Monday, December 8, 2008

Core Strength and Chiropractic

We’ve said it before, and we’ll say it again: Core strength is important to your spinal health. But why? Why should we care? The answer is in the natural balance of your body. The core muscles are the deep intrinsic muscles of the trunk, including the transverse abdominus, the abdominal obliques and all the tiny muscles that support the joints of the spine. When these muscles are weak, we tend to let our belly hang forward and let our low backs have increased curvature. This position puts more stress on the joints of the low back, causing increased risk of arthritis and facet syndrome AND it puts more pressure on the intervertebral discs, increasing the risk of disc derangement and herniation. When the core muscles are strong, however, they allow the spine to be well supported. Because the spine is well supported, it is better able to respond to other stresses, such as the positions maintained while engaging in sports or working. This means that the well-supported spine is less likely to be injured. In addition, the well-supported spine holds chiropractic adjustments better than a spine with weak core musculature. This translates into fewer office visits and faster healing for chiropractic patients, both when they are on maintenance care and when they have a new injury.

With this in mind, we hope you will all re-consider the importance to your core. Please ask us for advice if you are unsure as to the appropriateness of your core workout. We are here to help you and your joints be the best they can be!

Friday, November 7, 2008

Case Study: Toe Pain

Patient: 45 year old male construction worker
Complaint: Right first toe pain, especially with running.

The patient presents with a chronic, intermittent complain of right first toe pain. He reports that the toe does not hurt if he avoids running, but that when he does go for a run the toe pain comes on in the first few minutes of the run and will last for several days afterward. The pain is local, and he denies and sharp, shooting or electrical pain.

Upon examination, observation reveals the right first toe's metatarsal to be hypertrophic, with excessive bone formation at the proximal end. This causes a bump on the dorsal surface of the patient's foot. Palpation of the joints and muscles reveal a hypertonic adductor pollicus and decreased joint motion at the metatarso-cuneiform joint.

Discussion: This patient is suffering from a very common condition: Osteoarthritis. Through no real fault of the patient, his joint has begun to degrade with the forces of time and stress. This causes his toe's joints to not move as well, which in turn causes muscles to become tense and painful. When he runs, he aggravates the condition by putting further stress on an already-stressed joint.

Treatment: We will focus on pain control. The current deformation of bone from the arthritis is nearly impossible to reverse, but we can slow any further progression of the disease. We will massage the adductor pollicus muscle to help it relax and then adjust the toes, foot, knee and hip as needed to make sure the entire limb is moving as best it can. Then, we will make sure the patient's sure are providing the proper foot support. In this case, the patient's high arches need to be considered and orthotics are recommended.

Friday, October 10, 2008

Happy October!

We LOVE Halloween in our office, so we celebrate all month long. Dr. Mazgaloff's birthday is the 31st, which makes it extra special! We've got bats on the bulletin board, ghosts on the white boards and pumpkins on the windows, and, to top it all off, it actually is cool enough to feel like fall today!

In honor of this kid-friendly holiday, I'd like to remind you all that your kids need chirorpactic, too. Not to say that most kids need to be adjusted all the time, but people of ALL ages benefit when their body is properly aligned.

In our office, we recommend kids get checked if they have had a big fall, or if they are complaining of nagging pain.

A great way to keep your kids out of the doctor's office in the first place is to make sure they exercise. Specifically, exercise in a smart way: train for balance! Training for better balance is something anyone can do, no matter how "out of shape" they may be. It can be as simple as standing on one leg, sitting on an exercise ball, or using a rocker board. And the whole family can benefit from balance training!

When we have good balance, we have improved feedback from our feet and legs to our brain. When this happens, the muscles in the legs and feet function better, allowing them to help support you in any situation. People who train in balance are much less likely to injury themselves when they stumble, because their muscles are strong enough to catch them before they fall.

So try it with your family today! The average healthy adult should be able to stand on one leg with their eyes open for 10 seconds without wobbling. If that's too easy for you, try closing your eyes - careful! Make sure you have something you can grab onto in case you need to steady yourself.

Have fun with this, and remember that balance is something that lasts a lifetime. From childhood falls to elderly mis-steps, improved balance can mean the difference between a band-aid and a trip to the doctor's office.

Friday, September 26, 2008

School's back in session

Well, you can tell school is back in session because our office is packed! Most chiropractic offices experience a lull around the time that school starts again, but not ours. We treat so many families, they all want to be at their best for the new school year. So, they come see us:) Of course, there's also the occasional summer injuries that finally make their way in...we've had several surfers with whiplash this year. Be careful our there, folks!

This post, I want to talk to you a bit about Lupus. The official name is Systemic Lupus Erythematosis. Also called SLE, or more simply, Lupus, it is a condition that can go unrecognized for years. Lupus is a chronic, inflammatory, auto-immune condition. It causes the body’s own cells to attack themselves, resulting in tissue damage in joints, the skin, the kidneys, the heart, the lungs, blood vessels and the brain. It typically affects women (all races are affected, but most commonly African American) between the ages of 15 and 45, though all ages and both sexes can be affected. The cause of Lupus is unknown, and there is no known cure. Because of its effect on the vital organs, Lupus can be fatal.

Interestingly, in the literature, the characteristic of Lupus most often mentioned is a malar or "Butterfly" shaped rash on the face, where two wing-like red areas cover the patient's cheeks. However, because this disease is less common in Caucasians, the likelihood of the rash being present is significantly diminished. We need new markers to help doctors diagnose this condition more accurately. Without them, doctors often treat a variety of symptoms for years before finally diagnosing Lupus.

In our office, we help Lupus patients cope with their illness by reducing joint and tissue inflammation and swelling. By using gentle massage and chiropractic adjusting, we can help our patients’ joints move as freely as possible. We often co-treat Lupus patients with a variety of other healthcare professionals, from rheumatologists to acupuncturists to general practitioners. When we work together as a team, the patient always wins.

Our office works in conjunction with the Alliance for Lupus Research. Please visit their website to learn how you can help. They hold a walk every year, and are able to provide valuable insight for patients who have been struggling with the disease.

Thursday, August 28, 2008

Busy! Busy! Busy!

