The Power of ART – Active Release Technique

December 18, 2013/in Conditions, Sports Injury/by admin

Struggling with carpal tunnel can be a debilitating experience. The inflammation around tissues and nerves in the wrist can make it difficult to perform daily tasks. The classic symptoms of carpal tunnel include numbness or pain that occurs on the thumb-side of the hand, pain that radiates up to the shoulder, and the muscles in the thumb becoming severely distorted. However, there is no need to suffer with this condition when there is ART (Active Release Technique) to help you relieve the symptoms.

One can experience the relief of the pain and numbness without invasive surgery or traditional procedures of medicine. The continuance of these symptoms is the direct result of misdiagnosis and the misinterpretation of what carpal tunnel actually is. It’s more than just the entrapment of one single nerve in the thumb; rather, it’s a more common problem that takes place further up the arm, in the muscle called the Pronator Terres. Because of this, adding a brace to the wrist can actually make the problem worse.

ART, on the other hand, is designed to eliminate the problem from the get-go, allowing patients to make a much faster recovery than with conventional methods. Instead of focusing on just one area, ART aims to restore unimpeded range of motion and function to the soft tissues of the arm and wrist.

Professionals who are trained in the technique of ART can evaluate the texture and mobility of soft tissue, and, using hand pressure, removes or breaks up the fibrous adhesions that are present in the soft tissues. This can drastically improve the recovery from this debilitating condition, and abate the symptoms for much longer periods of time between each treatment.

There are typically three levels of ART that are performed by the practitioner himself while the fourth requires the patient to be involved with the active movement of the tissue while the practitioner applies the required tension to improve the results of the treatment even more. It has been scientifically proven that patients who are actively involved with the process of their treatment are more likely to make a better recovery than those who don’t.

Understand the true source of the pain you’re experiencing, and take steps to resolving your condition before it becomes too much to handle.

Selecting the Best Office Chair

July 23, 2013/in Back Pain Prevention, Ergonmoics/by admin

Not all chairs fit all body types. When selecting the best office chair for your workstation, there are a few different factors that you should keep in mind. When sitting in a chair, your back will be most comfortable in a slightly reclined and neutral position. Each element of the chair should help you maintain this neutral position.

What To Look For When Selecting the Best Office Chair

Seat

The key to choosing the right chair is the ability to adjust the seat depth, height, and tilt. Choose a seat depth that supports your hips and legs, and look for a chair with sliding seat options. There should be a 1-2” space between the back of your knees and the front of the seat. The height of the chair needs to adjust according to your height. Your feet should be flat on the ground when your hips are pushed to the back of the seat, and you should be able to tilt the chair back to recline or sit upright. A reclining mechanism can also help with increasing movement while working.

Backrest

Back support is very important when selecting an ergonomic chair. The chair should provide lumbar support for your lower back. If this is missing, it can lead to slouching and strain on the back. The back of the chair should allow for height and angle adjustments. The contour of the backrest should allow for free arm movements while still supporting the upper and lower back. If you tend to recline often, you may need a backrest that supports your shoulders and neck. The angle of the backrest should adjust independently from the seat at a 100° to a 110° angle.

Armrests

When your shoulders are relaxed, your forearms should be able to rest on the armrests fully and comfortably. Adjust the armrest inward or outward to affect the width based on your stature. Armrests can support your upper back when taking breaks from typing.
A single chair or adjustment may not be applicable for all tasks, so you may need to experiment with different chairs or adjustments. The goal of an ergonomic chair is to provide you with the comfort and support your body needs.

Best Chiropractor in Mission Valley

December 3, 2012/in Uncategorized/by Dr. Kevin Rose

Congratulations to Dr. Rose, DC on being voted 2012 Best Chiropractor in Mission Valley by Mission Valley News.

Click Here for the entire release.

Mission Valley News offers community news and information on Mission Valley, Old Town, Linda Vista and surrounding areas.

Piriformis Syndrome Part III- Treatment

November 16, 2012/in Conditions/by Dr. Kevin Rose

Piriformis Syndrome Treatment

The two main goals of treatment are 1) to relief irritation to the sciatic nerve and 2) address any functional problems that may be contributing.

