The Injured Athlete

How Kinesio Tex Tape Benefits the Athlete

2015-11-16T15:39:00.000-08:00

Unlike other types of athletic tapes, Kinesio Tex Tape is designed to mimic the superficial layers of the skin - very thin and light with an effective logitudinal stretch between 40 to 60%, roughly the stretch capacity of the epidermis in areas like the knee, low back and cervical regions. When applied properly, it lifts the epidermis in waves as the athlete moves, promoting the movement of interstitial lymphatic fluid and thus reducing the edema and pain that are generally associated with muscle dysfunction. In essence, a walking massage! Secondly, unlike other imitation tapes, the 40 to 60% stretch is longitudinal only (stretches lengthwise only, not cross wise) which allows the therapist to facilitate or inhibit muscle action. The sensitive nerve receptors in the skin communicate with the mechanoreceptors in the muscles that initiate either muscle contraction or release. By orienting the bias and intensity of the stretch applied, the therapist can encourage the muscles to contract or release. Combinations of these two major effects can be used to aid in a number of beneficial corrections in the athlete’s body.

Overall, the tape can be used to follow-up and enhance the therapist’s treatments for 3-5 days after the athlete has left the treatment room.

The effectiveness of Kinesio Tex Tape depends entirely on the skill level of the therapist applying it. As always, safety first – the person applying the tape should be a certified therapist, athletic trainer, chiropractor or medical professional who has a thorough understanding of anatomy & kinesiology, all the body’s systems and the contraindications for using the tape. There are few general contraindications, but they need to be respected, and then applications must be considered on a case by case basis, allowing for the athletes history of activities, injuries, surgeries and conditions. Secondly, in depth training insures a solid understanding of theory and application – a Certified Kinesio Tape Practitioner (CKTP) has this training, so look for those initials! Lastly, focus and care are crucial! Increased pressure and speedy standard applications often “feel great” to the athlete who is used to the restriction of athletic tape, but athletic tape and kinesio tape in general are used for two different purposes. Athletic tape is heavier and used to provide limits to support and protect the athlete. Kinesio tape is light and designed to move with the athlete, wrinkling/lifting the skin with movement, and should barely be felt, if at all.

Kinesio Tex Tape is a powerful tool to help my athletes heal faster and perform at their optimal level. I look forward to helping you all excel with it.

Core - It's Not Just for Breakfast Anymore!

2012-01-03T12:28:00.000-08:00

Had to laugh at this one! One of my swimmers came to me last week with pain in both his groin and shoulder. We tested, identified the lesions and then went on to evaluate the cause. The overall cause was compensation due to dysfunctional and weak core musculature. He was surprised - he'd heard of the connection between low back pain and weak core musculature in swimmers, but had no idea is could be the cause of more distal repetitive stress injuries. Not being a fan of core exercises, he was not pleased. After I explained and recommended he talk to his ATC about intervention and his CSCS about an appropriate post season program, he chuckled and parodied the old beer joke cynically stating "Core - its not just for bad backs anymore!".

As amusing as this anecdote may seem, it is true. Dysfunctional and weak core musculature can lead to compensation and injuries in the distal aspects of an athlete's body. In cases like a swimmer, where a dysfunctional core is a weak link between the upper and lower body, or a baseball pitcher who has to coil and explosively uncoil his body, compensation by the extremities for power loss in the core is obvious. But the cause or partial cause of conditions like Achilles tendonitis and various knee conditions in many sports can also be traced to a dysfunctional core.

Bringing an athlete out of pain and restoring function is the job of the Athletic Trainer (AT) and I am blessed to work with some of the best among the universities sports medicine staff in Boston. Keeping them out of pain and improving their athleticism is the job of the certified strength and conditioning specialist (CSCS, NSCA) or a certified personal trainer (CPT) who has a background in periodization training. I have the cards of both great CSCS and CPT on the desk in my office, all very capable of helping the athlete develop a functional core appropriate to their sport.

Medford/Somerville/Tufts Runners Rejoice!

2011-10-17T13:08:00.000-07:00

Big news for all those Somerville/Medford runners, bikers, marathoners and triathletes.The Alewife Brook Greenway is really showing some promise of completion! The final bridges are now being constructed and they laid the entry stones today!

This stone marks the spot where you will soon be able to bypass route 16 and run on the quite side of Alewife Brook!

This addition to the other greenways links the Mystic River running/biking routes with the Charles River and the Minute Man Trail. You will very soon be able to run/bike from the Mystic River to the Minute Man Trail without more then 100 yards exposure to Route 16 - a very nice run or ride! Come check it out!

Cardiovascular Conditioning: adaptations to aerobic training

2011-09-13T11:20:00.000-07:00

This piece is written for those with little background in exercise physiology, breaking concepts down as much as possible without losing the integrity of the general concept, adaptations our body makes to aerobic training. For health, safety and performance sake, however, I feel it needs to be made clear from the outset that aerobic training is not the “be all and end all” in taking care of our bodies. Other types of training are necessary for a variety of health and safety reasons. Emphasizing only aerobic training can compromise our ability to respond to emergency situations with the speed and power necessary to protect ourselves and can prevent us from maintaining tissues that have the type of mass, flexibility and elasticity needed to respond with quick movements and absorb minor fall. Please feel free to ask me or your trainer more about this.

Cardiovascular Adaptations

Aerobic training, as the adjective implies, develops our ability to utilize oxygen in processing energy. The aerobic response in the body involves the nervous, endocrine (hormonal), cardiopulmonary and muscular systems most directly. The ability of the heart to transport oxidized blood to the muscle tissue is the dominant and easiest response to measure. With the appropriate stimulus, the primal part of our brains triggers a neural and hormonal response that dilates the arteries that supply the skeletal muscles and constricts those that supply less essential structures. Neural and hormonal responses also trigger the heart to expand as fully as possible and contact as forcefully as possible to bring in as much blood as possible and push out as much blood as possible. The complete filling of the heart causes this muscle to stretch to its fullest capacity, therefore enhancing the expulsion blood by way of an added elastic release to the powerful muscular contraction. This allows more blood to be ejected with fewer contractions. This characteristic is maintained and developed in the cardiovascular system with training, so that at rest the heart will continue to need fewer contractions to provide the body with the oxygen it needs to process energy. This, over time, presents itself as a lower resting heart rate in aerobic athletes.

Energetic Adaptations

The advantage behind supplying so much oxygen so quickly to the muscles is that it allows for a very efficient energy processing system called the oxidative system. This system can produce a lot more energy than the other two major energy systems in our body and better utilizes more fuel sources. Aerobic training encourages the production of those enzymes that aid in the oxidative process, allowing the breakdown of carbohydrates and fats to produce energy.

Neuromuscular Adaptations

Processing energy using large quantities of oxygen happens in the muscle cell within an organelle called a mitochondria. This is a complex structure and in itself requires considerable resources. Some muscle tissues are better adapted to utilizing mitochondria. These are the type I muscle fibers. Aerobic training emphasizes the development of type I muscle tissue. As training continues, muscle filaments and neural connections that are deemed as unnecessary in the type I muscle fibers are replaced with mitochondria to process oxygen. Collagen (a light, tough element in the connective tissue) is added to support the muscle cell in the absence of contractile filaments.

The Overall Result

With continued aerobic training, the athlete develops a cardiovascular system that can transport great quantities of oxygen to an oxidative system that supplies the enzymes that produce energy within very light, efficient muscles that are able to produce movement over and over again for long period of time without rest.
This is perfect for the distance runner and has health benefits for us all but, as stated above, it should never be the only form of exercise one gets. It can diminish flexibility, strength, balance and power (the ability to respond quickly with strength) and by itself is not the best way to lose weight or maintain a healthy weight or body mass.

For the complete story…

The above explanation has gaps big enough to drive a truck through. The full story covers a couple of hundred pages in an exercise physiology book and it’s probably best if you’ve had your biology and chemistry before reading it. If you have any questions about this or the body’s adaptation to different types of training stimuli, feel free to book an appointment with me.

Cardiovascular Conditioning: Maximum Heart Rate

2011-09-09T12:04:00.000-07:00

Most people and most athletes don’t fully understand the relationship of cardiovascular to their training goals. We’ve had a string of over-training injuries and conditions during August. Cross country runners pumping out 100 mile weeks and soccer players determined to toughen up quickly with excessive road work, to name just a few. This is no surprise – aerobic training is addictive, easy to do and it is not a simple subject to understand. Even the rationale for the standard formula currently accepted for maximum heart rate is questionable for training purposes. Since the gyms seem to be full of people wearing fashionable heart rate monitors, maximum heart rate seems like a good starting point, for athlete and non-athlete alike, to better understand the cardiovascular response to training in their bodies.

MHR = 220 – age

The standard formula for maximum heart rate (MHR) and its derivatives is MHR = 220 – age. It’s so commonly used in the training world one would think the scientific foundation for the statement was solid and profound and absolutely the last word. It’s none of the above. The equation was derived in the 1960’s from an observation of data Dr. William Haskell had collected and graphed from a study about heart disease. The subjects were male, under fifty, not in particularly good shape, and many smoked. The original goal of his study was to determine just how hard heart disease patients could push themselves and was not designed at all to evaluate healthy individuals or conditioned athletes. So, how did it become "law"? It wasn’t the study, but the timing of its release. Cardiovascular training was just becoming popular in gyms and on the streets (I can still remember neighbors teasing me, yelling “Hey, what are you running from?” when running in 1968!). Doctors and trainers were hungry for an answer to the question “How hard should I run?”. The formula stuck. Not very scientific when it comes to training perhaps, but whole industries grew up around it so it’s probably going to be in people’s repertoire for a while.

For training purposes we like to manipulate different physiological responses within the body which we know are related to how oxygen is exchanged, which can be roughly related to percentages of the maximum heart rate. Therefore, a Target Maximum Heart Rate formula (TMHR - a percentage of the MHR) is used to target these changes.

For example:

A 40 year old woman is instructed to run at an intensity of 75 to 80% of her maximum heart rate.

TMHR(lower limit) = (220 – 40).75 = (180).75 = 135bpm (or about 23b/10sec)
TMHR(upper limit) = (220 – 40).80 = (180).80 = 144bpm (or about 24b/10sec)

Now for my money, if we are going to use a set formula like this, we need to be looking for the percent of change between the minimum heart rate (resting heart rate, RHR) and maximum heart rate. We can then add in the resting heart rate at the end to provide us with a real countable beats per minute number.