August is Foot Health Month. A lot of you out there are probably wondering what a chiropractor cares about foot health. You’re thinking, “Isn’t that a podiatrist’s forte?” Not so! While podiatrists are an invaluable part of the medical community, we chiropractors care a lot about feet, too. Why? Because we’re all about balance. If you feet are having problems, what are the chances that the res of your body is being well-supported? Not very good. Your feet are your foundation. When they ache or when you use them improperly, the rest of your body has to compensate. Thus, we end up seeing patient for things like knee pain, hip problems and even low back and neck complains all because of their feet.

So, we are on a crusade! We want to check your feet. All this month, we’ve been doing it for free! We want to look at your shoes and your insoles and make sure your feet are getting the support and attention they deserve. A lot of you already have custom insoles, and that’s great. But how long ago did you have someone check to make sure they are still performing their desired function? Our bodies go through changes over time, with ligaments losing collagen and joints becoming less mobile. These changes can make your custom insole more of a problem than a solution. Let us check to make sure yours are still in good shape.
Bring us your heel pain, your toe pain and shin splints. Chances are, we’ll be able to identify your problem in one visit and give you suggestions on how to fix it. If you don’t see us, see another chiropractor. If they aren’t comfortable with foot problems, ask them for a recommendation of a chiropractor who is. This is serious, people. It’s your FEET we’re talking about.

Ok, so I’m off my soap box for now…

Monday, July 7, 2008

Summer Safety Tips

Did you know this is the time of year we see the most preventable injuries? Here are a few tips to keep your summer a little safer:

- Wear sunscreen and reapply every few hours during exposure
- Take plenty of water breaks when exercising
- When boating, carry a life preserver for each person on board
- When swimming, ensure proper supervision
- One application of bug spray should last the day, unless it is washed off
- When on wheels, wear a helmet! Bikes, scooters, skates, etc.
- Avoid using fireworks at home; enjoy public displays where firefighters are supervising
- When hiking or camping, using the buddy system. Never go out into the wilderness alone.
- Check the air pressure in your tires
- Tell a neighbor when you are gone on vacation so they can report any suspicious activity at your home while you are away
Use some common sense and have a happy, healthy season!

Wednesday, June 18, 2008

ART - Active Release Technique

A lot of people have heard of ART, or Active Release Technique, but most don't know what it is or how it can be helpful. ART is just one of the many methods of treatment we use in our office to help our patients get better as fast as possible. It is a specialized form of massage commonly used in sports medicine, and its goal is to reduce muscle tension while re-aligning muscle fibers and breaking up scar tissue. Because of its multiple effects, ART is a very powerful therapy. It can easily be over-done or done incorrectly, resulting in significant and long-lasting muscle soreness after treatment. For this reason, it is important to only ever receive ART from a licensed ART practitioner.

A common use for ART is for rotator cuff muscles. In this case, the patient is usually seated with the doctor standing behind them. The patient will shorten the muscle being treated and the doctor will use their hand to "pin down" the muscle in the appropriate location. The patient then moves their arm through a prescribed range of motion while the doctor maintains pressure, causing the muscle to move under the doctor's hand. This motion is what separates ART from other forms of massage. By having the patient actively use their arm, the neurologic input to the area of treatment is significantly increased. In addition, by "pulling" along the muscle fibers, the fibers themselves can be re-aligned and any scar tissue in the area is broken up.

As you might imagine, this is an extremely effective therapy!

Friday, June 6, 2008

Case of the Week: Reynaud's Syndrome

Raynaud’s Syndrome is actually more common than most people think. The symptoms typically present as numbness or a feeling of cold in the hands or fingers, caused by constrictionof the small bloodvessels, called capillaries. In our office, our most recent patient presented with her fingers noticeably white from base to tip. She was complaining of numbness in her fingers and a feeling of constantly being cold. She was also under a significant amount of stress at work and at home, and the increase in her hand symptoms over the last few weeks had added to the stress. She reported that the feeling of numbness and cold seemed to get better and worse throughout the day and night, without any apparent pattern. She had tried wearing gloves and using hot packs on her hands, but the relief they provided was only temporary.

Raynaud’s is most common in women from the ages 18-30, and is typically aggravated by emotional stress. In order to actually be diagnosed with Raynaud's syndrome, the patient is supposed to have had symptoms for at least 2 years. Otherwise, it is supposed to be called Raynaud's phenomenon.

In our patient’s case, there was really very little physically wrong with her. Her pulses were strong and regular, her sensation in her hand was normal, and there were no muscles or joints affecting the ability of the nerves to transmit information. Our recommendation for the patient was to find a way to decrease her emotional stress. We recommended seeing a counselor and arranging to take some time off work. In the mean time, reducing her exposure to cold temperatures, especially to her hands, would help decrease symptoms.

A follow-up revealed the patient’s symptoms had decreased to a manageable level within a few weeks of focusing on stress-reduction.

Wednesday, May 28, 2008

Chiropractic Care for Infants and Children

I’ve had a lot of people ask me, lately, “Kids don’t need chiropractic care, right?”. WRONG! Kids need chiropractic care most of all! Think about it. Chiropractic teaches the body how to maintain itself in a healthy position to allow maximum function. If a child’s body is taught how to maintain its health, they have a much sturdier foundation for the rest of their life. Studies have shown that kids who receive chiropractic check-ups have less chance of developing health problems like scoliosis. There are even case studies that indicate colicy infants just need to be adjusted!

The other great things about kids getting chiropractic care is how easy it is. Kids’ joints adjust very easily and they don’t need many adjustments before their body learns the proper alignment. And it’s fun! Every little kid I have ever adjusted giggles afterward. It doesn’t hurt and it’s not scary. In fact, I know one toddler who refuses to see her pediatrician without kicking and screaming, but will literally run into the arms of her chiropractor. Kids have an innate sense of what is best for their body, and they know chiropractic helps them with that.

So, take your kids in for a check up. Make sure you see a chiropractor who is comfortable treating children, because, as much as we love them, kids do come with their own unique set of complications. In my office, we often check the kids for free when the parents come for treatment. It’s that important to us that these young bodies are put on the right path.

For more information on infant and childhood chiropractic care, visit the International Chiropractic Pediatric Association. I should warn you that the ICPA is a little over-zealous on some topics, so take it with a grain of salt. They are a great resource for finding a kid-friendly chiro in your area, though.

