All posts by sikorskychiro

Another reason for ARM and hand pain and numbness

PRONATOR TERES SYNDROME

Do you have a painful forearm or weird sensations in your thumb and pointer finger? Maybe your forearm, wrist, and elbow have been aching. A quick online search for symptoms yields dozens of results for painful hand, wrist, and elbow conditions, making fact-finding confusing. Your pain and discomfort may partially match common wrist complaints like carpal tunnel syndrome, hand tendonitis, elbow pain, and other related conditions, or your symptoms don’t seem to fit any single situation — making it hard to tell what exactly is going on with yourself. One lesser-known condition that causes finger tendon and forearm discomfort is called pronator teres syndrome, and this culprit for finger, hand, wrist, and forearm pain lies close to the elbow. Pronator teres syndrome imitates other conditions; however, it is discernable.

Pronator Teres compress this nerve

But what exactly is pronator teres syndrome, and how can you tell pronator teres syndrome from other related wrist and hand conditions? What is pronator teres syndrome?

The elbow is a structure connecting bones, ligaments, connective tissues, the elbow joint, several muscles, bursa (fluid-filled sacs designed to absorb forces), and nerves. Repetitive or excessive movement causes injury and damage to these structures.

1) With this syndrome, a specific muscle is the victim: the pronator teres muscle of the forearm.

2) Excessive or repetitive movement can have many causes: carpentry, assembly line work, basketball, plumbing, weightlifting, mechanic work, or any repetitive movement that causes the wrist to bend and the forearm to go palm-down.

These excessive movements contribute to stress and strain on the pronator teres. This muscle lives in the upper forearm and has two ends or heads. When it becomes swollen or inflamed, it can affect other structures nearby, such as the median nerve of the forearm and wrist.2 Additionally, the median nerve can also be compressed by a local ligament coming off the bicep muscle: the lacertus fibrosis.

The median nerve is one of three nerves that supply our upper extremity. This nerve begins in the upper arms and extends into the wrist and fingers. When the pronator teres muscle compresses this nerve, it creates aching in the forearm and wrist, possible muscle weakness, and changes in sensation to the thumb and index finger.3 Pronator teres syndrome is like carpal tunnel syndrome, defined as compression of the median nerve at the wrist.3,4 However, pronator teres syndrome affects both the hand and the forearm, whereas carpal tunnel syndrome largely affects the wrist and hand only.

Common signs that the median nerve is being entrapped at the elbow include the following3,4:

  • Aching discomfort in the forearm and tenderness on palpating (pressing) into the pronator teres muscle
  • Tingling sensation in the forearm, palm, and/or fingers (including the thumb)
  • Numbness in the forearm, hand, and/or fingers (including the thumb)
  • Pain and discomfort in the forearm, hand, and/or fingers (including the thumb)
  • Muscle weakness in the forearm, wrist, and/or fingers (including the thumb)

With pronator teres syndrome, there may not be a history of trauma or injury associated with symptoms. Instead, the symptoms may come on gradually and worsen over time.3,4

Who gets pronator teres syndrome?

Several factors can put people at higher risk of developing pronator teres syndrome. (4) These include:

• People employed in occupations that increase the bulk of the pronator teres muscle such as mechanics, plumbers, and athletes in weightlifting or racket sports

• People with a history of trauma to the elbow resulting in restrictive bands of scar tissue or fibrous tissue in the forearm

The typical age of onset is in the fifth decade, and the condition is more common in women than men. Patients with metabolic disorders like diabetes, alcoholism, or hypothyroidism are predisposed to this condition.5

How do I know if I have pronator teres syndrome?

Symptoms of pronator teres include aching pain and discomfort on the volar (front) side of the forearm with sensory disturbances along the thumb, pointer finger, and even the palm of the hand. The pain may span the lower arm. You may notice discomfort when turning your wrist to go palm-down (pronation), or this maneuver may make your pain and changes in sensation worse.2,3,4 Is pronator teres syndrome essentially the same thing as carpal tunnel syndrome? Not really. Although the symptoms may be similar, the causes are very different and require different treatment approaches. Compression of the median nerve causes carpal tunnel syndrome by inflamed tendons where the wrist meets the hand; pronator teres syndrome is compression of the median nerve near the elbow due to hypertonic (tight) muscles, muscle adhesions, and/or the presence of scar tissue or fibrous tissue that compress the nerve.2,3 How is pronator teres syndrome treated? For mild to moderate cases of pronator teres syndrome, conservative treatments like chiropractic care and rehabilitation are the first line of defense to attempt resolution of the condition.

These non-surgical methods may include one or more of the following:

  • Manual therapy
  • Rest from the inciting activity
  • Anti-inflammatory pain medications
  • Forearm splinting to prevent rotating
  • Targeted exercises and rehabilitation Severe cases may require a minimally        invasive surgical intervention to relieve the pressure on the median nerve.

Thankfully, most cases don’t need it.

 References

1. Chumbley EM, O’Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician. 2000 Feb 1;61(3):691-700.

2. Plancher KD, Peterson RK, Steichen JB. Compressive neuropathies and tendinopathies in the athletic elbow and wrist. Clin Sports Med. 1996 Apr;15(2):331-71.

3. Posner MA. Compressive neuropathies of the median and radial nerves at the elbow. Clin Sports Med. 1990 Apr;9(2):343-63.

4. Howard FM. Compression neuropathies in the anterior forearm. Hand Clin. 1986;2:737-745.

 5. Tetro AM, Pichora DR. High median nerve entrapments. An obscure cause of upper-extremity pain. Hand Clin. 1996;12:691-703. 6. Dididze M, Tafti D, Sherman Al. Pronator Teres Syndrome. [Updated 2021 Aug 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526090

Where is her Foot pain coming from?

