IT Band Syndrome is often also referred to as runners’ knee. It is a condition that creates pain on the lateral (or outside) of the knee. This condition is often exacerbated by running, especially running downhill.
In order to better understand the condition, it is important to understand the anatomy involved. On the front part of our thigh is a group of muscles called the quadriceps, for the sake of this discussion we are concerned primarily with one muscle of the quadriceps, the Vastus Lateralis. On the outside of the thigh we have a small muscle called the Tenser Fascia Latae or TFL; this muscle turns into a long flat tendon called the Iliotibial Tendon commonly referred to as the IT Band. When we run at maximum speed the IT Band must be able to glide across the Vastus Lateralis, friction and pain will develop if it does not freely move. Over time, a chronic inflammatory response can develop and left untreated scar tissue and other fibrous changes to the tissues may result.
Traditionally, the strategy of RICE (Rest, Ice, Compress, and Elevate) is implemented. Some non-steroidal anti-inflammatories may be prescribed, and physical therapy may also be recommended. For some patients these approaches may have some benefit.
We take a more direct approach and attempt to re-establish the normal glide between the Vastus Lateralis and the IT Brand….after all that was “the cause”. For a complete recovery we perform a more global assessment i.e. we examine and evaluate to find out if there is another condition in the body that predisposes the person or athlete to this condition. Some examples would be muscular imbalance, pelvic and hip positioning, knee, ankle and foot alignment, gait abnormalities like over pronation or even over supination, balance and coordination problems, etc. Most athletes can expect little down time (if any) and can return to their sport.
Headaches can come with a number of diagnosis and symptoms. Tension HA, Migraines classical and non-classical, cluster HA, allergic HA, Occipital Neuralgia and other nerve entrapments to name a few. The possible culprits of headaches range from hormone imbalances (for both men and women), vascular problems, visual problems, problems with the Temporal Mandibular Joint (TMJ) dysfunctions, allergies, electrolyte imbalances, dehydration, heat and temperature changes, to name a few.
Because the list of possible headaches is so extensive we will discuss the more common headaches we see in our office.
Tension headaches are caused by muscular tension and typically, the first symptom is tension at the top of the shoulders. The headache usually starts at the occipital bone (bone at the base of skull) and then migrates to the frontal bone, sometimes the pain is perceived as a band around the head. Some of the muscles that are most often involved in these headaches are the upper Trapezius, Semispinalis Capitis, and a very special group of muscles worthy of their own article the Subocciptal Triangle or the SOT muscles (referrer to diagram below).
So what can be done? The above muscles and usually some others are assessed for tone, texture, tenderness and so on. Only the muscles that have been affected are treated and the aim for treatment depends on the stage of injury the muscles are experiencing. For the fastest and longest lasting fix, the cervical (neck) and thoracic (upper back) spine are evaluated, as are the cranial bones (bones of the head). If indicated they may be treated as well. Once the muscles have been treated and the headache is reduced, exercises for the muscles treated are prescribed as are specific stretches.
Occipital Neuralgia, or C2 Neuralgia, is a condition in which the nerves at the base of the skull and/or upper neck become irritated. This can occur for many reasons such as trauma, fibrotic changes to the muscles around the area, postural changes, and physical stress to name a few. The symptoms usually begin with pain felt at the base of the head and then migrate behind the eyes.
So what can be done? Like tension headaches the involved structures must be determined and treated. Often the Greater and Lesser Occipital nerves need some attention. Nerves, like other body tissues need the ability to glide in relation to tissues in the same area. Often when a nerve loses this ability it can become painful and even create other symptoms such as numbness, tingling, or loss of sensation. This can be sudden or a slow process. Treatment is aimed at restoring this relative motion between the involved soft tissue structures. For a more complete resolution it is also important to evaluate the joint structures in the area, again insuring their relative movement to the joints above and below. Specific exercises and stretches should be aimed at stabilizing the area of instability and mobilizing the area of immobility.
