Treating an Anterior Humeral Head

Practitioners in the joint world often speak of "bone out of place" or "positional faults."¹ Chiropractors in particular have experienced significant results when using joint-play techniques to treat these types of joint lesions.

Mulligan has a technique for the shoulder that, in my experience, is very effective in relieving shoulder pain. Coupling this technique with information in the literature as to why it may be effective lends much credibility to the method.

According to McKenna, et al.,² anterior position of the humeral head in relation to the acromion may compromise the subacromial space because the humerus is in greater proximity to anterior structures in elevation. These authors proposed a palpation method of evaluating the anteriority of the humeral head in relation to the acromion

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Treating an Anterior Humeral Head

Practitioners in the joint world often speak of "bone out of place" or "positional faults."¹ Chiropractors in particular have experienced significant results when using joint-play techniques to treat these types of joint lesions.

 

Mulligan has a technique for the shoulder that, in my experience, is very effective in relieving shoulder pain. Coupling this technique with information in the literature as to why it may be effective lends much credibility to the method.http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=54922

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The Latest on Tendinopathy

There is an ongoing debate on the role of inflammation and degeneration in tendons, especially from overuse injury. If the primary problem is due to inflammation, then an anti-inflammatory approach is regarded as the answer - but has not been found to be a satisfactory solution.

An excellent study by Bisset and colleagues¹ showed that in the short term, corticosteroid injections or physiotherapy (elbow manipulation and exercise) was better than a wait-and-see program over the first six weeks, but in the long term, the manipulation and exercise method was recommended over corticosteroid injections.

 Biopsy examination of tendons has shown that inflammatory cells are scarce, while degeneration is common. One problem with this statement is that most of the biopsies were taken in the chronic stages, often during surgery. But recent human biopsies of tendons with smaller tears with a less degenerative picture revealed a significant inflammatory infiltrate of mast cells and macrophages.² Still, it appears that in the chronic stage, the term tendinosis is more applicable than tendinitis

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Anatomy Texts Got It All Wrong

Almost all of the major anatomical textbooks - Netter's Atlas of Human Anatomy and Gray's Anatomy, for example - show beautiful photos and illustrations of muscles attached to bones. Unfortunately, based on this type of muscular description, they are describing only part of a structure and giving the impression that this represents the muscle in its entirety. What is being left out is the part of the muscle that transmits its force and even more importantly, the part of the muscle that allows it to function.

As stated by Jaap Van Der Wall, MD, PhD,¹ at the last fascial conference in Amsterdam, the most important part missing in the term musculoskeletal system is the connective tissue. For years, anatomists have been cutting away an essential portion of the muscles: the fascia. Many muscle fibers insert into intermuscular and epimysial fascia without being attached directly into bone.²

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First Multidisciplinary U.S. Soft-Tissue Conference

Before I decide whether to attend a conference, I ask myself two important questions: will the information be beneficial to my understanding of the subject and will I be instituting any permanent changes the following Monday morning? It is often said that if a conference is able to give the practitioner one significant thing they will find useful for the rest of their career, then the weekend is worthwhile.

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Palpation for Sciatica

According to a recent study, palpation of inflamed sciatic, tibial and common peroneal nerves can be another procedure added to the slump test and the straight leg raise (SLR), for example, to determine if there is neural involvement.¹ The study by Walsh and Hall states that nerve palpation is one of the key factors in the classification of low-back related leg pain.^2,3 Of the three nerves palpated, the sciatic nerve exhibited the greatest accuracy followed, in order, by the tibial and common peroneal nerves. A negative finding of no positive palpation sites thus indicates that the target condition (sciatic nerve mechanosensitivity) can be ruled out. Two or more positive palpation sites had the greatest overall diagnostic accuracy, so it is important to palpate all three sites.

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An Important Shoulder Test Not Often Used

As I've said previously, most orthopedic tests for the shoulder cannot truly isolate a particular structure, since when we use tests that compress or stretch an area, adjacent structures also have to be compressed, stretched or contracted.¹ While there is definite truth in this statement, most of us arrive at a diagnosis by using as many credible tests in the literature as possible. There is a test that, while not that specific in determining the exact lesion source, has the ability to determine whether the problem is located in a particular area, which can then be followed by other specific tests. The test is called the internal rotation resistance strength test (IRRST).² This test, as discussed by Zaslav, helps to differentiate between an outlet impingement and a non-outlet impingement.

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The Iliopsoas: A Possible Cause of Acetabular Labrum Tear

An anatomic study that appeared recently in the American Journal of Sports Medicine¹identified - for the first time - the cross-sectional anatomy of the iliopsoas tendon at the level of the labrum. Several authors have implicated iliopsoas impingement on the anterior labrum as a cause of labral tears. They have stated that a tight iliopsoas tendon could cause compression over the anterior capsulolabral complex, leading to labral lesions. Labral tears at the 2 o'clock to 3 o'clock position of the acetabulum (see image below) are directly under the iliopsoas tendon. This labral tear is considered an anterior tear, while most labral tears caused by trauma, femoroacetabular impingement, capsular laxity/hip mobility, dysplasia or degeneration  are usually found at the 11:30 to 1 o'clock position.

