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)

Osteoarthritis

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.

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: http://findarticles.com/p/articles/mi_qa3841/is_200104/ai_n8931215/pg_1

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.

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. (http://www.aidslifecycle.org/) 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 (http://www.stresscure.com/), 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 http://www.aidslifecycle.org/ 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

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 http://darkwing.uoregon.edu/~athmed/aclrehab/anat.html

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.

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.

Discussion:

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: http://www.performbetter.com/catalog/assets/Exercisesheets/PDF/FoamRoller.pdf. 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.

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. http://en.wikipedia.org/wiki/The_Secret_(2006_film) 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? http://www.whatthebleep.com/