resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Avoiding "Just a Pop Doc" Syndrome
Yes, it's harsh. Patients don't like to admit it. They have an unspoken plan when they first visit you: to come one time, get rid of their pain and then get rid of you. They know it's unrealistic, but they'd like to pay nothing for this service.
Chinese Medicine: The Natural Way to Children's Wellness
As a child, I did not like going to the doctor. For the most part, when I had to go I wasn't feeling good to begin with, and I was heading into a sterile environment to be awkwardly probed by a man in a white coat for a very short, impersonal period of time.
Are You Ignoring the 10,000-Hour Rule?
Having trained interns and mentored new practitioners, it has been my observation that their No. 1 clinical concern is adjusting skills. Their second clinical concern is their ability to read X-rays. Physical diagnostic skills are a distant third.
Meat in the Middle
Have you ever wondered what's the truth about meat? Is it really as bad as many people think?
Micro-Needle Dermal Roller Use in the Treatment Room
Recently micro-needle dermal rollers have been getting a lot of media attention. As a practitioner who specializes in acupuncture facial rejuvenation, I know that skin needling with a dermal roller (also known as collagen induction therapy), promotes the natural reproduction of collagen and elastin, making the skin feel smoother and tighter.
DC App – The Next Generation
According to a survey by technology firm CDW, health care professionals gain approximately 1.2 hours per day in productivity simply by using a tablet computer in practice.
Make Low-Level Laser Therapy Part of Your Evidence-Based Practice
Low-level laser therapy (LLLT), also referred to as photobiomodulation, has been increasingly utilized in the clinical setting over the past decade.
Introduce Your Patients to Collagen Induction Therapy
Cutaneous (skin) aging generally occurs from either intrinsic or extrinsic processes. Intrinsic aging results from natural skin tissue damage and degeneration.
The Acupuncture Now Foundation: What Our Profession Needs
Although acupuncture is growing in popularity it continues to be underutilized due to misunderstandings about its true potential. Only a fraction of those who could be helped by acupuncture know enough to seek it out.
Implications of Section 2706: The Non-Discrimination Provision Survey
In late April 2014, NCCAOM diplomates received an email survey with the subject line: "End discrimination against acupuncturists" polling CAM practitioners for a Request for Information from the Department of Health and Human Services, released in mid-March.
Acupuncture Detox as Part of Drug Rehabilitation
In the U.S., more than 2,000 alcohol and drug rehabilitation programs have added ear acupuncture to their practice. The development of the protocol was determined by Lincoln Hospital as it delivered 100 acupuncture treatments daily.
We Get Letters & Email
Is It Time for a Popeye Moment? The Flaw in Recommending Chiropractic as a Career.
Following the Thinking of the Classics
I have heard about the "best time of day" to carry out certain examinations or therapies. For example, I remember making a note years ago that early morning is the best time to take someone's pulses.
Peer Points: Promoting TCM Knowledge
When Elaine Wolf Komarow, LAc, received her first acupuncture treatment in 1989, she said it changed her life. "I felt more aware, calmer, and happier. I was so fascinated by the changes that I began to learn everything I could about the underlying philosophy of Chinese medicine," said Komarow.
Chronic heightened emotional states create a perfect breeding ground for illness. Through my practice I noted the increasingly obvious relationship between one's mental focus on negative thinking, emotions, resistance to experiencing feelings and disease.
Inspire Your Patients to Make Healthy Choices
Have you tried to get your patients to change their eating habits or their diet and couldn't get them to succeed? Were they confused and unsure of what the right thing was to eat? You are not alone!
Treating Acute and Chronic Neck Pain With Ischemic Compression and Exercise
There are many reasons not to manipulate the neck with cavitation: the patient is too old, their neck is too tight, etc. But the most common reason is that plenty of patients are afraid of "the crack," mostly because of the bad publicity about that procedure.
Capturing the Essence of Tai Chi
Over the last 12 years, I have been working on one of the few documentaries about Tai Chi. It's called The Professor: Tai Chi's Journey West and it's about Cheng Man-Ching who moved to New York in the 1960s.
Treating Chronic Depression with Acupressure
In Traditional Chinese Medicine there already exists a comprehensive theory linking the body and mind.
The Power of Mu Xiang to Treat Irritable Bowel Disease
Bloating and gas pain is something that everyone has had to deal with at one point or another; however, that's usually reserved for holiday dinners and other large gatherings.
Five Element Acupuncture Can Enhance Your Practice
For eight years I have been teaching and supervising TCM students at an acupuncture college in Colorado, in Five Element acupuncture.
Why Drugs and Supplements Can't Cure Disease
Chronic diseases are the outcome of disease-promoting, goal-oriented behaviors. So, the notion that diseases can be cured with drugs or supplements should be abandoned. Hypertension is the best example of this.
Treating Menopausal Women in Your Practice
I love what I do for a living. It's a great way to trade health for bread. And no topic of health, with the right bedside manner, is taboo.
It Pays to be a Foodie
If there is an inner foodie in you, just waiting to burst out—this article is for you! Do you want to know how I know? I'm that girl. My middle name might as well be "Foodie." I love food! And if my patients are any indication, many of them do as well.
Step by Step: Long-Term Treatment of Soft-Tissue Injuries Combines Skill and Care
Treating soft-tissue injuries with long-lasting results starts the moment an individual enters the office. When it comes to pain, the only thing that matters to the patient is relief.
Foundation for Chiropractic Progress Announces First Group Member
The Michigan Association of Chiropractors has joined the Foundation for Chiropractic Progress as its first group member.
Solving the Pain Puzzle
Legendary former New York Yankees baseball player Yogi Berra once said, "You can observe a lot just by watching." He would have been a great chiropractor. We are trained to become experts with our hands: palpation, adjusting, soft-tissue release, etc.
Home Safety: Help Families Avoid Common Injury Hazards at Home
These days, many parents childproof their homes before a baby is even mobile. You will see an array of electrical outlet covers, bumpers on the corners of the coffee table and safety latches on the cupboards.
The Death of the Travel Card
As long as I have been in practice, the travel card has stood as the primary style of documentation for chiropractic. It is quick, simple and direct. Unfortunately, the rules have changed.
News in Brief
Life to Open Branch Campus in Italy; Northwestern Research Arm Benefits From Big Donation.
August, 2009, Vol. 9, Issue 08
Deadbeat Diagnosis: "Chasing the Pain"
By Erik Dalton, PhD
The iliotibial band (ITB) syndrome is typically regarded as an overuse injury common in runners and cyclists. Lately, this controversial condition has gained greater attention due to recent articles that include my "IT-Band Friction Fallacy?"1; Mark Charrette's "Lateral Knee Pain and Orthotic Support"2 and Whitney Lowe's "New Perspectives on ITB Friction Syndrome".3
Although many researchers and clinicians are convinced that the patho-anatomy of iliotibial band friction syndrome (ITBF) is well-known and well-understood, the jury is still out on the exact cause(s) of this lateral knee pain condition. Blindly following conventional wisdom may often point good clinicians to the wrong therapeutic path. The following example clearly demonstrates how "chasing the pain" led physicians into a linear treatment protocol resulting in months of unwarranted pain and unnecessary medical interventions.
Recently, a 44-year-old orthopedist, who for our purposes will called Dr. Smith, was referred to me complaining of eight months of debilitating, self-diagnosed, IT-band friction pain. During his history intake, he admitted suffering sporadic foot, hip and low back soreness but dismissed these issues as "unrelated." A self-described "weekend-warrior," Dr. Smith's knee pain flared with excessive running or cycling. Both he and his staff (a physical therapist and physiatrist) had carefully scrutinized the painful knee and arrived at a unanimous diagnosis of ITBF based on results from Ober's Test (determines the tightness of the ITB), Renne's test (specifies the area of pain during weight bearing) and Noble's test (identifies the area of pain when the leg is flexed at a certain angle). To further strengthen their diagnosis, MRI studies showed a thickened iliotibial band over the lateral femoral epicondyle. The summation: diagnosis confirmed as ITBF. Case closed.
Dr. Smith related that his group's initial treatment goals focused on relieving the (supposed) inflammation via ice treatments and anti-inflammatory medications followed by a series of physical therapy sessions. Sadly, the "series" of physical therapy slowly evolved into months of heartbreaking disappointment. Typical treatment modalities (stretching, ultrasound, electrical stim, cross-fiber frictioning and trigger point work) brought little relief. Discouraged with the lack of progress, Dr. Smith and his physiatrist partner began a more aggressive approach with corticosteroid and proliferation injections (Fig. 1). Although many of their ITBF patients responded favorably to this treatment protocol, Dr. Smith did not. Desperate to get back to his biking and running regime, Smith decided to undergo a surgical release of the ITB at the posterior 2 cm where it passes over the lateral epicondyle, but still no relief. So how did eight months of aggressive treatment lead to abysmal failure?
ITBF is generally thought to be a multi-factorial, non-traumatic, overuse condition in which the distal aspect of the iliotibial band rubs over the lateral femoral epicondyle during repetitive knee flexion and extension movements (Fig. 2). This ultimately leads to irritation of the iliotibial band, bursa and lateral synovial recess. In this popular theoretical model, the deep posterior ITB fibers are more vulnerable to back-and-forth rubbing on the knee's epicondyle. Several studies4,5,6 have described a dynamic "impingement zone" at approximately 30 degrees of knee flexion where the ITB is subject to microfiber tearing and associated inflammation.
Therapists who abide by this "conventional wisdom" often seek out the sore spots around the condyle and cross-fiber friction the affected tissue in an effort to break down weak-linked adhesions, enhance fibroblastic activity and encourage tissue remodeling.7 Follow-up treatments often include elbow "fascia-mashing" and manual ITB stretching routines. All of these approaches can be effective if ITB fibers truly are damaged.
Science vs. Conventional Wisdom
In a compelling paper published in the Journal of Science and Medicine in Sport (2007), a prestigious research team led by John Fairclough and seven co-authors8 challenged the idea that excessive friction between the ITB and the lateral femoral epicondyle creates microscopic tears and "inflames" the tract or a bursa. These researchers found that several basic anatomical ITB principles had been overlooked: (1) The ITB is not a discrete structure but a thickened part of the fascia lata which envelops the entire thigh; (2) It is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands which are not pathological adhesions; and (3) A bursa is rarely present but can be mistaken for the lateral recess of the knee.
According to their findings, it appears the ITB is actually prevented from rolling over the epicondyle, partly because of its femoral anchorage and partly because its fibers are bound tightly to the tough enveloping fascia lata.
Although Fairclough and his team were able to induce slight medial-lateral movement across the condyle, they proposed that ITB pain was primarily caused by increased compression of a highly vascularized and innervated layer of fat and loose connective tissue separating the ITB from the epicondyle (Fig. 3). Dr. John Fairclough concludes that "ITB syndrome is related to impaired function of hip and leg musculature and its resolution can only be achieved through proper restoration of lower quadrant muscle balance."
Myoskeletal Treatment Plan
One of the first things that caught my attention while observing Dr. Smith's gait was the presence of a cavus right foot (high rigid arch) presenting on the same side as his ITB pain. As he walked down my hallway, it was obvious the stiff supinated foot was preventing internal tibial rotation during heel strike. This seemed rather unusual since friction or compression of the ITB is generally thought to result from foot hyperpronation coupled with excessive internal tibial rotation.9
Although gait observations, anatomical landmark assessments and functional testing revealed myoskeletal imbalances through the hips and lumbar spine, I initially decided to address the cavus foot problem. (See before-and-after pics Fig. 4.) My experience has shown that a rigid cavus foot stresses all myoskeletal structures (foot to lumbar spine) leading to disorders such as peroneus tendinosis, stress fractures, trochanteric bursitis, plantar fasciitis, tibiofibular fixations, and hip/back pain, but not IT-band friction syndrome.
Some cavus feet (particularly those with claw toes) do not respond well to manual therapy. Fortunately, Dr. Smith's foot did regain flexibility as the muscles of the lateral fascial compartment were separated. Once myofascial flexibility improved, rear and forefoot joint mobilization routines helped restore glide to the rigid tarsal bones (navicular, cuboid and cuneiforms) and the talocalcaneal joint. Although this myofascial/joint mob protocol flattened some of the concavity in his arch, it quickly became apparent that most of Dr. Smith's foot rigidity was coming from a severely fixated tibiofibular (ankle) joint (Fig. 5).
I find this often neglected tib/fib joint to be the "key lesion" in many lower extremity disorders. Optimum "stirrup spring system" functioning [see my Massage Today "Don't Get Married" articles Part 1 (Feb. 2008 issue) and Part 2 (Aug. 2008 issue) www.massagetoday.com] demands that both ends of the tibia and fibula (proximal and distal), maintain smooth cephalad and caudal movements (Fig. 6). If working properly, the tib/fib articulations should perform as magnificent shock absorbers with their actions enhanced by tibialis anterior and peroneus longus and kept in sync by a resilient but tough interosseous membrane.
The "figure 8" plantar and dorsi flexion technique shown in Fig. 7 was successful in loosening fibrotic ankle ligaments and articular cartilages which improved anterior/posterior and superior/inferior glide, but the distal fibular shaft was resistant. Searching for the restriction, I moved up to the proximal fibular head and tested for A/P glide there. Bingo! Finally, the "main event" likely responsible for months of mysterious lateral knee pain Dr. Smith had been experiencing was exposed. With the knee flexed, my fingers and thumb were unable to budge the fibula in an anterior direction and any attempt to pressure it back into place replicated the intense pain Dr. Smith identified as the source of his problem (Fig. 8).
Runners like Dr. Smith share a high risk for hamstring injuries with the most commonly torn of the group the biceps femoris. When asked about past hamstring problems, Smith related that he had suffered a chronic pull a year before the knee began to flare. Therefore, with each step, the injury-shortened biceps femoris tugged on the fibular head causing chronic repetitive microtrauma at the tib/fib articulation. In time, the fibula became posteriorly fixated on the tibia causing joint play loss and lateral knee pain. By applying the simple contract/relax technique shown in Fig. 9, we were finally able to establish normal movement to the fixated tib/fib articulation thereby resolving his painful condition.
As with many conventional protocols, stepping outside the box provided that important distinction to Dr. Smith's recovery - relying more on accurate identification and restoration of the functional biomechanical deficits in the entire kinetic chain rather than focusing on a specific injured tissue. Incorporating myofascial and skeletal mobilizations to Dr. Smith's foot, ankle, proximal fibular head, hip and pelvis proved the "key" factors allowing his return to normal running and biking activities.
Click here for more information about Erik Dalton, PhD.
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