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Fascial Manipulation

This past November, I was privileged to speak on Graston Technique at the 2^nd Fascia Research Conference in Amsterdam. There is much to report about the new material that was presented at the conference, which I will do in this and future articles. I became especially interested at the final day of the six-day conference when I attended a workshop titled "The Fascial Manipulation Technique and Its Biomechanical Model - A Guide to the Human Fascial System." The course was presented by Carla Stecco, MD, an orthopedic surgeon and assistant professor of human anatomy and movement sciences, University of Padova, Italy; and Julie Ann Day, a physiotherapist also from Padova.

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Finally, an Accurate Test for a Meniscus Tear?

It often appears that when the author of a particular test states high accuracy for the test, other scientists down the line, using MRI or other tests, reach opposite conclusions regarding its validity. This is certainly true for shoulder labral tests.¹ If you've read my previous few articles, you realize this is also probably true for muscle testing. Thus, no matter how logical and accurate any test seems, we must always question it. That is one reason why it pays to use a number of tests to reach any conclusion.

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Lag Signs Are Important in Diagnosing Shoulder Lesions

Two primary ways of testing for rotator cuff ruptures is to determine whether the shoulder has enough strength to maintain a position against resistance, and by passive testing whereby the examiner attempts to determine if a passive position can be maintained in space (Lag sign). Resistive tests are more likely to cause increased pain leading to reflex muscle weakness, even in the presence of an intact cuff.¹ Lag tests therefore may be more accurate since the arm is supported by the examiner and the pain level is decreased. Another reason this passive test may be superior to resistive testing for cuff rupture is that the influence of surrounding muscles, such as the deltoid and pectoralis major, is reduced.

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How Valid Are Shoulder Tests?

It appears that the validity of almost all of the shoulder tests we perform on a daily basis are in question. This is rather frustrating and brings up questions regarding our treatment locations. Our soft-tissue treatments and joint manipulations decrease patient pain and often resolve their problems, but if the functional tests we use to determine the sites of pain are controversial, then how do we know we are actually on the source of the pain? If we are not on the source of the pain, how valid is our treatment method? Maybe we don't have to be on the source of the pain. Maybe there is a hands-on mechanism at work that has nothing to do with our theories. Clearly, more studies are needed regarding the effects of soft-tissue treatment and the validity of functional testing.

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Movement Heals

There is an old saying that "movement heals." It is readily accepted that exercise benefits many musculoskeletal conditions by promoting repair and remodeling of tendon, muscle, articular cartilage and bone.^1-2 This occurs by way of mechanotransduction, a physiological process wherein cells sense and respond to mechanical loads.

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Preventing Osteoarthritis

It is very doubtful that a cure for osteoarthritis (OA) will be discovered in our lifetime. However, based on present-day information, there are definite ways to reduce its consequences. Three definite risk factors include being overweight, excessive musculoskeletal loading at work and injuries.¹ According to Felson, et al., losing weight would reduce OA by 27 percent to 53 percent; eliminating squatting, kneeling and carrying heavy loads during work would reduce OA in men by 15 percent to 30 percent; and preventing ligamentous or knee meniscus rupture injuries would reduce OA another 14 percent to 25 percent.²

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Competitive Sports in Youth May Predispose to Disk Degeneration

But Are Degenerative Disks Causative of Low Back Pain?

By Warren Hammer, MS, DC, DABCO

In a recent study, it was found thatathletes who trained from youthwere more likely to have degenerative disks (DD) compared to nonathletes.¹Comparing sports such as baseball, swimming, basketball, Kendo, soccer, and running, continuous competitive baseball and swimming were the most associated with DD. All of the participants in the above sports significantly experienced more low back pain than nonathletes in the study.

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Beware of the Anatomical Muscle Insertion

Beware of the Anatomical Muscle Insertion

By Warren Hammer, MS, DC, DABCO

Manual muscle testingis used to determine if a muscle is injured or causes pain, if weakness is associated with the pain or if there is weakness without pain. When the tendon is involved, there usually will be more of a full range of motion than if the belly is involved, due to possible muscle belly rupture and protective spasm limiting the range of motion.

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Manual Loading for Lateral Epicondylopathy

This article if featured at Dynamic Chiropractic

I've heard many practitioners state that their outcomes for treating tennis elbow using forms of manual loading such as Graston Technique, ART, friction massage, etc., are varied in terms of results. Sometimes the patient is pain-free within eight visits, 20 visits or anywhere in between; sometimes they don't improve at all. Obviously, more studies are necessary to compare techniques and determine the exact effect of various forms of mechanical load. There are numerous theories, but this article is not written for the purpose of evaluating them.

Clinically speaking, we know manual loading is effective. Until more double-blind studies appear, what is important at this stage is to at least understand more about the area we are attempting to treat. Knowledge of anatomy is extremely important before using our hands or instruments on an area. The extensor carpi radialis brevis (ECRB) is considered to be the prime muscle involved in lateral epicondylopathy. If we only pay attention to its origin and insertion regarding where we use our manual load, outcomes may not be as satisfactory as they could be.