Thanks to this patient for being a case study

Where is the pain coming from? Sometimes the problem is above or below where the patient is experiencing the pain.

This patient is having pain on the inside of her right foot. She reports it hurts to walk and stand for moderate periods.

Watching a patient walk and examine how the patient stands can help you find out where the problem is coming from. Standing and walking can give you clues into what causes the patient pain.

Look at the stickers on the patient foot and knee. See anything? There is an increase angle in the shin bone (tibia bone). It’s also called a valgus knee or knocked knee. Having this can cause increased load on the inside of the knee and foot/ankle.

When we are not symmetrical or vary off from normal, we will cause changes in the body. Some time we can deal with these changes and never develop any problems or pain. Other time these changes off can lead to break down and pain. Tissue in the body can breakdown when they fail to heal. Failed repair leads to tendonitis, tears, stress fracture, muscle strains and even disc herniations

In this patient she has developed pain on the inside of her right arch and plantar fascia. She has also developed tendonitis in a muscle called tibialis posterior.

Now to the video. The patient gait is even more telling. Patient has a very narrow gait, a kicking type leg swing and too much rocking of the hips and upper body. Her feet are turned outward or extrenally rotated

A narrow gait can lead to all types of problem, here just a few. Hip, knee and ankle/foot pain.

Weakness in the Glutes can cause a narrow gait along with a kicking type gait. The quadriceps are muscles in the front of the legs and can become dominant if the glutes become very weak.

Do you want to be fit & healthy at 80?

Age is nothing but a number, you can be fit at ANY age!

Can you be fit and healthy at 80? The answer is yes.

So how can you be fit and healthy at eighty? So what exercise should I do? What type of exercise will help me stay healthy or will help me become more healthy? You’re going to find out.   

The type of exercise will depend on what the end goals are. If you’re going to run a marathon it will be different than if you want to be a bodybuilder. This article will discuss exercising in the context of health and improving one longevity. 

Generally, speaking exercise can fall into two broad categories: Cardiorespiratory fitness and Strength/muscle mass. Both of these play the role of improving life span. The scientific literature shows that morbidity and mortality risk increase as fitness levels decline with age. Sarcopenia is associated with adverse health outcomes. 

Now for some definitions.

What are morbidity and mortality? Morbidity is the condition of suffering from a disease or medical condition. Mortality is the state of being subject to death. 

Cardiorespiratory fitness (CRF) refers to the capacity of the circulatory (heart and associated blood vessels) and respiratory (Lungs) systems to supply oxygen to skeletal muscle mitochondria for energy production needed during physical activity. Mitochondria are inside most cells and they make energy.

Muscular strength can be defined as the ability to exert force to overcome resistance In other words the ability to pick up or move objects around. 

Muscle mass is the amount of muscle in your body, including skeletal muscles, smooth muscles, and cardiac muscles. 

Loss of muscle mass and strength is known as Sarcopenia.  

Let’s talk about cardiorespiratory fitness

Cardiorespiratory fitness is measured in VO2 max. VO2 max, or maximal oxygen consumption, refers to the maximum amount of oxygen that an individual can utilize during intense or maximal exercise.  

Have you ever gone up a flight of stairs ran for the bus and got out of breath? You just tested your VO2 max. The better your VO2 max the better you’re able to exchange oxygen (O2) in the body. 

Here’s a study association of cardiorespiratory fitness with long-term mortality among adults undergoing exercise treadmill testing. The study found “The adjusted mortality risk of reduced performance on exercise treadmill test was comparable to, if not greater than, traditional clinical risk factors (eg, coronary artery disease, smoking). Importantly, there was no upper limit of the benefit of increased aerobic fitness”. So having poor cardiorespiratory fitness is as dangerous as smoking for your health and life span.  That right having low cardiorespiratory fitness is as dangerous as smoking.  The study broke down the participants into low, below average, average, high, elite. Going from just being low to being below average is a 50% reduction in mortality over a decade. If you then go from low to above average it’s about 60%  above average, it’s about a 60% or 70% reduction in mortality.   

How can we improve VO2 max? 

Well, it’s cardio. Any type of cardio, walking, rowing, or riding the bike. Any exercise that gets your heart rate up. You don’t have to do a bone-crushing workout every day to improve or keep your VO2. About 20 minutes once a week would be a good amount. So if walking is your form of cardio find a big hill and do hill repeats (walk up the hill quickly) and then walk down, let your heart rate recover, and do it again. The same principle can go for riding a bike. Go hard for 1 minute and then recover and repeat. Do that once a week and that will help your V02 max and improve your oxygen exchange.

Doing this type of cardio once a week is great for your health. Some tips start slow, no need to do 20 hill repeats the first time out. 

Start with 3-5 reps and build from there. If you feel any chest pain or thing that does not feel normal a call your doctor or heart doctor (Cardiologist). If the discomfort is too bad go to the ER. 

Now the other days you train, your cardio should be different. You should be training Zone 2. Zone 2 is steady training just coming above the easy zone, It’s not moderate or anything above. The main benefit form zone 2 heart rate or zone 2 power is that it builds an aerobic base and endurance. The best formula to figure out Zone 2 heart rate is the following.

(Your age)-180= Target heart rate.

I’m 48 years old so my target heart rate is 133. (180-47=133)

The benefits of Zone 2 training are, increased mitochondria (the power plant of the cell), increased mitochondrial efficiency, lower heart rate, lower blood pressure, and finally help with insulin resistance.

