Patient
Advisory
Services
by
Chiro-
re Don
ster
ca
Ca
Dr. Russell Banks
Chiropractor
© January 2012
Patient Advisory
Services
By Dr. Russell Banks
(Chiropractor)
2012
Introduction
I, Dr. Russell Banks (Chiropractor) have undertaken training at an undergraduate
level in Chiropractic Science. I have also completed a;
 Post-graduate qualification to become a Fellow of the Australasian College of
Chiropractic Science (emphasizing orthopedic / musculoskeletal conditions),
 Clinical Education (University of New South Wales),
 Health Administration,
 Training and Education and currently completing
 Diploma of Community Services (Case Management).
This gives me a great breadth of knowledge in;
 Musculoskeletal health and pathology, organ systems health and disease,
 How to teach people of all educational backgrounds about disruption of their
musculoskeletal and organ functions and disease
 To research topics using an appreciation of referenced ideas and applied
logic.
 Community services that are available both in gaining assistance to live with
incapacity, to learn more about conditions that have been diagnosed and
resources of financial help, where available.
This sounds great but the above are simply words with inherent meaning that is often
obscure. To enable you to appreciate how I may be able to assist you, let me
describe some of the conditions that I can assist in different ways.
Contents
Introduction............................................................................................................................................ 2
Chapter 1. Headaches......................................................................................................................... 6
Tension Headaches ......................................................................................................................... 6
Sinusitis.............................................................................................................................................. 6
Temporomandibular joint dysfunction ........................................................................................... 6
Brain tumor ........................................................................................................................................ 7
Referred pain from the neck ........................................................................................................... 7
Temporal arteritis ............................................................................................................................. 7
Chapter 2. Dizziness........................................................................................................................... 8
Vestibulitis ......................................................................................................................................... 8
Occluded eustachian tube .............................................................................................................. 8
Meniere’s disease ............................................................................................................................ 8
Benign paroxysmal positional vertigo............................................................................................ 8
Brain stem or cerebellum disease ................................................................................................. 9
Cervical spine dysfunction ............................................................................................................ 10
Orthostatic hypotension................................................................................................................. 10
Acoustic Neuroma .......................................................................................................................... 10
Pharmaceutical induced ................................................................................................................ 11
Cardiac fibrillation ........................................................................................................................... 11
Chapter 3. Neck pain ........................................................................................................................ 12
Osteoarthritis ................................................................................................................................... 12
Muscle spasm, wry neck, torticollis ............................................................................................. 12
Cervical facet joint sprain .............................................................................................................. 13
Cervical joint dysfunction, stiffness.............................................................................................. 13
Inflammatory arthritis ..................................................................................................................... 14
Myofascial pain from overuse, postural strain ........................................................................... 15
Cervical disc disruption, herniation .............................................................................................. 15
Cervical spine fracture, tumor ...................................................................................................... 16
Chapter 4. Shoulder pain ................................................................................................................. 17
Osteoarthritis ................................................................................................................................... 17
Glenoid labrum tear ....................................................................................................................... 17
Myofascial pain, muscle tear ........................................................................................................ 18
Tendonitis, tendon tear.................................................................................................................. 18
Adhesive capsulitis, frozen shoulder ........................................................................................... 19
Bursitis ............................................................................................................................................. 20
Fracture, avulsion fracture ............................................................................................................ 20
Polymyalgia Rheumatica............................................................................................................... 21
Chapter 5. Elbow pain ...................................................................................................................... 22
Osteoarthritis ................................................................................................................................... 22
Inflammatory arthritis ..................................................................................................................... 22
Tennis elbow, Golfer’s elbow ....................................................................................................... 23
Fracture............................................................................................................................................ 24
Tendonitis, muscle tear ................................................................................................................. 24
Ulnar nerve neuritis ........................................................................................................................ 25
Chapter 6. Wrist and hand pain ...................................................................................................... 26
Osteoarthritis ................................................................................................................................... 26
Inflammatory arthritis ..................................................................................................................... 27
Carpal tunnel syndrome ................................................................................................................ 28
Tendonitis ........................................................................................................................................ 28
Fracture............................................................................................................................................ 29
Meniscal damage ........................................................................................................................... 29
Trigger finger ................................................................................................................................... 29
Dupuytren's contracture ................................................................................................................ 30
Chapter 7. Upper arm pain or numbness ...................................................................................... 31
Radiculitis, radicular pain .............................................................................................................. 31
Reflex sympathetic dystrophy, regional pain syndrome ........................................................... 32
Peripheral neuritis .......................................................................................................................... 32
Musculoskeletal referral of pain ................................................................................................... 33
Chapter 8. Thoracic and Chest pain / disturbances .................................................................... 34
Osteoarthritis ................................................................................................................................... 34
Thoracic facet joint and costal joint sprains ............................................................................... 34
Sternocostal joint sprain, malposition.......................................................................................... 35
Thoracic spine or costal joint dysfunction, stiffness .................................................................. 36
Inflammatory arthritis ..................................................................................................................... 36
Myofascial pain from overuse, shoulder or coughing strain .................................................... 37
Thoracic disc disruption, herniation ............................................................................................. 37
Notalgia Paresthetica..................................................................................................................... 38
Thoracic spine fracture, tumor ..................................................................................................... 39
Costochondral inflammation, costochondritis ............................................................................ 39
Rib fracture, tumor ......................................................................................................................... 40
Sternal fracture, tumor ................................................................................................................... 40
Xiphoid process misalignment, manubriosternal inflammation ............................................... 40
Atherosclerosis, myocardial infarction / heart attack ................................................................ 40
Coronary artery spasm, Angina ................................................................................................... 41
Myocarditis, Pericarditis ................................................................................................................ 41
Pleurisy, Pneumonia, Pulmonary embolism, Bronchitis, pneumothorax ............................... 41
Gastro-esophageal reflux disease (GORD), Barrett's esophagus, achalasia....................... 42
Aortic aneurysm, thrombophlebitis .............................................................................................. 43
Direct trauma, wound to the chest ............................................................................................... 43
Mastitis, Pregnancy related breast pain...................................................................................... 44
Chapter 9. Lower back pain............................................................................................................. 45
Osteoarthritis ................................................................................................................................... 45
Lumbar facet syndrome................................................................................................................. 45
Lower back facet joint sprain ........................................................................................................ 46
Lower back joint dysfunction, stiffness........................................................................................ 46
Inflammatory arthritis, Ankylosing spondylitis ............................................................................ 47
Myofascial pain from overuse, postural strain ........................................................................... 48
Lumbar disc disruption, herniation............................................................................................... 48
Meralgia Paresthetica .................................................................................................................... 49
Lumbar spine fracture, Sacrum fracture, Pelvic fracture, tumor ............................................. 50
Lumbar spinal stenosis, Hemivertebra, Transitional vertebra ................................................. 50
Chapter 10. Hip pain ......................................................................................................................... 52
Osteoarthritis ................................................................................................................................... 52
Acetabular labrum tear .................................................................................................................. 52
Myofascial pain, muscle tear ........................................................................................................ 53
Apophysitis ...................................................................................................................................... 53
Inflammatory arthritis ..................................................................................................................... 54
Bursitis ............................................................................................................................................. 54
Fracture, bone pathology .............................................................................................................. 55
Polymyalgia Rheumatica............................................................................................................... 55
Inguinal and Femoral hernias ....................................................................................................... 55
Hematoma / Corked Thigh ............................................................................................................ 56
Chapter 11. Knee pain ..................................................................................................................... 57
Osteoarthritis ................................................................................................................................... 57
Inflammatory arthritis ..................................................................................................................... 57
Myofascial pain, muscle tear ........................................................................................................ 58
Infrapatellar tendonitis, tendon tear ............................................................................................. 59
Cruciate ligament, Collateral ligament tear ................................................................................ 59
Patella dislocation, Patella tracking dysfunction........................................................................ 60
Bursitis, Baker’s cyst ...................................................................................................................... 60
Osgood Schlatters disease, Osteochondritis Dissecans ......................................................... 60
Fracture, Tumor .............................................................................................................................. 61
Shin splints / Traction apophysitis ............................................................................................... 61
Chapter 12. Ankle and Foot pain .................................................................................................... 62
Osteoarthritis ................................................................................................................................... 62
Inflammatory arthritis ..................................................................................................................... 63
Myofascial pain, muscle tear ........................................................................................................ 64
Tendonitis, Traction spur / Heel spur .......................................................................................... 64
Plantar fasciitis................................................................................................................................ 64
Medial and lateral ankle ligament tear / Sprain ......................................................................... 65
Osteochondrosis, Sever’s disease .............................................................................................. 65
Bursitis, Osteochondral defect ..................................................................................................... 65
Fracture, Tumor .............................................................................................................................. 66
Chapter 13. Abdominal and Pelvic pain ........................................................................................ 67
Gastroenteritis................................................................................................................................. 67
Celiac disease, Fructose and Lactose malabsorption .............................................................. 67
Chapter 1. Headaches
Tension Headaches
Tension headaches are generally episodic but can be persistent and the pain
significant. It is not unusual for patients with tension-type headaches to
undertake / be referred for CT or MRI scans to check for more serious
pathology. The pain can be pressing, tightening or a mild to moderate
intensity. The pain can be on one or both sides. There are usually no other
symptoms such as nausea, visual disturbance or weakness. The relentless
nature, in some people, can be very worrying. Worry, stress and pain
somewhere nearby can be an aggravating factor.