Therefore, that same 40 year old female athlete with a resting heart rate of 60 beats per minute would be:

TMHR(lower limit) = (180 – 60).75 + 60 = 150bpm (or 25b/10sec)
TMHR(upper limit) = (180 – 60).80 + 60 = 156bpm (or 26b/10sec)

One of the reasons this formula has stuck around is that it is relatively safe for the average person. For general conditioning purposes, however, it has been suggested that rate of decrease in heart rate from maximum heart rate to resting heart rate after exercise might be a better indicator of when to increase the intensity of an aerobic workout. That is, in general, how long does it take your system to recover is a better indicator of your health and conditioning. In training athletes, perceived exertion levels are often used instead of specific heart rates, which really does make sense, especially with elite athletes whose heart rates often don’t fit the MHR format at all.

One final note – don’t trust the built-in heart rate monitors in the cardio equipment at the gym. The accuracy varies wildly – depends on the machine and the gym maintaining them. Check it yourself. Yes, your calculations are correct – the machine is wrong.

In future blogs, we will examine the specific changes cardiovascular training promotes in the body.

References Utilized:

1. Ultimate Fitness
Kolata, Gina Farrar, Straus and Giroux 2003 NY, NY

2. Essentials of Strength and Conditioning, 2nd Edition
Baechle, Thomas R., Earl, Roger W. Human Kinetics 2000 Champaign, IL

Vision Tests: Saving Life & Limb

2011-08-13T11:07:00.000-07:00

When addressing the topic of preseason pre-habilitation and competition readiness, a thorough screening and testing of athletes usually involves routines that check the cardiovascular, neuromuscular and connective tissue response to the demands of an athlete’s particular sport. One aspect that is often underappreciated is a thorough vision exam. A thorough vision exam is essential to insure optimal performance by the athlete and provide the highest degree of safety for the athlete. This is more than being sure that an athlete can read black-on-white lettering at 20 feet. In fact, bringing the athlete up to the 20/20 in most cases should not be the standard, but just the starting point.

There are four aspects of vision that an athlete should be checked for, their sport depending on how heavily to weigh the results: visual acuity, peripheral vision, contrast sensitivity, depth perception.

Visual Acuity – how clearly can an athlete see? Black-on-white clarity. Essential starting point.

Peripheral Vision – this is visual awareness outside of direct line of sight. All the plyometric exercises and agility drills won’t prevent an ACL injury or a concussion if an athlete can’t see a lateral hit coming.

Contrast Sensitivity – this is the ability to detect the subtle difference is shades of color. The shade of color a moving object or an angled object can make a huge difference in split second responses by the athlete.

Depth Perception – crucial for performance (quarter back) and safety (gymnast).

These tests take very little time and every second they do take is a valuable investment in the safety and success of our athletes.

If your organization does not offer these preseason vision screenings, please visit www.aoa.org/x5428.xml to find a doctor in your area.

References Utilized:

www.aoa.org

Prehabilitation: Hamstring

2011-07-11T10:31:00.000-07:00

One of the most frustrating injuries for any athlete to overcome is the hamstring strain. A strain can occur anywhere in the muscle but most commonly lesions can be found near the musculotendinous junction of the muscle/tendon unit. This is due to several factors. Two of the most important factors are inefficient recruitment patterns of the lumbopelvic (lumbopelvic core) musculature in gait and the accumulation of scar tissue in vulnerable areas of the muscle due to injury.

These two factors can be independent factors but often work together to cause injury and reinjury. It is not uncommon, for example, for a distance runner to have weak hip stabilizers, causing stress along the distal aspect of biceps femoris and the iliotibial band due to over reliance on gluteus maximus and tensor fasciae latae or for a field hockey player to experience to experience pain in her proximal left biceps femoris due to her right hip flexors being locked short. Once these patterns lead to injury, the accumulation of scar tissue near the musculotendinous junctions by itself make these points vulnerable to reinjury but may also interfere with the proprioceptors in the region possibly reinforcing and exaggerating the patterns that caused the injury in the first place.

Taking action before an injury occurs (prehabilitation) is always your best option. Appropriate core training and warm-up for the sport (which crosses a wide spectrum of training from weight training through plyometrics and active warm-ups) can strengthen the necessary structures and prevent overdependence on patterns that cause hamstring injuries. Manual therapy to open and loosen the muscle and break down the accumulation of scar tissue and resolve adhesion may also decrease the probability of injury. Once an injury has been incurred, both these procedures become important to the rehabilitation process as well.

If you want to know more about your specific hamstring injury and how to heal it more effectively, please schedule an appointment by visiting www.soarbody.com.

Prehabilitation: Resistance Training

2011-06-27T10:36:00.000-07:00

The summer season is post-season for many of my collegiate athletes, the perfect healing time to rebuild and rebalance some of the overworked structures in their bodies with resistance training. This is an extremely important phase in the training cycle for injury prevention as well as for performance. Adhering to a resistance training program appropriate for your sport is essential during this period.

Utilizing a personal trainer to help tweak the program your CSCS provided you is my first recommendation for a successful post season. With their expertise and objective perspective they can detect dysfunctional patterns that we cannot see in ourselves and they have the tools to get the job done at their disposal. If your CSCS is also a personal trainer and has hours available to you, that’s even better since they have specifically studied your sport (and often participated in it in college!).

If you feel going it alone this summer with the training program you have been given is your only option, follow it carefully and consistently. Most of the resistance programs that have been brought to me to review make sense in their structure and frequency. They do seem to assume the athlete knows the correct exercise sequence. Correct exercise sequence is important not only for optimal development but also for injury prevention. Dysfunctional patterns can develop through compensation due to fatigue. Strains, and trauma due to accidents, can also occur as a result of trying to perform the wrong exercises in a fatigued state. Below is listed an exercise sequence designed to protect the athlete and allow them to develop their greatest potential by themselves. (1)

1. Explosive whole power body lifts: Power cleans, Snatch, etc.

2. Multi-joint exercises: Bench press, squats, shoulder press, seated row

3. Single joint exercises: Triceps extensions, knee extensions, biceps curl

This may seem trivial to some, especially with the complexity of some of the more elaborate functional exercises woven into their programs as they progress, but the sequence is extremely important.

A final note: great form is essential. One of the themes of post/off season training is to correct, to some degree, the dysfunctional patterns developed by the athlete during the season through repetitive movements and postures necessary for their sport. This is something we always must work to perfect. If you cannot afford the time or money to employ a personal trainer, please book an appointment with me for a functional movement screen. This is not a substitute for a good personal trainer, but it can identify your major functional weaknesses so you can work on them to help prevent injury. If a personal trainer is an option for you, I’ve listed some of the best local independent trainers (they work in training facilities – no membership required) in the Cambridge/Somerville area below.

Maren Kravitz and Heidi Brown, The Training Room, Porter Square, Somerville
http://thetrainingroomboston.com/tr/home

Callie Durbrow, Durbrow Performance, Central Square, Cambridge
http://durbrowperformance.com

References:
1. Essentials of Strength and Conditioning, second edition p.404-405
Baechle, Thomas; Earl, Roger Human Kinetics, Champaign, IL 2000

"Summer's Back!" - ouch!

2011-06-21T09:32:00.000-07:00

As spring passes into summer and the bulk of my client population switches from student athletes to weekend warriors and garden gladiators, so do to the bulk of the "c/o's" from peripheral conditions to back pain, specifically low back pain. Three new cases just last week!

Back Pain is not easy to assess for the therapist or diagnose for the physician, either medical or chiropractic, and can be even harder to explain to the client or patient. This is because there can be, and usually is, more than one factor causing the pain. If there is one dominant factor directly causing the pain, then this is addressed first. Decreasing the major cause of pain allows for greater range of motion which will facilitate the natural healing process of the body as well as allow the therapist to address the imbalance that caused the pain, if this is possible. Sometime the lack of integrity in structures leaves no alternative but surgical intervention. Fortunately, this is usually not the case.

Who do I see about my pain?

If your pain is locally sharp and disabling, it's my duty to refer you out to an orthopedic physician and I recommend that you pursue that course before you see me if those are the symptoms you are experiencing. Be sure your physician is paying close attention to your history and takes the time to perform manual clinical tests on you. MRI's are not enough. In fact, MRI's can present very clear but misleading images. In the case of herniated nucleus pulposus (HNP) they have a 25% false positive rate (1). Where the pain is being referred from and what structures are referring the pain (nerve, ligament, joint or joint capsule) can and should, in my opinion, all be tentatively identified before radiographs are ordered. Medication or injections to decrease inflammation may be options as well as, in severe cases, surgery. Most Physicians will prescribe the most conservative treatment possible.

If your pain is not is not disabling and the pain is local, chiropractic care has been shown to be very effective on acute conditions, especially within the first 6 weeks. A good chiropractor will educate their patient about their condition and provide them with advice about how to prevent the condition from returning, if that is possible.

If physical therapy has been ordered by your physician, it can be the best road to travel toward healing if the patient is compliant. This is because many of the causes of low back pain are due to weaknesses and imbalances that the physical therapist can address. The mantra "Everything heals in the presence of motion" is most relevant in the case of low back pain where inactivity is often one the greatest contributing factors to onset as well as one of the greatest obstacles to healing.

There is much controversy about the role of passive manual therapy, specifically massage therapy, with respect to severe low back pain. For example, in the case of HNP, it has been noted by some that massage is often engaged during the natural healing cycle in which the natural spontaneous re-absorption of the effused nucleus pulposis would have occurred with normal return to movement regardless of the techniques applied. I have to disagree. Is massage is not contraindicated for the pain I would encourage the patient to engage the services of a therapist. Skillfully applied massage will help decrease both inflammation and tension which will facilitate movement, which will in turn aid the natural healing process. Everything heals in the presence of motion - massage therapy can help you regain that motion.

Summer is short! So if you are having back pain, please schedule an assessment with me so we can find the right direction for you to heal the fastest.

References:

1. http://emedicine.medscape.com/article/1263961-overview

References utilized:

Hammer, Warren I. “Functional Soft Tissue Examination and Treatment by Manual Methods, 3rd Edition” Sudbury, MA Jones and Bartlett Publishers, 2007

PRP and Blood Flow Restriction Exercise VS Dynamic Muscular Therapy

2011-02-21T07:48:00.000-08:00

Great strides are being made in developing new techniques that allow active people to remain active into the later decades of their life. Research is being conducted on methods of healing injuries to muscle tissue, primarily by manipulating or eliminating scar tissue formation. Unchecked scar tissue formation within muscle tissue after an injury can impede healing and result in weak connective tissue leading to increased probability of re-injury and muscle weakness. Platelet-rich plasma therapy (PRP) shows considerable promise, but much research still needs to be done to understand the exact mechanisms involved to determine the “when, where and how much” for safe effective prescription. Presently, injections are expensive and, without a universal protocol, show mixed results.

