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The Concussion-Subluxation Complex
In the Aug. 1, 2014 issue of Dynamic Chiropractic, I reviewed some of the literature demonstrating the role of the chiropractic adjustment in post-concussive care.
Too Many to Remember: Tips to Revive Your Ortho / Neuro Test Skills
When I was at Palmer in the mid-1980s, we were given a set of notes in one of our diagnostic courses. The notes covered approximately 70 orthopedic and neurological tests for various regions of the body.
Targeting the Bad Apples in the Bunch
While everyone was focused on the conversion to ICD-10, the Office of Inspector General for Health and Human Services released a new report on chiropractic titled "CMS Should Use Targeted Tactics to Curb Questionable and Inappropriate Payments for Chiropractic Services."
North Carolina Acupuncture Board Files Dry Needling Lawsuit
In early September, the NCALB filed a complaint against the North Carolina Board of Physical Therapy Examiners over the issue of dry needling, a form of acupuncture that uses solid needles to puncture the skin and muscle tissue to relieve pain.
Chinese Herbs and Pulmonary Fibrosis: A Case Study
"Mary M."* recently celebrated her 90th birthday. Even the former sheriff dropped by to kiss the hand of this diminutive retired teacher, to honor the years she interpreted for him during interviews with Latinas and Latinos.
Diagnose Sprain Injuries in MVA Cases With Dynamic X-Rays (Pt. 1)
Am I the only person to notice hospitals are doing a seemingly insufficient job lately in their initial radiological workup of motor vehicle accident (MVA) victims?
Tailor-Made Knee Pain: The Sartorius Muscle
A patient was referred to my office after receiving treatment from various providers with no results. The patient was training for the Olympics as a marathon runner and was unable to run or walk without severe medial knee pain.
F4CP Making a High-Impact Impression
The Foundation for Chiropractic Progress has released details of its 2016 strategy, certain elements of which are already in play. The strategy includes ads, posters and other resources available to all F4CP members.
It's Time to Review
It is amazing to see the changes that are occurring in the acupuncture profession. Let's look at some of the news and events that have contributed to this growth and awareness.
Pro-Con: Swaddling for Newborns
The practice of swaddling has been used for thousands of years and was popular until the 1700s, when it was slowly abandoned by many cultures that considered it old-fashioned or barbaric.
Acupuncture Rising: From Acupuncture Anesthesia to Assisted-IVF, Part 2
Acupuncture's cultural and historical roots go back to the emergence of Chinese civilization. For more than 2,000 years, acupuncture needling has been continuously practiced on the largest population in the world.
Which Way is the Energy Going? Are You Burning Yourself Out?
One of the simple methods that I use to define Yin/Yang theory to patients is to ask the question, "Which way is your energy going?"
Syncretism: Acupuncture and Public Health in Cuba
"Syncretism" is defined as a union of diverse tenets or practices. On a recent trip to Cuba designed to demonstrate the integration of Traditional Medicine and biomedicine, our group witnessed this union firsthand.
Your Billing Questions Answered
I hear a lot of the following questions: I am afraid I may doing something illegal. I have heard I cannot have different fees for the same service.
Born to Energize the Human Spirit: Recollections of Sig Miller
Sig Miller, longtime executive director of the Association of New Jersey Chiropractors (ANJC), passed away on Sept. 17 after a long battle with cancer.
Acupuncture and Oriental Medicine in the West
We know acupuncture and Oriental medicine as the indigenous medicine of East Asia; in particular China, Korea and Japan are the countries of origin of this wonderful healing system.
The Modern Application of Ancient Mei Rong
Chinese Medical Cosmetology (Mei Rong) has a well-documented and venerated history dating back to the Qin (221-206 BC) Dynasty.
Omega-3 Fish Oil: An Underappreciated Element of Men's Health
As a clinician with many male patients -- and as a man myself -- I am all too aware of the fact that we like to convince ourselves that we are doing great, when that may be the farthest thing from the truth.