Monday, May 5, 2008

Case of the Week: Bicyclist Knee Pain

Patient: 30 year old IT consultant

Presentation: Patient has signed up to participate in a week-long bicycle trek from Los Angeles to San Francisco in the first week of June. In his training for this ride, he has been taking longer and longer rides on the weekends and short rides during the week. This past weekend, he tried to take a 74 mile ride, but had to stop at 30 miles due to right knee pain. This pain has been nagging for the last few weeks, but only presents while cycling and usually goes away once the ride is over. This past week, the pain was significant enough that he stopped riding, and walked back to an area where he could call a friend to pick him up and bring him home. There is no radiation of pain, numbness, tingling or significant weakness. He has never had an injury to the right side and has not other complaints.

Examination: The right vastus medialis oblique (VMO) is tight and tender +2/4 with mild edema (swelling) at the insertion on the patella. Right knee range of motion is within normal limits. Muscle testing reveals a weak right VMO. Deep tendon reflexes are within normal, as is sensation in the lower extremities. Orthopedic tests for meniscus involvement, chondromalacia patella, cruciate ligament tears and medial or lateral instability were all negative.

Discussion: As we have previously discussed, the muscle balance in the knee is crucial. When performing a repetitive motion, such as cycling, the knee is repeatedly put under stress in both flexion and extension. If the muscles of the knee are not putting synchronized forces on it, irritation can result. In this case, the patient already had a weakness in his right VMO. He just never noticed it until he was training for this ride. The VMO is a common muscle to have a weakness in. It doesn’t mean he trained incorrectly or was somehow deficient. Many athletes, including runners, cyclists and skiers end up irritating their VMO’s with increased activity. The key is early detection and appropriate strengthening.

In this case, the patient has already significantly irritated the VMO. It is fortunate that he has decided to seek help at this time because continuing to train on an injured knee could lead to even more significant injuries later on. As the knee flexes and extends, the VMO and the Vastus Lateralis Oblique(VLO) must pull on the knee cap (patella) equally to ensure that it tracks in a straight line up and down. When the VMO is weak, the patella does not track properly, leading to pain, inflammation and eventual damage to the joint.

Treatment: First, we need to prevent further irritation and control pain. We do this by icing the affected area, gentle massage to promote lymphatic drainage, and myofascial release to reduce tension in the VMO. Once the VMO is loose and no longer irritated, the patient must begin a specific strengthening regime to build up the VMO. It is important to strengthen evenly on both legs to ensure proper muscle balance.

Outcome: The patient is improving steadily. He has been able to go on several short rides without pain, and is looking forward to increasing his distance now that his knee is balanced.

Suggestion of the Week:
Get good equipment

If you are a cyclist, buy the best bike you can afford. Then have it fitted to you by an expert. (This is a link to the best bike fit guy I know). A good bike fit should NOT take only 10 minutes. There are a lot of little aspects of fitting a bike to its rider that must be taken into account. Without a good bike fit, you are more prone to injury and you will be less efficient in your riding, making you slower and more fatigued. Same goes if you are a runner. Get your feet evaluated and buy shoes for your feet and your needs. Then, take care of them! Keep a log of how many miles your shoes have on them. Once a shoe has hit between 300 and 500 miles (depending on the brand) you need to make them your new gardening shoes. A running shoe has a lifespan and trying to push a shoe past its life will only result in decreased performance and possible injury.

Exercise of the Week:
VMO Strengthening
This is so easy, it’s ridiculous. Sit in a chair. Turn your foot out as much as you can. Straighten your leg. Return your foot to the floor. Repeat until you feel fatigue in the lower middle section of your thigh muscle. If you need more of a challenge, add a small weight to your ankle or use tubing tied to your foot and the chair leg. By turning your foot out, you isolate the VMO. Don’t be surprised if you have less endurance and strength in this position than you do with your leg straight. When the leg is straight, you are using all of your quadriceps. By isolating the VMO, you can strengthen focally and improve the muscle balance across your knee. (Image provided by Dr. Henry Domke, The Living Healthly Podcast)

Monday, April 28, 2008


This week's post is from our practice newsletter. Osteoartritis is something that affects all of us and I think it's important to stay informed.

Osteoarthritis and You
Did you know that 90% of all adults age 50 and older have some degree of osteoarthritis (OA)? That’s practically everybody! OA is arthritis that results from gravitational forces pulling on the body. Without intervention, OA can result in significant joint degeneration and will eventually result in joint fusion. Since we cannot avoid gravity, how are we supposed to prevent this from happening?

Then answer is movement. Studies show that when a joint is kept immobile, the process of OA accelerates dramatically. When movement is restored, the degeneration slows again. On a large scale, the best thing we can do is KEEP MOVING: take a walk, swim, stretch, roll your shoulders, make circles with your wrists and ankles. On the small scale, you need an expert. Chiropractors are trained to find joints that are not moving enough and help them move better. Every time you get adjusted it is one more step in the fight against OA.

If you want to learn more about OA or other types of arthritis, stop by the office to pick up a free brochure on your topic of interest. These are provided by the Arthritis Foundation to help our patients learn about the dangers of arthritis and how to prevent it from happening to them.

The Arthritis Foundation is also a great resource for information on local aquatic exercise programs. A lot of arthritis sufferers feel the worst when they are cold, making exercise such as swimming difficult. Because swimming is a low-gravity activity, it is the perfect exercise for people with arthritis. To solve the obvious problem, the Arthritis Foundation has begun aquatic exercise programs where the pools are HEATED. Not hot tub temperatures, just pleasantly warm. There are three heated pools in San Francisco, alone, and many others across the Bay Area. You can contact us at the office or the Arthritis Foundation to find a heated pool near you.

Tuesday, April 8, 2008

Case of the Week – TMJ Headache

Patient: 35 year old male police officer

Patient presents complaining of nagging headaches located on both sides of his head. The pain is throbbing but not pulsating; pain can spread to the forehead as the condition worsens. He has headaches 2-3 times per week, but there is no time of day or activity that seems to aggravate the symptoms. He has tried Advil, which helps, and increasing his water intake. The frequency of the headaches is increasing and he is concerned the pain will begin to affect his judgment at work. The patient has had temporomandibular joint (TMJ) issues in the past and has been prescribed a night guard by his dentist. He clenches and grinds his teeth in his sleep, causing him to wear through one night guard per year.