The beautiful thing about a tension-type headache is that the resolution can
be quite rapid and it is easy to undertake on your own. Contents
Sinusitis
There are many sinuses on both sides of the head and face, providing a
mechanism for producing resonance of sounds produced in the larynx, via
portals from the back of the nose. Through mechanisms of allergy, infection
coming from the mouth or teeth and chemical irritation, the sinuses can
become inflamed.
Sinusitis is a possible cause for facial pain, headaches, ongoing coughing,
post-nasal drip and tonsillitis. Two important characteristics of this condition
are confirming that sinusitis is present and the cause. An allergy cause will
often respond to medications such as nasonex but infections will often
respond to antibiotics.
There are many factors that can impact upon the clearing of waste from the
sinuses including smoking, pollution and infection. Some medications can be
detrimental if overused, such as nasal decongestants. Some people have
obstructions to ventilation of the sinuses such as a deviated septum.
Contents
Temporomandibular joint dysfunction
Many people have dysfunction of their temporomandibular joint. The joint is
made up of two bony surfaces, the temporal bone of the skull and the
mandible (jaw bone) and there is a cartilage that slides in between the two
bony surfaces. This joint can be damaged as a result of many common events
such as opening the mouth very wide, motor vehicle accidents, dental or
medical procedures where the mouth is opened fully and impacts to the jaw.
Small but repeated traumas can occur with grinding of the teeth / bruxism.
When trauma occurs, the joint will swell, sometimes bleed and the scar tissue
will tend to create adhesions between the cartilage / disc and the skull. When
this occurs the jaw can click, crack and get stuck open.
Frequently when dysfunction occurs, the joint will produce some pain or crack.
The greatest clinical decision is whether the joint is the cause of head / facial
pain or not and whether something can be done to help. The joint can be
mobilized / manipulated to gain greater function. Massage to nearby muscles
can relieve pain. A splint can be assistance if the trauma is due to grinding of
teeth. Contents
Brain tumor
A brain tumour is most variable with respect to symptoms it produces and
significance regard to prognosis. Sometimes the tumour will cause pain but
the pain can vary from a migrainous type headache to a slight but consistent
ache. Some tumours will cause sensory disturbances such as dizziness,
visual or hearing deficits and others will cause motor deficits such as epilepsy,
weakness of muscle and balance disturbances.
The important clinical decision with respect to symptoms involving sensory or
motor disturbances are whether there is a tumour or not and are the
symptoms experienced can be explained by the tumour found on
investigation. Finally, if there is a tumour, what can be done about it?
Sometimes tumours need and can be removed; other tumours cannot be
removed due to dangers associated with the process of extracting the tissue.
Oncologists can advise you and the General Practitioner what can be
achieved but sometimes it is not all that clear to the patient. What is needed is
someone who understands these problems and is prepared to explain it at
your pace and in words you can understand. Contents
Referred pain from the neck
The neck can refer pain to the head and down into the upper back, shoulder
and arms. A process of referred neck pain occurs due to the fact that the
sensation component of the trigeminal nerve, supplying the jaw, face and
forehead ends up in the lower part of the pons, a place where the nerves that
provide sensation to the back of the head and neck end up. The brain can
have difficulty working out where the sensation stimulus has originated. In
addition the nerves that supply the back of the head arise from the upper part
of the neck. Irritation of these nerves can occur in the upper part of the neck.
Contents
Temporal arteritis
Temporal arteritis / Cranial arteritis is a problem most commonly occurring in
people who are in their or approaching their advanced years. The larger
arteries around the head can become inflamed internally. This condition is
often associated with polymyalgia rheumatica. Temporal artery, which travels
through the temporal area on the side of the head, becomes enlarged and
ropey, very tender and produces pain in this area. Sometimes more than one
artery are affected. If the optic artery is inflamed, sudden blindness may
occur.
The issues relevant in this condition are; whether this condition is present and
what can you do about the problem? Contents
Chapter 2. Dizziness
Vestibulitis
Vestibulitis or labyrinthitis usually has an infection cause. Very often it is a
viral infection that affects the internal ear and in particular, the labyrinth – the
centre for balance. Massive disturbance of balance can occur with a
labyrinthitis. The symptoms are usually severe, protracted and totally
disabling. It will run its course usually over 1-2 weeks and then resolve
gradually. This condition is often associated with an infection in the throat,
adenoids or perhaps sinuses. It is frequently associated with vomiting and can
begin quickly. Contents
Occluded eustachian tube
An occluded Eustachian tube is a condition that usually is not particularly
severe. There will often be associated partial hearing loss and the dizziness
or vertigo will be episodic and last for seconds usually. The symptoms of a
blocked Eustachian tube are that similar to the effect of descending in a
plane. Equalisation of pressure should resolve the problems of dizziness.
It is possible that salt irrigation may assist with opening up the Eustachian
tube. It is possible to purchase a salt irrigator from a pharmacy or health food
shop or rarely an ENT specialist may be able to perform the procedure
specifically. Contents
Meniere’s disease
Meniere’s disease is a condition that usually occurs in middle-aged people. Its
onset is often gradual but sometimes appears to be sudden. Meniere’s
disease can be very disabling, due to the significant and enduring episodes of
dizziness or vertigo. The dizziness tends to last some time on each attack and
the uncertainty as to when the attack will occur, results in people staying at
home and choosing not to socialize. This creates the disability.
The condition is associated with some gradually increasing hearing loss and
tinnitus (ringing in the ears). The attacks can occur suddenly and last for
extended periods. The clinical questions that are relevant to this condition are
the confirmation of the diagnosis and what can be done to help. The diagnosis
is often difficult to confirm but the presence of hearing loss can be suggestive
and the duration of an attack is helpful. Treatment options are limited.
