The most common source of shoulder pain presenting to clinical practice is called SubAcromial Pain Syndrome (SAPS.) SAPS is shoulder pain that does not come from trauma. Continue reading “The most common source of shoulder pain in clinical practice is subacromial pain syndrome (SAPS)”
One of the challenges when I treat a patient who suffers from chronic pain is that there are various nuances along the pain pathway that can influence the pain. It starts at the end organ where there might be an injury or mechanical stress, but then the pain pathway makes its way towards your spine, to your spinal cord, up the cord to your brain stem, and then through your central thalamus and to parts of your brain for processing. Pain can be influenced along this pathway in multiple ways.
One of the traps that people fall into when they have had pain affecting the for a while is that at the very highest level of the pain experience, they will tend to “catastrophize” their pain. Pain catastrophizing is a way that your brain processes your pain, but it does so in an exaggerated way. You might be focusing more attention than what is healthy to your pain. You might be interpreting your pain in a way that is not actually true for the injury that you have. Your brain might be processing the pain differently because of your past experiences–experiences that magnify the level of pain that you experience. It might be simply an effect that the pain that you experience has been there for so long that your brain has made reinforced connections through neuroplasticity that is not allowing your to override these signals so easily.
Our pain experience is no longer thought of as 1:1. This is the old Cartesian model of pain. You sprain your ankle, and you experience pain to the same extent as there is tissue damage. But now we are learning about new mechanisms of pain. Brain interactions can influence your pain. It turns out if you have anxiety or depression syndromes, you are going to process pain differently. It’s all in your head, and literally so, because brain connections influence the important pain pathways and pain experience centers. There is emotion in pain and suffering, and this is a problem that was ignored for centuries, and is now being understood more and more.
A new study this year looks at people suffering from chronic shoulder pain. Shoulders are very mechanically vulnerable to imbalance. There’s lots of range of motion in your shoulders, and we as humans can allow this circumduction range of motion because our shoulders do not need to be weight bearing. We can also get away with poor shoulder biomechanics for a little while as long as we have the proper mechanisms in our central processing to inhibit mechanical pain. Your shoulder joint can rub against your subacromial bursa for a little while without consequences. But over time, and with a little emotional trauma added in, your shoulder might start to ache. For some people, they’ve met the perfect storm of trauma to the shoulder and trauma to their mental coping mechanisms.
This study by Coronado published in 2017 in the Journal of Orthopedic Sports Physical Therapy looked at the effects of increasing optimism on patients with chronic shoulder pain. It turns out that When you can adopt a more positive optimistic attitude, you will have less suffering, but the same amount of pain. You brain takes a more realistic assessment of the pain signals that you are experiencing. Pain intensity stayed the same, and the patients did not change their fear-avoidance behavior, but they did not catastrophize the pain like they did before.
Now the challenge remains, how do you treat a patient to de-catastrophize the pain, as well as simultaneous reduce pain levels and their fear avoidance behavior. It seems like an approach that will rely on a team of people to intervene, but also empower the patient to take matters into their own hands.
What are your thoughts?
When a patient comes to me with low back pain that radiates down their leg, then I know I have the potential to affect their quality of life in a dramatic way. This is the line between having great results from conservative therapies in a chiropractic office, and more invasive surgical procedures.
When you come in to my office and you are leaning to one side because of the pain, then I know you have a disc problem. Some of the physical exam procedures that I do will help us figure out where exactly that problem is. Nerve root? Sciatic nerve?
Radicular: Irritation or compression of the nerve root. It could be L4, L5, S1, S2, or S3 nerve roots
Sciatica: Irritation or compression of the sciatic nerve after these nerve roots leave the lumbar spine and converge together into the thick sciatic nerve.
When we do orthopedic or neurological tests to find out where a nerve compression is, you are experiencing stretches and compressions on multiple parts of your body. In your spine. blood vessels. discs. facet joints. nerves. So, orthopedic tests have varying sensitivity and specificity. They’re not perfect. But, we combine the best tests to increase our clinical certainty.