Physical examination reveals abnormal TMJ gait, with the jaw swinging out to the left upon opening and following the same course upon return. The action is accompanied by popping in the right TMJ. The TMJ muscle group (masseter, temporalis, medial and lateral pterygoids) is tight and tender with trigger points bilaterally. Trigger points in the lateral pterygoids reproduce the patient’s headache. There is restricted motion of the left TMJ and the right C1-2 vertebral facet joint. Other testing, including vascular, neurologic and orthopedic testing of the neck and head are within normal limits.

Discussion: In this case, the patient had increased muscle tension in the jaw complex, causing a referral headache similar in mechanism to a tension headache. As the muscles tighten, the TMJ is compressed which decreases its ability to move properly and causes pain and inflammation. Our goal here is to first release the tension in the muscles and joints of the complex, including the upper cervical vertebrae. This will help the patient get out of pain. The second and more important goal is to find the cause of muscle tension and eliminate it. Without finding the root cause, the problem will continue to crop-up, over and over again.

Many people don’t realize that it is possible to massage the muscles of the jaw from inside the mouth. This is really the best way to access them, especially the pterygoid group, and can be a very simple but effective procedure. The doctor uses a gloved finger to gently apply pressure to the areas of tension until the tension is released, just as in traditional myofascial release. Once the muscles of the jaw are relaxed, the TMJ itself can be adjusted. In this patient’s case, the left joint was not moving well, causing the right joint to be hypermobile. We adjusted the patient’s left TMJ using gentle chiropractic manipulation and also adjusted the upper cervical joints to complement the new motion in the jaw.

It is important to note that the TMJ and the upper cervical joints have a very close relationship. Often, adjusting only the neck will relieve the tension in the TMJ. Other times, the TMJ is really the source of neck pain and the TMJ should be addressed first. In this case, the TMJ was the primary issue, so the treatment to the neck was only in relation to the TMJ’s needs.

It is also very common for people to suddenly develop TMJ problems after protracted dental work, orthodontics or a motor vehicle accident.

For a cool perspective from a dentist who later became a chirorpactor, visit this link:

Outcome: With a course of myofascial release and chiropractic manipulation, the patient’s headaches decreased and finally disappeared within 3 weeks. In this case, we found that the patient’s night guard from his dentist was not fitted properly. This, combined with increased stress at work, was causing irritation to the muscles and resulting in headaches. With a new night guard and stress-reduction techniques, the patient was had a full recovery.

Exercise of the week: If you suspect you have TMJ pain, try this: Wrap the eraser end of a pencil in a sturdy paper towel, creating a bulb of about 2cm in thickness. Using the writing end of the pencil as a handle, place the bulb at the very back of the mouth, to the side where your teeth end and the soft tissue of the jaw begins. Bite down slowly on the bulb. This creates a gapping motion in the TMJ itself and can give pain relief to a compressed joint. Make sure to try both sides. If this exercise provided pain relief for your jaw, you may want to seek a chiropractic consultation to evaluate your TMJ complex.
Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Suggestion of the week: Evaluate your own TMJ gait
Stand facing a mirror and very slowly open and close your mouth repeatedly. Open it all the way and close it all the way. Watch your chin. Your chin should follow a straight line up and down. If it curves off to one side in a C shape or S shaped pattern, your TMJs are not functioning properly. Also, if you have significant clicking or popping in your jaw with opening and closing the mouth, it can indicate a problem with the TMJ. Try it today and see how your jaw is doing!
Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Tuesday, April 1, 2008

Events, Events and More Events!

Spring is here and that means community outreach! Now that the warmer weather is upon us, we are working hard to educate people about chiropractic with every free moment we have.

This past weekend, we were at the AIDS Lifecycle expo. ( For those who don’t know, the AIDS Lifecycle is a week-long bike ride from San Francisco to LA that takes place every summer. The riders pledge to raise at least $2500 each and the money goes to AIDS education and awareness. This is such an awesome event to be a part of, and I love helping the riders. Many of the riders are not experienced cyclists and it is fun to watch them grow in their training rides. Many of them end up on my chiropractic table at some point and we work through those injuries as well. It is so rewarding to be helping people participate in such a great event. Maybe one of these years I’ll be on the ride with them:)

Also, because April is Stress Awareness Month (, we are going to be in local bank branches doing quick and fun public education on stress and its effects on health. Next week we’re going to be at the local B of A and the week after that we’ll be at WaMu (woohoo!). I’m excited about it because it’s always fun to get out into the public and answer people’s health questions. I find that a lot of people really do care about their health, they’ve just never have the opportunity to get all their questions answered by a professional. Most doctors spend less than 5 minutes per patient, which doesn’t leave time for much in the way of questions. I’m hoping these events in the banks will be helpful for everyone. Especially this time of year, when taxes are due, and with the way the economy is tanking, I think we can all use a little extra stress relief!

In closing I just want to say that I’m really looking forward to spring and I hope some of you will stop by and see us one of these days. We’re always out on the town and would love to say hi.

Suggestion of the week: Visit and donate to help the riders. It doesn’t have to be much. Even a dollar is more than they had before you donated. Or, if you prefer, find out how you can help by volunteering or find a way to support the riders like we do, with healthcare. Find a way to donate bike clothes, get reduced prices on tune-ups, or some other creative way to show you care. Have fun with it! You’ll feel better when you’re done:)

Exercise fo the week: Breathe.
No, seriously. Breathing is an exercise. Most of us spend our days hunched over a computer or in a car and our lungs are constantly under-inflated. Sit up straight and breath in slowly while counting to 4 in your head. Hold the breath for a count of 4 and then exhale slowly for a count of 4. Take a break and repeat. This is called 4x4x4 breathing. Advanced athletes can breathe at higher counts, like 7x7x7, and some of you may want to start at 3x3x3, but try it and see. Bringing your consciousness to your breathe helps quiet the mind AND increases the amount of oxygen available to your tissues…always a good thing!

