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.
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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.
CHIROPRACTORS HAVE CLAIMED FOR YEARS THAT WE CAN BE MORE COST-EFFECTIVE. BCBS HAS THE DATABASE THAT WOULD PROVE OUR THESIS, BUT THERE SEEMS TO BE A RELUCTANCE TO ALLOW OUR PROFESSION TO ACCESS THE DATA THAT WOULD PROVE US RIGHT.
In August 1999, Blue Cross/Blue Shield (BCBS) of Kansas presented a study titled �Lumbago Treatment.� This data was made available from a new program installed by BCBS called the McKesson Episode Profiler.
This program gave BCBS the ability to sort data according to specific diagnoses and compared the costs, frequency, and other factors between peer groups.
The data revealed that while less than eight percent of the study group were chiropractors, 38 percent of the patients chose to seek chiropractic care rather that allopathic medicine. This fact indicates that patients desire and are satisfied with the management techniques of the chiropractor.
The study did not include any hospitalization costs for surgery or any fees paid to orthopedists or neurosurgeons for costs associated with surgery. If the data included costs for these procedures, the savings for chiropractic would have been much greater.
When sorted by the average cost per episode, chiropractic is more cost-effective than anesthesiology; neurosurgery; neurology; registered physical therapy; orthopedic reconstructive surgery; physical medicine and rehabilitation; and rheumatology.
The greatest cost-effectiveness of chiropractic is demonstrated when one considers the global cost of allopathic care. The physical therapist can only receive referrals from an allopathic provider. An allopath can only write prescriptions. The allopathic provider primarily orders surgeries, nerve conduction tests MRIs, and CT scans. Hospitalization charges are totally allopathic charges that cannot be associated with chiropractic. When these charges are considered, the tremendous economy of chiropractic management becomes indelibly clear.
The majority of chiropractic charges were associated with the basic office-treatment-related services performed. Eighty-nine percent of the chiropractic charges were for services related to the treatment, while only 45 percent of the family practice costs were related to treatment of the condition. The remainder of the costs were for expensive diagnostics.
Patients who visit the family practice provider have about a 15 percent chance that they will have a MRI or CAT scan. These services cost an average of over $1,000 and provide no treatment, only a diagnosis.
For each 100 episodes, the chiropractor provided 265 modalities. For each 100 episodes, the registered physical therapist provided 885 modalities: over three times as many units of physical therapy provided by RPTs than chiropractors. This is a cost that has to be globally charged to the family practice providers, since patients cannot access RPTs without a referral from a medical doctor.
Registered physical therapists provided 303 office visits per 100 episodes, compared to 255 by the chiropractor. When RPTs are combined with the other allopathic portals, there are 598 office visits per 100 episodes. Therefore, the myth claiming chiropractors treat the patient more than the allopathic portals is obviously just diversionary, and not based on facts.
Patients had a willingness to return to the chiropractor that was 22 percent greater than the combined totals of allopathic portals. This indicates a level of satisfaction that is demonstrated by the patient�s willingness to return, based on results and confidence.
The BCBS lumbago study demonstrates that chiropractic is not only cost-effective but also quality effective. Adding chiropractic services would only decrease the cost to the plan. What is hard to explain is the prejudice against chiropractic in the design of BCBS plans, and their reluctance to push the study and analysis of the data to the next level. It almost seems as though there is a fear that exists in the minds of those in positions of power, preventing them from presenting the cost comparisons with the global cost of allopathic portals to chiropractic. Chiropractors have claimed for years that we can be more cost-effective. BCBS has the database that would prove our thesis, but there seems to be a reluctance to allow our profession to access the data that would prove us right.
I guess the million-dollar questions are �Why?� and �What are they afraid of?� Perhaps it is the fear of knowing how to handle the data once it proved that chiropractic was more cost-effective. Perhaps it is getting past the mindset that adding chiropractic benefits is going to increase reimbursement levels. Perhaps they cannot see that there would not be a cost increase but a cost savings from directing patients to more cost-effective portals. Allowing osteopaths to treat broken arms did not increase the number of fractures; it simply shifted the point of access to treatment. Likewise, allowing patients to freely access chiropractic services would not increase the number of spinal related injuries; it would simply allow the patient access to desired and more cost-effective services.