Contents
Benign paroxysmal positional vertigo
In this condition vertigo is associated with the formation of particles within the
vestibular apparatus in the inner ear. This is a process that probably happens
in most people but the particles sit within the sacule and not within the semicircular canals of the vestibular apparatus. When the particles drift into the
canal, they stimulate the sensory fibres within the canal and cause a sense of
movement, even when you have stopped moving your head. Motion initiates
this condition and the episodes / attacks last usually less than 5 seconds.
Benign (not a condition that develops into something more serious)
Paroxysmal (lasts only briefly) Positional (associated with positions /
movements of the head) Vertigo (feeling of imbalance) is a condition that can
occur in just about all age-groups. It is usually not associated with vomiting or
hearing loss.
Exercises such as the Cawthorne-Cooksie exercises can be helpful to
eliminating the condition in the short term. However, episodes tend to be
grouped and groups of dizziness tend to recur over a life-time. If you leave the
condition long enough, often symptoms will abate. Tests can be undertaken to
see which of the semi-circular canals are involved and thus how you can
reduce the episodes within the group of attacks. Contents
Brain stem or cerebellum disease
The brain-stem conducts nerves from the cortex (higher brain centres) down
to the spinal cord and from the extremities to the higher centres of the brain
via the spinal cord. There are a number of centres within the brain-stem that
control and process input from the eyes, ears and provides signals to the vital
organs of the body including sympathetic and parasympathetic nervous
systems. These parts of the nervous system are grouped under the name
autonomic nervous system. They coordinate the functions of the body that
preserve life and control the vital systems of the body. A lesion, whether it is a
tumour, bleeding, ischemia due to arterial occlusion or trauma will affect these
vital organ functions. They will also affect the processing of information from
the ears and eyes and this can produce dizziness or vertigo.
The cerebellum coordinates movement in the body. If you desire to reach out
and pick up something, the cerebellum will coordinate the activation of
muscles to stabilize the trunk, providing a solid base for the shoulder and
elbow and hand to move to reach out, grip and retrieve. With respect to
movements of the head, the cerebellum will take information with respect to
head movements, movement perceived by the neck and information from the
eyes. If the sources of perceived information fit, the brain appreciates the
movement that has occurred. If the information contradicts each other,
dizziness will occur. Also if the cerebellum is damaged or affected by drugs
such as alcohol, the brain will also not cope and a lack of balance will occur.
The important thing with either of these parts of the brain being affected is to
find out what is being affected and what type of problem it is. When this is
ascertained solutions, that may be available, can be sought. Often a
neurologist can be useful to direct the investigation and options with regard to
treatment. A good primary care practitioner is very useful as they can often
spend more time with you and have a greater appreciation as to what
difficulties you are having. Contents
Cervical spine dysfunction
As mentioned previously, the cerebellum will take information with respect to
head movements, movement perceived by the neck and information from the
eyes. If the sources of perceived information fit, the brain appreciates the
movement that has occurred. If the information contradicts each other,
dizziness will occur. Neck sensation and information provided to the
cerebellum can be affected by joint stiffness and myospasm. Sensation from
movement of the head needs to match the other sensory input. Confusion can
be a significant problem with respect to dizziness or vertigo.
The cause of stiffness of the neck will usually dictate the effectiveness of
treatment. If the neck stiffness is due to osteoarthritic spurring, bridging and
pain, success of treatment may be hampered. If stiffness is due to a transitory
restriction of joints, manipulation or mobilisation can be extremely effective.
The results can be spectacular with respect to speed of improvement.
Contents
Orthostatic hypotension
Orthostatic hypotension is low blood pressure in the arteries supplying the
head following standing up after a period of sitting or lying down. The
symptoms are a lack of perceived balance or vertigo. This condition appears
to be associated with delayed responses to lowering pressure when the blood
goes down to the legs and doesn’t return as quickly as it should.
There are a number of theories with respect to why it happens, including in
lack of or slowed ability to convey the pressure level within the carotid bodies
within the carotid artery in the neck, up to the brainstem and cerebellum,
where an appropriate response is initiated. The response is to constrict
arteries in the extremities and thus increase blood pressure.
Secondly it is possible that abnormal input into the brainstem and cerebellum
can result in processing errors and an inadequate or delayed response.
Research has shown that stiffness or dysfunction of the neck can result in a
delayed reaction time and the symptoms of orthostatic hypotension. Therefore
it is important to correct these problems in the neck, if possible, and learn
techniques to stimulate constriction of the blood vessels in the extremities at
the time of the symptoms. Contents
Acoustic Neuroma
An acoustic neuroma is a benign tumour in the region of the brainstem, at the
base of the brain. The tumour occurs in the proximity to the acoustic nerve
that provides hearing and balance senses to the brain. It is common to have
diminished hearing on one side. The feeling of disturbance of balance has
been described as having water in the ear and when you tilt your head to one
side the natural mechanism to right yourself doesn’t work well. You feel that
you will continue to fall to that side.
Brain scans can precisely identify the size and position of the acoustic
neuroma. An oncologist or Neurosurgeon can advise whether removing the
lesion is best. Very often hearing is lost when the slow growing tumour is
removed. The neuroma is difficult to cut out. Contents
Pharmaceutical induced
Dizziness can occur due to some medication. Anti-depressants are commonly
a source of a lack of balance but fortunately the effect is usually mild. In this
situation, most people get used to the medication and therefore can tolerate it
after a while. The anti-depressants will often cause dizziness also when
gradually coming off the medication or reducing the dose. Again, this effect is
usually temporary.
Other medications occasionally cause disturbance of perceived balance
including the medication to stop the onset of malaria and blood pressure overdosage. It is best to seek medical advice with respect to these possible
causes of dizziness and if your GP is unwilling to consider the possibility, seek
a second opinion. Contents
Cardiac fibrillation
Atrial fibrillation is where the electrical stimulus or timing of the atrial
contractions is disturbed and the muscle contracts quickly like it is quivering.
Unfortunately the pumping action of the heart requires the heart to stop
contracting to enable blood to fill it and then pump. Without the atrium
contracting in a controlled fashion, the ventricles receive insufficient blood and
do not function efficiently. Your blood pressure drops and light-headedness
occurs. Often people feel that their heart is racing or a fluttering.
The effect of fibrillation can be similar to but less striking than orthostatic
hypotension. A feeling of light headedness or even loss of consciousness may
occur. Appropriate investigation needs to be undertaken to determine whether
the problem is fibrillation. This condition needs to be sensibly managed.
Contents
Chapter 3. Neck pain
Osteoarthritis
Osteoarthritis of any joint in the body tends to occur as the body ages.
However, the deterioration of joints usually is related to factors that either
damage the joint surface or place additional stress or strain on the joints. The
factors or situations that result in damage to the joint surface include a
whiplash injury to the neck and compressive injury to the head. Whiplash is an
injury that can occur in any direction but is sudden. An impact where the chin
is suddenly forced up is the most likely to damage the joint surfaces. This
could include an automobile accident where one is hit from behind or when
someone is whacked on the back by someone’s hand or in a contact sport.
These injuries tend to produce pain that is long term and if the joint surface is
damaged, osteoarthritis will eventually occur.
Stress or strain of joints occurs when more force is applied to a tissue than
what it is designed to take. To some degree a trauma is an excessive and
sudden stress applied to tissue. However it can also be damaging if applied in
lesser force over a sustained period or repeated application. If some of the
joints in the spine are stiff or dysfunctional, increased strain will occur to
nearby joints. The most obvious situation is where some joints in the neck
have been fused, either naturally or surgically. The forces then impacted on
nearby tissues tends to cause deterioration over many years.