So doing both types of cardio will help you balance your cardiorespiratory fitness. A good ratio is 80% zone 2 and 20% hard. 

Strength/Muscle mass

Sarcopenia, or the decline of skeletal muscle tissue with age, is one of the most important causes of functional decline and loss of independence in older adults. An average person can lose 1-4% of their lean mass (muscle) and year. 

Figure 9. Strength loss with aging in literature (Keller and Engelhardt, 2013).

If you have low muscle strength, then you have probable sarcopenia. 

AS we age we replace our muscle fibers with fat and connective tissue. 

So the muscle loses its ability to contract (contractile function) and muscle metabolic function. Muscles need lots of energy, so they use a lot of blood glucose (sugar). If a person has less muscle then they use less sugar/blood glucose leading to insulin resistance and then type 2 diabetes

Two ways to see how well you’re doing are the sit-to-stand test and grip strength test. This study Strength, But Not Muscle Mass, Is Associated With Mortality in the Health, Aging and Body Composition Study Cohort.  The authors used sit-to-stand test and grip strength test, in their study to see how strength affects Mortality.

 Low muscle mass did not explain the strong association of strength with mortality, demonstrating that muscle strength as a marker of muscle quality is more important than quantity in estimating mortality risk. Grip strength provided risk estimates similar to those of quadriceps strength.  

The ability to get out of a chair without using your arms is very important. This movement is a squat. If you trip over a sock while going to the bathroom at night you need the strength in your leg to prevent you from falling and potentially hitting your head or breaking a bone when you fall.

30-second Chair Stand test is a great way to test how strong your legs are.  Try it out and see if you’re at risk for falling.  If you are get to work and improve your muscle strength in your legs.

https://peterattiamd.com/wp-content/uploads/2021/09/f13-ama27-1024x861.png

Figure 13. Fall death rates in the U.S. from 2007 to 2016 for adults aged 65 and older. (CDC)

Figure 13. Fall death rates in the U.S. from 2007 to 2016 for adults aged 65 and older. (CDC)

From 2007 to 2016, 10 years, we saw the deaths per 100,000 in the United States as a result of falls go from about 46 to 60 (That’s a 30% increase). At this rate, by 2030, we’re going to see seven fall deaths every hour

The other day I slip on some clothes my kids left on the stairs. What stopped me from fall down stairs? Grip strength, the ability to grab the railing and stop my fall.

Grip strength.

Grip strength is harder to test but still important. So start working on hand strength by carrying heavy objects or get yourself a hand gripper. Carrying heavy objects for a workout is called a farmer’s carry. Farmer carry are good for your core as well as your hand/grip strength.

So as we age it’s critical to work on maintaining muscle mass and strength to improve the quality of our lives. The stronger we are the more muscle we have the lower the morbidity and mortality. It’s never too late to start. It’s better never to stop building muscle.  

Get a Grip! – YouTube

Pushing, Pulling, Squatting & More! – YouTube (Farmer’s Carry)

Figure 15. Paddon-Jones Curve.

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A lot of people think that there’s a linear or gradual decline in muscle mass or muscle size as we age. The reality is that it’s a lot more staggered as you get into older age…if you’re injured or if you’re bedridden, for example, that accelerates the decline.

Much like saving money the more you have when you retire the more you have to withdraw from.  So start now and build as much muscle as possible.  Your life could depend on it.

So where to start:

  1. Get off the couch, the hardest lift is lifting yourself off the couch.
  2. Get outside and walk. It’s easy and free. 
  3. Find a big hill and walk up and down it once a week.
  4. Start lifting weights. A gallon of milk/water is a great start. If you need an idea on what to do go over to our YouTube page.
  5. Start doing Chair squats. Here’s a link to show how to do them
  6. Find something heavy and do farmers carries or static holds till you feel the burn.
  7. Anything is better than nothing.

Risk of Treatment Escalation in Recipients vs Nonrecipients of Spinal Manipulation for Musculoskeletal Cervical Spine Disorders: An Analysis of Insurance Claims

I treat a lot of patient who have seen other doctors before walking into my office. Lots of them have had lots of testing (MRI’s, C.T’s, EMG/NCV) before they even see me. Many of times these tests are a waste of time and money. This study shows if patients see a chiropractor first they would have less testing and in turn save money . This study found patients who did not see a chiropractor first had 2x risk of escalation. This means being sent for  imaging, injection, emergency room, or surgery. A simple rule of thumb to follow is chiropractic first, medicine second and surgery last. A high quality exam will direct care and must be done first. Here’s the study.

Chiropractic FIRST, Medicine SECOND, Surgery LAST.

The Study: Risk of Treatment Escalation in Recipients vs Nonrecipients of Spinal Manipulation for Musculoskeletal Cervical Spine Disorders: An Analysis of Insurance Claims

Results

The sample was 55% women, with a mean age of 44 years (range, 18-103). Treatment escalation was present in 42% of episodes overall: 2448 (46%) associated with other care and 876 (26%) associated with spinal manipulation. The estimated risk of any treatment escalation was 2.38 times higher in those who received other care than in those who received spinal manipulation (95% confidence interval, 2.22-2.55, P = .001).

Conclusion

Among episodes of care associated with neck pain diagnoses, those associated with other care had twice the risk of any treatment escalation compared with those associated with spinal manipulation. In the United States, over 90% of spinal manipulation is provided by doctors of chiropractic; therefore, these findings are relevant and should be considered in addressing solutions for neck pain. Additional research investigating the factors influencing treatment escalation is necessary to moderate the use of high-cost and guideline-incongruent procedures in people with neck pain.