I imagine that BCBS of Kansas regrets releasing the amount of information they already have. There seems to be a reluctance to push the analysis of the data to the next level. It is now up to the profession to �hold their feet to the fire� and push for more data to support the fact that chiropractic can be more cost-effective.
“Lumbago Study”�reveals 38 percent of patients chose to seek chiropractic care rather that allopathic medicine. This fact shows�that patients desire and are satisfied with management techniques of chiropractic care.
Chiropractic Care & The Department of Veterans Affairs
The Foundation for Chiropractic Progress (F4CP) notes that for more than 10 years, the U.S. Department of Veterans Affairs (VA) has included chiropractic services as part of the standard medical benefits package offered to all enrolled veterans. According to a new study conducted by researchers from the VA Connecticut Healthcare System, published in the Journal of Manipulative and Physiological Therapeutics, the use of chiropractic services and the chiropractic workforce in VA has grown substantially since their introduction over a decade ago. The annual number of chiropractic visits has increased by nearly 700 percent, thus demonstrating more veterans have access to chiropractic care than ever before.
�Our work shows that VA has steadily and substantially increased its use of chiropractic services each year following their implementation in late 2004,� states lead author of the study Anthony J. Lisi, DC, Director of the VA Chiropractic Program, and Chiropractic Section Chief at the VA Connecticut Healthcare System. He adds, �VA chiropractic care includes evidence-based, patient-centered treatment options that are in demand by veterans and referring providers. VA continues its efforts to ensure appropriate access to chiropractic care across the whole system, but as this paper shows, the progress to date has been remarkable.�
Military Healthcare/Chiropractic
Among the multitude of findings during an 11 year period, the study showed that:
? The annual number of patients seen in VA chiropractic clinics increased by 821 percent.
? The annual number of chiropractic visits grew by 693 percent.
? The total number of VA chiropractic clinics climbed 9 percent annually, and the number of chiropractor employees increased by 21 percent annually.
? The average VA chiropractic patient is male, between the ages of 45 and 64, is seen for low back and/or neck conditions, and receives examination, chiropractic spinal manipulation and other health care services.
Co-Author Cynthia A. Brandt, MD, MPH, Health Services Researcher at the VA Connecticut Healthcare System and Professor at Yale University School of Medicine states, �Chiropractic care is an important component in the treatment of veterans with spinal pain conditions. The trends we identified provide a foundation for further research to examine the optimal models of care delivery for patients.�
The study notes: �Our results indicate that VA chiropractic clinics saw a greater percentage of female and younger patients compared with the national VA outpatient population. This demographic tendency is consistent with the cohort of veterans from the recent conflicts in Iraq and Afghanistan, which is known to have a high prevalence of musculoskeletal conditions.�
An Army report recommended the use of alternatives to pain drugs, including chiropractic care, massage and acupuncture. Here, Dr. Frank Lawler gives Spc. David Ash chiropractic treatment, January 7, 2011, in Tacoma, Washington. (Mark Harrison/Seattle Times/MCT)
Veterans With Back Pain
�The growing utilization of chiropractic services among veterans for pain management and other health concerns, particularly those in the Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn and older adult populations, showcases the clear-cut demand for chiropractic care and is a direct reflection of the improved clinical outcomes and high patient satisfaction scores that have been documented previously,� says Sherry McAllister, DC, executive vice president, F4CP. �We commend VA for its participation in ongoing chiropractic research to help further improve the health and well-being of our respected and valued veterans.�
The authors also state that the growth in VA chiropractic use has occurred without additional laws mandating expansion. This suggests an increasing recognition of the value of chiropractic care in VA. In a recent editorial, VA Under Secretary for Health, David J. Shulkin, MD, cited VA�s chiropractic program as one example of the important health care expertise provided to veterans.
Doctors of chiropractic (DCs) � who receive a minimum of seven years of higher level education � provide non-operative management of conditions such as headaches, back pain, neck pain, or pain in joints, via a comprehensive approach including manual techniques and active rehabilitation. Chiropractic services are integrated with primary care, specialty clinics and rehabilitation, and provide a non-pharmacologic option for pain management, as well as general health and wellness concerns.