The symptoms of osteoarthritis tends to occur decades following trauma or
after a significant period of increased strain. Usually stiffness will be noticed
first and at times the degenerating joints can become inflamed and painful.
The inflamed joints can be solitary or multiple. There are commonly very slow
fluctuations of pain. The fluctuations can last weeks and months and be
affected by activity. However gentle activity is often the best thing to assist
with pain control. Sometimes the pain can ease completely and at other times
the pain can continue for many months or years.
The strategies to help revolve around management that can ease the
inflammatory processes in the joints and strategies to relieve pain or manage
pain. Keeping busy is often a useful strategy. Contents
Muscle spasm, wry neck, torticollis
A torticollis or myospasm is an extremely painful and disabling condition
where movement is often partially or totally prohibited by painful movement of
the neck. There are various theories with respect to why these problems start.
Sometimes they can begin following birth trauma or for unexplained reasons
in early childhood. In children and adults the problem most often has at least
one inflamed joint in the neck / cervical spine that is present. Inflamed cervical
joints produce an incredibly sharp / exquisite pain when the surfaces of the
joints are compressed against one another. This occurs on rotating the neck
toward the painful side, bending the ear to the side of the pain and looking up
toward the ceiling. The extreme pain causes the muscles to react and spasm.
The extreme and painful limitation of movement is termed a torticollis.
So, in this condition it is valuable to determine whether an inflamed joint is
present and if so, manage this problem satisfactorily. If the joints are not
inflamed the emphasis can be on reducing the myospasm. Heat, massage
and movement without pain are greatly beneficial. Stretching can be useful
and occasionally surgery is undertaken in children to eliminate the relentless
distortion. Contents
Cervical facet joint sprain
Cervical facet joint sprains / Neck sprain account for about 90% of the acute
pain conditions that involve the neck. They can occur with substantial trauma
such as whiplash or due to very minor trauma that is frequently due to
everyday life activities. Often it is associated with waking up in the morning
and activities in the first hour following waking. It has been suggested that it is
a result of trauma the previous day and doesn’t hurt until the following
morning. This makes no sense. The minor injury occurs when the pain is first
felt. It is likely that in many cases the injury occurs on rising from bed.
Following a sustained period of relative inactivity, the muscles and joints do
not function always as they should. If the joints are moved by muscles due to
a lack of coordination that occurs after inactivity, small injuries can occur.
Washing the hair in the morning is another common activity that can result in
minor injury.
A small injury can produce incredibly severe pain. The torn tissues are
exquisitely sensitive and when stretched give you a sharp / knife like pain.
The stretching will occur when bending away from the painful side at times but
consistently when compressing the involved joint. Swelling accompanies all
sprained joints. The swelling / fluid in the joint will bulge and stretch the
sensitive tissues when the joint surfaces are squashed together.
The first step in assisting a patient with a cervical / neck sprain is identifying
where the problem is and how many joints are affected. The management that
helps is all associated with reducing the inflammatory swelling in the joint. Ice
has been advocated for swollen joints and may be successful in the first 24
hours. Often I witness more benefit from the application of heat. The forces in
the joints of the neck need to be widely distributed. Stiffness due to transient
or more permanent reasons can increase the strain on inflamed joints.
Removing the stiffness can be of great assistance. Muscle tension can also
localise the forces in the area of the injury. Heat, that helps muscles lose
some of their tension, can be a great help. Contents
Cervical joint dysfunction, stiffness
Cervical joint dysfunction or stiffness can occur in many different conditions in
the neck. Some can be long-term and others transient. Osteoarthritis and disc
degeneration can produce long term stiffness. Muscle spasm and transient
stiffness of the joints in the spine can frequently be relieved quickly and easily
by manipulation and massage techniques in the spine.
The problem with dysfunction and stiffness is the localisation of increased
stress on some areas in the spine. It is usually nearby joints that are most
commonly adversely affected. The adverse effects can be pain, degenerative
changes and osteoarthritis. Contents
Inflammatory arthritis
Inflammatory arthritis is different to osteoarthritis in its cause and also
associated symptoms and signs. There are many causes of inflammatory
arthritis but all are associated with systemic / widespread diseases such as
rheumatoid arthritis.
Rheumatoid arthritis can affect multiple joints, causing destruction and
pathological fusion. It can be associated with inflamed tendons, contracture of
muscles and significant distortions of the body including the wrist and hand
and softening of bone. The severity of the damage in Rheumatoid arthritis is
often severe and the damage to the joints can be so severe that the natural
processes of osteoarthritis can take over and completely fuse the two bones
together.
The other forms of inflammatory arthritis are different in their unique ways.
This includes psoriatic arthritis that affects usually less than 5 joints in an
irregular pattern. Lupus can be severe producing dramatic effects on the
hands and may have the characteristic butterfly rash over the cheeks and
nose. Gout is a condition that presents fairly commonly and usually the
presentation is sudden onset of severe pain and swelling. The joints are
usually solitary or few in number and will settle over some time until the next
episode.
Each form of inflammatory arthritis has a different pattern usually and while
the diagnosis of these arthritides is often difficult, the patterns can often be
helpful to narrow down the possibilities. Blood tests, including anti-bodies to
specific tissue types have been gaining greater and greater value.
Inflammatory arthritis is thought to be an auto-immune condition in most
cases (except gout and pseudogout) and therefore antibodies will be present
in the blood, that for some reason attack its own tissue.
In the neck or cervical spine gout will never occur. The tissues are too warm
for crystals of uric acid to form and then provide attacks of irritation to the
joints. In the cervical spine rheumatoid and psoriatic arthritis appear to be the
greatest concern. Fortunately they are not common but the importance is
severe. It has been identified that an inflammatory arthritis can weaken or
destroy the ligaments in the upper part of the neck that ensure stability and
safety of the nerves running down into the spine.
The pain associated with inflammatory arthritis is similar in characteristics to
inflammatory osteoarthritis. The joints are extremely sensitive, producing a
sharp pain on compressing the joint surfaces. There are normally acute
limitations of movement of the neck due to pain. The main challenge with
inflammatory conditions of the neck is to find out what is the cause and
therefore what the future has install? Contents
Myofascial pain from overuse, postural strain
Muscles in the neck and shoulders produce a considerable amount of the pain
in people that present for treatment. Muscles often produce a pain that is
relatively dull or without spikes of more intense pain. There is an exception,
where this characteristic pain does become sharp, and it is associated with a
tearing of muscle. Muscle tears can occur in the neck but are fortunately
uncommon.
The factors that contribute to the presence of aching muscular pain are
postural strain, occupational stress and mental stress and anxiety and a
reaction to pain in the region. Muscles will always react to pain in the vicinity,
whatever the source. Muscles will eventually react to ongoing use, by
becoming tighter and eventually painful. Some occupations are commonly
affected by this condition. Computer programmers, data entry personnel,
people undertaking home duties and window cleaners for a start. Some
people have a spine shaped so that their head pokes forward. This creates
ongoing strain on the muscles at the back of the neck and shoulder that
maintain the head’s peculiar position and effectively stop it from falling
forward. In all of these situations it is not the extreme of the forces involved
but the consistency of the need.