Research is also being done on popular methods of rebuilding active muscle tissue, such as blood-flow restriction exercise which tricks the body into believing it needs to boost the protein necessary to build muscle tissue. Although the potential benefit to older active adults would considerable, the safety of this procedure for older adults is still being studied, blood clotting being a major concern.

Fortunately, there is a time proven method for controlling scar tissue formation and maintaining optimal tissue health in active adults and athletes of all ages – sports massage and dynamic muscular therapy. Sports massage during training and competition can prevent the need for medical intervention later and dynamic muscular therapy can resolve many chronic athletic injuries years after they have occurred – without the need of medication, injections or surgery.

Continued research into methods of medical intervention is essential and I believe breakthroughs for those people who need those options are close at hand. However, the most conservative, safest and effective method for maintaining musculotendinous health is still guided exercise reinforced and maintained by manual therapy.

References utilized:

http://www.boston.com/lifestyle/health/articles/2011/02/21/targeting_sports_related_injuries_with_new_treatments/

Sports Massage: maintaining your edge

2011-01-28T14:23:00.000-08:00

Where dynamic muscular therapy is all about treating chronic repetitive athletic injuries and resolving dysfunctional movement patterns, sports massage is all about maintaining your hard earned training gains and managing chronic conditions at their best possible level. That is, maintaining the most appropriate range of motion (for their event), minimizing discomfort and maintaining optimal tissue health in the athlete.

How often and when?

How often to receive sports massage and when to receive depends entirely on what type of work you need to maintain your conditioning and when your major events occur. With respect to timing, therapists will often provide a set schedule themselves. This may or may not be appropriate, depending on how much experience a client has in judging their body’s needs. For a non-athlete or an inexperienced athlete, a set schedule determined by the therapist may be the best alternative until the client develops a sense of their need for massage. For the experienced athlete, I prefer to have them note how they feel and perform 24 to 48 hours after treatment and track how long it takes to start lose that “edge” they’ve gained from the work. We want to time the work to make sure the edge stays sharp, not to wait until it gets dull. This is important for both excelling at your event and for injury prevention. At the point when their performance starts to waiver, an athlete will strive to keep up with their competition by pushing their performance past their current conditioning, compensating any which way we have to, risking both traumatic and chronic injury. So tracking when you start to lose your edge, rather than waiting until you are in pain, is important for considering how often an athlete needs to schedule sports massage.

Timing around intense events (workouts, games, meets) is also very important. If the athlete has a chronic injury that has tendency to adhere to the tissue around it, this may require more intensive work that may not be appropriate close to an intense workout or event, so the bodywork has to be scheduled with this in mind. Less intensive work may be extremely beneficial to the athlete’s performance directly before, during and after an intensive event. All of this must be considered by both the athlete and the therapist as a team when considering when treatment is most beneficial.

Learning to make these judgment calls is part of the athlete’s educational process and is why education plays such a significant role in treatment at Soarbody Therapeutics.

Treating Chronic Injuries: How long, how often?

2011-01-17T17:03:00.000-08:00

Two services are offered at Soarbody Therapeutics: Dynamic Muscular Therapy and Sports Massage. The goal of sports massage is maintenance of the client’s tissues for optimal performance. The treatment plan is short, simple, and completed within each session. The goal of Dynamic Muscular Therapy is to resolve chronic athletic musculoskeletal conditions. The treatment plan may be quite complex and take several weeks to complete. There is often some doubt among new clients about the need for the frequency and the duration of the treatments. A clear and simple explanation is provided below.

Chronicity: practice makes permanent; history is everything

The old saw practice makes perfect may be true, but with respect to how the body is wired, a more appropriate expression may be practice makes permanent. When you practice the piano, for example, the nervous system is programming specific pathways to fire in certain patterns, specific muscles are developing characteristics (strength, speed, local endurance) based on what the nervous system is demanding, and the fascial system adjusts itself to support the needs of the muscular system. The earlier you learn to play and the more often you practice, the more ingrained these patterns become. This is a good thing! If basic patterns were not executed thoughtlessly and effortlessly, we couldn’t so much as walk never mind play the piano. However, if one learns in their mid thirties that they have been playing the piano incorrectly since they were eight years old, it’s going to be more difficult to reroute the nervous system and create the changes in the soft tissues needed to form new patterns.

So it is with chronic injuries. There may indeed be a specific lesion that needs to be directly addressed (hamstring strain, lateral epicondylitis, etc), but the lesion may well be only the head of the dandelion – eliminating only the flower leaves the root cause of the injury intact to come back with even more devastating effects. Additionally, the body is smart! Once you’ve incurred an injury to one part of the body, the rest of the body will compensate around the injury to continue to meet the demands placed upon it. This compensation can allow movement and eliminate pain for some time – sometimes many years. But these compensational patterns are always inefficient and will eventually fail. For a great many clients, they don’t seek help until these compensational patterns fail, more damage is done and they cannot continue their activities effectively.

Duration: How long will treatment take?

Obviously, the sooner we can stop the body from practicing these compensational patterns, the easier it will be to heal the lesion and learn efficient movement patterns. This is why you have to fill out such an extensive history of activities, injuries, and surgeries, from childhood to present day, for your initial assessment. It provides us with clues as to the root cause of the pain as well as providing a rough idea as to how long it will take to resolve the root cause to best state possible. The older the inefficient patterns, the longer the duration of the treatment plan is likely to be.

Frequency: How many times per week will I need to have treatment?

The appropriate frequency of treatment in a treatment plan is crucial to success. After the first the first manual treatment the client will experience a decrease in pain and an increase in freedom of movement – for a little while. After that short relief, their condition will return back to it’s about its initial state. This makes sense – we can’t expect our piano performance to improve much if we practice once a week. But if we practice several times per week we can capitalize on the success of each subsequent practice, starting at a slightly higher performance level each time. There will be diminishing returns of course as we meet our potential, at which point we have the option of moving on to practicing different, more challenging pieces, which incorporate maintenance of our older skills.

So it is with treatment for chronic injuries. Without the proper frequency to improve at steady rate, the condition is not going to change significantly. We have to catch the improvement after each treatment to start at a higher level than the previous session in order to make steady improvement. See the graphs below.

Graph A illustrates little progress with a frequency of one treatment per week. This may be effective for optimal maintenance of the tissue’s condition once the lesion is healed and the patterns have been changed, but this frequency will probably not be effective for creating the change necessary to heal the lesion and change compensational patterns.

Graph B illustrates effective progress when the frequency of treatment is great enough to capitalize on the improvements made in each prior treatment. Progress is made more quickly and optimal tissue condition is achieved sooner.

Extensive patterns, conditions: Why must I see other practitioners?

Dysfunctional patterns often extend beyond the musculoskeletal system. Such patterns fall outside my scope of practice, which is why I have an extensive referral list of nutritionists, psychologists, physical therapists, structural integration practitioners, chiropractors and physicians. We are multidimensional beings and sometimes require a multidimensional approach to healing.

References utilized:

Joseph E. Muscolino, DC (2011) Treatment Planning and Client Education Massage Therapy Journal, Winter 2010, 4(4) 91-95

Hammer, Warren I. “Functional Soft Tissue Examination and Treatment by Manual Methods, 3rd Edition” Sudbury, MA Jones and Bartlett Publishers, 2007

Injury prevention - Falls over 50

2011-01-12T12:06:00.000-08:00

Some sobering facts and suggestions as a follow-up to the June, 2010 entry about sarcopenia. Falling is the leading cause of accidental death in adults over 70 years of age and after 50 the incidence of hip fracture, often resulting in a fall or from a fall, increases dramatically and many of those victims do not survive the injury or are left immobilized and institutionalized. Some of the factors that increase fall risk are arthritis, orthostasis, decreased muscle strength, balance, coordination, reflexive response time, and the use of 4 or more prescription medications. (1)

There are a number of interventions that are very effective to decrease these factors or their effects. Tai Chi is great discipline as a functional approach to intervention. Resistance training is the most overall effective tool to deal with these factors and slow the onset of the effects of aging. Strength, power, flexibility, balance and coordination can all be very effectively enhanced with resistance training. For the above 50 population, however, this will require a well trained and experienced trainer. For those individuals with little experience in resistance training, a trainer that can accurately evaluate your baseline condition and that understands the special needs of this population is a must for safe training that yields significant results. For those with extensive experience in resistance training, a skilled trainer is essential for guidance and to break poor habits which, although have been tolerated up until now, could spell disaster if not corrected. I have an extensive referral list of very talented personal trainers all around the greater metropolitan area of Boston, so please feel free to ask me for a referral.

Although a good trainer will train the whole person, incorporating all aspects of the body, the lower extremities, hips and pelvis often take longer to recover than the arms, neck and torso. Sports massage can be tremendously beneficial in helping recover from intense workouts and help to maintain appropriate flexibility and elasticity for your activities of daily living and sports. So always consider including sports massage in your training program.

References:

1. Christina A. Geithner, PhD, Diane R. McKenny, BS (2010) Strategies for Aging Well. Strength and Conditioning Journal, 32(5), 36-49

Health & Safety - winter feet

2011-01-11T17:35:00.000-08:00

Dry, cracked feet and toe nails are an invitation to infection. This is common among all people, but especially so in winter athletes. Although TV commercials push products to treat relatively harmless bacterial colonization under the nail, more serious infections, like cellulitis, which can be life threatening if left untreated, can invade the body through cracks in the callus. Streptococcus or staphylococcus are the most frequent bacteria involved, but although cuts, abrasions, and dried, cracked compromised skin are all avenues for infection, why some people are more susceptible is not clear. Nobody is immuned. The symptoms are not always clear either. Where most people will experience inflammation and point tenderness, some people feel little. Cellulitis can spread quickly, become systemic and, if left untreated, can be fatal.

The bottom line here is to take care of your feet. One good option is a medical pedicure (a medi pedi) offered by some podiatrists. One stop shopping - foot care and a check-up for your feet! What better way to keep you on the top of your game? Check out what Dr. Jordana Szpiro has to say about medical pedicures at
http://www.bostoncommonpodiatry.com/content/view/47/57/

Take care of those feet and I hope to see you in the treatment room soon!

Training package specials are back!

2011-01-05T17:51:00.000-08:00

2011 is your year! You have some serious training objectives and you're letting nothing stand in your way. Excellent! Soarbody Therapeutics is here as always to help you reach your goals. With this in mind, we have brought back the Training Package. Training packages offers discount on sports massage to those clients seriously striving for a specific training goal. The savings are significant! Check it out:

60 minute sports massage package = 5 treatments for $375
90 minute sports massage package = 5 treatments for for $450

That comes out to $75 for each 60 minute treatment and $90 for each 90 minute treatment! That's a great deal!