Natural Immunity Versus Vaccine-Induced Immunity

The Study: Comparing SARS-CoV-2 natural immunity to vaccine-induced immunity: reinfections versus breakthrough infections

covid-19 vaccine

I wanted to share this interesting study. I’m sure this study will receive a lot of criticism because of the controversial findings. NOTE: This study is NOT anti vaccination per se but rather may be highlighting some early findings in the differences between how a immunity is conveyed via mRNA vaccination versus exposure to the whole virus which occurs following natural infection. 

  

Overview: This paper is a very straightforward, retrospective study out of Israel which compares three groups: 1) Fully vaccinated subjects with NO HISTORY of prior COVID infection, 2) previously infected individuals who had not been vaccinated, and (3)  previously infected infected individuals who had also received a single vaccine dose.                                                                                                 

Results SARS-CoV-2-naïve vaccinees had a 13.06-fold (95% CI, 8.08 to 21.11) increased risk for breakthrough infection with the Delta variant compared to those previously infected, when the first event (infection or vaccination) occurred during January and February of 2021. The increased risk was significant (P<0.001) for symptomatic disease as well. When allowing the infection to occur at any time before vaccination (from March 2020 to February 2021), evidence of waning natural immunity was demonstrated, though SARS-CoV-2 naïve vaccinees had a 5.96-fold (95% CI, 4.85 to 7.33) increased risk for breakthrough infection and a 7.13-fold (95% CI, 5.51 to 9.21) increased risk for symptomatic disease. SARS-CoV-2-naïve vaccinees were also at a greater risk for COVID-19-related-hospitalizations compared to those that were previously infected.

Conclusions This study demonstrated that natural immunity confers longer lasting and stronger protection against infection, symptomatic disease and hospitalization caused by the Delta variant of SARS-CoV-2, compared to the BNT162b2 two-dose vaccine-induced immunity. Individuals who were both previously infected with SARS-CoV-2 and given a single dose of the vaccine gained additional protection against the Delta variant.

Sivan Gazit, Roei Shlezinger, Galit Perez, Roni Lotan, Asaf Peretz, Amir Ben-Tov, Dani Cohen, Khitam Muhsen, Gabriel Chodick, Tal Patalon Comparing SARS-CoV-2 natural immunity to vaccine-induced immunity: reinfections versus breakthrough infections. Published in medRxiv. Preprint server for health sciences. Aug 25,2021

https://www.medrxiv.org/content/10.1101/2021.08.24.21262415v1.full-text

Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

Are you experiencing pain, numbness, tingling, and weakness in the hand and fingers?  Do your fingers or hands feel like they’re “falling asleep” while you type at a keyboard, grip a steering wheel, work out at the gym, or pick up groceries or even your child?

There are several conditions of the head, neck, shoulder, elbow, and wrist that cause sensations of tingling, numbness, pain, and weakness with grip strength. More common conditions include carpal tunnel syndrome1, tennis elbow (lateral epicondylitis)2, compression of the nerves exiting the neck spine (cervical radiculopathy)3, and pinched nerve (impingement syndromes) of the shoulder.  Less common injuries involve brachial plexus injuries, such as Thoracic Outlet Syndrome, or TOS for short.  

Normal Cervical X-ray

What is Thoracic Outlet Syndrome? 

The thoracic outlet is a space in the body that sits between the lower part of the neck and the collar bone (cervicothoracobrachial region), close to the first rib of our ribcage. This region stretches to the upper part of the arm and contains a network of nerves and blood vessels supplying the arm. 

Thoracic Outlet Syndrome describes a series of conditions that cause compression of the major nerves and/or blood vessels that run through that thoracic outlet space.  However, the term “TOS” does not specify the structure being compressed. 

There are three different types of thoracic outlet syndrome4, and all of these are named after the type of vessel or structure being compressed.  Categories include:

Neurogenic

  • Compression of the brachial nerve plexus 
  • Slower onset of symptoms
  • Decreased sensation along the arm
  • Possible weakness with grip strength and hand muscles
  • About 90% of all TOS cases

Venous

  • Compression of the axillary or subclavian vein 
  • Symptoms are more abrupt in onset
  • Includes venous distention in the neck
  • Pain ranges from the arm to the forearm
  • Less than 10% of all TOS cases

Arterial

  • Compression of the axillary or subclavian artery
  • Symptoms are also more abrupt in onset
  • May cause color changes in the fingers
  • May cause diminished pulses in the upper extremity
  • Less than 10% of all TOS cases

What structures can compress the neurovascular bundle in the thoracic outlet?

The compression of the neurovascular bundle in TOS can have multiple causes, ranging from anatomic anomalies to poor posture.

Cervical ribs and the fibromuscular bands connected to them are identified as the most common cause of neurovascular compression in TOS.  Cervical ribs are not like the first rib of our ribcage, which is the uppermost rib and projects off the first thoracic vertebrae.  Instead, cervical ribs are an anatomic anomaly where an extra rib branches off the lowest cervical vertebrae.  It is known that about 1 in 500 people present with a cervical rib, making it a common genetic occurrence.  Not everyone with a cervical rib will develop TOS; it is simply a contributing factor.

Another major cause of TOS is muscle tightness in the thoracic outlet.  Affected muscles include pectoralis minor and scalene muscles. 

Alterations in posture can be another cause of TOS.  Slouched posture with forward rounding of the shoulder narrows down the thoracic outlet, which can compress any neurovascular structures.  This can occur with prolonged poor posture or in individuals with additional breast tissue.

Finally, TOS can be seen in athletes who engage in repetitive extreme shoulder motions such as competitive swimming or baseball pitchers identified to narrow the thoracic outlet.

How do we treat thoracic outlet syndrome?