Miller, 2007, recommends that low back sciatica tests be done in a seated position, even though most tests are done supine. A seated position really puts pressure on the disc, and it is often the position where you feel the pain the most.
A patient’s antalgic lean can tell me a lot about the nature of the herniated disc. If you are leaning away from your pain, then you are telling me about your problem. Must disc problems go to the back and the side of the disc. Posterolaterally. Away from the center of your body. And once it’s to the side, the protrusion from your disc will be to the inside or the lateral side of the nerve root.
A medial disc herniation is a disc that goes to the inside of your nerve root. A lateral disc herniation is a disc that goes to the outside of your nerve root. They are both lateral to the midline of your body. If you have a lateral disc herniation, you’ll want to lean away from the side of the herniation. If you have a medial disc herniation, you’ll want to lean towards the side of the disc.
Lumbar Lateral Bending
Miller recommends doing the classic Kemp’s test in a seated position, while most people do this standing. Kemp’s test will challenge your discs by bending you to ones side with or without rotation to see what position will aggravate the disc. The seated poison increases intradiskal pressure, and it also stabilizes the pelvis and legs to take out any confounding variables.
When seated, you are automatically in hip flexion. When you extend your leg, and you feel pain, this is a positive seated Lasegue test. When you are on your back, and I flex your hip, then extend your knee, this is a positive supine Lasegue test. When your leg starts out straight, and I keep it straight as I flex your thigh, this is a straight leg test. Both of these tests, supine or seated, end up in the “jackknife” position.
Flexing the neck can produce tension along the spinal cord dura mater lining, and can reproduce disc symptoms. Depending on your symptoms, this can help differentiate other problems in your spine that may arise.
Hip Internal Rotation
Internal rotation at the hip stretches the piriformis muscle. The piriformis muscle is involved sometimes with sciatica. It can tighten and pinch around the sciatic nerve.
Pulling your straight leg across your body will stretch the sciatic nerve. The Bonnet test is a straight leg raise, hip adduction and hip internal rotation.
Dejerine Triad and Valsalva
The Valsalva maneuver is when you strain while holding your breath. This increases the pressure in your disc and spinal cord lining. It’s like the strain when you have a bowel movement. Dejerine’s triad is couching, Valsalva, and sneezing. These tests can also point to other space-occupying lesions in your central nervous system, like a tumor. But, a tumor would have different symptoms than regular sciatica.
If you have pain, or numbness and tingling down your leg, then it’s important to find a doctor who has an understanding not only of what named tests exist on a sheet of orthopedic tests, but they must also understand the mechanisms behind the test. Doing so helps isolate the cause and mechanism of the pain or compression, and it can help with a more efficient recovery.
This morning, Greg Lehman’s new video is making the rounds amongst my social media channels. Greg Lehman is a biomechanist, a chiropractor, and an educator. In this video, he argues that there are certain biomechanical faults that you can safely ignore, in certain situations. And in other high-impact-heavy load situations where biomechanical positioning becomes more important.
He gives demonstrations on how amazing people are to adapt to injuries, like missing limbs, and they are able to perform at their peak despite an obvious deviation from normal.
He also talks about expectations of posture and pain. If you expect pain form a certain posture, then you probably won’t be disappointed. You sit in a position that is supposed to be bad for you, then you will meet your expectations.
This video provides an interesting point of view.
In Gray Cook’s Lectures, of which I listen on Audible, I learned this morning of the importance of toe touching progressions. Apparently, when Gray Cook use to lecture on stage for Reebok and for Perform Better, he would pull people on stage and demonstrate that most adults cannot do a toe-touch. For many of us, when we go through our teenage growth spurts, we start to lose our sense of balance and movement, and our bodies lose that neurological ability to allow the hamstrings and gastrocnemius muscles to allow for extra movement.
Most people do not rock backward in order to properly reach downward. When you do a toe-touch, you need to keep your center of mass over your feet. But if you reach forward without rocking backward, you will fall forward on to your face. If you try, your hamstrings will not allow the length required to reach down, and they will be “tight.” But, this tightness is a neurological effect. They are guarding against you falling.