About Foundation for Chiropractic Progress:
A not-for-profit organization, the Foundation for Chiropractic Progress (F4CP) informs and educates the general public about the value of chiropractic care. Visit www.f4cp.com or call 866-901-F4CP (3427). Social media: Facebook, Twitter, LinkedIn, Pinterest, YouTube.
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Substantial Growth in the Use of Chiropractic Care by the Department of Veterans Affairs. The Foundation for Chiropractic Progress (F4CP) notes that for more than 10 years, the U.S. Department of Veterans Affairs (VA) has included chiropractic services as part of the standard medical benefits package offered to all enrolled veterans.
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.
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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 .
When an individual has experienced an injury or they�ve developed a condition as a result of trauma from an accident, or due to the natural process of degeneration over time, deciding on the best healthcare provider to receive treatment from is an essential choice. If you�ve been harmed, it�s in your best interest to find the most effective form of treatment according to your special needs and choosing the right doctor can greatly affect your overall improvement.
By educating yourself with the proper information regarding the various types of care that different healthcare specialists can provide as well as asking providers the most convenient questions about their treatment methods can help individuals make informed decisions when choosing the best healthcare professional. Not all medical services are right for everyone. In addition, the individual�s health plan may or may not provide coverage for all forms of care. It�s important to understand your financial responsibilities before using any medical services.
Chiropractic care is one of the most popular, alternative treatment options utilized to treat common symptoms, such as neck and back pain. Doctors of chiropractic, abbreviated as DCs, focus on the diagnosis, treatment and prevention of disorders associated with the musculoskeletal and the nervous system. Primarily specializing in the structure and function of the spine, as well as other tissues surrounding the spinal bones, a chiropractor can restore the original health and wellness of the body naturally, without the use of medications and/or surgery. Chiropractic treatment consists of spinal adjustments and manual manipulations to cure injuries or conditions which may have altered the alignment of the spine.
Dr. Alex Jimenez D.C.,C.C.S.T’s insight:
There are many chiropractic offices in the United States and every one of them can provide the essential treatment and care you will need to recover from an injury or condition. However, each individual may be looking to have their specific, personal needs met depending on their type of complication and finding the right healthcare professional at that point can make a huge difference in their overall recovery experience. Gathering information before choosing the best chiropractor is essential to achieve overall health. For more information, please feel free to ask Dr. Jimenez or contact us at (915) 850-0900.
The goals of the chiropractic treatment of a thoracic disc herniation are to reduce pain and dysfunction while the body heals itself.
Since most disc extrusions naturally regress in a few months, chiropractors will attempt to reduce the pain and pressure caused by the disc herniation. Chiropractic treatment of a thoracic disc herniation may include one or a combination of the following:
Some chiropractors will recommend nutritional support, such as proteolytic enzymes, to reduce the pain and swelling associated with a disc herniation.
Contents
More Chiropractic Treatments for Upper Back Problems
In addition to joint dysfunction, myofascial pain syndrome, and thoracic herniated disc, which have already been reviewed in this article, chiropractic care may be a treatment option for additional upper back problems, such as thoracic joint dysfunction, thoracic outlet syndrome, and shoulder dysfunction related to the upper spine.
Will your back pain become chronic?
Joint dysfunction
The thoracic spine is a marvel of joint interaction and complex motion patterns. Composed of a total of 220 separate joints,1 it makes up the lion�s share of the 313 total joints in the entire spine. With this many interactive articulations it is easy to see that maintaining normal joint function, motion, and position is important. Chiropractors treat thoracic joint dysfunction with chiropractic adjustments.
There are a variety of chiropractic-adjustment techniques that can be used to adjust a dysfunctional joint:
Most chiropractors employ manual adjusting techniques that utilize precise thrusting adjustments to help normalize joint function.
Chiropractors can also use softer directional adjusting techniques or adjusting instruments to accommodate the needs of the patient.
Thoracic outlet syndrome
Thoracic outlet syndrome (TOS) is a disorder in which the nerves of the brachial plexus and blood vessels are compressed. This compression can cause great pain and altered sensations such as a �pins and needles� sensation in the hands.
Treatment of thoracic outlet syndrome can include stretching, manual trigger-point therapy, and myofascial anchor-and-stretch release techniques to the affected muscles. Chiropractors may also include adjustments and postural instruction.