In our Elgin Chiropractic practice, we perform a detailed history of your injury, followed by a functional movement assessment and examination.

Mechanical causes of TOS such as poor posture or tightness of certain muscles respond well to conservative chiropractic treatment. Often, TOS will be caused due to a combination of tight muscles and poor posture. Tight muscles would be treated with a muscle release technique called Active Release Technique and Graston Technique. Poor posture will be addressed with sports rehabilitation exercises to strengthen the mid-back and deep neck flexor muscles.

Frequently Asked Questions (FAQ)

How do I know if a chiropractor is right for me? Do I need surgery?

At our chiropractic office, we take ample time to perform a detailed history and physical examination to find the cause of your pain. Once we have found the cause of your pain, we will develop a specific treatment plan that will suit your care.

In abrupt vascular symptoms such as diminished pulses, severe discoloration of the fingers, and cold hands, the patient will be sent out for an orthopedic consult to discuss surgical treatment.

With the absence of vascular symptoms, we would consider a conservative trial of care that includes releasing tight muscles, strengthening weak muscles to improve posture, and adjusting any restricted joints.

If a patient does not respond to a conservative management plan, the patient will also be sent out for an orthopedic consult to discuss possible surgical treatment.

A conservative treatment approach has fewer side effects than surgery and a faster return to normalcy than the extensive rehabilitation required after surgery.

How long will it take to recover from Thoracic Outlet Syndrome?

Unfortunately, this depends. According to the most recent research, an average conservative trial of care will take about eight visits, after which the symptoms will be re-assessed.

Recovery can be dependent on many things, including the body’s response to healing, lifestyle, ergonomics, and compliance to rehabilitation exercises. Depending on the severity of your symptoms, you may also need collaboration with other healthcare providers.

When should I see a chiropractor for my pain?

If you are dealing with any of the above-mentioned symptoms, we are here for you. If you want a same-day examination and treatment for your injury, call our Elgin office at 847-695-0464 or schedule online.

A diet high in refined carbohydrates is not good for health.

There is a study that found having seven servings of refined grains (white bread, pasta/noodles, breakfast cereals, crackers, and bakery products, etc.) per day was associated with a 27 per cent greater risk for early death. 33 percent greater risk for heart disease and 47 per cent greater risk for stroke.

Food that is delicious, but not healthy.

The Prospective Urban Rural Epidemiology (PURE) study has been examining diets from diverse populations in low-, middle- and high-income countries around the world. Over 16 years of analysis of 137,130 participants in 21 countries, including Canada, the researchers found the intake of refined grains and added sugars have greatly increased over the years

Since this was an observational study it has the disadvantage of not being able to establish causation. Although, their data was adjusted for several possible confounding factors such as obesity, wealth status, etc. there are almost certain, that other factors that were not defined in this study that could be at play. Eating a diet high in refined carbohydrates increases small, dense LDL particles which are very atherogenic.

Another study including over 400,000 people found that those with the highest refined sugar intake had a four-fold increase in heart attacks compared to those with the lowest intakes.

A diet high in refined carbohydrates is not good for health.

Eating more refined grains increases risk of heart attack, early death: The researchers examined diets from diverse populations in low, middle and high-income countries. — ScienceDaily

Dead butt! (syndrome)

No kidding, it’s a real thing!

A dead butt isn’t a phrase you use to describe an awkward joke, although having a dead butt can be a downer. The phrase “dead butt” refers to a painful condition caused by inflammation in the tendons of the gluteus Medius muscle, one of several major muscles composing the buttocks. This condition, known medically as gluteus Medius tendinopathy1, is also called “dead butt syndrome.”

What is dead butt syndrome? Do the muscles in your backside die?

While the name may have a level of seriousness to it, our bodies are naturally resilient; unless the muscle is cut off from its blood supply, it doesn’t die easily. However, gluteus Medius syndrome is painful, and pain experienced during this tendinopathy can bring the buttocks to the front and center of your attention.

Although a person’s posterior may look relatively simple, our backsides are actually quite complex. Gluteus medius is a smaller, lesser-known muscle in the buttocks with an essential function. The gluteus medius muscle actively contracts during weight-bearing while we run or walk.1 The gluteal muscles (there are three) are just several muscles that compose the familiar anatomical structure we call the “butt” and originate from the bony pelvis (ilium) and insert on the long leg bone (femur).

To best understand gluteus medius tendinopathy, we need to understand what happens with tendinopathies in general, how exercise or well-intentioned but poorly managed daily routines can contribute to our butts becoming “dead,” what to do about it!

Explaining the “dead” butt of dead butt syndrome

There are several options to weigh regarding muscle-based conditions that cause pain in our backsides. Although the gluteus Medius helps compose our buttocks, the location of this tiny but powerful muscle is essential. Because of its connection to the lateral part of the hip, it is important to consider gluteus Medius tendinopathy as a possible cause of outer hip pain1. In particular, the moderate to intense pain associated with this condition can be found on the bony part of the femur called the greater trochanter, a bony eminence located at the top of our leg bone near the outer part of our hips. This pain does not always stay localized, either, and sometimes extends down into the lateral thigh.

The causes for gluteus medius tendinopathy are opposite of one another. One cause stems from chronic underuse of our butt muscles, such as that experienced during a sedentary lifestyle.  Sedentary lifestyles cause hip flexor muscles to tighten while lengthening gluteal muscles, leading to inefficient muscle activation.  Sedentary lifestyles also cause gluteal compression2; an example is sitting for extended periods.  Think of having a career involving driving for long hours or commuting for a job only to sit in an office chair for more hours, with few breaks to get up and exercise.  That’s a lot of time spent with your butt compressed into a (hopefully comfortable) flat surface!

