such as numbness and paresthesia.
The pain and other symptoms associated with lumbar radiculopathy occurs due to a combination of nerve root ischemia from compression and due to inflammation caused by the chemicals released from a ruptured disc. During a herniation, the nucleus pulposus places unnecessary pressure against the weakened areas of the annulus, protruding through these weakened sites in the outer structure of the disc, ultimately forming a herniation. It�s important to note that when a lumbar disc herniation occurs, in a majority of cases, some form of disc degeneration may have existed before.
The Process of Lumbar Disc Herniation
Unlike other musculoskeletal tissues of the body, intervertebral discs generally degenerate sooner than other structures. Some studies have shown adolescents between the ages of 11 to 16 with signs of degeneration. As people age, the discs will naturally degenerate further. In a research study conducted using normal, healthy subjects between the ages of 21 to 30, more than one third of the individuals presented degenerated discs.
While the spinal discs may be at risk of injury in practically all fundamental planes of motion, these are often more susceptible to damage or injury during constant and repetitive flexion or hyperflexion along with lateral bending or rotation. Trauma from an injury caused by an excessive axial compression can also harm the internal structure of the discs. This can commonly result after the individual has suffered a fall or due to strong muscular forces being placed against the spine during specific activities, such as heavy weight lifting.
When it comes to athletes, they are frequently exposed to conditions of higher loading. A herniated disc can be categorized according to its location: central, posterolateral, foraminal or far lateral. Herniation varieties can also be classified as: protrusion, extrusion or sequestered fragment. Finally, disc herniation may be identified according to the level where they occurred on the spine. Most develop along the lumbar spine, often affecting the lumbar nerve roots which may lead to symptoms of sciatica. Upper lever herniated discs are rare, but when they do occur along with radiculopathy, they generally affect the femoral nerve.
Disc Herniation in Athletes
Athletes who participate in sports or physical activities which utilized combined trunk flexion and rotation have an increased chance of experiencing herniated discs. Individuals between 20 to 35 years of age are the most common group to herniate a disc, most likely as a result of the nature of the nucleus pulposis and due to behavior. This age group is most likely to be involved in sports which require higher loads of flexion and rotation or they may practice improper postures and positions when carrying weight.
The sports most at risk of disc herniation include: hockey, wrestling, football, swimming, basketball, golf, tennis, weight lifting, rowing and throwing activities, because these sports involve either high loads or high exposure to combined flexion and rotation mechanisms. Additionally, athletes who engage in more intense, continuous training routines appear to be at an increased risk of developing spinal injuries or conditions, similar to those involved in impact sports.
Signs and Symptoms Indicating Discectomy
An athlete is generally driven by motivation and goals when they choose to undergo surgery to treat a lumbar disc herniation. Rather than waiting for the symptoms to decrease over a period of rehabilitation, athletes prefer a relatively simple microdiscectomy.
A conservative period of management for symptoms of a lumbar herniated disc may involve: medication therapy, epidural injections, relative rest and trunk muscle rehabilitation, acupuncture and chiropractic care with massage. However, athletes who experience low back pain with pain radiating down one or both legs, neurological signs and symptoms, mild weakness of distal muscles, such as extensor hallucis longus, peroneals, tibialis anterior and soleus and those who demonstrated positive on the straight leg raise test, may meet the criteria to follow through with a surgical intervention for their lumbar herniated disc.
Generally, elite athletes have a shorter time span in which to allow conservative rehabilitation to be effective. For a majority of the population, medical practitioners often prescribe a minimum 6-week conservative period of treatment with a review at 6 weeks to decide whether they should extend the rehabilitation or to seek treatment from a specialist. This particular healthcare professional may then offer other alternative interventions to treat the issue.
For athletes, however, these time frames are compressed. Epidural injections are often offered to athletes to assess the issue quicker, and if there are no results within a determined period, an immediate lumbar spine microdiscectomy may follow.
Imaging
Magnetic resonance imaging, or MRI, are considered to be the preferred method for identifying lumbar disc herniation, as these are also very sensitive when detecting nerve root impingements. Because abnormal MRI scans can occur in otherwise asymptomatic individuals, it�s essential to establish a clinical correlation of symptoms before any surgical considerations. Additionally, individuals may present clinical signs and symptoms suggesting the presence of a lumbar herniated disc but they may lack sufficient evidence on MRI to meet the criteria to follow through with surgical interventions. Accordingly, it�s been proposed that a volumetric analysis of a lumbar herniated disc on MRI may be potentially valuable for assessing an individual�s and athlete�s suitability to receive surgery.