Thoracic/shoulder dysfunction
The function of the shoulder and the upper back are interrelated. Studies have shown that thrusting manipulations applied to the thoracic spine and ribs have reduced shoulder pain and dysfunction. Chiropractic adjustments to the thoracic region can be beneficial to certain types of shoulder dysfunction.
There are many causes and treatment options for thoracic spine disorders. Chiropractors have a wide range of treatment options for treating these conditions. Chiropractors are increasingly joining collaborative spinal care teams as a drug-free option for treating spinal and musculoskeletal conditions.
The thoracic spine is a marvel of joint interaction and complex motion patterns. Composed of a total of 220 separate joints, it makes up the lion�s share of the 313 total joints in the entire spine. �It’s easy to see that maintaining normal joint function, motion, and position is important. Chiropractors treat thoracic joint dysfunction with chiropractic adjustments.
When an individual has experienced an injury or developed a condition as a result of trauma from an accident or due to the natural process of degeneration over time, deciding on the best healthcare provider to receive treatment from is an essential choice. If you’ve been harmed, it’s in your best interest to find the most effective form of treatment according to your special needs, and choosing the right doctor can greatly affect your overall improvement.
Not all medical services are right for everyone. In addition, the individual’s health plan may or may not provide coverage for all forms of care. It’s important to understand your financial responsibilities before using any medical services. Educating yourself with the proper information regarding the various types of care that different healthcare specialists can provide and asking providers the most convenient questions about their treatment methods can help individuals make informed decisions when choosing the best healthcare professional.
Contents
Choosing the Best Chiropractor
Chiropractic care is one of the most popular alternative treatments utilized to treat common symptoms, such as neck and back pain. Doctors of chiropractic, abbreviated as DCs, focus on diagnosing, treating, and preventing disorders associated with the musculoskeletal and the nervous system. Primarily specializing in the structure and function of the spine and other tissues surrounding the spinal bones, a chiropractor can restore the original health and wellness of the body naturally, without the use of medications and/or surgery. Chiropractic treatment consists of spinal adjustments and manual manipulations to cure injuries or conditions that may have altered the spine’s alignment.
Choosing a chiropractor is a personal choice. There are many chiropractic offices in the United States, and every one of them can provide the essential treatment and care you will need to recover from an injury or condition. However, each individual may be looking to have their specific; personal needs met depending on their type of complication. To start, you may want to ask for recommendations from several friends or loved ones who’ve received treatment from a chiropractor before. Finding the right healthcare professional at that point can make a huge difference in their overall recovery experience.
Also, you can ask your primary healthcare physician for the names of chiropractors that offer high-quality chiropractic treatment services. Furthermore, asking questions can help people make an informed choice. You may want to meet with more than one chiropractor before choosing the right chiropractor for you.
Before asking the important questions, it’s fundamental to know whether the chiropractor you are visiting is licensed to practice in your state of residence. Then, make sure to find out if the doctor of chiropractic, or DC, has any area of specialty and inform yourself on what that is. Several chiropractors, for instance, specialize in automobile accident injuries, while others may specialize in sports injuries. Likewise, you can ask the chiropractor how many years of experience they have working in their specific field. More years of experience can often make a difference in their whole treatment performance.
Important Points to Consider
Chiropractic care is a conservative form of treatment, meaning it does not involve the prescription of drugs, nor are surgeries performed to cure patients either. Chiropractic treatment commonly utilizes spinal adjustments, manipulative procedures, and other therapeutic methods to restore the original structure and function of the spine and its surrounding tissues.
On your first visit to a chiropractor’s office, the doctor will begin by performing a full evaluation to determine the source of the individual’s symptoms. The healthcare specialist may also look at your medical history to identify whether past issues could be causing the current complications. The use of X-rays is not necessarily required to begin treatment. However, the chiropractor may either provide one or refer you to another facility to have one taken for you to rule out the possibility of a more serious injury or condition, such as a fracture, dislocation, or another form of bone disease.
Chiropractic is frequently utilized to correct spinal misalignments, or subluxations, which could be affecting the health of the spine. This treatment is also utilized to decrease pain and discomfort; reduce nerve irritation and inflammation; increase blood flow; diminish muscle spasms; and improve strength, flexibility, and mobility. Chiropractors may also recommend a series of stretches or exercises and lifestyle changes to promote a faster recovery.