Never engage in an exercise before consulting your chiropractic physician to determine if it is same for you and your unique conditions

Monday, March 17, 2008

Case of the Week - Pes Anserine Pain

Even those with some anatomy background might be wondering, Did I miss something? Where is the pes anserine? The name pes anserine means goose foot. We use it to describe three tendons that splay out like the toes of a goose. These tendons, the gracilis, sartorius and semitendonosis, all belong to muscles with different functions. As a unit, however, they often cause pain in the medial knee. Patient with pes anserine pain often complain of ITB syndrome, and vice versa. See last week’s blog for information on ITB syndrome.

Patients with pes anserine pain often complain of pain in their knee, specifically the inner side toward the back. It should be noted that patients with pain within the knee joint itself are usually describing a different condition.

As with ITB Syndrome, pes anserine pain’s root cause is often muscle imbalance. The muscles that control the knee muscle contract with equal force, quality and endurance on all sides of the joint. When one group is weaker, it becomes overworked leading to tendonitis, pain with exercise and eventual pain at rest. Last week we discussed the importance of VMO strength in alleviating ITB syndrome in runners. With pes anserine pain, the strength of the ITB is key. The pes anserine tendons support the knee from the inner side and the ITB supports the joint from the outer side. As the quads and hamstrings flex and extend the knee, the supportive structures on the sides help guide the movement. If the ITB is weak at the knee, the pes anserine tendons must work harder to stabilize the joint. Eventually, this will cause pain and inflammation in the area.

The short-term solution is to alleviate the excess tension. Massage of the pes anserine tendons, including use of the foam roller, will decrease local tension. Patients should also stretch their thigh adductors and hamstrings on a regular basis. Massage of the ITB may also be indicated.

The long-term treatment plan should involve identifying and correcting muscle imbalances in the knee, hip and ankle. In the most common presentation, this involves strengthening the tensor fascia lata and gluteus medius (hip abductors) at the hip and stretching the hip adductors.

For a great article on knee anatomy, visit

Exercise: Adductor and hamstring stretch

Stretching your adductors and hamstrings is something most people have done at some point. The key here is quality. Always lean into a stretch slowly. For these stretches, keeping your spine straight and hinging your movement from the hip will give a better stretch, faster. Breathe into each stretch for 10 seconds and slowly return to center before moving on.

Suggestion of the week: Increase new exercise slowly

Especially with running, but with any sport, increase the intensity slowly to build up muscle and avoid injury. If starting a new running routine, increase by small increments depending on your fitness level. A beginner should start with increases of minutes, instead of distance. An experienced runner can increase at 2-3 mile intervals so long as they provide adequate recuperation time in between runs.

Monday, March 10, 2008

Case of the Week - Iliotibial Band Syndrome

Patient: 27 year old female legal assistant

The patient presents complaining of knee pain. The pain came on without any injury she can remember. It gets worse with jogging; she no longer jogs due to pain. She is a former dancer, now working a desk job. She reports mild numbness across the tops of her feet and some right sided buttock achiness. She has tried to increase her warm-up and cool-down, but this only helps decrease the pain slightly. She is concerned she will not be able to run anymore and wonders what sort of exercise she should be doing instead.

Examination: Significant tension and tenderness in both iliotibial bands from the medial portion, distally to the band’s insertion on the tibia. Pressure applied to the medial portion of the band increases the numbness perceived on the feet. The right piriformis and gluteus medius are also significantly tight and tender. Provocation of the sacroiliac joint was positive for local pain. Patrick’s test was positive for pain on the right hip. Ober’s test for ITB tension was negative bilaterally, but Renne’s test for ITB tension reproduced symptoms on both legs. Nerve and circulatory testing in both lower extremities were within normal limits. Low back orthopedics were negative.


The iliotibial band or ITB is a common source of complaint for many athletes, especially runners and cyclists. The ITB runs from its muscle at the hip, the tensor fascia lata, to past the knee on the outside of the thigh. Because of its location, it works to stabilize the hip and knee, and can even become involved in pelvis and low back problems. In this patient’s case, an increase in running and a decrease in other aerobic activity caused increased stress on her knee stability. The ITB became inflamed as it increased tension in an attempt to improve knee stability. As the tension increased, the symptoms traveled up the leg into the hip. As the ITB got tighter, it began to cause abnormal sensations in the foot. It is important to note that testing proved the patient did not have any actual nerve damage or irritation. The numbness she experienced was a result of deep-referred symptoms.

In this case, the patient was instructed to stop running for two weeks and underwent intensive treatment to reduce the tension on her ITB’s and related musculature. Once the tension was decreased, the patient was able to return slowly to exercise with a new program for warming up and cooling down that included stretching of the ITB’s.

Outcome: The patient has had a complete resolution of the ITB Syndrome in both legs. She uses a foam roller regularly to help maintain healthy tension levels in the ITB’s and related muscles. She receives maintenance chiropractic care approximately one time per month, as needed.

Suggestion of the Week: When you have knee pain, it is important to remember the knee’s muscles must be balanced for the joint to function properly. This means that both the front and back and the inside and outside of the knee must have equal support. One of the most commonly weak knee muscles is the Vastus Medialis Oblique or VMO. If this muscle is weak, the knee cap cannot track properly during knee bending, and this can cause many different problems, including ITB Syndrome. Get your knee evaluated for muscle balance to ensure good joint motion and biomechanics.

Exercise of the Week: Use a foam roller to self-massage difficult areas on your body. You can use the roller on your back muscles, buttock, thighs, calves, shins and shoulders. Make sure you only stay on an area for about 30 seconds, and be careful not to roll over a joint. Daily use of the foam roller on problem areas can help people decrease the frequency of their chiropractic maintenance visits because they are able to provide some maintenance care themselves. Follow this link for more detailed instruction: Please be aware that this link also includes instruction for balance training exercises using the foam roller. While this is an excellent use of the product, this is not the intended use in reducing muscle tension.
Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Tuesday, March 4, 2008

A Departure - The Mind-Body Connection

This week, instead of writing about a case, I want to explore some thoughts on the connection between the mind and the body. As a chiropractor, I mainly treat joints of the body, and the muscles and nerves associated with those joints. But joints are not isolated occurences. A joint has a purpose: it is there to allow movement. Movement allows us to interact with our environment. Interaction with our environment is what we call living life. And that same environment also interacts with us.