Footsteps of the Sages: An Apprenticeship with Dr. Kezhan Zhang
When I met Dr. Kezhen Zhang in May 2013, I was his translator and the integrity, creativity, and passion he demonstrated as a practitioner and advocate of the medicine convinced me to travel to Beijing to study with him.
Dietary Fat and Prostate Cancer: An Important Update
K.M. Di Sebastiano and M. Mourtzakis published a review paper examining the role of dietary fat on prostate cancer development and progression late last year that does a stellar job of summarizing the available data on fat and prostate cancer.
Designing a Fitness Plan (Part 1)
It doesn't matter if you come to my practice for pain relief, weight loss, healthy aging or something else. The formula I talk about for each patient's fitness strategy is pretty much the same.
One Size Does Not Fit All: Exercise and Nutrition According to Your Yin/Yang Body Type
There are countless new exercise and nutrition plans out there, emphasizing the latest ground-breaking research and claiming to revolutionize the way we view health.
Making Sense of an Increasingly Obvious Conclusion
Where's U.S. health care heading? Like it or not, the list of telltale signs is growing to a point that stands out to even the most myopic observer. Consider this list of facts as you look into the future of health care in the United States:
Mechanism: Experimental Approaches to Understanding Acupuncture, Part 1
The clinical benefits of acupuncture are difficult to ignore, but also can be difficult to explain to a Western audience. For nearly 50 years, relentlessly inquisitive scientists and physicians have been working toward a conceptual model to explain acupuncture.
December, 2012, Vol. 12, Issue 12
A Chronicle of a Kyphotic Tennis Player
By Nicole Nelson
Shoulder pain among tennis players is a widespread problem. This plague is likely a consequence of many things, most notably our cultural shift toward sitting, video games and computers. Kyphotic postures resultant of a routinely sedentary lifestyle place the shoulders of our weekend athletes in some very precarious positions on the court, particularly during the service motion.Although the serve exposes our clients to shoulder mayhem, they are not going to stop playing tennis, so we as therapists must be prepared to take on the challenge of keeping them healthy and pain free.
Here is the chronicle of a kyphotic tennis player named Suzie, a fictional character, yet quite representative of many of the clients we treat on a daily basis. It details her postural misadventures on and off court, and offers some treatment strategies to keep her out of pain and playing the sport she loves.
Suzie is a 34-year-old accomplished dentist and weekend tennis enthusiast. She has been suffering from pain in her right shoulder for many years. She recently has begun noticing a relative weakness in her right arm, with occasional right wrist pain. In spite of her recurrent pain, she never misses her much loved Saturday morning tennis camp. Subsequent to hitting a few shopping carts worth of forehands, backhands and serves, she typically heads to the gym for a 45 minute workout on the elliptical machine. While on the elliptical, she catches up on the news, watching the TV that is mounted to the wall five feet above her. At this point, it's probably redundant to say that her head has found itself four inches in front of her body.
The service motion involves many components that can leave Suzie vulnerable to injury, but for the purposes of this discussion, I will limit it to four main items: posture, biomechanics, anatomy and repetition.
Try slumping forward and then raise both arms overhead. Not happening, huh? When the thoracic spine is slumped forward, the shoulder loses its ability to flex completely, a very necessary component if you expect to serve overhead. Research by Janda suggests there is a group of postural muscles (i.e. upper traps, SCM, pecs) that are involved in tasks such as sitting or standing, additionally these muscles tend to become overactive and shorten.1,2
Janda's work also pointed out that the antagonists of the postural muscles (i.e. deep neck flexors, rhomboids, mid and lower traps) tend to loose their ability to communicate with the CNS, and eventually become weak and inhibited. Upward rotation of the scapula is required for the service motion, this is primarily a function of the serratus anterior, rhomboids, mid and lower traps.3 Unfortunately for Suzie, these inhibited yet functionally necessary muscles will be of little assistance when she attempts any overhead motion. Without a stable scapular platform, the service action will be as effective as shooting a cannon off of a canoe. This begs the question, how is Suzie accomplishing this movement when her poor posture has precluded her from flexing her shoulder and recruiting key stabilizing muscles? According to the developer of the Functional Movement System, and author of the book Movement, Gray Cook, "the human system will migrate toward predictable patterns of movement in response to pain or in the presence of weakness, tightness or structural abnormality." In essence, her body has found different pathways to complete the task of serving. It doesn't really care about optimal movement; its priority is more about getting the job done. I'm wincing at the thought of the possible recruitment scenarios that are involved in her adaptive stroke production.