One of the best things to do about tension of muscles in the neck and
shoulder is to change your head position. The Alexander technique describes
this particularly well. In addition it is desirable to take regular breaks and
change the muscles demands on a regular basis. Contents
Cervical disc disruption, herniation
The discs in the spine consist of a flexible combination of a fibrous perimeter
and relatively soft centre. They are built this way to enable flexibility but cope
with the axial forces down through the body. It could be said that people were
not supposed to live as long as they do. Even as recently as a 100-150 years
ago, you were quite unusual to live beyond 50 years of age and many people
did not reach 40 years of age. The discs in the spine deteriorate over the
decades of life. They start off fresh and functional. By the time you get to thirty
years of age, the fibrous perimeters of the disc have usually deteriorated,
developing cracks and defects that can produce significant problems. It is
often in one’s thirties that disc prolapses occur, where the soft centre can be
forced out through the cracks in the fibrous perimeter and interfere with the
nerves arising from the neck.
When the soft centre loses some of its vitality or fluid, the whole disc structure
tends to lose height and the fibrous perimeter will bulge. The body copes with
this usually but it can reduce the space for nerves to sit without interference.
When the disc continues to lose hydration, it becomes more like gristle than
soft jelly and a prolapse of disc material will be very unusual following your
50th year of life. As the disc narrows and perhaps associated with some
inherent instability, the body reacts by creating bony bridges between
vertebrae in the spine (“spurs”). Eventually the vertebra in the spine, where
the disc has deteriorated, will fuse together but this process takes years. If we
only lived to 50 years of age, we would in most cases have little problems.
What causes the discs to deteriorate? In many cases the deterioration is
initiated by trauma. Damage to the bone on either side of the disc will affect
the supply of nutrients to the disc and deterioration will occur. Sometimes the
perimeter of the disc can be damaged by severe impact such as in a whiplash
injury. The other factors include deterioration of the nearby spinal joints,
pressure on the discs due to curved shapes in the spine and stiffness of
nearby joints. Exercise of the discs tends to increase the supply of nutrients to
the disc and reduce the likelihood of disc disease.
While the prolapsed disc will tend to shrink via becoming dehydrated over
time, a prolapsed or herniated disc is only able to be corrected by surgical
intervention. The soft centre has been described as being like toothpaste in
young people. You know how difficult it is to suck toothpaste back into a tube.
The only way to get the toothpaste away is by using your finger or a
toothbrush. However, if there is no herniation, the disc can be assisted by
strategies to increase nutrients supplied to the disc. Contents
Cervical spine fracture, tumor
Fractures of the cervical spine vary in significance. A hangman’s fracture can
be lethal. Many patients suffer from small fractures to the vertebral bodies and
apart from pain the impact can be minimal. The secret is gaining advice with
respect to where the fracture is located and what needs to be done to ensure
that you survive. A neurological opinion can be extremely important.
Tumours can also occur in the Cervical spine. The tumours can vary in their
significance and impact on the nervous system and your health. The more
information that you can obtain and have about a problem such as a tumour,
the better. Contents
Chapter 4. Shoulder pain
Osteoarthritis
Osteoarthritis of any joint in the body tends to occur as the body ages.
However, the deterioration of joints usually is related to factors that either
damage the joint surface or place additional stress or strain on the joints. The
factors or situations that result in damage to the joint surface include a fall on
an outstretched hand or a collision to the side of the shoulder. These injuries
tend to produce pain that is long term and if the joint surface is damaged,
osteoarthritis will eventually occur.
Stress or strain of joints occurs when more force is applied to a tissue than
what it is designed to take. To some degree a trauma is an excessive and
sudden stress applied to tissue. However it can also be damaging if applied in
lesser force over a sustained period or repeated application. If some of the
joints in the cervical spine are stiff or dysfunctional, increased strain will occur
to nearby joints including the shoulder joints. The shoulder consists of two
joints; the large ball (at the top of the arm) and shallow cup type joint called
the glenohumeral joint and the small strut style joint called the
acromioclavicular joint. Both can develop osteoarthritis.
The symptoms of osteoarthritis tends to occur decades following trauma or
after a significant period of increased strain. Usually stiffness will be noticed
first and at times the degenerating joints can become inflamed and painful.
Both the glenohumeral and acromioclavicular joints can become inflamed due
to osteoarthritis. There are commonly fluctuations of pain. The fluctuations
can last days and weeks and be aggravated by activity. Frequently sleeping
on the affected shoulder will aggravate the pain in osteoarthritis, whether it
affects the large or small joint. Keeping busy is often the best thing to assist
with pain control. Sometimes the pain can ease completely and at other times
the pain can continue for many months or years.
The strategies to help revolve around treatment that can ease the
inflammatory processes in the joints and strategies to relieve pain or manage
pain. The first thing to try is to avoid sleeping on the bad side. Sewing a small
object on the bad side of night-wear can help to prompt you to move if you
unconsciously choose the wrong side to lie on. Contents
Glenoid labrum tear
The glenoid labrum is a small ring of cartilage that creates a deeper cup on
the cup side of the glenohumeral joint. The labrum, made of a type of cartilage
is attached strongly to the glenoid but if excessive force is applied can be torn
or detached from the glenoid. The result is pain. The pain is usually striking,
sharp pain. The pain is aggravated by compressing the labrum by bringing the
arm toward the labrum that is torn. It is possible to irritate the tear / disruption
by sliding the ball side of the joint toward area of the injury.
A tear in a labrum does not repair easily. It is possible that it will never actually
join back together. Apparent healing may be observed by a reduction or
resolution in the inflammatory process and pain but the tear may still remain.
It is possible that scarring may re-attach a detached labrum. In this type of
lesion advanced scanning such as a MRI may demonstrate the lesion but
good clinical testing is often effective. Normally, to enable the problem to
resolve avoidance of further aggravation is the most effective strategy.
Contents
Myofascial pain, muscle tear
Muscles in the shoulders produce a considerable amount of the pain in people
that present for treatment. Muscles often produce a pain that is relatively dull
or without spikes of more intense pain. There is an exception, where this
characteristic pain does become sharp, and it is associated with a tearing of
muscle. Muscle tears can occur in the shoulder but more commonly the tears
occur in the muscle tendons, which attach the muscles to bone.
The factors that contribute to the presence of aching muscular pain are
postural strain and occupational stress and a reaction to pain in the region.
Muscles will always react to pain in the vicinity, whatever the source. Muscles
will eventually react to ongoing use, by becoming tighter and eventually
painful. Some occupations are commonly affected by this condition. Computer
programmers, data entry personnel, people undertaking home duties and
Nurses for a start. Some people have shoulders that rotate forward. This
creates ongoing strain on the muscles on the top of the shoulder that maintain
the two bony surfaces location or stop it from falling down and dislocating. In
this situation it is not the extreme of the forces involved but the consistency of
the contraction involved.
One of the best things to do about tension of muscles in the shoulders is to
change your shoulder positions, to keep them back and relaxed. In addition it
is desirable to take regular breaks, use massage and the application of heat.
Contents
Tendonitis, tendon tear
There are many tendons around the shoulder that can become irritated and
inflamed as a result of overuse or muscular strain of the relevant muscles.
Some of the more common musculotendinous units include the supraspinatus
(sits on top of the shoulder joint and its action is to keep the humerus located
correctly within the cup of the glenoid. It may help to initiate the movement of
lifting the arm up from the side towards the ear. This muscle works very hard
when the shoulders are rotated forward. The shoulder has a very shallow cup,
slightly deeper due to the labrum that surrounds ball of the humeral head.
When the shoulders are rotated forward, the cup tends to angle down and out.