After the health assessment, a chiropractor will outline an appropriate course of treatment for the individual and establish certain recovery goals for their health issue. The chiropractor should discuss with you the full details of treatment and how long it should take for the treatment to work for you. Your chiropractor will change your treatment plan as needed to help you heal as soon as possible. Whichever treatment the chiropractor suggests, they should also inform you about the benefits and risks.
If your injury or condition requires additional treatment, the chiropractor should be able to refer you to other health care professionals.
Other Points to Consider
Finally, when choosing the best chiropractor, you should expect the chiropractor’s office staff to treat their patients with courtesy. Both the doctor and the staff alike should be prompt and professional, and they should be able to answer your questions and doubts. Be sure to pay special attention to how the office staff treats you. Be sure to pay attention to how the office staff treats you. After asking yourself the questions listed above and meeting the chiropractor and office staff, think about your answers before choosing the right chiropractor for you. Once you feel comfortable with all the information you have gathered about the doctor of chiropractic, it’ll be easier to make an educated choice for treatment.
As you can see, there are plenty of things to think about when choosing a chiropractor. Because you deserve the best care possible, it’s ultimately essential to do the most research you can do before making a choice. In addition, be sure to talk to different doctors. Most of all, take the time you need to make a choice you feel good about; after all, it’s your overall health and wellness you have to worry about to regain your original well-being.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900.
Chiropractic is the third largest healing profession in the country. Doctors of Chiropractic (DCs) are well-trained health care professionals. They are experts in the diagnosis, treatment, and prevention of disorders of the musculoskeletal system. This system includes your muscles and bones. Above all, these doctors are experts in the structure and function of the spine (backbone).
Selecting a chiropractic doctor is a personal choice. You may want to ask a few friends or loved ones if they know a chiropractor they like. You may also want to ask your family doctor or other health care providers for names of chiropractors or centers that offer high quality chiropractic services.
Asking questions can help you make an informed choice. You may want to meet with more than one chiropractor before you make your choice.
Questions You Can Ask
What training, licensure, and experience do you have?
Before you ask any questions, make sure that the chiropractor is licensed to practice in your state. Then find out if the DC chiropractor has an area of specialty and what that is. Also ask the chiropractor how many years of experience he or she has.
What is treatment like for people with a health problem like my own? How often would I come in for treatment? How long should I expect treatment to last?
Chiropractors will outline a course of treatment and goals for your health problem. The chiropractor will talk to you about how long it should take for treatment to work for you. Your chiropractor will change your treatment as needed to help you reach your treatment goals.
What treatment would you suggest for my health problem or health goals?
Chiropractors do not prescribe drugs. They do not perform surgery either. Most chiropractors will suggest an adjustment/manipulative treatment. This treatment is used to:
Bring back normal joint function
Decrease pain and nerve irritation
Increase blood flow
Reduce muscle spasms
Improve range of motion
Chiropractors may also use other treatments, such as:
Exercise therapy
Massage and other soft tissue methods
Ultrasound
Electrical muscle stimulation
Appliances (such as lower back supports)
Whichever treatment the chiropractor suggests, he or she should also tell you about the benefits and risks.
What if I need treatment beyond your scope of care? Will you refer me to one of your contacts if needed?
You may need to get non-chiropractic treatment for your health problem. In this case, you will want your doctor to be able to refer you to other health care professionals.
Chiropractic Cuts Costs
Will I need to have an X-ray taken?
An X-ray is not always needed to start treatment. After going through your health history and an exam, the doctor may take an X-ray to confirm or rule out a larger health problem. An X-ray can check for conditions, such as:
Bone disease
Fracture
Dislocation
Will you suggest exercises or other steps I can take to help my health problem?
It�s key that you take an active part in your treatment and healing process. You should expect your chiropractor to give you guidelines and training. This training may include an overview of proper exercises needed to take care of your health problem. Your chiropractor may suggest that you use other home-based treatments as well. This might include putting ice or heat on a certain part of your body.
Other Points to Consider
You should expect the chiropractor�s office staff to treat you with courtesy. When you call, are they prompt and professional? Do they answer all your questions? Do they help schedule future appointments? Be sure to pay attention to how the office staff treats you. Will you be comfortable working with the chiropractor and their staff?