The human shoulder is the most mobile joint in the body.5 This mobility can lend itself to stability issues. Although ligaments and the labrum offer support, the true worker bees in stabilization of the GH joint are the rotator cuff muscles. The Supraspinatus, Infraspinatus, Subscapularis and Teres Minor (aka S.I.T.S.) are primarily responsible for keeping the head of the humerus from sliding around the glenoid fossa. These muscles perform many actions, the most clinically significant for our tennis player include the following:
Suzie's shoulder blades are in a protracted position, the cuff muscles attaching on to the scapula are now at a mechanical disadvantage. If the cuff muscles are not in ideal position to fire, her humeral head will begin to travel. Needless to say, this is more bad news for the health of her shoulder.
One of the most salient features of the GH joint, is the limited space under the hood of the acromion process. During the service motion, the humeral head and its overlying biceps tendon and rotator cuff must pass under the coraco-acromial arch. Any increase in the size of the structures (either by inflammation or hypertrophy) underneath the arch may lead to impingement.6 Considering Suzie's humeral head is probably shifting around within the fossa, the probability of an inflammatory response is likely, thus creating a perfect environment for impingement. Additionally, a decreased space available underneath the arch secondary to osteophyte formation of the acromion and fibrosis of the subacromial space may lead to impingement.6 To make matters worse, not all acromions are shaped exactly the same. There are three classifications of acromions. Type I, decent room under the hood. Type II, not bad, but the hood is a bit overhanging. Type III, this acromion is the devil. It has a big hook on the end limiting the capacity of the shoulder to flex without impinging on something. We can only hope that Suzie has some genetic luck on her side.
A biomechanically sound service motion involves a sequence of perfectly timed force couplings and torques generated from the legs, hips and upper body.4 The entire kinetic chain, from the feet to the shoulder, shares in the power production of a serve. Even though the lower body is a large driver of power in a good serve, it is well documented that the greatest forces and moments are applied at the shoulder and overtime presents the risk of injury to the muscles of the rotator cuff, as well as the ligamentous and capsular structures.3,4,5 If a technically proficient serve significantly loads the shoulder, consider the loading on Suzie's shoulder. Not to be critical, but her strokes resemble a rigid, muscling of the shoulder to the exclusion of all the great power generating muscles in the body. She has effectively eliminated three fourths of the kinetic chain, thereby increasing the reliance on her shoulder which will most assuredly lead to tissue overload.
The job of the cuff muscles in a tennis player is a complex one at best. For things to run smoothly, a balance must be struck between the concentric work to position and accelerate the arm, the eccentric work to stabilize and decelerate the shoulder, and the effective depression of the humeral head to avoid impingement in the overhead position.4 EMG analysis of a biomechanically efficient serve suggests that in the windup, cocking and acceleration phase of motion, the firing of the scapular stabilizers and anterior eccentric shoulder preceeds the firing of the rotator cuff.4 This spells more trouble for Suzie. Her load sequencing will be disturbed due to the inhibition of her scapular stabilizers, creating more opportunity for impingement.