Therefore the supraspinatus is required to work harder due to the poor
shoulder posture. With respect to supraspinatus, better shoulder position
relieves the muscle from being overworked and it can improve. In addition the
supraspinatus tendon can be irritated by a roughness of the bone that sits
over the top of the tendon when you are in an upright position. The acromion
process can become roughened over time and the tendon will often become
inflamed when this happens. The subacromial bursa may also become
irritated in this situation.
The biceps has two heads; one long and one short. The long head of the
biceps runs in a groove, in the front of the shoulder. It is not particularly deep
but is covered by a ligament that keeps the tendon correctly lying in its
groove. By doing so, the tendon is able to perform, flexing the elbow and
assisting in elevating the shoulder up in front of the body. If the tendon
becomes irritated by over use or by some irregularity of bone in the groove,
where it slides, a tendonitis can occur. You would expect pain in the front of
the shoulder, down into the upper arm and the pain, occasionally sharp, would
be aggravated my moving the upper arm forward and back like a sawing
action or in rotating the shoulder out or in. This is the action where your arm is
by your side, bending the elbow to 90 degrees and then rotating the hand out
to the side and then in towards the abdomen. Restrictions should be
undertaken to limit the irritation of these aggravating movements.
There are other tendons that can become inflamed. Each will usually have a
pattern of movement producing pain and a pattern of pain referral. With
respect to tendons, a reduction in aggravating activity is essential. In addition
ice and massage of the relevant muscles is usually helpful. One thing that is
commonly observed is that a tendonitis in the shoulder is usually associated
with degenerative changes within the neck / Cervical spine. The association is
probably age-related deterioration of both these regions of the body but it has
been proposed that when the cervical spine deteriorates, so does the
coordination of muscle actions in the shoulders, thus resulting in abnormal
use and subsequent deterioration. Contents
Adhesive capsulitis, frozen shoulder
A frozen shoulder is one of the most painful and disabling conditions of the
shoulder. It is caused by an inflammatory condition within the shoulder joint /
capsule. The inflammatory process causes scarring that begins as fine
threads binding different sides of the joint capsule and can end up with solid
bands of scar tissue that restrict movement of the shoulder and creates
incredibly sharp pain when certain directions of movement occurs in the
shoulder. It has been suggested that pulling of the supraspinatus tendon that
partially attaches to the capsule may be important. Therefore good shoulder
posture may prevent this condition. An inflammatory process may follow some
trauma but you rarely hear of trauma preceding this problem. Almost all
people that develop a frozen shoulder have a degree of degeneration of the
cervical spine / neck. How these conditions are related has not yet been
established.
The movements that tend to be affected by a frozen shoulder / adhesive
capsulitis are lifting the arm away from the side (usually when you get to
greater than 90 degrees), rotating the shoulder externally or internally also
predictably results in debilitating pain. External rotation is where your arm is
by your side, bending the elbow to 90 degrees and then rotating the hand out
to the side and internal rotation is when you bring the hand in towards the
abdomen. Pain caused by an action like doing up a bra at the back is
extremely indicative of a frozen shoulder.
The management of a frozen shoulder can vary depending on the stage of
progress through the condition. Initially, inflammation is the most prominent
part of the condition and it is possible that reduction of the inflammatory
process via an injection of cortisone or hydro-dilatation can be successful. In
the second stage, the inflammatory process reduces but stiffness increases
with scar tissue maturing and probably gathering into more durable bands of
connective tissue. In the third stage, the inflammatory process is quite minimal
but the scar tissue is well established. The aim within this third stage is to try
to re-establish more normal movement in the joint. Gentle stretching and
activity is usually beneficial.
Within two years, approximately half the inflicted persons will develop a frozen
shoulder in the opposite side. Knowing what happens in this condition may be
very helpful if you are someone that is affected on both sides. Contents
Bursitis
There are bursas in many places within the shoulder and other parts of the
body. The sub-deltoid bursa is commonly identified as being the cause of
shoulder pain. The inflammation of a bursa can be due to excessive
compression of the bursa from overlying muscles and tendons. The harder
the muscles are working, the more irritation the bursa will suffer. It is possible
that an inflamed adjacent structure may also produce an inflammation of the
bursa. The acromion process, lying above the sub-acromial bursa, can
become roughened over time and in turn, may irritate the subacromial bursa.
Supraspinatus (sits on top of the shoulder joint and its action is to keep the
humerus located correctly within the cup of the glenoid. It may help to initiate
the movement of lifting the arm up from the side towards the ear. This muscle
works very hard when the shoulders are rotated forward. The shoulder has a
very shallow cup, slightly deeper due to the labrum that surrounds ball of the
humeral head. When the shoulders are rotated forward, the cup tends to
angle down and out. Therefore the supraspinatus is required to work harder
due to the poor shoulder posture. With respect to supraspinatus, better
shoulder position relieves the muscle from being overworked and a subacromial bursitis can improve. Contents
Fracture, avulsion fracture
Fractures certainly can occur of bones that make up the shoulder. The most
common are avulsion fractures of the humeral head and fractures of the collar
bone / clavicle. An avulsion fracture is where the tendon pulls a bit of the bone
right off in the area where it attaches. This commonly occurs where
supraspinatus attaches to the head of the humerus. In most cases, the
problem is allowed to resolve without reattaching the tendon or bone to where
it was previously attached. The shoulder has an amazing ability to get other
muscles to take over the function of others. People usually have pain for
some months and then it improves. It is possible that people learn to
accomplish activities slightly differently to do what they need to.
It also fascinates me that, in more recent times, a fracture of the collar bone is
often not braced so that healing occurs between the two broken ends. It
appears that healing can occur regardless of whether bracing occurs or not. It
is possible that the development of ideas with respect to management of
fractures will evolve in the future, depending on the development of
technology, materials and research findings. Contents
Polymyalgia Rheumatica
Polymyalgia rheumatica often affects the neck and shoulder region, with pain
extending into the arms. It usually affects the older person (> 60 years) on one
side and the pain is usually significant, aching and has a tendency to be more
disabling in the morning before 11am. After this time of day, the pain eases a
little but does continue.
Polymyalgia rheumatica can be associated with temporal arteritis, that is
explained above. The larger arteries around the head can become inflamed
internally.
The issues relevant in this condition are; whether this condition is present and
what can you do about the problem? Blood tests are quite helpful with respect
to treating this condition and cortisone can resolve symptoms in less than 2
days. However, with cortisone there are some risks and complications. For
example, the heart does not cope well with increased blood pressure and
corticosteroids do tend to increase blood pressure. Contents
Chapter 5. Elbow pain
Osteoarthritis
Osteoarthritis of any joint in the body tends to occur as the body ages.
However, the deterioration of joints usually is related to factors that either
damage the joint surface or place additional stress or strain on the joints. The
factors or situations that result in damage to the joint surface include a fall on
an outstretched hand, especially when the fracture line extends to involve the
joint itself, or hard physical work involving the elbow. If the joint surface is
damaged, osteoarthritis will eventually occur.
Stress or strain of joints occurs when more force is applied to a tissue than
what it is designed to take. To some degree a trauma is an excessive and
sudden stress applied to tissue. However it can also be damaging if applied in
lesser force over a sustained period or repeated application. If joints in either
the shoulder or wrist are stiff or dysfunctional, increased strain will occur to
nearby joints including the elbow joints. The elbow consists of three joints; the
large ball (at the top of the forearm) and cup (at the end of the upper arm)
type joint called the humero-ulnar joint and the small pencil like joint called the
humero-radial joint on the outside of the elbow. Between the radius and ulnar
bones there is a third joint as they rest next to each other. Both first two joints
can develop osteoarthritis.
The symptoms of osteoarthritis tend to occur many years following trauma or
after a significant period of increased strain. Usually stiffness will be noticed
first and at times the degenerating joints can become inflamed and painful.