The other cause for gluteus medius tendinopathy is overuse. Repetitive exposure to overloading, such as during long-distance running, can also contribute to the development of this condition.3

On an ideal day, the tendon undergoes a cycle of balanced movements, including weight-bearing, bending, expanding, contracting, and adapting to our regular activities. When our tendons experience changes in loading type — think of increased intensity such as taking up a new exercise routine or lifting more weights for a personal record, or daily habits that fail to engage in consistent loading and movement — this disrupts the tendon’s ability to adapt over time.3 Sustained compression can be just as damaging as improper loading. Loading during rapid increases in intense or frequent exercises with insufficient recovery times can reduce the capacity of the tendon to adapt, predisposing it to injury. Dead butt syndrome refers specifically to the tendons of the gluteus medius muscle failing to adapt.

Both too little and too much movement contribute to a dead butt!

Pain and dysfunction with gluteus medius tendinopathy

Pain, the type of pain, and the location of pain help point a person toward a diagnosis of dead butt syndrome. Not all types of pain are equal. Lateral hip pain with an insidious onset can be several conditions of the low back or hips, such as hip osteoarthritis. Therefore, pain alone isn’t enough to make a definitive diagnosis. Dysfunction of the gluteus medius tendon should be considered in the following scenarios where the pain accompanies other situations4, such as:

  • Pain into the lateral thigh and knee
  • Pain with prolonged sitting or sitting in a crossed-legs position
  • Pain with weight-bearing activities such as walking, climbing stairs, running, and standing
  • Tenderness on the hip with palpation, especially along the greater trochanter
  • Pain while laying on the affected hip, such as experienced in bed
  • Weakness with other muscles of the affected leg

If you’re experiencing any of these signs or symptoms, you should give your Doctor of Chiropractic a call and make an appointment for a thorough evaluation.

How to diagnose gluteus medius tendinopathy

A thorough hip examination is required to diagnose gluteus medius tendinopathy.  Your exam will not only include obtaining your patient history but also a physical examination combined with clinical and hands-on musculoskeletal tests, including orthopedic tests.  Movement of the hip, including range of motion for both legs, should be obtained. 

Some tests may elicit discomfort due to the tightness or inflammation of potential tendons, muscles, and other soft tissue structures associated with the buttocks. Any discomfort experienced during testing should be communicated to your chiropractor.  Pain provocation and reproduction of your symptoms through muscle loading and testing can be a desired outcome!  If a test is designed to create discomfort, your doctor will tell you this in advance, and any pain experienced should be relayed to the doctor. This will help clinically determine what is going on with your hips, and the correct diagnosis will guide your treatment and musculoskeletal care.

How to treat gluteus medius tendinopathy

Imaging is rarely utilized for most gluteus medius tendinopathies. Ultrasound or MRI may be used to rule out another possible diagnosis if the diagnosis is unclear or if conservative treatment has failed.

Correct management of gluteus medius dysfunction is imperative. The wrong exercise or rehabilitation approach may delay or decrease optimal recovery!

Management of this condition1,5 includes specific loading exercises and management strategies for the affected tendon(s), rehabilitation including guided exercises and movements, ergonomic changes to your work or home, or co-management with another doctor.  Certain exercises may need to be modified or changed from your usual workout routine, or you may have new exercises introduced as a home exercise program.  You may be asked to avoid or change other postures4,5; for example, avoid sitting with your legs crossed or adding a pillow between your knees while you sleep at night.

Some treatment options are more invasive than the conservative musculoskeletal route and may be considered if recovery is slow or progress is less than optimal. These include corticosteroid injections, platelet-rich plasma (PrP) injections, and surgery.5

Is a chiropractor the right doctor for managing dead butt syndrome?

Absolutely.  If you’re not sure about what step is appropriate to take, call your chiropractor.  An evaluation will determine the extent of muscle injury and if further intervention is required, especially since proper assessment and early diagnosis lead to the best outcome possible.  
However, not all patients will respond to conservative musculoskeletal care.  If you have gluteus medius tendinopathy and this describes you, discuss with your chiropractor about other options for treatment.  Every case is unique, and your situation may call for further intervention.

References

1. Allison, K., Vicenzino, B., Wrigley, T.V., Grimaldi, A., Hodges, P.W., and Bennell, K.L. (2016). Hip abductor muscle weakness in individuals with gluteal tendinopathy. Medicine and Science in Sports and Exercise;48(3):346-52.

2. Almekinders, L.C., Weinhold, P.S., and Maffulli, N. (2003). Compression etiology in tendinopathy. Clinics in sports medicine;22(4):703-10.

3. Cook, J.L., and Purdam, C.R. (3009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine;43:409-416.

4. Grimaldi, A., and Fearon, A. (3015). Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. Journal of Orthopaedic & Sports Physical Therapy;45(11):910-33. 5. Bennell, K., Wajswelner, H., and Vicenzino, B. (2015) Gluteal tendinopathy: a review of mechanisms, assessment, and management. Sports Medicine;45(8):1107-19.

Is it Back Pain or a Herniated Disc?

Is it Back Pain or a Herniated Disc?

If you are one of 31 million Americans experiencing back pain, neck pain, or low back pain, a “slipped” disc1 or herniated disc may be the cause.

You may ask, “what exactly is a herniated disc, and how does it become injured”?

The spine consists of 24 blocky bones (vertebra) stacked on top of each other in a flexible column that allows our body to move. Between each vertebra sits a soft, rubbery cushion made of cartilaginous fibers and hydrated proteins known as an intervertebral disc2.