If the sciatic nerve is inflamed the first step is to decrease aggravation from compression. Things to avoid are leg crossing, sitting on your wallet, and sitting on hard surfaces. Things you should begin doing are applying ice to the piriformis, stretching of the piriformi, and taking oral anti-inflammatories (as directed). Stretching every 2-3 hours (while awake) is a key to the success of non-operative treatment. Prolonged stretching of the piriformis muscle is accomplished in while lying on your back with the hip flexed and passively adducted/internally rotated (see picture). Another exercise that can be helpful to decrease irritation between the piriformis and sciatic nerve is a nerve gliding exercise. This exercise tensions the sciatic nerve and allows it to move relative to the piriformis. It is sometimes called nerve flossing to better describe how the nerve moves through other structures. Two types of nerve gliding exercises are pictured below. (Pictures from http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53203)

Manual therapy can be extremely helpful in releasing tension on the sciatic nerve and addressing functional deficits. Soft tissue therapies, including myofascial release and Graston®, aimed at releasing tension and muscular adhesions within the piriformis can be beneficial. Chiropractic spinal adjustments can help address functional contributions from the spine such as sacroiliac joint hypomobility and low back dysfunction. Hyperpronation of the foot can be addressed through orthotics in the short term and foot strengthening in the long term. Pronation is a normal foot motion however overpronation may lead to increased external rotation of the hip with walking putting tension on the piriformis and sciatic nerve.

Treatment may take several months of consistent work and it is important not to get discouraged. As long as there is no progression of neurological symptoms conservative treatment is the best option. Your symptoms should be monitored by a healthcare practitioner to ensure there is no progression.

-Dr. Kevin Rose, DC

Piriformis Syndrome Part II- Evaluation

October 22, 2012/in Conditions/by Dr. Kevin Rose

Clinical Diagnosis

Piriformis syndrome occurs most frequently between ages 40-60 and is more common in women than men. Some reports suggest a 6:1 female-to-male ratio for piriformis syndrome; , possibly because of biomechanics associated with the wider quadriceps femoris muscle angle (ie, “Q angle”) in the pelvis of women. Reported incidence rates for piriformis syndrome among patients with low back pain vary widely, from 5% to 36%.

The most common symptom of patients with piriformis syndrome is increasing pain after sitting for longer than 15 to 20 minutes. Many patients complain of pain over the piriformis muscle (ie, in the buttocks), especially over the muscle’s attachments at the sacrum and medial greater trochanter. Symptoms, which may be of sudden or gradual onset, are usually associated with spasm of the piriformis muscle or compression of the sciatic nerve; these symptoms include radiating/shooting pain or tingling or numbness in the back of the thigh, leg, or foot. These symptoms must be evaluated by a healthcare provider to differentiate the possible causes. Patients may also complain of difficulty walking and of pain with internal rotation of the involved leg, such as occurs during cross-legged sitting or walking. X-rays or an MRI offer little help in directly diagnosing piriformis syndrome but may be used to rule out other causes of sciatica such as a herniated disc in the lumbar spine.

Functional Evaluation

There are many functional abnormalities that may have either caused or resulted from this condition. Once the diagnosis has been made, these underlying, perpetuating biomechanical factors must be addressed.

Functional biomechanical deficits associated with piriformis syndrome may include the following:

Tight hip external rotators including pirifromis
Tight adductors (groin)
Hip abductor weakness
Lower lumbar spine dysfunction
Sacroiliac joint hypomobility
Hyperpronation of the foot and prolonged toe-off

Functional adaptations to these deficits include the following:

Ambulation with the thigh in external rotation
Functional limb length shortening
Shortened stride length

Next post will discuss treatment options for piriformis syndrome

Piriformis Syndrome: Overview and Causes

October 19, 2012/in Conditions/by Dr. Kevin Rose

Piriformis syndrome is a unique cause if sciatic nerve irritation (neuritis) or sciatica. The condition, which can mimic lumbar disc herniation, usually is caused by irritation of the sciatic nerve due to spasm and/or contracture of the piriformis muscle. Piriformis syndrome is also referred to as “pseudosciatica”, “wallet sciatica”, and “hip socket neuropathy”.
It frequently goes unrecognized or is misdiagnosed in clinical settings. Piriformis syndrome can “masquerade” as other common somatic dysfunctions, such as intervertebral discitis, lumbar radiculopathy, primary sacral dysfunction, sacroiliitis, sciatica, and trochanteric bursitis.