Both the humero-ulnar and humero-radial joints can become inflamed due to
osteoarthritis. There are commonly fluctuations of pain. The fluctuations can
last days and weeks and be aggravated by activity. Frequently carrying heavy
objects, using weights at the gymnasium and undertaking jobs such as
carpentry will aggravate the pain in osteoarthritis, whether it affects the large
or small joint. Keeping busy is often the best thing to assist with pain control.
Sometimes the pain can ease completely and at other times the pain can
continue for many months or years.
The strategies to help osteoarthritis revolve around treatment that can ease
the inflammatory processes in the joints and strategies to relieve pain or
manage pain. The first thing to try is to avoid aggravation by finding
alternatives to lifting heavy objects. Using a thermal brace over the elbow can
be an advantage because it provides some stimulation of nerves that
camouflage the pain, it reminds you to take more care and possibly supports
the deteriorating joints. Contents
Inflammatory arthritis
Inflammatory arthritis is different to osteoarthritis in its cause and also
associated symptoms and signs. There are many causes of inflammatory
arthritis but all are associated with systemic / widespread diseases such as
rheumatoid arthritis.
Rheumatoid arthritis can affect multiple joints, causing destruction and
pathological fusion. It can be associated with inflamed tendons, contracture of
muscles and significant distortions of the body including the wrist and hand
and softening of bone. The severity of the damage in Rheumatoid arthritis is
often severe and the damage to the joints can be so severe that the natural
processes of osteoarthritis can take over and completely fuse the two bones
together.
The other forms of inflammatory arthritis are different in their unique ways.
This includes psoriatic arthritis that affects usually less than 5 joints in an
irregular pattern. Lupus can be severe producing dramatic effects on the
hands and may have the characteristic butterfly rash over the cheeks and
nose. Gout is a condition that presents fairly commonly and usually the
presentation is sudden onset of severe pain and swelling. The joints are
usually solitary or few in number and will settle over some time until the next
episode.
Each form of inflammatory arthritis has a different pattern usually and while
the diagnosis of these arthritides is often difficult, the patterns can often be
helpful to narrow down the possibilities. Blood tests, including anti-bodies to
specific tissue types have been gaining greater and greater value.
Inflammatory arthritis is thought to be an auto-immune condition in most
cases (except gout and pseudogout) and therefore antibodies will be present
in the blood, that for some reason attack its own tissue.
In the elbow, rheumatoid and psoriatic arthritis appear to be the greatest
concern. Fortunately they are not common but the importance is severe. Both
these forms of inflammatory arthritis can completely destroy the elbow joint(s)
and this can make life very difficult.
The pain associated with inflammatory arthritis is similar in characteristics to
inflammatory osteoarthritis. The joints are extremely sensitive, producing a
sharp pain on compressing the joint surfaces. There are normally acute
limitations of movement of the elbow due to pain. The main challenge with
inflammatory conditions of the elbow is to find out what is the cause and
therefore what the future has install? Contents
Tennis elbow, Golfer’s elbow
A tennis elbow is a tendonitis and traction apophysitis involving the muscles
that attach on the outside of the elbow and the golfer’s elbow is a tendonitis
and traction apophysitis involving the muscles that attach to the inside of the
elbow. A tendonitis and traction apophysitis develop due to overuse in most
cases. This can be strenuous use of these muscle groups over a short period
of time or extended periods of time with less significant strain involved. This
latter situation is termed a repetitive strain injury. A tendonitis we have
discussed before in the shoulder region. An apophysitis is where the tendon
attaches to the bone is irritated and become inflamed at the attachment due to
overuse.
The causes for a tennis elbow are plenty, including tennis, using a
screwdriver, table tennis, gripping a small object tightly such as a luggage
handle, a broom, spanner or weights at the gymnasium. A golfer’s elbow can
be caused by similar things involving gripping firmly but also where the arm
forcefully rotates with the thumb turning towards the inside (from a position
pointing up). The term golfer’s elbow relates to the action of rolling the right
hand over following striking the golf ball when playing right handed golf.
A tendonitis and apophysitis may be treated by using ice when recently
aggravated, using heat on the muscle tension, stretching and massaging the
tight muscle and tendinous attachments. Contents
Fracture
Fractures occur near the bones of the elbow commonly. In children fractures
often occur above the elbow, such as an epicondylar fracture. You can obtain
a fracture to the olecranon process, particularly in older people who have a
fall onto the point of the elbow. When fractured, the olecranon can receive
multiple fractures and become a mess, creating great difficulty to heal in a
functional way. People do experience avulsion fractures of the tendons that
attach the triceps and the biceps to their points on the elbow. An avulsion
fracture is where the tendon pulls off a little bone where it attaches.
People usually have pain for some months and then follow with gradual
improvement. Any fractures involving a joint surface will be more complicated
and usually follow with osteoarthritis years later.
Most fractures of the elbow are braced, plastered or splinted with metal. It is
possible that the development of ideas with respect to management of
fractures will evolve in the future, depending on the development of
technology, materials and research findings. Contents
Tendonitis, muscle tear
There are many tendons around the elbow that can become irritated and
inflamed as a result of overuse or muscular strain of the relevant muscles.
Some of the more common musculotendinous units include the biceps tendon
(lies in front of the elbow joint and its action is to bend the elbow. It also turns
the hand so that the thumb is rotated in toward the body. This muscle works
very hard when lifting while bending the elbow. Irritation of this tendon can be
relieved when lifting is undertaken without elbow bend. The biceps muscle
can tear. In this situation it is common for a major canyon to be felt between
both sides of the muscle. The lower end tends to bunch up near the elbow.
The triceps attaches to the back of the elbow and its function is to straighten
the elbow. Activities that involve forceful extension of the elbow can irritate
this tendon and it can become inflamed. This includes forceful pushing away
from yourself, push up exercises, throwing a ball or the result of protecting
your face when falling. If a tendonitis is present, restrictions should be
undertaken to limit the irritation of these aggravating movements. Contents
Ulnar nerve neuritis
The ulnar nerve is situated on the inside of the elbow, in between the bony
prominence at the back of the elbow and the smaller prominence on the
inside of the elbow. People do refer to this structure as a “funny bone” and
when knocked, sends a tingling feeling into the forearm and hand. The nerve,
situated on the inside of the elbow, tends to be relatively protected against
injury or irritation. However, relatively gentle pressure applied to the nerve
consistently can result in an irritation / inflammation of the ulnar nerve. It sets
up a neuritis. The inflammatory process will often cause scar tissue to develop
around the nerve and creates an effective tunnel. Subsequent irritation to the
region does not have much tolerance because the swelling will cause
compression of the nerve very easily when there is a tunnel of scar tissue
surrounding it.
People experiencing this condition will often feel tingly twinges down towards
the hand even when doing fairly ordinary activities using the elbow. The nerve
is also compressed (resulting in the tingling) even when the pressure on the
nerve is extremely gentle. Some people find that resting their elbow on the
arm rest of the chair can be extremely uncomfortable. Once diagnosed, using
careful clinical testing and nerve conduction tests to differentiate between this
condition and a carpal tunnel syndrome, the key is to avoid irritation of the
nerve in the area of the elbow. Contents
Chapter 6. Wrist and hand pain
Osteoarthritis
Osteoarthritis of any joint in the body tends to occur as the body ages.