Migraines, are a category of headaches that are vast. We most commonly see Classical Migraines and Common Migraines. Depending on the type of migraine, different internal or external factors may stimulate a migraine. The treatment options vary and depend on the type of migraine the patient presents with.
Headaches vary in cause and treatment. Correct diagnosis is vital in order for proper treatment and resolution. All factors must be evaluated, often time’s seemingly unrelated issues can be the cause such as allergies, hormones, tension both mental and physical etc.
Frozen Shoulder or Adhesive Capsulitis is a problem that involves the shoulder joints (mainly the Glenohumeral joint) the joint capsule and the muscles which move the joint complex. The patient has a significant decrease in range of motion (ROM). Pain is often worse at night and will interfere with daily life including affecting sleep.
Traditionally treatment for frozen shoulder has involved stretching exercises and sometimes the injection of corticosteroids and numbing medications into the joint capsule. In some cases, surgery has been used to loosen the joint capsule so that it can move more freely.
How do we differ? This condition is complex and as such it is quite involved in terms of structures affected and consequently structures treated. The rotator cuff (referrer to diagram below) is a group of four muscles that are important for both shoulder stability and proper mobility. The para-scapular muscles (referrer to diagram below) are the muscles around the shoulder blade. These muscles are responsible for the strength and movement of the shoulder. The joints in and around the shoulder (referrer to diagram below) must also be evaluated. In the case of frozen shoulder the Glenohumeral joint (often thought of as “the shoulder joint”) becomes fibrotic forcing a loss of range of motion or ROM. All of the above structures must be evaluated, treated, and strengthened.
The global movement of the patient needs to be assessed, meaning the way the Scapula or “shoulder blade” moves in relation to the thorax or “upper back”, and the way the scapula and the humerus or “upper arm” move together. The nerves which innervate all the above structures should also be evaluated in case of an entrapment exist and treated as indicated. Often, treatment will be aimed at re-establishing normal muscle and tendon tone and texture, then the ligamentous (joint) structures/capsules are worked and released over the process of a few sessions.
As you can imagine there is a lot which must be addressed when caring for a patient with frozen shoulder or Adhesive Capsulitis. Consequently, most patients become overwhelmed with this condition, having tried other interventions in the past with little or no relief. It has been our experience that for the fastest and most complete recovery all structures must be assessed, treated, and rehabbed.
What causes a rotator cuff tear? The cause of a rotator cuff tear can vary from patient to patient. Muscle imbalance can be a factor, the muscles that internally rotate the shoulder are much bigger and often times “over power” the external rotators of the shoulder. Muscle spasm of one of the rotator cuff muscles, mainly the Subscapularis, can predispose a person to tear a muscle of the rotator cuff. The slant of the Acromian (boney projection off of the shoulder blade) can be accentuated and predispose a patient to tear their rotator cuff. Another possibility is the tear results from fiberous changes that have occurred to the soft tissue due to “overuse” or “cumulative trauma”.
Traditional treatment often includes rest, ice, compression, and elevation or RICE, steroidal and non-steroidal anti-inflamitories, stretching and exerscie, and in some cases surgery.
How are we different? Treatment is first aimed at decreasing pain, improving strength and range of motion. The rotator cuff and the other involved structures of the injury are assessed and treated. Usually, there is a problem with more than one structure, ie it is seldom to find only one problem with a rotator cuff tear. Next, the goal is to assess what caused or allowed the tear to happen and treat that as well. Exercises are given to ensure the best possible chance of avoiding a re-injury. Most athletes can expect little down time (if any), and can return to their sport.
So what is the problem? Tendonosis is a problem in which blood flow to an area has been decreased. This can be the result of an underlying muscular imbalance between the wrist flexors and wrist extensors. Muscle imbalances are common, they occur in athletes but also in people with careers or jobs where the person is griping, or holding something for an extended period of time. The imbalances between the muscles can also be a result of typing at a key board, or yep you guessed it TEXTING! In instances where trauma was sustained, the lack of blood flow is believed to have been caused from local blood vessel spasm and muscle spasm from the trauma. Often times this decrease in blood flow can lead to ischemic changes to the involved tissues and over time can progress to fibrotic changes in tissue, turning the once somewhat elastic tissues into less resilient structures “think of a healthy muscle like a rubber band and a fibrotic muscle like a rope”. Now that the tissue has degenerated it is very common to have minor tearing where the muscle/tendon attaches to the bone (medial or lateral epicondyle). Pain, loss of strength, and loss of normal range of motion (ROM) can occur as a result of the above changes in tissue at any time durring the conditions progression.