MRI Lumbar Spine Disc Herniation
Chiropractic and Massage
Fortunately, before considering surgical intervention, although more time and patience may be required, there are several effective, alternative treatment options that can help reduce and eliminate the symptoms associated with a lumbar herniated disc. Chiropractic is a healthcare profession that focuses on injuries and conditions of the musculoskeletal system and the nervous system as well as the effects of these on general health. Chiropractic care emphasizes the treatment of the body as a whole rather than focusing on a single injury or condition. Through the use of spinal adjustments and manual manipulations, two of the most common techniques used in chiropractic, a chiropractor can carefully re-align the spine, helping to restore and reduce the pain and swelling caused by a lumbar herniated disc.
Along with a combination of massage, chiropractic care can ultimately help rehabilitate an injured athlete or individual. A massage, best referred to as myofascial release, is a hands-on technique that involves applying gentle, sustained pressure into the myofascial connective tissue restrictions, to eliminate pain and restore function. Massage can increase blood flow, which delivers more oxygen and nutrients to the muscles surrounding the affected region of the spine. The increased blood flow may also help carry away unnecessary substances which may have accumulated through time. Chiropractic care and massage are safe and effective treatments that can help rehabilitate athletes with lumbar disc herniation without side effects.
Sports injuries can become a difficult situation for any athlete, especially if the symptoms become more severe, leading to further complications. When recovering from an injury, an athlete’s main concern involves them returning to play as soon as possible. Chiropractic care and the use of physical therapy as well as other types of treatment methods and massage can help individuals effectively recover from their injuries.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Low Back Pain 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. An auto collision can ultimately affect the bones, muscles, tendons, ligaments and other tissues surrounding the spine, commonly the lumbar region of the spine, causing symptoms such as low back pain. Sciatica is a common set of symptoms after an automobile accident, which may require immediate medical attention to determine its source and follow through with treatment.
Athletes who perform daily rigorous training and/or participate in regular competitions can often be at a higher risk of suffering an injury or developing an injury. Because most sports or physical activities require the repetitive and constant use of the lower extremities, experiencing a complication which affects the lower back, buttocks, thighs and even the feet of the athlete can ultimately alter their performance.
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.
Shin splints, or MTSS, occurs most frequently in specific groups of the athletic population, accounting for 13-20 percent of injuries in runners and up to 35 percent in military service members. Medial tibial stress syndrome is characterized as pain along the posterior-medial border of the lower half of the tibia, which is active during exercise and generally inactive during rest. Athletes describe 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 speculated 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 evaluated a single leg from 5 male and 11 female adult cadavers. Through the study, they confirmed that in these specimens, the muscles of the posterior section of muscles was 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 believed 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 concluded 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 is unable to 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 display 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-known. 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 proposed 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 suffer 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 evaluated accordingly. The specialist performing the 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 healthcare professional 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, otherwise known as shin splints, ultimately is a painful condition that can greatly restrict an athlete�s ability to walk or run. As mentioned above, several evaluations 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 visit additional specialists to ensure the athlete has received the correct diagnosis for their injuries or conditions.
Sciatica is best referred to as a set of symptoms that originate from the lower back and is 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 characterized 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 disorders. A chiropractor can help diagnose an athlete�s MTSS as well as overrule the presence of sciatica as a cause of the symptoms. In addition, 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.
Chiropractic care is an effective form of alternative treatment which is commonly preferred by many athletes as it can help with the recovery of an injury and/or condition without the need for medications or surgery. Most athletes are specially trained to prevent injuries, however, the constant and repetitive overworking of the structures of the body can gradually begin to degenerate, leading to issues like shin splints which may potentially manifest symptoms of sciatica if left untreated for an extended period of time.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Low Back Pain 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. An auto collision can ultimately affect the bones, muscles, tendons, ligaments and other tissues surrounding the spine, commonly the lumbar region of the spine, causing symptoms such as low back pain. Sciatica is a common set of symptoms after an automobile accident, which may require immediate medical attention to determine its source and follow through with treatment.
Sometime after Kyle Gibson starts for the Twins in their home opener Monday afternoon, the durable young right-hander will connect with perhaps the most important member of his support team this year: his Chiropractor.
Gibson is still just 28, smack in the prime of his career, but there were times during the second half last season when his lower back started to bark at him. In early August in Toronto, for instance, he was shelled for eight earned runs in just 4 2/3 innings.
�I had a problem in Toronto,� Gibson said.
�There were a couple starts where I didn�t sit down in between innings,� Gibson said, �because if I sat down, my hips just got tight.�
Meanwhile, fellow Twins pitcher Trevor May, 26, was dealing with lower back issues of his own. In May�s case, the additional pounding of making multiple relief appearances without much recovery time had caused issues with the hip and lower-back area of his left (landing) leg, as well.