(Image from http://www.concordortho.com/patient-education/topic-detail-popup.aspx?topicID=4214fc65d020761633286131e407d037)

Anatomical Considerations

The proper understanding of piriformis syndrome requires knowledge of the anatomy and anatomical variations in the relationships between the sciatic nerve and the piriformis muscle.

The piriformis muscle is flat, pyramid-shaped, and oblique. This muscle originates on the front of the sacrum and inserts at the greater trochanter of the femur. With the hip extended, the piriformis muscle is an external rotator of the hip; however, with the hip flexed, the muscle becomes a hip abductor.

In most of the population, the sciatic nerve exits the pelvis deep along the lower surface of the piriformis muscle. However, many developmental variations of the relationship between the sciatic nerve in the pelvis and piriformis muscle have been observed. In as much as 22% of the population, the sciatic nerve pierces the piriformis muscle, splits the piriformis muscle, or both, predisposing these individuals to irritation of the sciatic nerve.

From http://www.anatomyatlases.org/AnatomicVariants/NervousSystem/Images/70.shtml

Causes of Piriformis Syndrome

Piriformis syndrome can be caused by a variety of issues. The underlying mechanism is from irritation to the sciatic nerve. Below are some causes of irritation to the sciatic nerve as it passes the piriformis muscle:

1. Muscular problems

Spasms and adhesions in the piriformis muscle cause compression and irritation of the sciatic nerve. Muscular damage or tightness can develop from a single injury or repetitive use injury. Vigorous physical activity can lead to such an injury- (commonly seen in athletes such as runners, cyclists, and dancers).

2. Postural

Hyperlordosis (increased curvature of the low back) and increased foot pronation are both risk factors for piriformis syndrome

3. Traumatic

Direct compression of the piriformis and/or sciatic nerve from an external soure such as a wallet.

4. Partial or total nerve anatomical abnormalities

An anomaly in the nerve itself as it passes through the piriformis muscle can lead to dysfunction

5. Other causes can include the following:

Pseudoaneurysms of the inferior gluteal artery adjacent to the piriformis syndrome
Bilateral piriformis syndrome due to prolonged sitting during an extended neurosurgical procedure
Cerebral Palsy
Total hip arthroplasty
Myositis ossificans

Stay tuned…… the next post will talk about how this problem is diagnosed and treated.

Lateral Demipointe Compressed - Xray of Ankle

POSTERIOR IMPINGEMENT IN DANCERS

September 7, 2012/in Sports Injury/by Dr. Kevin Rose

Posterior ankle impingement is a common cause of pain in ballet dancers. Other names for this condition are “os trigonum syndrome” and “nutcracker syndrome”. It is called “nutcracker syndrome” not because of its common occurrence in ballet at Christmas-time but because of the way the tissue of the ankle is squeezed at the ankle. The following is a brief overview of this condition and how it relates to dancers.

Posterior impingement of the ankle is often attributable to the presence of an accessory bone growth called an os trigonum or a Stieda process that is located just behind the talus (see x-ray for anatomy). The stress from repetitive plantarflexion by dancers, especially at a young age, is the suspected cause of the development of the os trigonum. Pain in posterior impingement occurs when the soft tissue of the ankle is pinched between the posterior lip of the tibia and the calcaneus. This occurs when the foot is in extreme plantarﬂexion such as during releve in the demipointe or en pointe positions.

Diagnosis

Proper diagnosis of posterior impingement is imperative for recovery from this injury. Posterior impingement attributable to an os trigonum is usually misdiagnosed as Achilles’ tendonitis/tendonopathy, peroneal tendonitis or flexor hallucis longus strain.

The two main symptoms of posterior impingement are a decrease in plantarﬂexion compared with the unaffected ankle and pain in the posterior region of the ankle. Often dancers are aware of a lack of ability to fully pointe in one foot compared to the other, this may be an early sign of impingement. Another common description dancer’s use is it feels like pinching in the heel during releve. Diagnosis is often aided by x-Rays of the ankle. It is best to request an x-ray to be taken during releve to evaluate the biomechanics of the injury. If there has been persistent pain for a period of 1– 4 months, local swelling, and radiographic assessment indicating a posterior ankle impingement, then an MRI should be performed.