Now, these packages are for those striving to meet a specific goal, so there are some specific conditions that come with the package. They are a contract - one person, one goal, one package. You must buy your package by the end of February and the whole package must be used by September 1st. The package is nontransferable. We sit down to discuss your goals, how sports massage may help them and then you sign a contract agreeing to all the above conditions. Its all very personal, very focused and very success orientated - you'd expect nothing less from Soarbody Therapeutics!

I'm looking forward to helping you all reach your goals in 2011. See you in the treatment room!

2010-12-30T06:58:00.000-08:00

Happy New Year!

Thank you all for supporting the Soarbody Therapeutics in 2010!
Our mission is help clients address the underlying cause of their
musculoskeletal pain and dysfunction and support them in their
efforts to make the very most of the wonderful gifts they have been given. It has truly been an honor to work with you all in 2010 and I hope to see you all in the treatment room in 2011.

There are still a few openings left early New Years Eve and later
New Years Day, so if you need to shake off that New Years Eve 10K
or looking for the perfect low effort start on tackling your lofty training goals for 2011, I would be honored to help you start off on the right foot.

Hope to see you soon!

Sincerely,
Sam

Preventing Tendinitis

2010-12-06T13:47:00.000-08:00

Tendinitis results over time when the force applied to the tendon continually exceeds the force it was intended to absorb. Proper conditioning of the muscles and proper body mechanics are our most powerful tool in preventing tendinitis, but sports massage can be a very important tool in prevention as well. If proper conditioning has been embraced and body mechanics respected, sports massage can help prevent damage to the tendons when the stress is necessarily high (typing for long periods of time, running track, playing basketball, etc) by keeping the muscle tissue open and elastic, resolving adhesion, and breaking down scar tissue, all of which decrease the stress on the muscle tendon. This is not a casual endeavor and takes a knowledgeable and experienced therapist to perform. For athletes of all types (sports, musical, performing arts) as well as working people, its an important tool in preventing tendinitis and facilitating peak performance.

To book an sports massage treatment, please visit my website at www.soarbody.com .

Run for the Arts!

2010-10-16T14:49:00.000-07:00

Boston Arts Academy is the city’s first and only high school for the visual and performing arts. Founded in 1998, the arts are integrated throughout the academic curriculum, with the aim to motivate students to pursue higher education. Boston Arts Academy provides a rigorous arts and academic education to urban youth who seldom have the opportunity to focus on the arts.

This year they are training a Boston Arts Academy team to run the 2011 Boston Marathon to raise money for the school and Soarbody Therapeutics is doing what it does best of course, supporting the team!

In addition to a long list of perks for joining the team, all team members will receive a discount on their post marathon sports massage at Soarbody Therapeutics. If you are interested in joining the team, you must submit an application by November 1st, 2010. Please contact me for applications.

Career decisions: therapeutic options

2010-10-05T11:47:00.000-07:00

These are tough economic times. People are reflecting on just what is of real lasting value in life and seeking to make career moves based on their revelations. Financial considerations and job security are important, of course, but it also becomes quite apparent that, when the chips are down and material gains become scarce, the value of those rewards that cannot be measured in dollars and cents are really what enriches our lives the most.

There are, of course, many paths one can take in applying this insight. Whether you are a university student considering which direction to take you studies or a more mature person such as myself considering a career change, I would like to offer up to you the option of embracing therapy as your next direction in life. Below are three great options for undergrad and graduate candidates.

Occupational Therapy

Extraordinary people restoring and enriching everyday lives

Looking to draw all your talents into a broader, closer, more functional therapeutic experience? Check out the website below and the personal reflection of occupational therapist Deb Kelly that follows.

http://www.aota.org/Consumers.aspx

"Being an OT is the best career I could have chosen as I have truly impacted others and made people’s lives better and they in turn have enriched mine.
I have been an OT for 30 years and have worked in many different and wonderful settings. I started out at New England Rehabilitation Hospital in Woburn Massachusetts where there were many OT’s to learn from and work alongside as well as learning a lot of wisdom from the older people that were there. The younger patients in rehab often achieve results from sheer determination and hard work that the OT’s and PT’s can help happen. I then worked in an acute care hospital for a short stint before going into Pediatrics. In Pediatrics you can work in regular education or special education and both are wonderful experiences. Imagine helping a child learn how to do something that is very hard and frustrating; just imagine the wonder of finally being able to tie your shoe or cut out a shape without help. The flexibility of hours makes it career that you can easily work either part time or full time. Helping others achieve daily successes is very rewarding!"

Deb Yoerger Kelly, OTR/L
Boston School of Occupational Therapy
Tufts University - Class of 1981

Physical Therapy

Restoring hope, fulfilling dreams

Love being cutting edge? Crave the latest research, being ahead of the therapeutic curve and recognized as such by the medical community? Physical therapy may be for you! Click the link below for more information and then read what two of the finest physical therapists I know have to say about the industry.

http://www.apta.org//AM/Template.cfm?Section=Home

In a hospital setting

“The physical therapy path seemed to fall into place for me. Looking back, I had no idea what I was getting into. A cardiopulmonary course my first year of grad school sent my head spinning and I have never looked back. Here is a system of pumps that, depending on flows, volumes and hundreds of physiologic factors can make someone feel wonderful, terrible or even mean the difference between life and death. It still sometimes surprises me what an effect exercise can have on that system.

As an inpatient physical therapist on cardiothoracic service of a world-class hospital, I have the pleasure of taking the knowledge I have about physiology and the effects of the right types of exercise and a patient with his or her goals and aspirations and marrying the two. Sometimes it is the simplest of interventions that has the greatest impact. Sometimes I am applying the world of the known to the unknown: a patient with a new type of circulatory assist device undergoing clinical trials
I work with some of the most brilliant minds in physical therapy, medicine, nursing, speech therapy, respiratory therapy, occupational therapy and numerous other disciplines. Each day we push each other toward new horizons to help the patients for whom we work”

Abby Folger, PT, DPT, CCS
Board Certified Specialist, Cardiovascular and Pulmonary Physical Therapy
Simmons College, class of 2005

In a clinic setting

"I had always loved helping people and I knew I wanted to work directly with people. I was drawn to the medical profession though I wasn't sure that medical school or nursing were my calling. My cousin is an occupational therapist and I spent some time with her, a speech pathologist, and a physical therapist to help me learn more about these professions. I really enjoyed what physical therapy was all about, particularly orthopedics and sports injuries. I played all kinds of sports growing up and though I'd had my share of stitches, broken bones, etc. I'd never needed physical therapy. I found that physical therapists worked directly with many different people in a variety of settings. I was lucky to choose physical therapy as a profession upon entering college and truly love it. It is a very challenging as well as satisfying and rewarding. It's a job where you can continue to learn more and find the best ways to help people achieve their own personal goals to return to full function and recreation"

Kim Mace, MSPT

Certified Athletic Trainer (ATC)

Saving lives, restoring dreams - the crucial link between medicine and therapy

Do you enjoy working in an exciting environment, take pride in your technical expertise, and are fearless in making quick, perhaps life saving, decisions? ATC may be your road to fulfillment! I hate to show bias, but this is where my heart lays, the direction in which I’d love to go. You are the physician’s right hand. You are on the field, the first to respond to trauma, and in the treatment room, guiding patients through rehabilitation. Prehabilitation, prevention, intervention, rehabilitation are all in your scope of practice. Pretty exciting stuff! For more information on athletic training, click the link below. The reflection on the life and career opportunities of ATCs that follows was donated by one of the sharpest athletic trainers in the industry. They have exercised their background as an ATC in a variety of environments and they provide a valuable, unbiased perspective on what to expect from the degree and the industry. A must read!

http://www.nata.org/

“Athletic Training requires at least a Bachelor’s degree from an accredited university, and most do go on to receive a Master’s degree. Alternately, one can pursue an entry-level Master’s degree if they already hold a Bachelor’s in another area. To practice as an athletic trainer you must also pass a national certification exam and apply for licensure in the state in which you will be working. ATC’s can practice in a variety of settings including traditional high school or college positions, as well as clinics, hospitals, doctor’s offices, and corporations. Our main responsibilities include the prevention, evaluation, treatment, and rehabilitation of injuries acquired by physically active individuals. It is a very rewarding career as days are spent helping others overcome injuries and other physical challenges. Rarely does a day go by where we do not feel gratification, and most ATCs truly enjoy what they do. Perhaps the best feeling is seeing an athlete succeed back on the court/field after they’ve suffered a serious injury, and spent many grueling hours rehabilitating under your supervision. But beware, no career is perfect! Athletic trainers are often overworked and underpaid. Night and weekend work is a must, as well as flexibility in scheduling. Overall, the benefits definitely outweigh the drawbacks; there are few careers where people can say they spend their days helping others achieve their goals and dreams, and athletic training is one of them.”

Anonymous, BS, MS, ATC, CSCS

This is indeed an exciting time for all of us considering new career directions. Good luck to all of you seeking new horizons and I hope to see some of you walking the therapeutic path with me.

Time and Touch: Indispensable Assessment Tools

2010-09-21T09:58:00.000-07:00

In our culture, time is money. As such, the more time we can save, the more productive and wealthy we become. We organize and miniaturize, striving to develop systems and products that will allow us to do more in less time. We honor this axiom and praise those who embrace it with religious fevor. And it's killing us.

There's no need to wax poetic here. Most people are aware that our culture's obsession with productivity has led to increased work hours and decreased direct human interaction. Real listening and touching take time and require the full presence of two people. Too often listening has been reduced to "communication" in the form of emails, texts, voice mails and the occasional phone call and touch has been reduced to sex. With decreased interaction through intimate whole person listening and meaningful touch comes an increase in cortisol production in the body which, when out of balance with the anabolic hormones, can have serious long term detrimental effects and increase the healing time for musculotendinous injuries. Intimate communication between people takes time and is essential to good health.