May�s physical woes left him unavailable for days at a time while the Twins chased their first postseason berth since 2010. Massage and electronic stimulation could only do so much to keep May on the mound.
A few sporadic sessions with a chiropractor didn�t provide immediate results, so May discontinued them.
Upon returning to Seattle this offseason, the yoga devotee decided to up the ante and visit a chiropractor weekly for hour-long sessions. This time, he began to see the benefits.
�A couple weeks before spring training, I felt it coming on a little bit again,� May said. �I was like, what is going on? I got it adjusted and my chiropractor said, �Man, you are way, way out of whack.� He explained to me where my pain was and why the hip was pressing against where it was and if we get that moved back, just lengthened out, it�s going to be really sore for a few weeks, but then it�s just going to go back to normal.�
OVERCOMING FEARS
In 2014, his first full season in the majors, Gibson saw a chiropractor a few times at the recommendation of Twins closer Glen Perkins.
Gibson missed a start in late July after getting shelled at home for six earned runs against the Tampa Bay Rays.
�One of Perk�s guys came in and adjusted me,� recalled Gibson, who threw seven shutout innings at Kansas City his next time out.
That never led to a regular appointment, partly because of Gibson�s relative youth but also because of a long-held fear of what a chiropractor might do to a young athlete�s spine.
�My view of them was, �OK, I want you to lay on a table and I�m going to pop your back and you can come back in a week,� � Gibson said. �Once you start doing it, you�ve got to keep doing it the rest of your life. That was my view.�
A conversation with May early in spring training this year left him more open to chiropractic manipulation.
Hoping to build on the gains of a breakthrough 2015 but still bothered by soreness in his lower back, Gibson asked May for feedback on his chiropractor. May, who by then was going once at week to Darin Stokke at Lifestyles Chiropractic, had nothing but good things to say about the sessions.
Dr. Stokke
�We found that baseball players get skeletally out of line,� May said. �They do one motion one way much harder (than most people), and my hips were really, really out of line. Seeing a chiropractor consistently has helped me make sure I�m getting readjusted and staying in line as much as possible.�
While initially there was some concern that the bullpen simply did not agree with May�s back, his chiropractic sessions convinced him (and the Twins) that he could manage the additional workload with proper preparation.
What derailed him in September 2015, as it turns out, was a problem with the set joint, where the left hip and lower back meet.
�It was all muscular,� May said. �It was just because one hip was closer to the spine than the other side. The other side was normal. (The left side) was just pressing so much and you get so much inflammation. It was just a perfect storm. It was just a little extra torque being in the �pen. That�s why it was bothering me. Now I�m on top of it.�
As May explained it to Gibson, realignment of the spine would allow the overtaxed areas of a pitcher�s core to meet the challenge of persistent pounding.
�Letting those muscles unflare and then heal and rebuild them back to where they�re supposed to be, that�s what we�re doing,� May said.
After doing some �normal treatment stuff� as a warmup, Stokke would check May�s alignment much the way a tire installer might need to check an automobile before sending it back out into traffic.
�He checks where you legs are,� May said. �If he sees you�re out of line, he puts you back in line, and the next day I try to do some exercises and heavy strength stuff, just to build those muscles back up. I�m seeing soreness go and I feel more in line and healthier.�
BELIEF SYSTEM
Despite taking the loss in his season debut in Baltimore, Gibson reports much the same results from his twice-weekly chiropractic sessions this spring.
�Toward the beginning of spring training my back started getting sore again,� Gibson said. �Going twice a week helped get things moving in the right direction.�
Now that he feels his lower-back problems are under control, Gibson plans to scale back to a single visit per homestand. That way he won�t have to find somebody to visit on the road, while also limiting those realignment sessions to perhaps two per month.
�It has made a big difference in my hips and just everything,� said Gibson, who set career highs for starts (32) and innings (194 2/3) last season. �My skeletal system was basically allowing my muscular system to stay tight and not function properly. That caused some nerve irritation.�
While May features the classic �drop and drive� delivery, Gibson is from the �tall and fall� school that should, in theory, produce less strain on a pitcher�s hips and back. That didn�t prove to be the case over Gibson�s first few seasons in the majors, so he finally realized adjustments were needed.