Here’s a video by a physical therapist going over toe touching progressions:
And here is a video presented by a fellow chiropractor that goes over the same drills:
And another perspective:
Give these a try. Could you touch your toes before doing the drills? Did doing the drill help you progress?
When I consult with my patients about plantar fasciitis, the symptoms vary greatly. For some, it’s like stepping on glass when walking. For others, they only feel it when going on long runs. Most people have had it for a long time, which makes it difficult to treat with my expected fast results. It’s not my favorite thing to treat because of this reason, but results is something that I do get; it just takes time.
Because of a few recent cases of plantar fasciitis presenting to my clinic, I have been doing research on the condition more and more. My typical approach is to do what I can to improve the function of the feet and ankles, and to address the kinetic chain all the way up to the pelvis and beyond. I want to make sure that the 26 bones in the foot are gliding past each other with firm, but appropriate movement. I want to make sure the windlass mechanism in the hallux extension up to the knee is intact and fluid. I want to be sure that the patient’s mid foot is moving with the proper give, but without any instability. I make sure the calcaneus is in a neutral position, and inversion or eversion has their proper range of motion. I make sure the subtalar joint is dorsiflexing as it should, with proper rotation about the axis at the neck of the talus.
On the knee, I want to make sure the alignment of the tibia to the femur is true. I want to be sure there isn’t any orthopedic instability in the knee that causes your body to guard in any direction. I want to make sure that the proximal fibula is mobile against the tibia. and that the joint play matches the distal fibular at the lateral malleolus at the talus.
On the pelvis, I want to be sure there is even joint play at the sacroiliac joints. I check for asymmetries at the SI joints and the hips. I want to make sure the acetabular hip joints are moving through full rotation. I check my grind tests for an y orthopedic problems at the acetabulum. Even in the lumbar spine, I check joint play, tissue turgor, and muscle tone for anything that could be disrupting the normal action of the hip flexors originating at the lumbar spine.
We need to have your gait cycle normal again. It starts at the cycle in the feet where the feet need to relax and firm up with ever step. The arch needs to drop, but then it needs to rise up again as the big toe toes-off. It absorbs energy, and it transfers the energy back to the body as you push away from the step. There are subtle twists in the knee as it transfers forces back up to the hips. Nutation in the SI joints on both sides of the pelvis absorbs more shock and transfers the forces through the swinging of your thighs.
These all have to work in harmony for fluid, symmetrical gait.
But if you have improper foot mechanics, stresses build up over time. Irritation occurs at the enthesis where the tendon attaches to the heal bone. Inflammation happens. It becomes painful. Bone spurs form because of this irritation at the periosteum at the bone. Cells called osteoblasts lay down now bone matrix at the site of inflammation that create these bone spurs.
Weak intrinsic foot muscles cause bad biomechanics. Old injuries do too. Old injuries can also lead to weak muscles, but importantly, you have been deconditioning your foot muscles. You have been walking in cushioning shoes when you should have been going around challenging your foot muscles more. You should have been spending more time barefoot through the years. Be careful, though, because if you suddenly try to go barefoot to make up for lost time, you’re going to irritate your heels further.
Do some things to improve the flexibility of your feet. Do some short foot exercises. Learn how to exercise your abductor hallucis longs by telling your big toe to flare out away from the other toes. This muscle ties directly into the aponeurosis that is the plantar fascia.
Learn to walk barefoot again, but be careful. You need to understand the concept of hormesis. Hormesis is when you do small doses of something that is healthful and beneficial, but if you overdo said activity, you’ll injure yourself. Do some barefoot walking, which naturally strengthens the barefoot muscles in your feet, but only do a little bit at a time. The internet is full of comments where people tried to do barefoot running, and where this made them worse. Just like gyms across America are full of people trying to lift weights beyond their capacity, and left up with DOMS. Do a little at a time. Work your way up.