During the interactions between our body and the environment surrounding it, stress occurs. It can be your boss yelling at you, breathing the cigarette smoke of the guy next to you, or typing reports for several hours in a row. These are all stressors and they ALL affect the body, usually resulting in joint dysfunction, fatigue, muscle tension and muscle group imbalances. Mental stress causes us to grow physically tense, muscles go into spasm and cause joint dysfunction. If this is serious enough or goes on long enough, it can inhibit nerve function. Environmental toxins likes cigarette smoke are stresors because our body has to put energy into processing these chemicals when it should be using its energy for more important things, like our immune system and brain function. The physical stress of working long hours is the most obvious example because it makes sense that an inherantly physical problem would have a physcial outcome.

Think about this for a moment: Every stressor we encounter MUST be processed by the body in a PHYSICAL way. Even mental and emotional stressors impact our physical body. With this in mind, how can we possibly stay well? We are constantly bombarded with stressors. Even if we saw a chiropractor every day, we couldn't combat the onslaught. Or could we?

What about our most powerful weapon? The MIND! As humans our minds are treasure troves of untapped resources. We have the power to impact our body in a physical way with our mental intention. Stay with me here... By now, thanks to Oprah, everyone with a pulse has heard about The Secret. This book/movement deals with the power of intention and the law of attraction. Simply stated, we get what we ask for. If we spend all our time worrying about how we are going to get yelled at by the boss, we WILL be yelled at by the boss. Conversely, if we put our intention toward, say, moving out of the apartment and into a house, we will attain that goal. The universe is a generous place and all you have to do is ask for what you want.

So what does this have to do with health? In order to truly have the power to manifest our intentions, we must be fully mentally present within our bodies. When we are fully present in our body, we begin to realize that the body sends us messages about what it needs. This is where I come in. Many times, on the road to a higher level of mental awareness, a patient realizes their body needs help to achieve its highest level of functioning. I help by adjusting joints and re-balancing muscle groups to provide a stable environment for the mind to work in. Once a person's body is functioning at its best, the mind can focus its intentions more acutely and accurately.

I guess my point is that as we try to better ourselves and our lives, often the first step is to start with our body. Once the body is sound, the mind is free to reach its fullest potential. This is why I truly believe everyone needs a chiropractor. If everyone on earth had regular chiropractic check-ups to help combat the constant stressors of living, then everyone would be freer to function on a higher mental plane. And I think we all know that a collective higher consciouness can only mean good things for us as a people and our planet.

I'll get off my soap box, now. Thanks for listening.

Other resources for those who are interested: The Celestine Prophecy by James Redfield, What The Bleep Do We Know?

Monday, February 25, 2008

Case of the Week - Acute Plantar Fasciitis

Case of the Week – Acute Plantar Fasciitis

Patient: 24 year old female college student complaining of bilateral sharp, stabbing foot pain increasing in severity in the last three weeks. The patient recently took a trip to Paris where she walked the city for one week. Upon her return, she began experiencing occasional sharp pain on the soles of her feet. The symptoms have progressed in intensity and frequency. She currently has the most severe symptoms upon waking, and in the shower in the morning. The pain is severe enough that it causes her to “try to walk without putting my feet on the ground”. Relief position is lying on her back with a pillow under her Achilles tendons, allowing her feet to hang in plantar flexion.

Examination: Plantar fascia of both feet is tight and very tender to the touch. Tight and tender bilateral calf muscles (gastrocnemius and soleus). Tender calcaneous on lateral margins. No significant tenderness at the medial tubercle of the calcaneous. Joint dysfunction of the metatarsophalangeal joints and the calcaenocuneiform joints. The tibialis anterior was weak bilaterally. Orthopedic testing for a sprain or strain, nerve irritation or circulatory problem was negative. Muscle testing of the calf was within normal limits.

Discussion: This case is a fairly common presentation for plantar fasciitis. The patient is female, relatively inactive and recently had and increase in physical activity. In addition, she has weak tibilalis anterior muscles and tight calf muscles. The action of the tibialis anterior is to bring the foot up to a 90 degree angle, allowing us to walk without our toes dragging on the ground. The calf muscles do to opposite, helping to point the toes. It is important that these muscles have equal strength and pull on the ankle. If, as in this case, they are unbalanced, joints are unstable and problems ensue.

In plantar fasciitis, the calf muscles pull on the Achilles tendon, which pulls across the calcaneous on the plantar fascia. The fascia becomes very tight, pulling the ball of the foot closer to the heel. When this tight fascia is suddenly stretched, as in the case of our patient standing in the concave basin of her shower, the patient experiences a sharp pain.

Outcome: In a case of acute plantar fasciitis, the key is to remove the tension on the plantar fascia and then focus on correcting the imbalance. In this case, the patient wore a small heel lift which slackened the fascia. During her treatment, she received massage on the tight fascia and calf muscles, as well as adjusting to ensure proper motion of the feet and knees. At home, she was trained to stretch the calves and strengthen the tibialis anterior muscles. In chronic cases of plantar fasciitis, recovery is a longer process and may even require specialized footwear or custom orthotics. Night splints are also a common treatment method.

For more in-depth information into plantar fasciitis, especially in athletes, visit This is an article written by a chiropractor who is also a track coach. He goes into much more depth on all the complicated factors that predispose someone to plantar fasciitis.

Suggestion: Ice bottle
During a flare-up of plantar fasciitis, or any time your feet have been over-worked, try using an ice bottle to reduce pain and inflammation. Keep a plastic water bottle (like Arrowhead or Evian) in the freezer. When you foot is bothering you, place the bottle on the floor and roll your foot on the bottle. The ice will help decrease pain and inflammation, and the pressure of your foot on the bottle will help to stretch tight tissues. Just remember that water expands as it freezes, so make sure there is some extra room in the top of your water bottle before you freeze it.
Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Exercise: Calf and toe stretches

One of the best ways to prevent plantar fasciitis is to maintain muscle balance across the ankle. Try adding stretching of the calves and toe flexors to your daily routine. For the calves, stand in a lunge with your hands bracing you on the wall. The back leg calf is being stretched. Now bend the back knee to bring the stretch down toward the ankle. For the toes, sit and hold your foot in your lap. Pull the toes back in a gentle stretch. Hold each of these positions for 10 seconds on each leg for a great stretching series.

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Tuesday, February 19, 2008

Case of the week - Sacroiliac Tension

Patient: 30 year old female office worker complains of right sacroiliac pain of several years duration. Pain has increased recently with increased time spent sitting at work and increased stress level. Pain is worst in the morning, feeling as though pressure needs to be released. Patient has tried massage and exercise, but the pressure remains. These treatments helped alleviate pain, but did not affect the “pressure”.

Examination: Significant bilateral sacroiliac joint dysfunction and lumbar joint dysfunction at L4 and L5 levels. Fortin Finger Sign. Tight and tender muscles in the right piriformis, right lumbar paraspinal muscles. Tight and tender right upper thoracic spine with right rib joint dysfunction. Range of motion, muscle testing and nerve testing were within normal.

Discussion: This patient displayed a classic finding in sacroiliac joint cases: the Fortin Finger Sign. Elegant in its simplicity, the Fortin Finger Sign indicates that the patient points directly to the sacroiliac joint when describing their pain. This sign is highly specific for the diagnosis of a sacroiliac joint problem. Lest you think Fortin to be moronic, it is actually very common for a patient to complain of pain in one location, while the source of that pain is located elsewhere. In this case, the patient’s pain and feeling of pressure were due to a chronic joint dysfunction of the sacroiliac joints. This dysfunction was so longstanding, it began to affect other areas of the spine, including the lumbar and thoracic spines. The patient’s long hours using a mouse at a computer were contributory to the thoracic pain.

Outcome: The patient underwent a series of treatments involving adjusting of the sacroiliac joints, the lumbar spine and the thoracic spine and ribs. Treatment also involved significant ergonomic corrections to the patient’s workstation and included postural re-training exercises to help the patient maintain the effects of her care.

Exercise: Knees to Chest – A great way to reduce tension on your sacroiliac joint is to stretch it in a flexed position. To achieve this, lay on your back on a comfortable surface. Slowly bring both knees to your chest and hug them with your arms. Take a deep breath, and, as you exhale, sue your arms to pull your knees closer to your chest. Repeat until you feel a stretch in your low back, just above your buttocks. Hold the stretch for 10 seconds, and then release very slowly, returning your legs to the ground. Do this once in the morning and once at night to help maintain your sacroiliac joint flexibility.

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Suggestion: Ergonomic Support – For all the hours we spend seated, we need to make sure our spines are supported. Evaluate your chair to make sure it allows your spine to be supported, with a lumbar curve and arm rests at the proper height. Ask your chiropractor to help you fix your chair for your specific needs, and watch your productivity soar!

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Monday, February 11, 2008

Case of the Week - Tension Headache

Image by Getty Images

Case: 26 year old female complaining of headaches several times per week, always in the afternoon or at the end of the day. The pain starts at the base of the neck and slowly moves up until it is at her forehead. The movement from neck to forehead takes about a hour. The patient has tried eating more regularly and drinking more water and decreasing or increasing caffeine intake, but none of these is effective. When she has a headache, the only thing that helps is to lie down and close her eyes. The headaches seem to be worse with increased time at the computer.

The muscles of the neck, especially the sub-occipital muscle group, are very tight and tender. There are multiple trigger points in the sub-occipital muscles and in the sternocleidomastoid on the right. Pressure on the sub-occipital trigger points reproduces the headache. Range of motion is decreased in neck flexion and right rotation. Other orthopedic testing for nerve, muscle and joint involvement was negative. The temporomandibular joint (TMJ) was not contributory.

This is a classic tension headache case. As the patient works at her desk, poor posture and fatigue cause her to slump in her chair. This causes excess tension in the posterior neck muscles, especially those at the base or the skull (the sub-occipital muscle group). Treatment involves massage to release the muscle tension, adjusting of the thoracic and cervical spine (mid back and neck) to achieve good joint motion, and then training the patient on proper posture and ergonomics. The patient education is key in this case. Without good posture, her headaches will continue to develop. Our goal in the office is to ensure her spine is able to provide that posture.

The patient feels fully in control of her headaches. She continues to receive regular chiropractic check-ups to maintain her spinal health. She maintains healthly posture by exercising at her desk and taking regular breaks. Now, on the rare occassion that she does get a headache, she knows why and she knows what to do about it.

Posture pod – check out this link for a great 2 minute posture re-fresher. Once at the page, click on Posture Pod. These were designed to be done by anyone, regardless of their physical fitness. Have fun!

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.


Take a posture break! – Every hour you are at work, take 5 seconds to do the opposite of what you have been doing. If you are at a desk, stand up and walk around. If you are standing, sit down and relax. Roll your shoulders back. Stretch your neck. Get moving! Your muscles need to be reminded that they have a job to do: holding you up! Take a few seconds every hour to get refreshed.

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Monday, February 4, 2008

Case of the Week - Medial Epicondylitis

Patient: 40 year old male, office worker

Complains of bilateral medial elbow pain with a duration of the last several weeks. Pain has steadily increased with increased time spent bicycling. All symptoms are greater on the right. Patient is right-handed. Some bilateral medial tingling in the forearms. No reported loss of grip strength. No shoulder or neck pain. Ice, tiger balm and OTC anti-inflammatories relieve only temporarily. Patient is concerned he will not be able to continue his exercise program and compete in an upcoming event due to pain.


All findings greater on right than left. Bilateral mild edema at the medial elbows. Tight and tender medial and anterior forearm muscles (Flexor carpi radialis and ulnaris, palmaris longus, pronator teres) especially at the common flexor tendon insertion. Mild tight and tender distal triceps tendons. Active range of motion within normal limits, but painful if stressed in extension and supination (elbow straight with hand facing out). Neurological testing for deep tendon reflexes, muscle strength and sensation were within normal limits. Palpation of the elbow joints was impeded by regional swelling. The shoulder and wrist joints were within normal limits bilaterally.


Here is a website that may be helpful in visualising the area. Bear in mind that this is an orthopedic website and typically recommends less conservative treatments than we perform. The picture in this post is from this website also and is provided by the Mayo Foundation.