�Some of my problem was just that I had some tight hips pulling my pelvis out of line and causing some irritation in the nerve,� Gibson said. �There were certain things I realized I could pitch through. You find ways to get around certain sorenesses and aches and pains.�
If the Twins can get 200 innings out of Gibson and 65 to 75 relief appearances out of May, they won�t just have a better chance to end a postseason drought that has reached five years and counting. They could have additional members of their pitching staff lining up for realignment sessions.
Kyle Gibson, last season his lower back started to bark at him. The durable young right-hander connected with the most important member of his support team, his Chiropractor. While Trevor May, was dealing with lower back issues of his own. In May�s case, the additional pounding of making multiple relief appearances without much recovery time had caused issues with his�hip and lower-back area of his left (landing) leg, as well.
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 .
This Sunday over 111 million people will tune into watch the SuperBowl. Behind the scenes both teams and coaches have been fine tuning their game plans as they prepare for the biggest game of their lives. As part of the players preparation there have been a few lucky individuals with direct access to care for these athletes. �Referred to as the �magic workers� by some players these men are the team Chiropractors who serve both the Seattle Seahawks and New England Patriots.
For the last 12 years, Dr. Gerry Ramogida and Dr. Jim Kurtz have had front-row seats to the spectacle of NFL games as chiropractic consultants for the Seattle Seahawks. Attending every game, �Dr. Ramogida was supposed to stay with the team for just a couple of years so he could show the trainers how to use some of his soft-tissue techniques. But as players got used to getting adjusted by him on�game days, a temporary job turned into a permanent one.
�There�s so much behind the scenes that you don�t get a sense for when you�re watching a game. It�s a massive effort. I am just happy to be a part of the preparation as these guys get ready to go out and do what they do best, compete.�
In a interview with Global News�Dr. Ramogida stated, �Over the period of that first season and into the next year, things very quickly became integrated. It�s been a great experience,� he says.
In recent news, The Professional Football Chiropractic Society (PFCS) has taken pride in announcing that all 32 teams in the National Football League offer their players and personnel chiropractic physician services as part of the triage in managing and preventing injuries. According to the Foundation for Chiropractic Progress, this distinction is a benchmark for the profession and documents the important role that chiropractic care plays in optimizing athletic performance.
�The robust need for chiropractic care in the NFL has been deeply driven by the players� desire for peak physical conditioning and not simply for injuries,� states Spencer Baron, D.C., �From the earliest years of full contact football, their bodies are subject to structural stress that doctor of Chiroprctic (DCs) are specially trained to care for. �
Attending this weekend to the New England Patriots is Dr. Mike Miller. �Over twenty five years ago he became the official chiropractor of the New England Patriots. Since that time, he�s treated hundreds of players, watched ownership of the team change hands three times, and seen the Patriots go from one of the worst franchises in the National Football League to a team readying themselves to play in the Superbowl this weekend.
In a interview with Dynamic Chiropractic Dr. Miller states that his position with the Patriots involves him being present during mini-camps, training camp, preseason games, regular-season games (both home and away), and postseason games.
During the games, I see an average of at least 40 players, coaches, and other personnel who are affiliated with the team. I would say just about 90 percent get chiropractic services, because the present coaching staff of the Patriots has almost mandated chiropractic care with the players. The coaches speak about it at team meetings, as the new players and rookies come into the team in the preseason. During mini-camps, they explain the significance of chiropractic, and that we have a chiropractor who has had phenomenal results in dealing with injuries and preventing them from occurring, and that they would like the players to proactively be treated [by] me and begin a chiropractic course of care.
During the season, if there are any injuries, they (the medical staff) will generally send the player to my office to be evaluated. By game time, just about everyone on the roster is adjusted, and you start to learn the idiosyncrasies of each player, because each one wants certain things checked on them. Some are very firm with extremity adjusting; others enjoy use of a specialized technique that we use, called Graston Technique. Basically, it takes me about four hours before the game to go through the entire roster.
The NFL has just released a statement advocating for�all NFL teams as now employing a Chiropractor as part of their medical staff.
If you are interested in learning more about how to be an NFL Chiropractor you can connect with the Professional Football Chiropractic Association�on their website or on their Facebook page.
No matter what the outcome of this weekends game may be, rest assured that both teams will have been well adjusted and their nervous systems tuned on and ready to perform on the biggest stage of all.
Behind the bright lights of the stadium, there is another team that keeps these players and their performance at their optimal level. The healers�if you will, that audiences don’t see, but should know about. These are the Chiropractors!
Super Bowl 50 showcased the leading players in the NFL along with Joshua Kollmann, DC and Brad Wiest, DC � chiropractors for the Carolina Panthers � and Shawn Caldwell, DC for the Denver Broncos. These doctors of chiropractic helped the players achieve optimal performance.