The other day while commuting, I was listening to Gray Cook’s lectures from my Audible account. In one of the lectures, he starts talking about jumping rope, and how it is a great, portable way to do high intensity interval training (HIIT.) The got the gears in my mind turning, because I haven’t even thought about jumping rope in decades, let alone even tried it. To me, it was something kids do to fight off boredom before they invented iPads, or it’s a way for Rocky Balboa to make himself look busy in between punching his heavy bag at Mick’s Gym.
But then Gray started talking about how intense the exercise is, and how it’s such a great promoter of movement for your lower body, just like lifting a kettlebell is for your upper body. And with both, you get a full body movement drill in. Then to top it off, my Taekwondo training son started talking about how he wants to jump rope to train.
Well, we both had to get them, and now we both have them.
It turns out that jumping rope is a non-specific, but highly effective way to condition your body to enhance your athletic conditioning, your balance, and your coordination. Trecroci did a study where they took two groups of soccer players and sent them through a circuit test called the Harre Circuit test, and the Lower Quarter Y balance test. One group did regular soccer training, but the other group did jump rope training. They found that the jump ropers reduced their circuit training time by 9%, while the regular group had no change. Jump rope practice enhances general motor coordination and balance.
Other studies show similar gains in performance for children athletes, and one study even shows that when you jump rope for 8 weeks, your measure of self-concept improves. You think a little better about yourself. You know who you are and how you fit into the world. You understand yourself better. You are able to integrate your past self with your present and future self.
When I got my jump rope fitted, and I tried to somehow connect what I wanted to do with the rope to the coordination of my feet, I found it challenging. I hopped, landed, then some time later the rope came to me. Then next time, the rope came to my legs, hit my legs, then I hopped, then I landed. To my horror, I felt like my back was stiff and vulnerable to this hopping, and I guess that’s my fault for being 40 years old, not the rope’s fault. Another time, I tried to jump the rope with a full stomach, but that was uncomfortable too. Finally, I got back on the rope while wearing appropriate clothing and with a reasonably empty stomach, and kind of warmed up, and I finally was a able to muster the coordination to do 5 consecutive jumps. Then I got to 10. Then, I ran out of breath. The effort it takes to do this is no joke. It really is HIIT. I had to take a break, but I didn’t want to. I was having fun, and I was blasting my heart doing it.
The crazy thing is, I handed my rope to my wife, Felicia, and she put everyone to shame. She picked it up with no effort at all, and was doing rope tricks right in our car port. My son and I were slack-jawed in amazement. She was skipping right along, and she was swapping hands without losing rhythm. “How do you know how to do that?” And she said, “Didn’t I tell you that I was on a jump team when I was in middle school?”
What a pro.
So now I have a new goal in life: Jump road and reach 50 jumps in a row. I might even reach this tomorrow with my superior neuroplasticity ability.
I’ve listened to the audio version of Neurowisdom twice now on my daily commute. Neurowisdom is a book that combines neuroscience with the application of principles that allow you to achieve your goals. Notably: monetary goals. In the book, they argue that money does contribute to happiness. The happiest people are also the people who are living in comfortable wealth. Wealth allows you to care for yourself. Wealth allows you to care for your family. Wealth provides a stash of money you might need in case of emergency. You live comfortably and securely in your own property. You maintain your possessions and you avoid fix-it tickets when you drive your car with a broken tail light. You avoid penalties and fees when you get into trouble because you can pay it all at once. While having possessions doesn’t make you happy, being able to afford experiences makes you happy. Experiencing activities with your loved ones provides happiness, and that many times involves spending money. Not always. But, most of the time.
So at the risk of coming across shallow, which the book does not, the authors outline the four pillars of wealth. And the four pillars of wealth involved listing brain regions that ties into our ancestral, primal motivators. Here are my notes from reading this section of the book:
The Four Pillars of Wealth
- Motivation. The brain tends to move toward the object of desire. You might be motivated by the security of having more money, or you might be motivated by having things or experiences. This is our primal drive to acquire more wealth. It all starts in the nucleus accumbens, and this is where Dopamine is released. As long as dopamine is released, it motivates us to move toward our goals.