After asking the questions listed above and meeting the chiropractor and office staff, think about the answers you were given. Does the chiropractor�s personality and approach seem like they will work for you? If so, you should feel comfortable that you have made an informed choice.
Your Checklist
Look for a Doctor of Chiropractic that:
Is licensed in your state
Treats you with respect and professionalism
Listens to your health concerns
Answers your questions in a way that you can understand
Makes every effort to help you improve your health
Gives you advice about exercise, body mechanics, stretching, and posture to help avoid future problems
Takes X-rays only when needed and explains why they are being taken
Refers you to specialists or back to your primary doctor as needed
As you can see, there are plenty of things to think about when choosing a chiropractor. You deserve the best care possible. So do some research. And be sure to talk to different doctors. Most of all, take the time you need to make a choice you feel good about.
[prisna-wp-translate-show-hide behavior=”hide”][/prisna-wp-translate-show-hide]By Dr. Alex Jimenez
Chiropractic is the third largest healing profession in the country. Selecting a chiropractor can be a bit daunting, and discouraging. But there’s no need�to be scared. Here are some tips on choosing a chiropractor for you.
Sciatica is a frequent diagnosis among the general population of individuals who report low back pain as well as pain and discomfort along their buttocks, thighs, and legs. While these set of symptoms are the most prevalent cause for painful symptoms in the thighs of athletes and others alike, thigh pain can also be attributed to other factors and causes. As a matter of fact, injury or complications affecting the tensor fascia latae muscle found within the thigh has been known to cause issues among the population.
The tensor fascia latae, or TFL, is a well-known hip muscle among healthcare professionals and rehabilitation specialists. Because of its function, this muscle may be responsible for pain and dysfunction in the lower extremities, pelvis and spine. Research studies conclude however, that this muscle is poorly understood and needs further examination. Furthermore, the majority of research which has been already conducted have in fact simplified the accurate anatomy of, not only the TFL, but also its anatomical relationship to the iliotibial band, or ITB.
The TFL, or tensor fascia latae, is a complex muscle which is intricately arrangement anatomically with the ITB, or iliotibial band, and it performs various essential functions, such as allowing hip mobility as well as transmitting fascial tension through the fascia latae located in the thigh and the iliotibial band. The TFL also provides postural support during one-legged stance and limits the tensile stress on the femur caused by the combination of bodyweight, ground reaction force and how these create individual bending forces against the femur.
Dr. Alex Jimenez D.C.,C.C.S.T’s insight:
The symptoms of sciatica can manifest as a result of a variety of injuries and/or conditions, commonly described as low back pain that extends down the buttocks and thighs. Although sciatica can be a common symptom, thigh pain may be the result of another complication. The tensor fasciae latae muscle may become injured, causing thigh pain similar to sciatica. For more information, please feel free to ask Dr. Jimenez or contact us at (915) 850-0900.
Chiropractors who provide care for children � and families � can attest to the many benefits of a healthy spine to a growing child. However, this relatively new area of focus for chiropractic is susceptible to many misconceptions, among the public and the health-care community. Many of the public perceptions about chiropractic care for children, however, are far from the truth. We explore these misconceptions and spoke to the experts to get the real facts about this thriving chiropractic focus area.
�Myth #1 Chiropractic care of children is new.
When some individuals first learn that DCs treat children as well as adults, they may get the wrong idea that chiropractic for kids is new � which is to say untested, experimental and dangerous.
That isn�t the case. Sure, the modern era of this field dates only as far back as the 1980s. But the fact is, the practice actually has much older and stronger roots. �If you go back to 1910, [founder of chiropractic] D.D. Palmer indicated how important it is to check a child�s spine from birth and throughout life,� notes Jeanne Ohm, CEO of the International Chiropractic Pediatrics Association (ICPA), a non-profit organization in Philadelphia.
By the 1980s, many DCs had developed their practices to treat adults specifically. In 1986, Dr. Larry Webster in the U.S. helped re-establish chiropractic care for children as a legitimate area of focus. He started teaching his child-friendly techniques, and he created the ICPA to further help chiropractors treat children.