Unfortunately, the physiological repercussions within our body are not the only health threat posed by our miserly use of time. The "time is money" principle rules our health care system as well. The health insurance systems that physicians, therapists, and chiropractors must work within precisely regulates the time spent on procedures. Procedures are coded and time limits are tight. Because of this, (and arguably other reasons)physicians often opt to order diagnostic lab tests and scans rather than spend time listening, palpating, and performing manual clinical tests. This a topic of much discussion within the medical community and I invite you to listen to the NPR link below for insight into this issue.

http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=4&islist=false

This issue is not restricted to physicians or the insurance industry for that matter. Any therapist or chiropractor that takes insurance is bound by codes as well. To spend more time on a patient than the code permits means they are not being reimbursed for some of their time. The temptation for chiropractic and therapeutic mass production is considerable. The therapists and both medical and chiropractic physicians on the Soarbody referral list do not succumb to this pressure and take the necessary time to perform their job to the highest standards. Some massage therapists, bound to our cultures desire to maximize their time and increase production, are too often focused on cranking out clients every hour on the hour, and then suggest the client book again based on the benefits of massage rather than the actual indications for the specific condition. You will not find these therapists on the Soarbody referral list either.

This is much of what dynamic muscular therapy is all about - plugging the "time lesion" in the health system. Clients have often asked me why I do not charge by time for dynamic muscular therapy and why I do not guarantee manual therapy during a session. Dynamic muscular therapy is about seeking a cause of a clients condition and then coming up with a plan to eliminate that cause if possible. This can not be done with a 5 minute intake interview and 50 minutes of massage therapy by itself. It takes careful listening, careful testing, and extensive palpation. You may or may not get massage therapy - in fact, you may be immediately referred to a medical physician. But you will receive the time, attention, and skill level your condition deserves and be much closer to eliminating your condition altogether while receiving all the health benefits that real listening and caring touch can provide.

ACL and MCL injuries: prevention through insight

2010-09-05T18:53:00.000-07:00

Summer has drawn to a close and preseason “Captains sessions” have transitioned to fitness evaluations and try-outs. Change is in the air - autumn is upon us and a brand new season is ahead, full of excitement and challenge! The crisp autumn air also heralds a refreshing transition from a focus on chronic RSI injuries, of the tri’s and marathoners, to good old fashion trauma as soccer, field hockey, volleyball, and football dominate the sportscape.

As refreshing as this change may be to those of us who work with athletic injuries, the onset of disabling traumatic injuries is a source of heartache and real grief for the athlete. Resolving this grief inevitably triggers the question, “How and why did this happen to me?”. Although a seasoned athlete resolves this stage quickly and gets busy with their rehabilitation a.s.a.p., the question itself becomes important outside of the grieving process. Exploring this question objectively can prevent their injury from reoccurring and prevent it in the future athletes they will be coaching. This is the perfect forum to do just that

The laundry list of standard traumatic injuries suffered in these sports is quite long and which one is the most significant depends on which one we are suffering from at the moment. This piece will focus on one of the most dramatic and feared by field and court athletes, the ACL rupture and Unhappy Triad. The topic was chosen because a number of my favorite athletes have already gone down to anterior cruciate ligament (ACL) type injuries just preparing for their season ahead – two of them seniors this year. This article is dedicated to them, their spirit, and their resolve to continue to contribute to their teams and come off their injuries even stronger than before. Heal well - my thoughts are with you.

The Triad: ACL, MCL, Medial Menicus

Simply stating that too great a valgus force snaps the medial collateral ligament (MCL), which rips away the medial meniscus, and, being left the sole supporter, pops the ACL is a text book explanation of a trauma and does not develop an understanding of the structures at risk needed to build a cautious and proactive attitude. Taking a look at the forces involved and the intricate devices used to direct those forces is a more effective approach. Let’s start with a very basic look at how the power for our locomotion is generated and how the body transmits the energy from that power to create the forces that produce motion. We can then look at the unique way in which the knee controls that energy and consider how to prevent the mechanisms involved in that control from being damaged.

Power transmission

Humans are bipedal - a unique and efficient means of long distance locomotion, indeed one which current evolutionary theory believes came long before the rest of the unique changes we attribute to our survival. The power for this locomotion is initiated at the hips. The human pelvis is specially adapted for this and the rest of the body has developed around it. To increase efficiency and decrease power losses, a series of levers and power supplies are provided between the hips and the ground. This series allows raw power to be transformed into what we experience as fluid motion. At the hips, relatively large, broad muscles with broad attachment sites work with relatively few but thick ligamentous structures to transmit energy through the thighs, legs, and feet to the ground. Although power and control elements are found throughout this power chain, the closer we are to the beginning in this series (the hips), the more power production is emphasized and the further along the chain we move, the more control becomes a factor.

The hip joint is a single ball in socket joint, capable of circumduction, but lacks fine control. The last set of levers in this power transmission series are the ankle and feet joints, a complex conglomeration of joints which allow us to negotiate uneven surfaces. Much of the power produced in the hips that is transformed into motion is done so only with the aid of muscles in the legs that channels that energy by moving the feet and legs into the necessary position to take advantage of the power produced in the hips and thighs. This means that the feet and legs have to move in unison with, although somewhat differently from, the hip and thighs as we move through the gait cycle. The joint that negotiates this difference is the knee.

Power transmission is often performed most efficiently in nature in waves of energy. Our bodies are no different. Complex waves of electrical, chemical, mechanical and kinetic energy are exchanged to provide motion. This is worth taking a look at because the structures that exchange the force and ground reaction force that provide our movement are designed around this wave like action.

Our locomotion is though our gait. This involves the sum of movement in the frontal, transverse, and sagital plane (see www.becomehealthynow.com/article/anatom/704/ for a quick review of the planes). The hip rises (frontal), rotates (transverse), and move forward (sagital). The two wave like movements (up and down, side to side) then occur while we are going forward.
Graphing this we get a familiar shape, a spiral, or more precisely, a helix. Our axes here then are:

y = frontal ≈ a cosine function
x = transverse ≈ a sine function
z = sagital ≈ some constant (we’ll call it t)

Although an oversimplified model, it illustrates the point that we “spiral” through space and that the mechanical structures within our bodies are designed around this movement. This is quite obvious with one look at the anatomy illustrations in the Soarbody treatment room. The knee is no different. The complexity of its design allows it to negotiate the spiral transmission of energy from the larger moving femur to the smaller fixed foot and tibia. Check out the illustrations below – it’s a transverse view, superior aspect, of the tibial plateau. The spiral in the ACL is obvious, but you’ll notice the orientation of much of the rest of the supportive tissues also have a spiral configuration to them.

Knee Mechanisms and the Triad

There is too much that occurs in gait to describe here, but to summarize, the foot, leg, and thigh oscillate from foot pronation, internal rotation of the tibia, and finally internal rotation of the thigh at heel strike to the opposite attitudes at toe off - sort of a coiling and uncoiling. To accomplish all this, there must be both flexion and rotation at the knee with the larger femur acting on the smaller tibia without slipping off the tibia or grinding down or fracturing the smaller tibial plateau. It’s a very neat trick that involves the triad (and more!) and some very exact timing.

Let’s start with how the big old femur can effectively transmit force to the smaller tibia without destroying the tibia. The meniscus shoulders much of this task. This unique structure is a semicircle of fibrocartilage secured to tibia tibia via the coronary ligament. It has a bowl shape, where its thicker vascular perimeter tapers down to where a very thin avascular part transitions to an opening that exposes the articular surface of the concave tibial condyle to the articular convex surface of the femur. Viewed from the center outward then, the slope of the meniscus increases rapidly as we move outward from the center to present a much thicker, vascular outer edge. This presents an increased surface contact area to the femur, distributing the force applied more evenly across the tibial condyle and thus decreasing wear on the articular surfaces (see figure below). The elastic quality of the fibrocartilage also allows it to distort somewhat, providing an extra cushion as axial and rotational force is applied to the knee. Notice I used the word “distort” above, rather than crush or squashed, when the pressure applied to the meniscus is controlled. The coronary ligament permits the meniscus to have some mobility and a number of other structures (which we will discuss below) are involved with keeping the meniscus in just the right place at the right time to keep from getting squashed and torn. See the illustration below.

Keeping the meniscus in the right place at the right time by itself is a nice trick not only because there is both flexion and rotation in the knee, but because flexion of the knee involves more than simple rolling. If the knee joint were simply a hinge joint that rolled, the bigger femur would roll right off the back of the smaller tibia. To deal with this incongruity, the condyles of the femur have adapted a shape that is not concentric, but rather a shape that creates a change in the radius from a changing axis of motion (an evolute for you geometry fans), allowing the condyles to rotate for only about the first 15-20 degrees after which it transitions into a sliding motion to complete the flexion. See illustration below.

Recalling that out knees are part of a conduit that transmits mechanical energy in a spiral fashion as it flexes and extends, it follows that there must be a rotational aspect to its flexion and extension. And so there is. To see this, while sitting (in shorts or buck naked is best), lift one thigh between your forearms and allow the knee to fall into passive flexion. Holding the thigh firmly between your forearms to prevent any influence from the hip rotators, extend the knee. You will see, through observation of the foot, that the tibia rotates medially as you approach full knee extension. This demonstrates rotation in the knee during extension, with the tibia medially rotating on the femur in this open chain configuration. With the foot planted in the closed chain model, it is the femur that rotates on the tibia. This aspect of the rotation in our cycle is what allows the femur to medially rotate and lock into place just in time to take the weight of the body. This is accomplished by a difference in size of the femoral condyles. The medial femoral condyle is actually bigger. This means that the lateral condyle will complete its roll and slide before the medial condyle. The medial continues it roll and slide, wheeling and locking the femur into a slightly medially rotated position when the foot is planted. See illustration below. (Note: because there is much focus on this “automatic locking mechanism”, I find people lose sight of the fact that it is only part of a continuum of rotation. Much of the rest of rotation through the knee into the leg is guided by the ligaments of the knee. This is worth your continued study.)

So how do the menisci keep up with all this rolling, sliding, and rotating without being crushed and torn? As it turns out there is a pretty precise dance that occurs between the muscles that flex and extend the knee and the positioning of the menisci. When we flex the knee, semimembranosus retracts the medial meniscus posteriorly in sync with the action of the medial femoral condyle. Popiteus performs the same trick with lateral meniscus. Then on extension, the meniscopatellar ligament pulls the menisci anteriorly through the action of the quads via the patella. It’s actually a whole lot more complex than this (again because of our spiral influence) with the end result of all the factors being more of rotation of both menisci in the same direction during knee flexion and both in the opposite direction during extension extension, but the idea is the same – it’s a complex dance!

Illustration inspired by Calais-Germain, 195

Just to stay on point here: Why all this sliding and rolling and rotating within the knee? Because it’s working within a spiral. The rolling, sliding, and rotating within the knee will demand some degree of lateral, medial, anterior, and posterior translation and, with that, structures that set limits on these movements will also be needed. Although the muscles that cross the knee play an important role in stabilizing the knee, the tough passive structures that limit rotation, anterior/posterior translation and lateral/medial flexion of the knee are the ACL, PCL, MCL, LCL. In limiting the range of these movements, they define the boundaries at this juncture of a conduit through which the energy can be transmitted to and from the hip. If disrespect these limits (and perhaps rupture one of these boundaries) we can expect a dramatic power loss. Take a look again at the two illustrations below. Can you see intuitively now where there are limits in magnitude to the helix and that passive elements are designed to both aid and set limits on that motion? You should also be able to recognize adopting postures (active or static) that push these passive structures to extremes also compromises, and possibly jeopardizes, the flow of energy between the hips and ground.