- Decision Making. Dopamine travels to the frontal lobe. The frontal lobe is the executive part of the brain where decisions are made. This is where you lead new skills, develop new habits, make decisions, talk to yourself with internal dialogue, and analyze. This is where the left and right brain talks to each other, balancing out logic and feelings.
- Creativity. Focusing on only tasks and problems will lead to mental fatigue. You need to be creative to allow breaks for your brain. The brain needs to relax with 30 second breaks. Mind wandering is a natural process that your brain uses to recharge. This influences your memory, your mental health, and it allows you to have direct access to creative talents. being creative and taking mental breaks allows you to increase your learning capacity.
- Awareness.When you reach your 20’s and your brain connections start to mature, then awareness really kicks in. Self awareness and social awareness both develop through mindfulness. Doing mindfulness exercises is an awareness enhancement activity.
Mindfulness practice leads to awareness of:
- Bodily sensations
- Positive and negative thoughts
- Positive and negative feelings
- Old habits and behaviors
- Self image and self esteem
- Belief systems
- Purpose and values
- Other people’s thoughts and feelings
- Social consequences of actions
- Awareness of awareness
According to the book, self awareness leads to social awareness. Your values should be aligned with your work. Social awareness is what leads you to work in your calling, to relate to others better, and to have fulfillment in your work. Mindfulness is now being taught in some business schools. Mindfulness brings you into your present moment. Mindfulness creates inner and outer wealth.
Mindfulness strengthens pillars 2, 3, and 4 so you can interact with others more effectively.
When professionals deliver services to a niche group of customers, they tend to attract more business. There is something inherently trusting about going to a professional who only focuses on one thing. People know that this focus will provide more expertise, more efficacy, and more value for the extra money.
I remember reading Harry Beckwith’s book Selling the Invisible about 20 years ago. In this book, he talks about a lawyer in Southern California who was struggling to get his law practice running. He couldn’t figure out out to get more clients. It turns out that he enjoyed riding motorcycles as a hobby. When he finally decided to market elusively to motorcycle riders who were injured in accidents, and he became known to be the attorney to turn to for this specific niche of injury, his business exploded. It turns out, that focusing on this specific niche allowed him to become busier with other types of clients that he didn’t even market to. Other people knew that if this attorney could navigate the muddied waters of motorcycle injuries and all of the facets of law involved, then he could represent their simple car accident claims well. Focusing on this niche really allowed him to expand his law practice.
I’ve seen other examples of chiropractic offices focusing on a niche, but I haven’t seen enough. I would like to see some practices focused solely on neck pain. If a chiropractor has a comprehensive clinical approach to neck pain, and not relying on a niche modality, but keeping it to a niche problem that patients have, then I would like to see it. I know the low back pain clinics exist, but I’m not aware of neck only. I would also like to see more clinics that are ballsy enough to have a lower extremity niche. I remember hearing chiropractic technique teacher Mark Charrett talk about how, if he wanted to, he could build a whole practice around a specific knee adjusting technique that he teaches. He said that if word gets out enough among people with knee pain that he could do the things he can do with this particular adjustment, then he could be as busy as he wants to be. Interesting.
I do know of one clinic in Boise that has developed a well-deserved niche. It’s Kevin Hearon’s clinic. I took Hearon’s classes 15 years ago while I was still in school, but I never bothered to look up his clinical set up until I took his class recently at the Parker Seminar in Las Vegas. Hearon’s got a whole shoe store set up in the front of his clinic. He’s a foot and ankle guy, and it shows. He’s got the treadmill with a camera for gait analysis. He’s doing his orthotic casting. And, as far as I can tell, he is the best guy in chiropractic to do foot and ankle adjustments. If you go to him, and you see the depth of his knowledge and focus, then you know you are in the right place, and you can take comfort in his giving you the best care. Oh yea, and he’s published books and posters for the profession.
San Francisco is aching to have a professional who knows the best clinical practices for neck pain. Especially that neck pain that radiates to the shoulders because the person suffering has been sitting behind a computer all day. The City is packed full of office workers suffering through this process. If the population of The City is 700,000, and on a work day the people here swell to almost a million. If that is the case, then there aren’t enough clinicians who focus solely on neck pain. A handful of them come to me, but I’m not seeing any overwhelming appointments. But if i were to market myself as a niche for this problem? That would be an interesting turn.