Briggs and Elliott dissected 139 limbs from embalmed specimens to reveal the attachments of extensor muscles in the area of the lateral epicondyle.¹ On only 29 limbs did they find a direct attachment of the ECRB to the lateral epicondyle. In all the other limbs, the ECRB had attachments to the extensor carpi radialis longus, extensor digitorum communis, supinator, radial collateral ligament, orbicular ligament, capsule of the elbow joint and deep fascia. Friction massage for what was called lateral epicondylitis was originally directed only to the lateral epicondyle and the musculotendinous portion of the ECRB.

This was the only area I treated for years, and many patients improved. Utilizing a Graston instrument on a difficult case, I scanned over the lateral supracondylar ridge of the humerus, proximal to the lateral epicondyle where the extensor carpi radialis longus (ECRL) originates, and found a restricted tender area. Treatment of this area resulted in complete alleviation of the pain in two visits. The ECRB is beneath the ECRL and attaches to it. Clearly, the restriction proximal to the site of pain was involved.

Muscle attachments to bone are called entheses and represent regions of high-stress concentration commonly affected by overuse injuries in sport.² There is now the concept of what is called an "enthesis organ," a collection of tissues adjacent to the enthesis itself that jointly serve a common function as a stress dissipation area. An important function of fascia, to which many muscles directly attach, is to dissipate stress concentration at the entheses and act as a protective sheet for underlying structures.³ Many tendons and ligaments flare out at their attachment sites as fascia to gain a wider grip on the bone.

So, for lateral epicondylopathy, for example, as in other enthesis areas, since tendinosis appears to be the tissue pathology and aggravated tendinosis palpates as a tender area, it is necessary to palpate proximally and distally to the involved area. Based on the anatomy and the fascial and muscular attachments, we should be looking for all surrounding tender areas that relate to the problem area and localizing our treatment on these sites. While resisted wrist extension happens to be a key test for determining that a lateral epicondylopathy exists, it pays to perform tests on associated areas that relate to the common tendon, such as resisted supination, extensor digitorum comminus (resisted finger extension) and even resisted wrist radial deviation.

With each test, ask the patient where they feel the pain. These painful sites represent areas for mechanical load treatment. As the condition improves, the patient often, on resisted testing, points only to the epicondyle where the remaining tenderness occurs. It is important to palpate in a circular manner all around the epicondyle for localized areas of pain. Often, treatment has to be directed to each site over several visits until resisted testing and local palpation for pain normalize. In my opinion, poor results may occur if we do not completely manually debride all of the pathological areas to allow final remodeling and healing.

References

1. Briggs CA, Elliott BG. Lateral epicondylitis. A review of structures associated with tennis elbow. Anat Clin, 1985;7:149-153.
2. Shaw HM, Benjamin M. Structure-function relationships of enthuses in relation to mechanical load and exercise. Scand J Med Sci Sports, 2007;17(4):303-15.
3. Benjamin M. The fascia of the limbs and back: a review. J Anat, 2009;214:1-18.

Gua Sha: Another Form of Mechanical Load

Every technique that creates compression or tensile stretch to soft tissue creates a mechanical load that is necessary for tissue change. Gua sha represents another form of mechanical load on soft tissue that claims healing results and, like all other soft-tissue methods, begs for research to prove its value. Arya Nielsen, PhD, adjunct faculty in the Department of Integrative Medicine at New York Beth Israel Medical Center, Continuum Center for Health & Healing, and a strong proponent of gua sha, wrote an interesting article in the January 2009 issue of the Journal of Bodywork and Movement Therapies (JBMT).1 She states that often the literature incorrectly describes the results of gua sha as causing battery trauma, bruising, burns, dermatitis, pseudo bleeding and even hematoma.

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The Benefits of Instrument-assisted Soft-tissue Mobilization Techniques

Experts agree that a crucial component of healing is soft-tissue treatment. Indeed, since the works of British orthopedist James Cyriax, clinicians have routinely employed cross-friction massage as a means of breaking up the web of adhesions and restrictions that normally form after injury. However, it is my contention that our profession is insufficiently informed about the advantages of soft-tissue methods in the healing process with regard to both the spine and extremities. Many doctors have steered clear of soft-tissue mobilization due to lack of exposure in their education or out of frustration—too many techniques from which to choose and there is minimal information available about most techniques. Others avoid soft-tissue mobilization because they fail to see the need—they are already successful at helping patients, so why abandon what works?

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The Chiropractic Profession: Facts and Myths, ECU 2004

I was honored to be invited to speak at the European Chiropractors' Union meeting in Helsinki, Finland, May 20-22, 2004. There were at least 22 countries represented, and the chiropractic spirit permeated the convention - with great fervor. I met many interesting and talented chiropractors, such as Anne Marie Yuroux-Fournier, whose parents were DCs, and whose family boasts 25 chiropractors - the most in any family, anywhere. Special thanks to Vassilis Maltezopoulos, DC, MD, PMR, the convention's academic organizer, for inviting me. There were many excellent presenters, and my synopsis of only a few of the presentations can never do enough justice to the information disseminated.

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