So here then are the primary responsibilities of main structures that facilitate the passage of and set limits on the energy that passes through the knee.

Anterior Cruciate Ligament

The main role of the ACL it to prevent the femur from slipping backwards off the tibia. It’s more robust counterpart, the posterior cruciate ligament (PCL) prevents the femur from slipping forward off the tibia. The way the fibers of the ACL are oriented, it’s taut in both extremes of flexion and extension, and offers the least support and the most slack at about 30 degrees of knee flexion. When the tibia is rotated inward (medial rotation) the ACL wraps around (crosses) the PLC to resist medial rotation. The cruciate ligaments pass between the condyles of the femur and are therefore outside of the synovial joint capsule.

The Medial Collateral Ligament

The collateral ligaments run along the inside and outside of the knee to prevent the knee from buckling inward or outward. The medial collateral ligament is taut and provides the most support when the knee is extended and the least support, when it’s lax, during full knee flexion.

The Medial Meniscus

The menisci are asymmetrical cartilaginous discs (sort of like horseshoes in shape, similar but not exactly the same shape) that lie on the tibial condyles within the synovial joint capsules and play an important role in weight distribution as the knee goes through its range of motion. They are thinner toward the middle and thicker toward the outside. The medial meniscus communicates with the medial collateral ligament through the joint capsule.

Onset of injury

These three passive elements (and more!), along with the muscles that surround the knee, support the knee to keep it stable. Stressing any of the ligaments past their tolerance can result in damaging the structure. The ACL in particular is at risk when the knee is at or near full extension or at 90 degrees of flexion and a force is applied from the outside of the knee toward the inside. This force can be applied by foreign body (getting tackled – “clipping”), or can be the result of the athletes stance and own force, which is often the case. Specifically, if an athlete has their tibia externally rotated, with their foot planted, and their femur has started to internally rotate as they apply force to the knee, they create their own valgus force at the knee. See the figure below. This can happen, for example, when a football player attempts to “cut” sharply, a soccer player attempts to reach out too far with their foot, or a volleyball player lands in that same position - that is, attempting deceleration in the position described above. If the force is great enough in this position, the MCL and the medial meniscus can also be ruptured, resulting in the “unhappy triad” of simultaneous injuries as the ACL ruptures as well.

When the force is great enough to rupture all three elements of the triad, the order of collapse and rupture is usually: MCL, meniscus, ACL. The force snaps the MCL, which rips away the meniscus with it, and with no support left the ACL then pops as well.

What about the active elements, the muscles? Can’t they stop the knee from collapsing inward? Unfortunately, no, not once the chain of events that results in the unhappy triad begins. Although conditioning and training can prevent the non-contact ACL/unhappy triad injuries from starting (providing more resilient connective tissue, increased awareness in the athlete, and quicker response times) once a “stance of no return” is adopted and the athlete’s weight is applied, the muscles will not be able to support the knee in time to stop the injury. The average time for the the reflex signal from the ligament to spine and back and to the muscle is 87 msecs and then to fully engage the muscles in the co-activation response needed to make an attempt to protect the ligaments is another 115 msecs. This is way to slow a response considering an MCL rupture can occur 73 msecs after pressure is applied and the spindles may not start their reflex communication until 128 msecs have passed. (Saidoff, p. 695) When the ACL ruptures by itself, the athlete often hears or feels a pop and experiences an involuntary collapse of the knee. Swelling occurs within 2 to 24 hours, but usually won’t occur at onset.

One of the more dangerous stances. Here, weight is applied to one side, near full extension, with tibia laterally rotated, femur is medially rotating. This can result while trying to pivot with foot planted (rather than on the ball of the foot), landing from a jump in this position, etc.

Probability of Injury

There are several factors that increase the probability of incurring a triad injury. Currently, the percentage of noncontact ACL lesions seems to be higher in female than male athletes. A greater Q-angle (see figure below) and a general tendency to have increased laxity of supportive connective tissues (ligaments and joint capsules) are some of the intrinsic factors that are thought to account for much the disparity between the percentage of women verses men that incur ACL and triad injuries. Training and experience can influence many of the extrinsic factors, making the best of increased strength, flexibility, resilience and elasticity of connective tissue, coordination, spacial awareness. The particular sport too, of course, increases the likelihood of these types of injuries.

The Q-angle is the angle formed between lines drawn between the ASIS and the center of the patella and from the center of the patella along the midline of the tibia. The greater the Q-angle, the greater the valgus pressure to the knee. Women in general have an average greater Q-angle because in general they have broader hips.

Prevention of Injury

Training and conditioning are used to decrease the likelihood of the triad injury. Drills that increase agility and improve alignment and sports specific training that focus on proper, safe execution of specific skills along with conditioning that builds the resilience of the connective tissue that support the knee are effective in decreasing the probability of injury.

Summary

The body moves through space by executing a combination of rotational movements that transmit energy through a spiral pattern. The body is designed to facilitate the transmission of this energy, as demonstrated by its spiral architecture. The knee facilitates this transmission at a juncture that negotiates the generation of power in the hips and thighs with the legs and feet that perform the complex adjustments necessary to transfer energy to and from ground potential. The structures within the knee permit a certain amount of flexibility to facilitate this negotiation and thereby set limits for this spiral transmission. If these limits are exceeded, the conduit will lose it’s integrity. Power may be lost immediately and entirely if the breach is severe enough and the conduit will need to be repaired to restore energy flow and power transmission. This is the case with the Unhappy Triad. To prevent such a breach, efforts should be made to strengthen the structures that support the knee and to train the athlete to adopt safe stances and avoid putting the knee into stances that risk violating the limits the connective tissues of the knee.

References Sited:

1)Saidoff, David C. , McDonough, Andrew L. “Critical Pathways in Therapeutic Intervention, Extremities and Spine” Ed. White, Kellie, St Louis, MO, Mosby, Inc., 2002

2) Calais-Germain, Blandine “Anatomy of Movement”
Seattle, WA Eastland Press, Inc 1993

Other texts used for research:

Houglum, Peggy. “Therapeutic Exercise for Musculoskeletal Injuries, 2nd Edition.” Primary and Secondary Healing. Ed. David H. Perrin. Champaign, IL, Human Kinetics, 2005.

Clemente, Carmine D. “Anatomy, A regional Atlas of the Human Body, 5th Edition”
Baltimore, MD, Lippincott Williams & Wilkins, 2007

Hyde, Thomas E., Gengenbach, Marianne S. “Conservative Management of Sports Injuries, 2nd Edition” Sudbury, MA Jones and Bartlett Publishers, 2007

Hammer, Warren I. “Functional Soft Tissue Examination and Treatment by Manual Methods, 3rd Edition” Sudbury, MA Jones and Bartlett Publishers, 2007

Moore, Keith L., Dalley, Arthur F. “Clinically Oriented Anatomy, 4th Edition”
Ed. Kelly, Paul J. Baltimore, MD, Lippincott Williams & Wilkins, 1999

Smith, Laura K., Weiss, Elizabeth L., Lehmkuhl, L. Don “Brunnstrom’s Clinical Kinesiology, 5th Edition” Philadelphia, PA F.A. Davis Company, 1996

Levangie, Pamela K., Norkin, Cynthia C. “Joint Structure and Function, A comprehensive Analysis, 3rd Edition” Philadelphia, PA F.A. Davis Company, 2001

Low Back Pain - preventing disc lesions

2010-07-18T15:11:00.000-07:00

Low back pain is one of the biggest contributors to lost work hours in the U.S. Without getting too technical (which it has been suggested I can be sometimes), it doesn’t take a lot of imagination to see why. When we flex at the lumbar spine, the low back is at the junction of two long lever arms, the lower lever arm consisting the legs, hips, and pelvis, the upper lever arm being the spine and all attached to it. The longer the lever arm, the greater the mechanical advantage (“Give me a long enough lever and I’ll move the world!” ~ Archimedes) but also the greater amount of force transmitted through the fulcrum. A great hands on example of this is a brush cutter that’s used on saplings and thick brush. It looks like a rose pruner, with the same 3 inch raptor type scissor blade, but the handles are long wooden affairs of 3 or 4 feet in length. It can feel rather empowering to cut through your first sapling like butter (not so much after 6 hours of such work of course!). Although effortless to us because of the long lever arms, if you touched the base of the blades near the fulcrum of the cutter after just a few cuts, you would find it hot to the touch. A lot of force is being felt at that fulcrum and being dissipated as heat.

So it is with our lumbar spine. When we flex it bending over, it feels pretty effortless to us, but the pressure being exerted is tremendous. It has been estimated that even utilizing proper lifting squat form, maintaining a neutral spine, lifting just 59 lbs. can create a compressive force in the lumbar spine of over 1568 lbs. (McGill, 82). And that’s with the all the active elements (musculature) of the back all firing to help support the load. When we flex the lumbar spine past a certain point, many of the major supporting muscles stop actively helping to support the load and the load is then almost entirely supported by only the passive elements (ligaments, vertebral discs, connective tissue in muscle). That’s a lot of pressure on Pinocchio’s strings! You can see why I am always instructing you on maintaining a neutral spine when lifting.

Know thyself!

It is important for everyone to maintain a healthy low back, but especially so as we age. Although all the structures of the low back are challenged with age (sarcopenia, osteopenia, osteoporosis, etc.) and use, this piece will focus on the intervertebral disc because it is especially vulnerable.

(Illustrations redrawn from McGill, 44 and 40)

The disc is placed between each vertebra to allow mobility and provide shock absorption for the spine. It’s built something like a jelly doughnut (more like a jelly bagel!) with a soft gelatinous middle (nucleus pulposus) and tough, though pliable, concentric, laminated bands of fibrous material (anulus fibrosus) that surround and contain the nucleus pulposus. Looking at the illustration above, one can see that these outer rings are configured much like plywood and depend on the coherence of the layers for its overall strength. The “flat” surfaces of each vertebra between which the disc is sandwiched (end plates) are pliable, somewhat like a drumhead, and provide some give each time the disc is compressed. Because the material within the bony body of the vertebrae is a matrix of spongy bone (trabecular bone), it provides “the give” allowing the plates to bend. The discs are also supported by ligaments that run in front of them along the spine (anterior longitudinal ligament) and behind them (posterior longitudinal ligament) and then the spine is stabilized by a network of active elements (muscles) and passive elements (ligaments, fasciae).