The Foundation for Chiropractic Progress (F4CP), a not-for-profit organization dedicated to raising awareness about the value of chiropractic care, points out that all 32 NFL teams include the professional services of a doctor of chiropractic (DC) as part of their integrated health care team approach.
Marking their fifth year with the Carolina Panthers, Drs. Kollmann (pic. left) and Wiest (pic. right) highlight the integrative role of chiropractic care: �We are in the stadium training room twice a week � and more often during play-offs � addressing specific sports injuries or providing preventive, maintenance care that the athletes want in order to achieve peak performance. Every player is individually assessed and the treatment plan is communicated and discussed with the training staff. Since the physical nature of the sport really impacts body structure, many players look forward to their pre- and post-game spinal and extremity adjustments as well as other advanced approaches.�
Shawn Caldwell, DC, who has served the Denver Broncos since 2004 and is now preparing for his second Super Bowl, says, �I work hand-in-hand with the athletic trainers and focus on performing chiropractic spine and extremity adjustments that restore joint function. The goal is to enable players to perform optimally or heal from injuries. I am at the facility two-three times weekly or more if necessary. Some players get an adjustment every time I am in the training room, while others when they are symptomatic so they can return to the playing field.�
According to Kyle Prusso, DC, team chiropractor for the Oakland Raiders since 2005 and president of Pro Football Chiropractic Society, an organization of chiropractors who provide the highest quality chiropractic health care to the elite athletes of professional Football: �It�s great to see chiropractic care integrated in all facets of health care, especially in professional and amateur sports. One of the reasons is that athletes are asking for us, with increased player requests driving utilization of chiropractic across all sports. Athletes are very in tune with their bodies and recognize that chiropractic care can boost optimal performance levels.�
All doctors are passionate about their roles as team chiropractors to an NFL Super Bowl contender, as Dr. Kollmann says, �I am humbled by this position and want the world to know that this is a great time to be a chiropractor. It means the world to me to ignite and advance our profession � especially for those who are pursuing a chiropractic education as well as veteran professionals. We are igniting the profession and honor those DCs who pioneered the opportunities that have helped us to become a part of the NFL teams.�
Dr. Caldwell, who is also the chiropractor for the Colorado Rockies Major League Baseball team, sums it up, �Chiropractors are playing an important role in the health care and performance of professional athletes. This is a fantastic experience for us and for the players.�
Doctors of chiropractic receive a minimum of seven years of higher level education, and are qualified to diagnose, treat and manage a broad spectrum of health conditions. They are the primary care professionals for spinal health and well-being. For athletes, chiropractic care helps to reduce the risk of injuries, and improve health and performance through enhancements in range of motion, flexibility, balance, muscle strength and other key factors.
If you are interested in learning more about how to be an NFL Chiropractor you can connect with the Professional Football Chiropractic Association on their website or on their Facebook page.
No matter what the outcome of this weekends game may be, rest assured that both teams will have been well adjusted and their nervous systems tuned on and ready to perform on the biggest stage of all.
Chiropractors swarm the field! Ready for some adjustments to help these players perform their best. The Foundation for Chiropractic Progress (F4CP), a non-profit organization dedicated to raising awareness about the value of chiropractic care share the fact that all 32 NFL teams utilize doctors of chiropractic (DC), as part of their health care programs.
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he could show the trainers how to use some of his soft-tissue techniques. But as players got used to getting adjusted by him on�game days, a temporary job turned into a permanent one.
In a interview with Dynamic Chiropractic Dr. Miller states that his position with the Patriots involves him being present during mini-camps, training camp, preseason games, regular-season games (both home and away), and postseason games.
Marking their fifth year with the Carolina Panthers, Drs. Kollmann (pic. left) and Wiest (pic. right) highlight the integrative role of chiropractic care: �We are in the stadium training room twice a week � and more often during play-offs � addressing specific sports injuries or providing preventive, 
maintenance care that the athletes want in order to achieve peak performance. Every player is individually assessed and the treatment plan is communicated and discussed with the training staff. Since the physical nature of the sport really impacts body structure, many players look forward to their pre- and post-game spinal and extremity adjustments as well as other advanced approaches.�
Shawn Caldwell, DC, who has served the Denver Broncos since 2004 and is now preparing for his second Super Bowl, says, �I work hand-in-hand with the athletic trainers and focus on performing chiropractic spine and extremity adjustments that restore joint function. The goal is to enable players to perform optimally or heal from injuries. I am at the facility two-three times weekly or more if necessary. Some players get an adjustment every time I am in the training room, while others when they are symptomatic so they can return to the playing field.�
