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Putting POLITE Into Practice
First came the acronym RICE (Rest, Ice, Compression, Elevation), which eventually became PRICE (Protect, Rest, Ice, Compression, Elevation). Then in 2015, we started hearing POLICE (Protect, Optimal Loading, Ice, Compression, Elevation).
Dealing with a Pain in the Butt
The patient came into my office with the classic antalgic stoop. She was bent over almost to ninety degrees, leaning on her husband for support and staggering to walk. She had been under supportive care for a long time, but this new pain scared her.
CE Regulations Are Hurting Chiropractic
During my 35 years in the chiropractic profession, I have been forced to attend available continuing-education programs that were occasionally incredibly beneficial, but frequently not worth my time.
HVLA Technique: Addressing Myths
In the annals of chiropractic history and literature, and in the imagination of the public, there is one manual adjusting technique that can produce a wide range of responses, both from patients and casual observers.
Physical Examination in an Evidence-Based World
I have always had a fascination with physical examination procedures, particularly orthopedic tests. The origin of my fascination began just after graduation when I began the chiropractic orthopedics program.
Concerns Regarding CDC Guidelines for Pain Management
In response to the epidemic rates of opioid and heroin addiction, the Centers for Disease Control and Prevention (CDC) set new guidelines for physicians regarding treatment for pain.
Comparing Costs of Care: DCs, MDs or PTs - Who Costs More?
In a health care era where evidence is increasingly the benchmark for insurance coverage, patient care and even cultural authority, we get plenty of it courtesy of a retrospective cost analysis spanning 10 years, more than 660,000 "covered lives" and nearly 7.5 million claims from Blue Cross Blue Shield of North Carolina.
Sacroiliac Joint Fusion: Where's the Wisdom?
We should be very skeptical of the purportedly less invasive version of the already defrocked sacroiliac fusion surgery, "minimally invasive" sacroiliac joint fusion; and concerned this procedure simply represents the device manufacturer's attempt to find yet another new market.
The Drug Epidemic: Are You Guilty, Too?
Attention-deficit / hyperactivity disorder (ADHD) has become epidemic among children in the United States. According to the Centers for Disease Control and Prevention (CDC), the percentage of school-aged children diagnosed with ADHD has grown from 7.8 percent in 2003 to 11.0 percent in 2011.
Letter to the Editor
On December 7, 1999, the U.S. FDA reclassified the status of acupuncture needles from class III (investigative devices subject to investigative device exemptions...) to class II (special controls).
We Get Letters & Email
Our Medicare Challenges Aren't an Education Issue; Passion to Succeed: More Pivotal Than GPA?
Case Study: 2-Year-Old Suffering From Urinary Reflux
A19-month-old female child presented to my office for treatment. Her mother reported the child had been diagnosed with urinary reflux and associated urinary tract infections, recurrent bouts of otitis media and inability to sleep.
Patience vs. Patients
How long have you been in practice? I began my journey more than 20 years ago and opened my first acupuncture clinic in 2008. Just like you, I've learned a lot over the years. Recently, I sat in an interview and was asked what made me successful.
Acupuncture Earns BLS Unique Code
The United States Bureau of Labor Statistics recently announced that acupuncturists will have their own unique occupational code in the 2018 BLS Handbook. The new Standard Occupational Code (SOC) is 29-1291, will be included in the next edition of the BLS Occupational Handbook, which will be published in 2018.
Infertility: Managing Irregular Menses
Infertility is an area where Chinese medicine is particularly helpful. In the main, in women below the age of 38 without organic disturbance, the success rate using TCM (Traditional Chinese Medicine) should exceed 85%.
Acupuncture's Essential Role
Acupuncture should play a more prominent role in U.S. healthcare during and after this post-Affordable Care Act era when chronic care and population health management are key concerns for all healthcare providers.
Six Things Every Chiropractor Should Know About Opioids
An increase in addictions and deaths due to opioids has raised significant concern and media attention. We offer this brief overview on this important public health problem for the practicing chiropractor.
The Lung Official
The Lung is known as the "Official Who Receives the Pure Chi From the Heavens." The act of breathing in, known as inspiration, brings oxygen into the body from the atmosphere. Each exhalation or expiration removes and releases carbon dioxide, a waste product of the body, into the atmosphere.
University of Bridgeport Acupuncture Students Make Rounds at Sisters of Notre Dame
Nuns are not stereotypical acupuncture patients, Dr. Jennifer Brett acknowledges with a laugh. But then again, acupuncture has gone mainstream, just like cappuccinos and recycling. "It's changed a lot from the '70s and '80s," said Brett.
Forward Head Carriage and the Feet: What's the Connection? (Pt. 2)
Clinical evaluation of standing posture using relatively low-tech tools has been confirmed as valid and reliable by several studies. The original device used to evaluate posture was the plumb line, which served as a reference line for the effects of gravity on body alignment.
NBCE Fumbles Computerized Testing Process
Imagine being a student again, about to take one of the four tests required to become a doctor of chiropractic. You've studied almost nonstop for the past few weeks. You can feel your anxiety level rise as you sit down in front of the computer screen.
Why We Need to Fix the Mechanoreceptors (Part 2)
The muscle spindle, a particular type of mechanoreceptor, is located deep within the muscle belly, encapsulated in fascia made up of intrafusal fibers, all within the extrafusal muscle fibers.
The Most Important Vitamin You've Never Heard Of: K2
Imagine if one in every three patients who walked through your door was afflicted with a debilitating, yet completely preventable and treatable disease.
September, 2012, Vol. 12, Issue 09
Locomotive Power and Femoroacetabular Impingement
By Debbie Roberts, LMT
To think about locomotive power you first need to think about the chain of muscles, tendons, ligaments and joint structures that allow us to walk, run, jump, climb and play. This action of moving forward from the foot all the way to the trunk is what defines kinetic chain energy or locomotive power.
Static and Functional Assessments
As a therapist, it's crucial to take static AND function postural assessments with new clients. The standard static assessment will show you if some part of the body is forward or rotated, indicating weakness or tightness. But it won't tell you where the problem is occurring.
For that, you'll need to conduct a functional assessment. This allows you to see how the body responds to loads. Then you're able to better understand where the muscular weakness and dysfunction are happening.
Femoroacetabular Impingement of the Hip Joint
One place these assessments can be useful is in recognizing Femoroacetabular Impingement (FAI) of the hip joint. Remember that old song from your childhood, "The foot bone's connected to the ankle bone, the ankle bone's connected to the knee bone," and so on? This old ditty gives us an important hint about understanding FAI. The key is in order to properly assess what's going on at the hip, you have to begin all the way down at the foot. The first step is to look at the way the foot strikes the ground and the way the body absorbs the load through the femur.
When seeing a patient who is at risk for FAI, it's helpful to know the six primary signs and symptoms:
If FAI appears to be a factor for your patient you can begin by performing a static test. In a static observation, an S-posture indicates Lower Cross Syndrome. This can be the result of a misaligned ankle that affects the knee, which in turn leads to a change in the pelvic position.
Since the hip joint is located between the knee and the pelvis, it's naturally affected as well. If this occurs, you're looking at a muscular imbalance and insufficiency of the lower kinetic chain energy, which leads to a dysfunction at the ball and socket joint of the hip and possible FAI.
The FABER test is another assessment you can use to determine if FAI is a factor. If you're not familiar with the FABER test, the name tells the whole story: F-lexion, AB-duction, E-xternal R-otation of the hip. When conducting a FABER test, start with the patient supine and then flex, abduct and externally rotate the hip by placing their left foot over their right thigh or knee. Then slowly lower the knee down toward the table as you look for restrictions or signs of pain. Repeat to the other side. (FABER) (Ganz R. Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Ortop. 2003; 417:112-8.)
Causes of FAI
There are many theories as to how and why individuals develop FAI. One theory is that during development structural abnormalities of the hip, such as hip dysplasia (femur dislocation), can occur (Pollare 2011). Another cause is physical stress or trauma, like that suffered from a femoral neck fracture (Byrd & Jones 2011). Genetics is another potential factor in FAI (Leunig, Beaule' & Ganz 2009).
Whether the cause is developmental, trauma induced or genetic, in all cases one thing is consistent: FAI occurs when there is an abnormality of the femoral head and its congruency to the acetabulum. This is the culprit in early "primary" osteoarthritis of the hip, especially in young, active patients (Tannast, Siebenrock & Anderson 2007).
How Does FAI Develop?
FAI can develop over time through repeated and excessive hip flexion and internal rotation. This results in maximal contact between the anterosuperior femoral head-neck junction and the acetabular labrum, especially when there is not enough clearance to avoid friction. The repetitive movements and compressive load create a torsion effect on the internal structures inside the hip socket (Emara et al. 2011).
A patient whose FAI has progressed will develop an abnormal, asymmetrical and accommodative movement pattern. Taking a kinetic chain assessment will help you see the full dysfunctional pattern, allowing you to create a more complete treatment plan. This allows you to stop chasing the pain by helping the patient to correct the muscular imbalances that have contributed to the impingement.
To truly understand the development of this condition, let's look at the function of the hip joint and the moving parts that contribute to its healthy movement. The main job of the hip joint is to bear weight (Banerjee & Mclean 2011). The femoral ball slides against the acetabular socket and allows the body to perform movements of flexion, extension, abduction, adduction and internal and external rotation (American Medical Association 2011). The joint is supported by bones, cartilage, muscles, ligaments and tendons and has two main components: the acetabulum and the femur. The femoral head fits into and moves against the acetabular surface.
Anatomically, the iliopsoas, gluteus medius, gluteus minimus and gluteus maximus all provide anterolateral stability. So it's easy to see how an S-posture, with tight hip flexors and quadriceps and a weak extensor chain (gluteus maximus, medius, minimus and hamstrings), can alter the load. This puts excessive forces onto the hip joint and alters the patient's movement or gait pattern.
How FAI Presents
In the last year, I have seen more than half a dozen women in their 50s suffering from FAI resulting in osteoarthritis of the hip. After doing static and functional assessments, I discovered that every one of these patients had the typical muscular imbalances of Lower Cross Syndrome.
During their assessments, I noticed that all of these women began their static posture in an S-curve. After a functional assessment, including a FABER test, Thomas test, squat test and toe touch, it was clear that each one also suffered from a muscle imbalance of a hypertonic psoas muscle and tightness in the quadriceps and IT band. This was accompanied by loss of strength in the extensor chain.
All of these patients were referred to me by a their orthopedist or chiropractor and each came with a report of findings and diagnosis in her file. This allowed me to focus on helping them with their muscular imbalances by creating a treatment plan based on their doctor's recommendations and their individual needs.
A few of the women I saw were on very conservative treatment that blended modalities such as massage, cupping, muscle energy, traction of the femur, treatment in side posturing and corrective exercises. Some have undergone debridement for labral tears. Still others have received injections of the trochanteric bursa combined with physical therapy.
Unfortunately, four of these women did have to undergo hip replacement surgery, with two of them needing bilateral hip replacements to correct congenital disorders.
What We Can Do As Therapists
With the rise in hip replacement surgeries among younger women, it's time for us to take an active role in helping our patients with muscular imbalances to protect their hips from FAI. Without proper assessment, you may be only chasing the pain and symptoms of FAI and not helping with the correction of postural imbalances.
With the right assessment tools, however, you may be able to help your patient properly position the hip simply by lengthening the appropriate muscles and correcting the S-posture. By learning to take both functional and static assessments you can play a positive role in helping your patients identify and correct FAI and prevent future osteoarthritis.
Click here for more information about Debbie Roberts, LMT.
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