How is this traditionally treated? Often time RICE is implemented: Rest, Ice, Compress, and Elevate. Steroidal and non-steroidal anti-inflammatories are sometimes prescribed. Ultrasound may be used as well as splinting and or bracing.
How do we differ? Therapy is aimed at re-establishing blood flow and tissue elasticity. Once this is accomplished the goal is to strengthen the weakened structures and to stretch the tightened structures. Once the condition resolves long term exercises and stretches are taught to the patient to ensure the best chance of the condition not reoccurring. Using this approach often allows for a faster recovery, and less (if any) down time. Most athletes are not required to stop their sport.
What causes back pain? What help with back pain? I’ve seen a Chiropractor before and it didn’t help, how are you different? I’ve tried physiotherapy and different forms of pain management, what’s next? What can be done for chronic or acute low back pain?
Back pain like any other pain, injury or condition is often multi-factorial. What that means is there is usually more than one underlying cause and more than one thing needs to be addressed. Chiropractic, massage, physiotherapy, strength training, stability training and flexibility training all have their strengths and weaknesses in the treatment of low back pain (and other conditions). Unfortunately, most physicians or therapists are good in one area and thus focus their attention in that area.
All cases of back pain are different, the intention of this article is not to explain every condition. Each patient needs to have a comprehensive exam by a competent doctor. When appropriate, imaging should be ordered, or even referrals should be made. There are some similarities which can be consistently seen in cases of low back pain.
Tightened or fibrotic muscles, usually the Psoas, Illiacus and the combination of the two muscles Illio-Psoas are tightened. In extreme or chronic cases the muscles are not only contracted but exhibit a degree of shortening. These muscles are important inlow back pain because when they on contracted or shortened it becomes difficult for the patient to stand erect. These group of muscles make up part of your hip flexors and thus when affected they do not allow your hips to extend. This is especially true when the patient has been seated for any length of time and then tries to stand up.
Both fascia and ligaments can be tightened (like a muscle) this is important because when contracted they can add undue tension to the structures they attach to. The ligaments often encountered in cases of low back pain are the Illio-sacral, Sacral-Tuberous, and Illio-lumbar. These ligaments are important in maintaining the alignment and integrity of the pelvis and Lumbar spine (low back). The fascia most often involved depends highly on the case however the Thoraco-Lumbar (mid back and low back) fascia often has to be addressed.
The concept of Kinetic-Chain is important when discussing weakened and unstable structures. This is the understanding of how certain structures work synergistically. In the case of low back pain, we are interested in the Posterior Kinetic Chain, this is comprised of the calves, hamstrings, gluteal muscle group, and erector spinae.
Other considerations for back pain include neurological involvement such as the sciatic nerve (commonly referred to as Sciatica) and/or other peripheral nerve irritations or entrapments. Central nervous system involvement and spinal stability issues such Spondolysis, Spondylosis etc. Movement disorders are often present as well, such as improper hip movement. Posture should also be assessed.
What can be done? Why are we different? In short, the tightened or fibrotic muscles, tendons, ligaments and nerves must be released. A number of treatments are aimed at accomplishing this most notably, Active Release Technique, Graston Technique and other forms of myofascial release. Then the unstable structures must be stabilized. Treatment could include: bracing, taping, splinting etc. Finally, exercise therapy and flexibility training should be employed as soon as possible to offer the fastest and longest lasting recovery for the patient. In closing all cases of low back pain, or any injury for that manner, deserve a comprehensive exam, diagnoses and treatment. For the fastest and most complete fix all the components of the injury must be addressed.