Treatment for Posterior Impingement of the Ankle

Once posterior impingement is diagnosed focused treatment should begin. Non-surgical care is usually successful and should be the first line treatment. Treatment should be focused on taking pressure off of the tissue being pinched. Exercises should focus on engaging the deep muscles of the leg especially the deep flexors. One exercise that is helpful and can be done at home is a self traction maneuver with plantarflexion (see picture). The patient holds his or her ankle, as shown, with downward pressure and performs the motion with a bent knee. Bending the knee helps disengage the gastrocnemius muscle and soleus forcing the deep flexors to engage. Another great exercise is ankle range of motion with traction applied by a therapist using very strong elastic bands. Dancers may experience relief with traction and feel they are able to fully plantarflex; this can also be a good way to support the diagnosis as Achilles’ tendonitis is often unchanged with traction. Manipulation of the ankle especially the talus can provide relief as well. Conservative therapy is successful in the majority of cases. Recovery may take several months.

A surgical approach should only be adopted in the following cases:

recurrent or unremitting symptoms in professional ballet dancers;
persistent decreased plantarﬂexion compared with the unaffected ankle;
failure of physical and medical therapies after 1– 4 months (depending on the level of the athlete/dancer);
posterior impingement clinically suspected and indicated by both x-ray and MRI.

Ankle pain and heel pain is a common symptom in dancers and posterior impingement is only one of the causes. If you think you may be suffering from posterior impingement seek advice from a qualified healthcare professional with expertise in dance injury.

-Dr. Rose, DC, CCSP®

Dr. Rose is a Certified Chiropractic Sports Practitioner® with experience in dance medicine. He is currently Director of Physical Rehabilitation at Ballet San Jose and a member of the International Association of Dance Medicine and Science.

REFERENCES

Albisetti W, Ometti M, Pascale V, De Bartolomeo O: Clinical evaluation and treatment of posterior impingement in dancers. Am J Phys Med Rehabil 2009;88:349–354.

Niek van Dijk C: Anterior and posterior ankle impingement. Foot Ankle Clin 2006;11:663– 83

F Cilli, M Akcaoglu: The incidence of accessory bones of the foot and their clinical signiﬁcance. Acta Orthop Traumatol Turc 2005;39:243– 6

POSTURAL STABILITY IN DANCERS AFTER INJURY

September 5, 2012/in Sports Injury/by Dr. Kevin Rose

Ballet dancers are widely known for their superior body control in various challenging body positions. In fact it has been found in recent studies that ballet dancers have better postural control when compared to other elite athletes. However, what has not been examined is the effect of injury on postural balance in dancers. A recent study in The American Journal of Sports Medicine by Lin, et al, addresses this vary issue.

Postural balance requires a combination of several different sensory inputs: visual, vestibular (inner ear), and somatosensory (from the skin, joints, muscles, etc). Somatosensory input gives the brain information about where the body is in space; this is called proprioception. These sensors can be damaged with ligamentous and muscular injuries such as ankle sprains and in turn lead to a deficit in proprioception. Proprioceptive deficits can put a dancer at more risk for re-injury or new injury.

The recent study by Lin was the first study that evaluated stability in dancers in ballet specific postures following an injury. Three different groups were studied: healthy dancers, injured dancers (with sprained ankles), and health non-dancers. Postural stability was evaluated on a balance sensor that monitors subtle deviations in stability. This was done with the eyes open and then again with the eyes closed to further stress the proprioceptive component of balance. As expected the injured dancers had decreased control not only in ballet specific positions but also in a simple single leg standing position when compared to healthy dancers. Surprisingly the injured dancers had worse stability control than the non-dancers. Many dancers, and other athletes, that I have treated often assume that a skill such as balancing will come back without training, however this is not the case, and as the study indicated it regresses to the point that is worse than untrained people.