When a client comes into your office and complains of shoulder pain, they are less likely to blame their less than perfect service motion or their slumpy posture. More likely, they will say the culprit is that they slept on their shoulder "funny" or lifted something heavy in the garage. Dr. Shirley Sahrmann, author of Diagnosis and Treatment of Movement Impairment Syndromes, postulates that our repetitious movements and everyday activities are the culprits behind muscle imbalance and pain. If you have ever been to a tennis clinic, you will undoubtedly see a shopping cart filled with tennis balls. I imagine your aching to know how many tennis balls fit in one basket. The answer is 350. Let's presume that Suzie hits three shopping carts worth of serves, forehands and backhands. That is more than one thousand repeated offenses to her shoulder.
Let's sum up Suzie's situation thus far: Kyphotic posture + suspect anatomy + poor biomechanics + repetition = train wreck. Her posture is setting her up for chronic pain and dysfunction. Her FHP won't permit adequate shoulder flexion. Inhibition of the inferior scapular fixators has nixed the quality movement patterns necessary for the service motion. Her winged scapular position has rendered the S.I.T.S. muscles ineffective at keeping the humeral head in place, consequently the supraspinatus, subacromial bursa and biceps tendon are getting pummeled. Her chronic pain is affecting her energy levels and mood, finally she decides to go to the doctor who tells her she has a rotator cuff tear.
The truth is most of your tennis players have rotator cuff tears and often times they go completely unnoticed. Some of the most recent literature on pain suggests that tissue injury does not equal pain. One study examined the prevalence of rotator cuff tears and pain. The researchers took MRIs on the shoulders of 96 asymptomatic subjects and found cuff tears in 34% of the cases, with 54% of those older than 60.7 Yet, another study found that out of a sample size of 30 shoulders, there were absolutely no completely normal rotator cuffs in those under the age of 50.8 This suggests that non-enhanced magnetic resonance imaging may be of limited value in defining rotator cuff injury in a patient with shoulder pain unless a full-thickness rotator cuff tear is suspected. In chronic pain, special diagnostic tests of localized areas (for example, low back radiographs) are often normal, although the patient complains of pain. This research indicates that it is something other than the structural deficit that causes certain people to experience pain.
Suzie's doctor has followed up with her and is not recommending surgery, stating it is a very small partial thickness tear of the supraspinatus tendon, and considering her age, location of the tear and relatively good health, believes more conservative therapies are appropriate at this time. So, the million dollar question is, what can a massage therapist do for Suzie?
Clearly, there is little we can do about fixing the tear to her tendon. I would say that our rotator cuff solution begins with improving her posture, thoracic spine mobility and her tissue quality. Janda believed that treatment should begin with the normalization of tight tissue prior to any type of strength training. Travell had similar thoughts, subscribing to the notion that trigger points need to be resolved before the strengthening phase of rehabilitation begins. A nice analog to their views is hitting the brakes in your car, while at the same time hitting the accelerator. You won't go very far, but once you release the brakes, you are off and running.
Once the soft tissue has responded to manual therapy, it is time to introduce your client to a person with corrective exercise experience. The biggest mistake clients can make once their pain has resolved is returning to tennis without strengthening the inhibited postural stabilizers and rotator cuff muscles. In Suzie's situation, the supraspinatis tear can lend itself to further instability that must be addressed in order to prevent the humeral head from shifting within the fossa. Manual therapy is just the beginning, if tennis players want to continue playing without chronic pain, they must re-educate these muscles to fire again with appropriate timing, strength and speed. Help your clients find corrective exercise specialists that are well versed in working with the special needs of overhead athletes.
Forward headed posture places our clients at a tremendous risk for injury particularly when they participate in sports involving movement which requires a perfectly organized body. As Suzie can attest, bad alignment coupled with repetitious poor loading of joints spells big time trouble for tennis players. Therapy directed toward optimizing posture, improving soft tissue quality, reclaiming strength of the scapular fixators and S.I.T.S. muscles, and establishing good movement patterns will give them a good chance at continuing to play tennis and will help prevent some very needless suffering.
Nicole Nelson a licensed massage therapist in Jacksonville, Fla. She has a masters degree in Health Science from the University of North Florida and is a certified Advanced Health and Fitness Specialist through ACE.
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