Intervertebral disc - Physiopedia

(picture from Google images)

Intervertebral discs act as shock absorbers2 for our spine, much like shocks in a car. Discs absorb the impact of numerous physical activities: running, bending over, sitting, jumping on a trampoline, and more. Intervertebral discs also absorb physical forces sustained in stationary positions, like sitting at a football game, or in front of a computer for long periods.

Intervertebral discs are located in the cervical, thoracic and lumbar regions. They bend and twist with movements of the spine, allowing our bodies to be flexible.

How do they accomplish this? Intervertebral discs are shaped like jelly donuts with a tough, fibrous outer portion known as the annulus fibrosis and a soft, gel-like2,3 inner portion called the nucleus pulposus. This combination of a more rigid exterior and softer interior allows it to distribute the forces we encounter with our everyday activities and physical exertion. All because, this bendable disc absorbs the forces of physics.

How does an injury occur to an intervertebral disc?  Imagine dropping a jelly doughnut onto the sidewalk and stepping on it.

The term, “slipped disc”, more accurately known as a bulging or herniated disc, refers to some damage that has occurred to either the annulus fibrosis, the nucleus pulposus, or both3,4.

The damage can be minor – think of a small papercut that heals just fine on its own. Sometimes, the outer portion of the intervertebral disc tears, resulting in large bulges in the annulus fibrosis4,5.  If the tearing and damage to the annulus fibrosis are extensive, the nucleus pulposus may leak out. 

Damage to this tough exterior of the intervertebral disc can also irritate the nerves on the outer third of the annulus fibrosis, causing pain and other sequelae to occur.

Compromise to the disc structure is commonly thought to occur from accidents or traumas, but it is not always the case. Although injuries from traumatic accidents like sporting injuries, vehicle collisions, or slips and falls can cause damage to the disc, degeneration or accumulated wear and tear on the body, it can also cause discs to become more susceptible to injury and damage!, Sometimes degeneration occurs from age, but it also can occur naturally.5

Thankfully, the rubbery discs in our spine are a lot stronger than a jelly doughnut!

Although intervertebral discs can be injured, there may not be any symptoms.  Having a disc injury may not always be painful or even result in pain or a loss of function. 

If there is a disc bulge or herniation, surgery is not always necessary6 to relieve the problem, either. Why is this?

Disc bulges can occur naturally in the body without producing any signs or symptoms that they exist. 

It’s when signs and symptoms, such as pain and a decreased ability to perform regular activities, may indicate the need for some intervention.

The mechanism of a disc herniation

The vertebrae and intervertebral discs of the spine surround and protect the spinal cord: the information highway connects the brain to the body’s nerves.  The nerves exiting the spinal cord travel outward. Innervating both, left and right sides of our bodies.

Injury to a disc can create a bulge that pinches one of the nerves exiting the spinal cord. This is known as nerve impingement. Signs or symptoms depend on where the disc is located and whether the disc bulge or injury is pressing on a nerve.

If this is the case, depending on where the pinched nerve is in the spine, it can result in pain, weakness, or odd sensations called paresthesia in an arm or leg!

Signs of a disc herniation causing nerve impingement include7:

  • Arm or leg pain. If pain is left in the upper or lower extremities, it is usually only on one side. 
    • A disc herniation in the neck may cause pain and discomfort in the shoulder and arm. 
    • If the disc herniation is in the lower back, it may cause pain and discomfort along the beltline, thigh, and even into the foot. 
    • This pain can feel sharp or shooting when you cough, sneeze, or move into certain positions.
  • Weakness. A disc herniation may pinch the nerve, resulting in muscles controlled by the nerve becoming weaker.
  • Paresthesia. This may feel like tingling, numbness, strange sensations, or even ants crawling on the skin. The areas of the body that experience these symptoms are often supplied by the nerve being impinged.

Certain conditions increase the risk of developing disc herniations and disc injury. These are:

  • Weight. Obesity and excess body weight places additional stress on the discs, primarily in the lower back.
  • Occupation. People with labor-intensive jobs have a greater risk of developing back problems. This includes repetitive lifting, pulling, pushing, twisting, bending at the waist, and leaning from side to side.
  • Genetics4,8. Some people inherit a predisposition to developing a disc herniation.
  • Smoking. Smoking decreases the oxygen supply to the disc, causing the cartilaginous fibers to break down more quickly.

Is your pain coming from a spinal disc injury?

What should you do if you suspect you have a disc herniation?  The nature of this injury is mechanical, which means it occurs in relation to the muscles, joints, and bones of the body. Addressing the musculoskeletal components and making changes to the overall bodily movement becomes a crucial part of an effective treatment plan.

This isn’t to say a person with a disc herniation needs to stop all activities and engage in bedrest.  This could be an undesirable course of action.  

Management of a disc herniation will depend on whether the condition is acute (sudden onset), or chronic, (repeatedly occurring over time). It may also depend on the severity of symptoms and the size of the injury to the disc.8

Thankfully, with the right interventions and tools, intervertebral discs can heal – although it can be slow!

What should you do if you suspect you have a disc herniation? To help prevent a herniated disc8, you can:

  • Exercise. Strengthen the trunk muscles (think core muscles: abs and back) as these muscles work together to stabilize and support the spine.
  • Change your ergonomics. Lift heavy objects properly, making your legs — not your back — do most of the work. Take breaks to change positions and move when sitting for long periods.
  • Maintain a healthy weight. Excess weight puts more pressure on the spine and discs, making them more susceptible to herniation.
  • Quit smoking. Avoid the use of any tobacco products.