Webster passed away in 1997, but his legacy continues. The ICPA now has more than 4,000 members and hundreds of DCs are studying to become chiropractors with a special focus on kids.
Myth #2 Children don�t need chiropractic care.
DCs who treat kids often hear questions along these lines: Why in the world would a child need to see a chiropractor? What good does chiropractic do for a toddler, or even a newborn?
Chiropractors have a few good answers.
�We may see a one-week-old child who is already showing signs of favoring, turning her head to one side versus the other,� says Dr. Judy Forrester, owner of Synergea Family Health Centre, a multidisciplinary clinic in Calgary, Alta. �That may seem minimal� but if we can determine any imbalances or asymmetry with the muscular function or the joint alignment, and we address it early, it�s better. Once those postural patterns and habits develop as they grow, they can be much more difficult to change.�
Dr. Liz Anderson-Peacock is a Barrie, Ont., chiropractor who focuses on care for children. She notes the link between the central nervous systems and various childhood afflictions.
�Children may have symptoms like ear infections, difficulty breathing, colic, attention deficit. We do not treat those things per se. We see those as expressions of the body not interpreting the world properly,� explains Anderson-Peacock, who also serves in the editorial board for the Journal of Maternal, Pediatric and Family Health.
�The organizing system for us to respond to the world is the nervous system. The questions we ask are: if there is something going on with the nervous system, what is it, and can chiropractic care help?�
Anderson-Peacock now spends most of her time travelling around the world doing lectures and other speaking engagements. She also conducts seminars for the ICPA about chiropractic care for children and families.
Ohm from the ICPA links chiropractic to the very moment a child emerges from the womb. �Birth can be traumatic,� she says. The event could cause physical damage that leads to difficulties later. So if a baby develops breathing trouble, �the real cause may simply be a misalignment to the spine from the birth process. Parents who get that will stop at the clinic on the way home from the birth centre to make sure everything is OK.�
Myth #3 Chiropractors use the same techniques on children as adults.
�That�s what terrifies a lot of chiropractors about adjusting children, as well as parents,� Anderson-Peacock says. �They think we�re going to adjust them like an adult.�
But DCs who treat children do not apply heavy pressure. �Often, it�s a matter of moving the child into a position of ease, holding that position and things will reset quite nicely on their own,� Anderson-Peacock says. Care, she points out, is nowhere near as forceful as it may be for adults.
�That�s why extra training is so crucial. These children are not like miniature adults. For example, spines are primarily cartilaginous until the age of six, and we know cartilage will deform when we have abnormal function. So we want to make sure that function is restored normally. And since the bones are immature, the alignment issues are different. We want to minimize rotations and traction, because children have different needs, due to the immaturity of their musculoskeletal and ligamentous structures.�
The ICPA aims to validate techniques for chiropractic care for children, particularly to help dispel the idea that DCs use the same pressure on kids as they do on adults, Ohm notes. The organization is working with Walter Herzog, co-director of the Human Performance Laboratory at the University of Calgary, to study the pressure required when caring for children. The report should be out by the end of 2015.
Myth #4 There are no real experts in chiropractic care for children.
In Canada, chiropractic care for children is not a recognized area of specialty, which leads some people to think there are no genuine experts in the field. But that isn�t true.
Many DCs follow accredited courses to develop child-specific skills. Anderson-Peacock spent three years studying at the International Chiropractors Association�s Council on Chiropractic Education (CCE)-accredited program in pediatric chiropractic. She achieved her Diplomate in Clinical Chiropractic Pediatrics (DICCP) in 1996.
Dr. Stacey Hornick is owner of Market Mall Family Chiropractic in Saskatoon, Sask. She attended McTimoney College of Chiropractic, operated by BPP University � a post-secondary institution in London, England. Over three years, she took courses by correspondence and traveled to Thailand, Hong Kong and Australia to complete the residency portion of the program. Having succeeded in her studies last year, she was granted a master�s degree in Chiropractic Paediatrics.
Hundreds of DCs have taken the ICPA�s programs. The ICPA Diplomate Program involves a total of 400 hours of learning and achieved through the successful completion of two levels of study.
The first part � a 200-hour certification program � involves 14 classroom modules, participation in two ICPA Practice Based Research Network projects, and successful completion of the comprehensive certification� final exam.