The postural deficits were most notable in side to side control with single leg standing and front to back control with first and fifth position. Compensation was noted at the knee and hip joints in an attempt to make up for the injured ankle. The en pointe position crated the most stability issues; injured dancers were inferior in all directions of stability. With lateral ankle sprains the most commonly damaged ligament is the anterior talofibular ligament. This ligament is stressed maximally when the ankle is plantar flexed, such as during en pointe positions. It is not surprising that when this ligament is damaged the proprioception during pointe is significantly disturbed.

This study brings to light the importance of a thorough rehabilitation program that includes proprioceptive training in ballet specific positions. Typically a sprained ankle takes 6-8 weeks to recover. During this time it is critical to begin proprioceptive training to ensure that the balance deficits do not lead to further injury. Additionally if a dancer has a past injury of ankle sprain without proper rehabilitation it is likely that postural stability still remains and there is an increased risk to further injury. If this is the case, dancers should begin a 3-4 week proprioceptive training plan that includes ballet specific posture.

Dance injuries and rehabilitation are unique and should be managed by a healthcare practitioner that is experienced with the subtleties of dance medicine. Proprioception training for ballet typically includes balance exercises on an unstable surface such as a Bosu ball or stability disc. These exercises should be done in normal stance position as well as ballet specific positions. Whole body vibration may additionally add value as a proprioceptive trainer especially early during rehab when range of motion is limited. KinesioTape or RockTape are also good taping methods that help protect the joint and provide increased proprioception when applied properly. Keep in mind that a training plan should be designed specifically for each injury and you should not attempt to manage the injury without the supervision of an experienced healthcare practitioner.

BACKPACK SAFETY

August 23, 2012/in Back Pain Prevention/by Dr. Kevin Rose

Backpacks are a practical way for students to carry schoolbooks and supplies. They are designed to distribute the weight of its contents among some of the body’s strongest muscles; however, in recent years, the weight of student backpacks has increased dramatically and has become a public health concern. Studies show that heavy backpacks can lead to both back pain and poor posture, notes the American Chiropractic Association (ACA). In fact, in 2001 backpacks were the cause of 7,000 emergency room visits and countless complaints of muscle spasms, neck and shoulder pain.

Here are some tips on purchasing a backpack, packing a backpack, and wearing a backpack to reduce the risk of injury.

Purchasing a backpack, what does a good backpack need

Wide( > 2), Padded Straps
The bag should have wide padded shoulder straps. Wide straps and padding distribute the load over more area of
the shoulder and alleviate pressure points.
Padded Back
The back of the backpack should padded as well to encourage the pack to sit flat against the back.
Lightweight
Reducing the overall weight carried begins with a light backpack. The stress on the back is caused by the weight of the bag, don’t forget that the weight of the bag contributes to the overall weight. Anything you can do to reduce that weight will reduce the stress.
Waist Strap
A waist strap dramatically helps direct the load away from the shoulders and onto the much stronger waist and hip muscle group.
Proper Size
Use the chart below for general recommendations by age or for more accuracy you can take measurements of your child’s back. The width should be from the outside ridge of the one shoulder blade to the other. The height should be from the shoulders to the waist line (belly button) plus two inches. See the diagram below to help with measuring.

Loading a Backpack

Load heavy items close to the back (the back of the pack)
Heavy flat items should be placed against the back. This increases the body’s ability to support the weight with stronger muscle groups such as the hips and core.
Don’t overload (see weight chart below)
As a general rule the weight of the backpack should not be more than 15-20% of the students body weight. It should not exceed 25 pounds in any case. Below is a table with the recommended weight to be carried based on the student’s weight.

How to wear a backpack properly

Wear BOTH straps
This helps distribute the load more evenly and helps hold the load more securely to the back. Wearing one strap can lead to shoulder and back pain.
Adjust shoulder straps so the backpack ﬁts snugly against the back
The back pack should rest no lower than 4 inches below the waist line. Remember that the waistline is in line with the belly button not the top of pelvis.
Fasten waist belt and adjust strap length to secure and distribute the weight evenly
The benefits of the waist strap can only be seen if the strap is worn. Don’t forget to have your student fasten it when wearing.
The lower bulk of the backpack should rest in the curve of the lower back and not more than four inches below the waist
This also contributes to allowing the stronger muscles of the hips and shoulders to support the load.