Over time, uneven application of pressure (flexion of the lumbar spine is the biggest culprit here) on the laminated, concentric laminated bands can cause the bands to separate and crack. Furthermore, as we age, the mass of spongy bone within our vertebrae can decrease, providing too much give in the end plates, causing them to split and leaking the gelatinous material into the body of the vertebrae. This in turn decreases the shock absorption ability of the disc, increasing the pressure and separation/cracking of the fibrous bands, causing them to bulge (protrude) out. If the cracking gets bad enough the inner gelatinous material can squirt out (effuse) of the disc. Either protrusion of the fibrous band or effusion of the gelatinous material can cause severe pain.

What you can do!

Before we all despair over our doomed low backs, know that there is hope. The collapse described is more of a function of overuse, improper use, than age. Much of this can be avoided. If fact, proper exercise can strengthen some of the structures involved. Since flexion of the lumbar spine is the main culprit in injury for most of us, one way to look at this is that we only have so many lumbar flexions we can do in one life time before our discs break down. We want to use them wisely, on only the good stuff (use your imagination!). A worthy goal is to have one lumbar flexion left just before you die – not a bad way to go out!

So here are some helpful hints so save your low back until the end.

1. Use proper lifting techniques. Some links are provided below for basic instruction.

www.mayoclinic.com/health/back-pain/LB00004_D

www.bnl.gov/esh/shsd/pdf/safe lifting and carrying techniques.pdf

2. Try to maintain proper alignment when sitting, but get up as often as possible and shift sitting positions. Sitting for long periods of time, even in proper alignment, loads the low back without almost any aid from core musculature, and the total lack of movement decreases circulation to the vertebral bodies themselves.

3. Walk briskly. Sauntering (mall walking) and standing loads the low back without much support from the core muscles. Walking briskly, swinging the arms from the shoulders (not just from the elbows!), engages the core muscles and shifts mass distribution to support the low back. This can be very therapeutic for back pain.

4. Don’t do movements that require flexion of the spine as soon as you wake up in the morning. You are taller in the morning then when you go to bed – perhaps as much as 19mm! This is because the intervertebral discs hydrate at night, swelling the discs. This can increase the disc bending stresses by 300% and the ligament stresses by 80%. 54% of this increase is lost within the first half hour after rising from bed (McGill, 96). So take your time and enjoy your coffee in the morning before dashing about to work, the gym, or yoga.

5. Don’t go right from activities that cause you to flex your spine for long periods of time (sitting in a car, sitting on a couch, sitting at your desk for hours, bent over gardening, sitting on the bus for hours before and after athletic competition, etc) to lifting loads. The soft tissue that support the spine have special nature to them (a thixotropic quality) that allows them to “creep” to a new length and hold that length when under pressure for extended time periods. The ligaments that limit how much the vertebrae can move will become longer and stay that length for a period time after sitting (see figure below). This takes away much of the passive support of the spine, risking injury when lifting.

(Illustration redrawn from McGill, 63)

6. Maintain strong core musculature. There are lots of rumors and old disproved theories on why a strong core helps support the spine, so see me for the real story some time. The bottom line is that a strong core is crucial to spinal health. Sit ups, crunches, curl ups, hang curls can put tremendous pressure on the low back. But the rectus abdominis and core muscles of the trunk can be strengthened without these exercises. Investing in a good trainer to help you is the best way to go with this. For a choice of independent personal trainers, check out the websites below and feel free to ask my advice when matching your needs to a particular trainer.

Somerville
The Training Room, www.thetrainingroomboston.com

Cambridge
Durbrow Performance, www.durbrowperformance.com

Back Bay
Balans, www.bostonbalans.com

Kenmore Square
Joint Ventures Physical therapy and Fitness, www.jointventurespt.com

There is much, much more to back pain than failure of intervertebral disc integrity. For more information about how different exercises affect the low back and advice on which exercises might be best for you, please schedule an appointment with me. My office hours can be found at www.soarbody.com.

References:

McGill, Stuart, Ph.D. “Low Back Disorders: Evidence-Based Prevention and Rehabilitation, 2nd Edition.” Ed. Robinson, Loarn Champaign, IL, Human Kinetics, 2007

Other references utilized:

Clemente, Carmine D. “Anatomy, A regional Atlas of the Human Body, 5th Edition”
Baltimore, MD, Lippincott Williams & Wilkins, 2007

www.mayoclinic.com

www.bnl.gov

Fighting Sarcopenia

2010-06-21T17:00:00.000-07:00

Sarcopenia (Gk, sarx, flesh, penia, poverty) in simplest terms is the age associated loss of muscle mass and functional capacity (1). It is a threat to athletes and non-athletes alike increasing the risk of both injury and disease with age. The image conjured up by the term is a frail man with a walker in his 90’s. Nothing could be further from the truth. Although decrease in muscle mass is the sign most easily recognized by the lay person, it really is the loss of functional capacity due to the aging process and disuse that define the condition. Simply put, loss of functional capacity means loss of strength and power, which involves the neuromuscular system as a whole. When considering the loss of functional capacity, due to the aging process and disuse, as the major indicator, nearly all woman and 70% of men over 50 would be at risk for sarcopenia (1).

To those of us over 50 in good shape, that’s shocking. We’re still 21 aren’t we? Reflect a little bit on that feeling before we go on. If you are 55 years old, you have experienced small changes occurring in your body for about the last ten years. You may still be quite proud of your race times and how well you can keep up with younger people, but are glad you are in the master’s division. If you are not experiencing an increasing rate of injuries, you are spending an increasing amount of time in the gym on specific exercise routines to prevent them. It is becoming increasing more difficult to come off injuries and heal them completely. You are not 21, just 55 in good shape. A natural decline, a running down of the clock, is occurring in our bodies that is out of our control and cannot be switched off. Isolating just the physiological mechanism of this decline, the main culprit seems to be a decreased rate of protein synthesis as well as a decrease in the production of anabolic hormones (1).

So does that mean we just fold, rot, turn into spindly legged pot bellied duffers who complain about our bad backs and struggle to get on and off the couch? Of course not! The deleterious effects of this decline (decreased muscle mass, decreased muscular innerviation, increased intramuscular fat/fiber), are accelerated by an aging/disuse cycle. Basically, if we don’t use our muscles and encourage the building of muscle and nervous tissue, break down of tissues is faster than build up. This leads to further decreased functional capacity of the muscle, leading to more muscle atrophy, leading to disability/injury (Ouch, my shoulder, back, knee, etc), which leads to more disuse, etc, etc. In our high stress culture where cortisol reigns supreme, where we sit at computers all day long and drive to and from work, this cycle can start to transform us into the disabled caricature described above pretty quickly. Fortunately this cycle can be broken with exercise to stimulate the anabolic (building up) response needed to counteract the breakdown.

“Well I get plenty of exercise, so why should I be concerned?” Well, because not just any exercise will do. Certainly, a variety of exercise is indicated for a healthy aging process. Yoga promotes flexibility, balance, and strength; running, cycling, and swimming promote aerobic cardiovascular conditioning; many sports and activities that require high levels of repetition promote muscular endurance. But because the sarcopenic process is a struggle between the build up and breakdown rates of muscle fiber and nervous tissue, the type II muscle fiber (with the greatest amount of active filaments and associated neural connections), the muscle fiber that produces power best, is affected most. Type II muscle fiber has more active elements and more nervous connection, which make for a faster, more powerful contraction because it does not have to depend on oxygen right away to produce energy. Type I muscle fibers have fewer active elements and nervous connections, making room for mitochondria that process oxygen to produce energy. Because of the architecture of the type II fiber and because we tend to do less power oriented (less jumping, throwing, sprinting) and heavy lifting activities as we get older and more cardio activities (walking, hiking, biking), the type II fibers are the most heavily targeted by sarcopenia. We cannot confront this loss with just balance, flexibility, cardio, or strength (learned muscle fiber recruitment). Hypertrophy (building muscle mass) and power development are required. Proper resistance training is needed for that.

Additionally, all the slow balance work and endurance training in the world won’t help you once you do start to fall. This is a hard sell for me to many clients. Because they can still run trails pretty well or stand like a stork for an extended period of time, the feel they are pretty well protected with respect to falls. This is not altogether true. Where both the aforementioned activities are beneficial and helpful to prevent and respond to a falling situation, they are not enough to counteract a fall. Fall situations are unexpected – you have lost balance and there is no range of response reaction as you might have running up or down hills. There is no initial resistance to, no preparation for, the downward movement. This means that for a split second your whole body mass is falling at a rate of 32ft/sec/sec – that’s a lot of force. Countering that force quickly (with respect to time) in order to prevent the fall is a power function, P(t) = F(t) . T(t), the domain of the type II muscle fiber. Again, resistance training is required to develop power.

Fortunately, our bodies retain the ability to build muscle mass and produce power as we age (Faigenbaum, 182). Of course, we can’t expect the same results we got at 21, but certainly enough to help us reach our objectives. And resistance training has been proven safe and effective and is indicated to build muscle mass and maintain bone density for senior citizens (1, Faigenbaum, 182). Nutrition plays a crucial role in maintaining muscle mass – one cannot expect to maintain or build mass without the proper materials. Certainly, for the specific nutritional needs and medical conditions we may develop as we age, it’s wise to confer with a nutritionist and sports physician first for specific guidelines. Also, an understanding of how the spine changes with age and use is essential whenever planning a resistance training program, but especially for those of us over 50. Like Stuart McGill, Ph.D, I am a big believer that our lumbar discs only have a set number of flexions they can endure and my goal is to have just one left on the morning of the day I die! A good strength and conditioning specialist or personal trainer is an essential resource to guide you in both the resistance training and the nutritional aspect of building muscle mass. Trying this on your own without proper guidance can be hazardous. I see silly and dangerous routines carried out by people all the time in gyms. Some they took off the internet, some are “monkey see, monkey do”, and some routines were actually provided by poor trainers. I have a list of excellent trainers. If you are a client of mine, please don’t hesitate to ask for one that best serves your needs.