References

1. Ju, K. (2020). “What’s a slipped disc?” Spine-Health. Retrieved January 2021 from https://www.spine-health.com/blog/what-s-slipped-disc

2. How does the spine work? (2019). Institute for Quality and Efficiency in Health Care. Retrieved January 2021 from https://www.ncbi.nlm.nih.gov/books/NBK279468/

3. Bridwell, K. “Intervertebral discs.” Spineuniverse. Retrieved January 2021 from https://www.spineuniverse.com/anatomy/intervertebral-discs

4. Roberts S, Evans H, Trivedi J, Menage J. (2006). Histology and pathology of the human intervertebral disc. J Bone Joint Surg Am. Suppl 2:10-4. 

5. McHugh, B. (2017). “What is degenerative disc disease?” Spine-Health. Retrieved January 2021 from spine-health.com/conditions/degenerative-disc-disease/what-degenerative-disc-disease

6. “Lumbar herniated disc: Should I have surgery?” University of Michigan – Michigan Medicine. Retrieved January 2021 from https://www.uofmhealth.org/health-library/aa6282

7. Herniated disk. Mayo Clinic. Retrieved January 2021 from https://www.mayoclinic.org/diseases-conditions/herniated-disk/symptoms-causes/syc-203540958. Williams, F.M.K., et al. (2007). Schmorl’s nodes: Common, highly heritable, and related to lumbar disc disease. Arthritis Care & Research. 57(5): 855-860.

The 5 Best Strategies to Restarting Your Exercise Programs

Push, Pull, Squat, Hip Hinge, Carrying 

It’s not uncommon for patients to tell me they would like to “get back to the gym” but they are not sure where to start.  They are confused about what exercises they should do, what exercises are safe, and sometimes feel discouraged because they can’t do what they used to be able to do. In this post, you will be given a strategy to easily implement in your Re-start to exercise.

What exercises you chose to do, for your resistance training which is an important part of any program but especially if you haven’t been back for a while, depends on many things but most importantly it depends on your goals.

For me, my goals are fairly simple: Feel strong to take care of any normal daily activity, perform sports at a decent level and not wake up not being able to walk.

Everyone has goals when it comes to health. It’s up to you to find something that you care about and go for it. It does not matter what you do , as long as you do something. This is a guide for the gym but can easily be used at home, when taking the groceries out of the trunk, lifting the car seat, gardening, cleaning, etc. All of these activities are just THAT. They require a certain level of muscular activity and if your body is not able to withstand the demands of all these activities over the course of the week, guess what? Your going to eventually hurt yourself.

EVERYONE is hyper focused on cardio related exercises to try to maximize their health. As much as I love running and cardio, if you’re planning to start exercising after a long layoff a couple weeks in a resistance based program will benefit you.

Although cardiovascular exercises are important this blog is about what resistance type exercises will help you reach your goals. According to renown exercise coach Dan John, there are 5 essential movements that you need to be able to do throughout your life: Push, Pull, Squat, Hip Hinge, and Carry. If you design a resistance program around these 5 essential movements you are off to an excellent start.

Push

Good examples of push exercises would be: bench press, pushups, overhead press (if your shoulders are healthy). Using your lawnmower, pushing a heavy shopping cart at Costco, and getting up from the ground requires a higher level of muscular activity. All of these movements are either partially essential (lawnmower) or HIGHLY essential (picking yourself up off the ground). You can see why consistently training these movements can be particularly helpful, especially as we all age.

Pull

Good pull exercises would be any of the rowing variations including, bent over rows, seated rows, renegade rows etc.  Pull-ups are also excellent. Bending and trying to grab the 2 milk jugs plus the other 12 bags of groceries is a perfect example of pulling weight from a lowered position. Because come on, who likes to take one bag of groceries at a time? 

Squat

As I write this I can think of more squat variations than almost any of the other movement patterns.  Basic ones would be: body weight squats, rear leg elevated split squats (Bulgarian split squats), sumo squats or any of the other dozen or more variations. 

Playing with your kids sometimes requires some version of a squat, lowering down to pick things off the ground (especially heavier things) and many other scenarios in which this is an essential movement in regular life. Don’t think of a squat as only the traditional movement. Use the position and exercise within its parameters, I have given you a couple different options above.

Hip Hinge

This is one of the most important of the patterns especially for those with sore backs and disc issues.  A good hip hinge will allow you to bend at the waist and pick stuff up safely.  Ironically I find this is often one of the hardest movements to help people get right.  Some exercises that help are deadlifts, one-legged deadlifts (Romanian deadlifts), good mornings, and kettlebell swings.

This movement is difficult because it goes into some of the other movements. This is ‘Mr. Versatile’. Movements typically start at the hip and if you don’t have this foundational movement, lifting things can be harder than they should be. For example a ‘bent over row’ requires you to hip hinge prior to pulling the weight. If you do not hinge, you’re at a disadvantage 1. You won’t be able to lift as much this way 2. You are putting your low back in a risky position/asking for a disk injury.

Carrying 

This sounds simple but is so very important for activities of daily lifting because a good carrying exercise also trains your grip.  Examples would be: suitcase carries, farmer walks, rack carries and waiter carries.

Going back to the grocery analogy, we want to carry all 12 bags right? How are you going to get from your car to the fridge if you do not have the capacity for it?

Key Takeaways

Designing a program around these 5 basic movement patterns and consistently implementing it can help ensure that you can function and move well for years to come, play with the grandkids, get up and down off the floor independently, get in and out of the tub without a pull support, go up the stairs when the elevator breaks and so on and so on.

So if you are wondering how to start, pick one or two exercises from each of the above movements and you are off to an excellent start to your health!