What do you think? When you have a medical problem, are you seeking out a niche clinic? Or, do you find someone who can do a good job with a variety of problems?
The musculoskeletal system is the most important system in your body for your quality of life. No other system has such a profound impression on the way you live your life moment to moment.
You might rely on your heart to pump blood to your organs and your brain. You might rely on your lungs to oxygenate the blood and expel spent gases. You might rely on your kidneys, liver, spleen, and lymph system to get rid of toxins and metabolic wastes. You might rely on your liver, spleen and intestines to digest food so you can survive. But, most of these functions aren’t creating pain, taking up mindshare, or holding you back from living your life as a human should.
The greatest cause of death in the United States is cardiovascular disease, but you don’t have a pandemic of disability from it like you do with low back pain. Low back pain is the greatest cause of disability, the greatest cost of work-related injury expenses, and the greatest factor on everyone’s quality of life. Over your lifetime, most of the people you know, and probably you will have some sort of low back pain. At any given time, almost a quarter of everyone around you is suffering from back pain.
If you have a low back of your own, then it’s time to double down on your efforts to keep your low back pain away.
If you don’t work on the health of your low back, you won’t be able to drive for long distances. You won’t be able to run in a playground like a kid. You won’t be able to pick things up around the house independent of outside help. You won’t be able to play with your kids, or your grandkids. You won’t be able to pick up new recreational sports that allow you to enjoy life more. You won’t be able to squat to use the toilet.
Think about that.
Fortunately, you still have a functioning back, and you can strengthen it. You can mobilize it. You can stretch if you feel tight. You can eat an anti-inflammatory diet. You can do an anti-inflammatory fast. You may be able to do a plank, and if you can’t do a plank, you can probably do some variation of a plank and progress to something more challenging.
You see, the formula for low back success is this: keep your back moving well, and keep the muscles strong. Do this with the mental attitude that helps keep you pain free, and self aware, and you will get back pain a lot less than others.
Chiropractic care where we manipulate the joints in your low back is a form of mobilization, and it may be necessary for you, but there are other forms of mobilization that you can do at home. Here’s one: stand up and walk around. Walking is a natural activity for the low back, and when you walk, the forces from every step you take go from your foot to your pelvis and to your low back. It shifts in real time from one leg to the next. Shock is absorbed in your feet, ankles, knees, and sacroiliac joints before the shock from your steps reach your lumbar spine in your low back. Also with every step, the muscles in your legs and core are engaged and they are dynamically contracting and coordinating movement with every step.
Another idea: do some push-ups. Push-ups are a dynamic kind of plank that works your core as well as your arms. If you can’t do a push-up, then you ought to become the kind of person that can do one. Start on your knees with the “girl” push-ups, and work up your strength. You can get there; I know you can because we are all adaptable. If you can do a set of push-ups comfortably, then you can do some other variations on the push-up, like doing them on one foot. Doing a hand-clap. Doing some alternating shoulder touches. Pretty soon, your low back will be so engaged, that you will have forgotten about the pain.
Why do I say that you should strengthen your muscles to get rid of the pain? May studies show that exercise has a positive effect on back pain disability ratings. Rehab, in general, to any part of your body is done best with tension applied to stimulate growth. MRI studies of people with low back pain show muscle atrophy in the muscles of the back, and the muscles also look diseased and full of fatty infiltration if you have a low back study with an MRI for low back pain.
If you have a ton of money so you can afford caregivers, if you are content to live in chronic pain morning and night, and if you don’t mind being the one in your group who moves the slowest, then maybe you don’t need to do some self-care for your back. But if you want to be the one who’s 80 years old and still living independently, still using the bathroom on your own, still taking showers on your own, and still having youthful mental health, then you need to adopt a routine of low back exercises you will do for the rest of your life.
Now excuse me while I do some kettlebell swings.