A final note: You may ask, “I am not an athlete, I don’t even like exercise, why should I care? And by the way, my parents did just fine without any exercise.” My response is, “Really??” How long did they live? How easily were they able to move around? How strong and independent were they in their final years? It really is a matter of safety and quality of life more than athleticism. Some of our parent’s generation, in general, may have had a few advantages over us. They had a shorter work week and greater physicality in their activities of daily living. Despite the popularity of the PBS show This Old House, the days when people performed major chores regularly (like their own roofing or mending stone walls) that maintain attributes like balance and muscular endurance while lifting heavy loads into their 60’s are, for most part, all done (pushing a power mower and driving to the dump, although good exercise, isn’t quite the same thing). Work days are longer now, stress is higher, sit-down computer type work and continuing education are required of most us now and, with the chances of, or desire for, retirement evaporating from our culture, it’s likely you will have to remain strong and healthy at least into your 80’s. Considering working some resistance training into a few hours of your life each week would be wise.

References:
1. Peterson, Mark, PhD, CSCS*D (2010) Resistance exercise for sarcopenic outcomes and muscular fitness in aging adults. Strength and Conditioning Journal, 32(3), 52-63

2. Faigenbaum, Avery “Essentials of Strength and Conditioning, 2nd Edition” Age and Sex Related Differences and Their Implications for Resistance Exercise. Eds. Baechle, Thomas R.; Earle, Roger W. Champaign, IL, Human Kinetics, 2000

Other research material utilized:

McGill, Stuart, Ph.D.. “Low Back Disorders: Evidence-Based Prevention and Rehabilitation, 2nd Edition.” Ed. Robinson, Loarn Champaign, IL, Human Kinetics, 2007

Seguin, Rebecca, B.S., CSCS, Nelson, Miriam, Ph.D, Buchner, David, M.D., M.P.H “Strength Training for Older Adults: Growing Stronger”, Tufts University, 2002

Current Opinion in Clinical Nutrition and Metabolic Care:
January 2004 - Volume 7 - Issue 1 - pp 15-20

Chronic Exertional Compartment Syndrome

2010-05-30T18:44:00.000-07:00

Chronic exertional compartment syndrome (CECS) is a painful condition of the legs. It’s characteristic signs are elevated pressure within the compartments of the legs, which causes pain and often disrupts normal neuromuscular function. When the pain and dysfunction become severe, surgery to relieve the pressure may be an option. The current thinking is that pressure builds within the compartments because the muscle mass and fluid within the compartment is simply greater than the compartment space allows. For a better understanding of what these compartments are all about, see the illustrations below. As always, please excuse me for being more of a Piccaso than a Leonardo when it comes to drawing and labeling graphic representations.

The above illustration is a cross section of the leg about midway between the knee and ankle. All the “stuff” (muscles, vessels, nerves, etc) have been left out so you can see the distinct compartments. Each compartment houses sets of muscles and, although in reality the muscles work together to provide movement and stability, each set of muscles has their own orientation. The lateral compartment is a sack that holds muscles that generally provide lateral stabilization, the anterior compartment is a sack that hold muscles that generally provide dorsi flexion and the posterior compartment is a sack that holds muscles that provide plantar flexion. These compartments are walled by the septa, the deep fascia of the leg and the interosseous membrane. If all the structures within the compartments fit just right, there is enough pressure to push the blood back up through the vein when the muscles of that compartment contact. Too tight a fit, fluid has trouble getting out; too loose a fit, the muscle have to work harder to push blood up the vessels and may need help. The most common and most dangerous scenario is too tight a fit. Check out the illustration below. It shows the compartments with all their contents. It doesn’t take much imagination to see how conditions in the legs can be tight and uncomfortable, even in normal health legs. No wonder it feels good (and is a good practice!) to put our legs up after a long day!

Anterior Compartment
TA - tibialis anterior
EDL - extensor digitorum longus
EHL - extensor hallucis longus

Lateral Compartment
fibularis longus
fibularis brevis

Deep Posterior Compartment
TP - tibialis posterior
FDL - flexor digitorum longus
FHL - flexor hallucis longus

Superficial Posterior Compartment
soleus
gastrocnemius

Special mention has to be made here of the name of the condition we are addressing. You’ll usually hear people refer to it as just “compartment syndrome” rather than give the full name of chronic exertional compartment syndrome (CECS). This understandable, because CECS is a mouthful, but it is somewhat a misnomer. Compartment syndrome can be either chronic or acute. Acute compartment syndrome (ACS) is brought on by trauma to the leg and is an emergency situation that needs to be addressed immediately. Requisites for determining if the pain in the legs is CECS include anatomical location (as discussed above, in one of the compartment), results from tests that there is increased pressure in the compartments, decreased circulation in the legs, and neuromuscular dysfunction in the structures within the compartments. The “gold standard” for determining pressure in the compartments is to actually insert at probe into the compartment to measure the pressure, although less invasive neurogical tests have recently shown some promise in determining if CECS is the cause of the patient’s pain and dysfunction.

If a diagnosis of CECS is returned, then a decompressive fasciotomy may be an option to relieve the pain and dysfunction. This procedure cuts open the walls of the compartments relieving the pressure on the structures inside. There are several different approaches to the procedure, but the basic procedure is the same. The illustrations below presents one approach where two incisions are made on the lateral aspect of the leg (yes, that illustration is supposed to be a leg!) and the epidermis and subcutaneous adipose is retracted to expose the deep fascia of the leg. Figure 1 clearly illustrates the anterior compartment and the lateral compartments. The darker line that separates them is the anterior intermuscular septum (see the first illustration above for clarity). Note the superficial peroneal nerve where it emerges from the deep fascia of the leg – it is important for both the surgeons performing the procedure and the therapists working with the patient/client to identify it. In figure 2, I have removed the hooks to make it easier to see where incisions have been made in the anterior and lateral compartments.

A similar procedure is execute on the medial side of the leg for the deep posterior compartment, but is complicated by the orientation of the soleus muscle where it attaches to the tibia and must be detached and retracted to expose the deep posterior compartment (see the second illustration for a better visual of why this is necessary). On the medial side, it is the saphenous nerve and vein that must be carefully worked around.

Therapeutic Considerations
Although most decompressive fasciotomies are successful in relieving the pain and dysfunction, allowing the athlete to return to their sport, they will likely need to maintain a regiment of self care in which circulatory massage and cross-fiber friction can play an important role. As with any surgery, massage therapy can help decrease adhesion around scar tissue. With the septa cut and the resistance to muscle contraction reduced, regular circulatory massage can also help maintain the health of the tissues by influencing venous flow. Care must be taken in the areas of scar tissue near nerves, particularly the superficial peroneal nerve.

References:

Williams, E.H, Detmer, D.E., Guyton, G.P., Dellon, A. L. (2009) Non-invasive neurosensory testing used to diagnose and confirm successful surgical management of lower extremity deep distal posterior compartment syndrome. Journal of Brachial Plexus and Peripheral Nerve Injury,4(4)

Rorabeck, C.H., Bourne, R.B., Fowler, P.J., (1983) The surgical treatment of exertional compartment syndrome in athletes. The Journal of Bone and Joint Surgery, 65: 1245-1251

www.mayoclinic.com/health/chronic-exertional-compartment-syndrome/DS00789/DSECTION=treatments-and-drugs

Houglum, Peggy. “Therapeutic Exercise for Musculoskeletal Injuries, 2nd Edition.” Primary and Secondary Healing. Ed. David H. Perrin. Champaign, IL, Human Kinetics, 2005.

Netter, Frank. “The Atlas of Human Anatomy”
Phiadelphia, PA, Saunders-Elsevier, 2003

Iliotibial Band Syndrome

2010-05-16T12:43:00.000-07:00

Spring has sprung early and beautifully this year. We can’t have the yin without the yang it seems, so along with early warmth, blue skies, and breathtaking buds comes allergies, knee, hip, and low back conditions. Just like allergies, musculoskeletal conditions come any time of year, but each season seems to bring more of one than the other. Spring and summer see a lot of knee conditions, but iliotibial band syndrome (ITB) is the unquestioned champion of Soarbody Therapeutics at this time of year.

A syndrome is distinct from a disease or specific condition in that is defined by the presence of a number of symptoms that characterize a condition and its usually ongoing, that is, it doesn’t run a specific course with an outcome. Generally, ITB syndrome is an overuse syndrome whose main symptom, pain at the lateral aspect of the knee, is caused by friction between the lateral epicondyle of the femur and the iliotibial band. So let’s step back and see what that means.

The iliotibial band is a tough band of connective tissue connects two muscles whose origin are on the ilium (gluteus maximus and tensor fasciae latae, TFL) to the anterior of the tibia, specifically to a lump on the more anterior aspect of the tibia called Gerdy’s Tubercle. Because of the way the ITB has to angle past the knee to get to the anterolateral aspect of the Tibia, it has to pass by the lateral epicondyle of the femur. When running, as gluteus maximus and TFL are engaged during heel strike phase to stabilize the leg and ready the hip for extension and the knee for flexion, great pressure is felt along the ITB. The ITB has to pass over the lateral epicondyle as the knee moves from being fully extended into flexion while still under great stress from gluteus maximus and TFL. It’s believed that that most of the friction takes place around 30 degrees of knee flexion. Although by no means restricted to runners, this scenario is played out most dramatically in distance runners.

So why don’t all runners experience this syndrome? Because there are a number of variables involved in how forcefully the ITB snaps over the lateral epicondyle. Training errors (scheduling too much distance, too much downhill too soon) are certainly one cause. Certain inherent traits are also factors (Q – angle, arch design and mechanics in the foot). The most frequent cause of stubborn cases of ITB syndrome in this therapist’s experience, however, is simply the over use of the muscles recruited to perform the athletes’ main action combined with the under utilization of other muscles that are usually used to provide stability in gait. This overuse may be due to training error or compensational patterns due to previous injuries.

In the case of ITB syndrome, over use of gluteus maximus and TFL and under utilization in the gluteus minimus and medius are often implicated as active structures in the hip to be addressed. However, keep in mind that imbalances to either side of the knee, proximal and distal, can present unbalanced stresses around the knee in gait. So a good therapist will be examining what is happening distal to the knee in the leg, ankle, and foot as well as what is occurring in the thigh and hip. Manual therapists, in fact, often neglect to address both the muscles of the leg (especially the peronials!) and adjustments to the ankle (be on the look-out for this error!).

Finally, be mindful of the stages of healing (see the last post). Chronic overuse injuries often come to those of us (myself included) who are crazed about having to do our sport. In fact, in all honesty, many of us get injured because we have been obsessively practicing our sport without giving our bodies a break to heal (no post season). You need to follow the therapist’s directives. No running means no running! You’ll survive, believe me. Cheating will just impede your progress. For those of you who are running to maintain your weight, there are better ways to do it (cardio is not the best, by the way) and a personal trainer or strength coach who can communicate with your therapist can help you maintain your ideal weight. If you are running to fight off depression, talk to a psychologist about other means of control while you are healing