Other considerations

Monitor what your child is carrying to school each day to help him or her avoid carrying unnecessary items which add weight to the backpack.
Periodically check to see if your child is wearing his or her backpack correctly.
Assist your child with cleaning out and organizing the backpack weekly.
If the backpack weighs more than 15% of your child’s body weight have child carry a heavy book or two under his or her arm.
Ask your child if he/she has any discomfort during or after wearing the backpack.
Help your child ﬁle work at home so he/she only needs to bring required work to school each day.
Talk to your child and teachers about ways to reduce backpack weight.
Some books can be found online at low cost. Consider purchasing a second copy to keep at home so your child doesn’t have to carry it back and forth.
Share any concerns about backpack weight with your child’s teacher or administrator.

Taking the time to make careful consideration regarding your child’s backpack use is important to prevent injury. If your child does develop back pain have him or her seen by a qualified health professional for proper diagnosis and treatment.

-Dr. Rose, DC

Dr. Rose is a San Diego Chiropractor located in Mission Valley. More information regarding the services he provides can be found at www.RoseChiropracticSD.com.

References

American Chiropractic Association. Backpack Misuse Leads to Chronic Back Pain, Doctors of Chiropractic Say. Accessed at acatoday.org

Admas, Chris. A Fitting Guide for a Child’s Backpack. 2006.

Howard County Public School System. Backpack Safety Guidelines

Labral tears of the shoulder: surgery or not?

July 25, 2012/in Sports Injury/by Dr. Kevin Rose

At the recent American Orthopaedic Society for Sports Medicine, a comparison of non-surgical treatment and surgical treatment for SLAP labral tears of the shoulder in baseball players was presented. The labrum is a cartilage structure that makes the socket of the shoulder deeper and helps hold the upper arm. SLAP tears are a specific type of labral injury that is mainly caused by repetitive throwing. Although surgical repair of SLAP tears is common, little is known about the effectiveness of nonsurgical pain relief and the effects of surgery on performance.

	Return to play	Return to same level of play
Surgery	48%	7%
Non-Surgery	40%	22%

The return to play rate in SLAP injuries is low, typically reported at less than 50%. In this study the return to play rate for those that underwent surgery was 48% while those that underwent rehabilitation was only slightly lower at 40%. The most interesting finding in this study however was that the group that had surgery rarely, only 7% of the time, returned to the level of play that they had previously attained. The non-surgery group in comparison returned to the same level of play 22% of the time.

John E. Kuhn, MD, associate professor of orthopedic surgery and rehabilitation and chief of shoulder surgery at Vanderbilt University Medical Center in Nashville, Tennessee described the findings as “very significant” and summed up the findings:

“A lot of these throwing athletes can be treated non-operatively,” Dr. Kuhn said. “They had very good success with rehabilitation. That suggests that patients can throw with SLAP tears, and that not every SLAP tear needs to be repaired,” he said. “Many can be rehabilitated; the sources of pain or disability may not even be the SLAP lesion itself,” he added. The research suggests that surgery in this patient population really should be a career-salvaging option, he explained. “It really shouldn’t be something you throw at somebody quickly or early. Rehab them, do everything you can to prevent surgery,” he concluded.

Another take home message from these findings that should be discussed further is the importance of avoiding shoulder injuries from throwing. As stated the percentage of those injured with SLAP tears that return to play is less than 50%. The best advice then logically is to avoid getting a SLAP tear altogether. Unfortunately, there is no sure fire way to avoid getting a tear if you are a pitcher. However what can be done is limiting the risk factors for injury. Risk factors for throwing injuries include a decrease in shoulder internal rotation, poor scapular control, and high pitching load. These risk factors should be screened for and proper preventative exercises should be built into any strength and conditioning program for baseball players, especially pitchers. Non surgical treatment in these cases included rehabilitation that focused on stretching the posterior capsule of the shoulder to increase internal rotation and training the scapular muscles to hold the scapula in a stable position during the wind-up and cocking phase of the throwing motion. These exercises should also be at the core of any preventative arm care program for baseball players. Manual therapy, including myofascial release and Graston treatment can also be beneficial to aid in increasing range of motion. These preventative strategies should be overseen by a healthcare provider knowledgeable in baseball injuries.

If you would like more information about how to recover from or prevent shoulder injuries contact our office today.

Another article outlining preventative exercises is coming soon…