The second part is a 200-hour advanced competency program. It requires 200 hours of work with more emphasis on research, including either a published research case study or a publishable thesis, as well as clinic work. Enrollment in the first level (200-hour certification program) is a prerequisite to enroll in part two.
Chiropractic care for kids may not be a recognized specialty in Canada, but chiropractic associations recognize it as a legitimate area of focus.
In a statement, the Alberta College and Association of Chiropractors (ACAC) has acknowledged, �chiropractic treatment is as beneficial to children as it is to adults and that the efficacy and benefits of the delivery of chiropractic care to individuals 18 years of age and under are well supported by a body of ongoing research and documented case histories.�
Myth #5 Chiropractors don�t collaborate with pediatricians and medical doctors.
Hornick says this simply isn�t the case.
�I often refer pediatric patients to their medical doctors and to medical specialists, and we communicate clearly in the best interests of the child. I see our roles as complementary.�
Forrester also says she has good ties with medical doctors. �The majority of them are very much in favor of working together. Every once in a while you run into someone who thinks we�re all a bunch of quacks and they�re not up to date with the sorts of things we do. But by far the relationship with pediatricians is healthy and puts the patients� best interests first.�
Reality recap Chiropractic care for kids is not new. Children benefit from chiropractic care. Techniques for children are safe and nowhere near as forceful as they may be for adults. Many DCs are qualified experts, and many child-focused chiropractors establish strong connections with medical doctors. The truth is, DCs can and do share the benefits of their profession with patients across the entire age spectrum.
Mastering pediatrics Late last year, Dr. Stacey Hornick, a Saskatoon, Sask.-based DC focused on chiropractic care for children became one of the first Canadians to attain a Master�s of Science in Chiropractic Paediatrics.She studied at McTimoney College of Chiropractic, operated by BPP University, a post-secondary institution in London, England. The McTimoney program is the only pediatric chiropractic program that meets the academic requirements for entry into doctoral studies (PhD) in the specific content area of chiropractic pediatrics, an opportunity never before afforded the chiropractic profession, she says. �For me, it was important to seek out a highly respected qualification in pediatric care,� Hornick says. �There were no university-accredited courses in pediatrics in North America that I was aware of at the time. I liked the idea of studying abroad and at the same time becoming an expert in pediatric-specific assessment, and adjusting techniques that were gentle yet neurologically precise.�
It takes stamina and smarts to get into and complete this tough three-year course. Read on for the requirements. Do you have what it takes?
To enter the program, a candidate must have: a professional qualification in chiropractic and registration with a relevant chiropractic governing body
In each of the first two years of the program, the student must complete:
Work at two residential schools � Hornick explains that usually, students complete their residencies at U.K. chiropractic facilities, but McTimoney also gives students the chance to practice outside of the U.K. For her part, Hornick completed her first-year residency in Thailand, which was memorable. �We stayed at the Children of the Golden Triangle Training Center. It�s a safe haven when kids can go to school and avoid the whole child-trafficking danger, which is a heart-wrenching reality in that part of the world. Many of the children at the facility were orphans � 450 of them. We got to stay with them, and between five chiropractors, we adjusted all of them in three days.� Online course work � Subjects range from the fundamentals of chiropractic pediatrics to specific requisite topics. Hornick says first-year courses include substrates of chiropractic pediatrics, physical assessment in chiropractic skills and pediatric neurology. �The second year is more application of knowledge.� Courses include normal and variant radiology anatomy in pediatrics, clinical research methodology, and four clinical pediatrics programs. Structured clinical education, directed and self-directed Objective structured clinical exam In the third year of the program, students must complete a research project, including project design, implementation and report at a publishable standard. Hornick�s dissertation: The Effect of Chiropractic on Cortisol Levels in Infants with Colic. The investigation aimed to help doctors understand why chiropractic adjustment has a positive influence on colicky infants. Hornick found that infants with colic who receive chiropractic care demonstrate salivary cortisol release patterns similar to those seen in infants with no colic.
Dr. Alex Jimenez D.C.,C.C.S.T’s insight:
Public�Perceptions about chiropractic care for children are far from the truth. Let’s�explore these misconceptions and speak to experts in order to get the real facts about chiropractic care for children.
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