This patient is suffering from a unique form of medial epicondylitis, commonly known as golfer's elbow. As you can see, there is no mention of the patient playing golf. Also, golfer's elbow is usually only present on the dominant swinging arm, not both arms. In this case, the inside of the patient’s elbow, the medial epicondyle, is irritated and inflamed because the muscles that attach to the area are being over-stressed. The patient has increased the amount of time he spends bicycling. With increased time on a bicycle, the wrists fatigue and the elbows are forced to absorb the shock to the arms from the handlebars. Due to a lack of fore-arm-specific strength training, the muscles of the patient’s wrist and forearm have become over-tight and swollen, causing pulling on the bone of the elbow, the ulna. This causes significant pain, especially during activities where these muscles are used, such as during the swing of a golf club. Because the patient needs to maintain a rigorous training schedule on the bicycle, our treatment will focus on pain-management until after his up-coming event. After the irritation of training rides is removed, the patient will be ready for the focal strength training and muscle re-balancing he needs to prevent this injury in the future. It should be noted that his examination showed the tingling he was feeling to be non-neurologic in origin. This means that he feels tingling, but it is not caused by a nerve problem. Often this sort of symptom is caused by the tension in the surrounding muscles and is relieved when the muscles relax.


After several weeks of therapeutic massage and chiropractic manipulation for the elbows, the patient experienced a significant reduction in symptoms and was able to continue training for and to eventually participate in his event. Since then, the patient continues to experience mild discomfort in his forearms, but only a few days per week, and only when he has performed an irritating activity. He is working on strengthening his forearms and stretching the over-tight muscles in his arms. When he over-stresses the area, ice relieves the symptoms. He continues to improve and our hope is that he will be in great condition for next year’s event.

Exercise of the week:
Soup Can Exercises - Hold the arm at the side of the body, with the elbow bent at 90o and the thumb facing the ceiling. Hold a can of soup in the hand. Move the wrist into flexion, that is bending the wrist to bring the can closer to your stomach. Now move the wrist into extension, that is bending the wrist back as far as it can go. These flexion/extension exercises are a great way to start re-strengthening your fore-arm after an injury. If you are strong enough, add gravity to your exercise: for flexion, hold the arm in the same position, but palm-up. Bend the wrist to bring the can closer to the stomach. For extension, turn the hand over so the palm is facing down. Bend the wrist back. Try starting with 10 reps on each side and see how your arm muscles feel!Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.
Suggestion of the week:
Stretch at your Desk! Most of us work with our hands in one way or another. Whether you are working as a laborer and use a shovel, or work at a desk and use a keyboard, your arms are busy. The muscles that keep your hands doing what they do are anchored in the forearm, mostly at your elbow. With that in mind, take a 40 second break every hour or so. Hold your right arm straight out in front of you and use your left hand to bend your right wrist down. Feel the stretch across the top of the forearm. Then turn the right arm over and use the left hand to pull the right hand back. Feel the stretch in the forearm. Repeat this on the left arm. Hold each position for 10 seconds, and breathe while you hold. This takes a total of 40 seconds. You CAN find time for stretching! And you’ll feel better and more productive to boot!Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.
See the following pictures for explanations of the exercises and suggestions of the week:

Stretching the forearms - Beginner

Stretching the forearms - Advanced

Strenghtening the forearms

Monday, January 28, 2008

Case of the Week - Osteoporosis

Patient: 57 year old female. Works as a rounds nurse.

Complains of low back pain attributed to an osteoporosis, diagnosed several years ago with a spinal x-ray. She denies having had a DEXA scan to confirm the diagnosis. The pain is local and does not radiate to the extremities. Pain increases with weigh bearing and is relieved by rest. Pain is least in the morning and increases as the day progresses. OTC Ibuprofen alleviates. Patient is reluctant to continue usage of OTC meds for fear of stomach and kidney complications. Denies previous fractures. No other meds.


Decreased range of motion in the lumbar and thoracic spine. Tight and tender paraspinal muscles in the low and mid back, bilateral piriformis hypertonicity. Orthopedic tests are negative for fractures, sprains, strains and disc herniations. No signs of nerve involvement. No circulatory problems.


Ms. Doe is a typical middle-aged woman concerned about her health. In this case, we see a common presentation: Someone took and x-ray of her back looking for a cause of her low back pain and told her she had osteoporosis. There are several problems here. One: Osteoporosis does not cause pain! The only way there is pain is if the bones are so weak that they fracture under the weight of the body, or with minor trauma like stepping heavily from a bus. Since the x-rays taken did not show any fractures, it is unlikely that Ms. Doe’s pain is related to her bone density. Two: x-ray is not a great way to diagnose osteoporosis. An error in taking or processing the x-ray can make bone appear osteoporotic that is actually healthy. To really diagnose osteoporosis, you need a bone-density test called a DEXA.

What really happened here is this: The doctor who took the x-ray couldn’t find anything wrong with Ms. Doe’s bones and joints that would explain her back pain. The only finding on the film was something called osteopenia. This means that it LOOKS like the bones are not as dense as they should be. It is NOT a diagnosis and is certainly not a reason for pain.


Ms. Doe underwent several chiropractic treatments for mechanical low back pain that involved chiropractic adjusting of her low back and pelvis, therapeutic massage and a home-care regime focused on flexibility and preventing future osteoporosis. Her back pain resolved and she has continued with her home-care to maintain her results.

Visit the National Osteoporosis Foundation for more information on the condition, its diagnosis and treatment.

Weight-bearing exerciseWhen an exercise is weight bearing, your spine and legs are holding up your body weight. That causes the muscles in your legs and back to contract, pulling on your bones, which causes the bones to grow a little thicker and helps prevent osteoporosis. The best exercises for osteoporosis combine weight bearing and balance-challenges. In addition to helping increase bone mass, the balance-challenge helps with stability. Better balance means less falls, which in turn can helps prevent broken hips and wrists. This is significant because 2/3 of women who break a hip due to osteoporosis die within one year of the break. The more breaks we can prevent, the better!Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Sink exercises are a great program for osteoporosis patients. They involve various balance-challenges while holding on to the edge of your kitchen sink for balance. Try this one: Stand facing the sink. With both hands holding onto the edge, rise up on your toes. Now, bend one knee so only one foot is touching the ground. Hold for 3 seconds. Repeat on the opposite leg. Do 10 reps on each side once per day. Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.