However, the deterioration of joints usually is related to factors that either
damage the joint surface or place additional stress or strain on the joints. The
factors or situations that result in damage to the joint surface include a fall on
an outstretched hand or a collision to either or both sides of the wrist, with the
hand anchored in some way. Osteoarthritis in the hand will often have similar
reasons for occurring but the impact is lower in the hand. These injuries tend
to produce pain that is long term and if the joint surface is damaged,
osteoarthritis will eventually occur.
Stress or strain of joints occurs when more force is applied to a tissue than
what it is designed to take. To some degree a trauma is an excessive and
sudden stress applied to tissue. However it can also be damaging if applied in
lesser force over a sustained period or repeated application. If some of the
joints in the hand or wrist are stiff or dysfunctional, increased strain will occur
to nearby joints including other joints in the wrist and hand. The wrist and
hand consists of a huge number of joints; some are pencil to pencil in type
(fingers for example) and others are irregular, with multiple joints contacting
with many other bones. All can develop osteoarthritis.
The symptoms of osteoarthritis tends to occur decades following trauma or
after a significant period of increased strain. Usually stiffness will be noticed
first and at times the degenerating joints can become inflamed and painful.
The joints at the base of the thumb, adjacent to the wrist, in the thumb where
the freely moving part of the thumb starts and joints at the end of the fingers
are the joints that seem to most commonly be affected by osteoarthritis. There
are commonly fluctuations of pain. The fluctuations can last days and weeks
and be aggravated by activity. Frequently grabbing objects or using objects
will aggravate the pain in osteoarthritis. Keeping busy is often the best thing to
assist with pain control. Sometimes the pain can ease completely and at other
times the pain can continue for many months or years.
The strategies to help revolve around treatment that can ease the
inflammatory processes in the joints and strategies to relieve pain or manage
pain. The first thing to try is to change taps in the house to lever operated
rather than knobs that need to be rotated. Some occupations involve
significant periods of time using hands with force. It may be ideal to change
duties to save your hands from aggravation. Light exercise is still helpful in
most cases. You can get a spongy exercise ball that mobilizes the joints in the
hand. Working it through the day gently can be helpful. Contents
Inflammatory arthritis
Inflammatory arthritis is different to osteoarthritis in its cause and also
associated symptoms and signs. There are many causes of inflammatory
arthritis but all are associated with systemic / widespread diseases such as
that associated with rheumatoid arthritis.
Rheumatoid arthritis can affect multiple joints, causing destruction and
pathological fusion. It can be associated with inflamed tendons, contracture of
muscles, softening of bone and significant distortions of the body including the
wrist and hand. Both wrists tend to end up twisted, toward the outside of the
hand. The fingers tend to be unable to straighten out, bent at the junction
between the hand and fingers. The severity of the damage in Rheumatoid
arthritis is often severe and the damage to the joints can be so severe that the
natural processes of osteoarthritis can take over and completely fuse the two
bones together.
The other forms of inflammatory arthritis are different in their unique ways.
This includes psoriatic arthritis that affects usually less than 5 joints in an
irregular pattern. Lupus can be severe producing dramatic effects on the
hands and may have the characteristic butterfly rash over the cheeks and
nose. Gout is a condition that presents fairly commonly and usually the
presentation is sudden onset of severe pain and swelling. The joints are
usually solitary or few in number and will settle over some time until the next
episode.
Each form of inflammatory arthritis has a different pattern usually and while
the diagnosis of these arthritides is often difficult, the patterns can often be
helpful to narrow down the possibilities. Blood tests, including anti-bodies to
specific tissue types have been gaining greater and greater value.
Inflammatory arthritis is thought to be an auto-immune condition in most
cases (except gout and pseudogout) and therefore antibodies will be present
in the blood, that for some reason attack its own tissue.
In the wrist and hand, rheumatoid arthritis is the greatest concern.
Rheumatoid arthritis can completely destroy the joints and this can make life
very difficult. Psoriatic arthritis can be extremely disabling in the hands as well
but less disfiguring. The joints in the hand are cold enough for gouty crystals
to affect them. Gouty arthritis will normally be associated with severe attacks
of pain and swelling.
The pain associated with inflammatory arthritis is similar in characteristics to
inflammatory osteoarthritis. The joints are extremely sensitive, producing a
sharp pain on compressing the joint surfaces. There are normally acute
limitations of movement of the elbow due to pain. The main challenge with
inflammatory conditions of the elbow is to find out what is the cause and
therefore what the future has install? Contents
Carpal tunnel syndrome
Carpal tunnel syndrome is quite often spoken about and treated surgically.
The median nerve runs through the front (soft side) of the wrist, supplying
sensation to the skin and muscular control to the muscles in the hand. During
its course into the hand it passes through a tunnel made up by the small
bones of the wrist on the back and a sheath (a type of flat lid) that makes up
the front. A carpal tunnel syndrome occurs when the space in this tunnel
diminishes or the pressure increases. The symptoms are either numbness of
the hand, particularly the middle finger across to the inside of the thumb and
weakness of muscles that lie in the hand itself. You may notice less control of
fine activities using your fingers.
The pressure can increase, without change of tunnel dimensions in pregnant
ladies. The swelling in their wrist associated with hormonal states commonly
results in a carpal tunnel syndrome at night. If someone develops a tendonitis
in the wrist, swelling can increase the pressure in the carpal tunnel. In addition
there are many instances when the tunnel size diminishes. For example, if the
carpal bones become malpositioned, the joints in the wrist develop spurs
associated with osteoarthritis, if gouty crystals occur in the area, if trauma
results in scar tissue, etc.
The main challenge with this condition is to find out exactly what is causing
the problem. Diagnostic nerve conduction tests can accurately determine
whether it is within the carpal tunnel where the nerve is affected. Sometimes
the causes are difficult to determine and at other times it can be easy. Surgery
is a very common thing to relieve the carpal tunnel of its pressure. Cuts are
made in the sheath covering the front of the tunnel so everything has more
room. The success of this procedure can be spectacular. It may be worth
trying to decrease the pressure in the carpal tunnel in other ways first.
Contents
Tendonitis
There are many tendons around the elbow that can become irritated and
inflamed as a result of overuse or muscular strain of the relevant muscles.
Some of the more common musculotendinous units include the wrist flexor
tendons (lie on the front of the lower forearm and its action is to bend the wrist
toward the arteries in the wrist. These muscles work very hard when lifting
while having a bent wrist. Irritation of these tendons can be relieved when
lifting is undertaken without wrist bend.
The wrist extensor muscles attach to the back of the hand and its function is
to lift the hand back towards the shoulder. Activities that involve forceful
extension of the wrist can irritate this tendon and it can become inflamed. This
includes forceful gripping of objects (particularly small) and hitting a backhand
with top-spin when playing table tennis. If a tendonitis is present, restrictions
should be undertaken to limit the irritation of these aggravating movements.
Contents
Fracture
Fractures occur in the bones of the wrist and hand commonly. The common
fracture sites in this region include a Colles fracture (across the bottom of both
bones at the end of the forearm), fracture to the end of the ulnar bone near
the wrist, the scaphoid bone in the middle of the wrist, fractures to the base of
the small finger and fractures of the fingers. Fractures to the bones at the end
of the forearm occur mainly as a result of falls onto outstretched hands. A
fracture to the lower end of the ulnar bone (on the inside of the wrist) will
commonly be caused by a fall as well. The scaphoid fracture can occur from a
fall or using the wrist as a hammer – the direct impact tends to cause the
damage. A fracture to the bone at the base of the little finger (metacarpal) is
classically caused by hitting the clenched hand on a bar or another solid
object. Fractures to fingers can occur when the fingers get caught but the
body keeps moving, by impacts of balls (attempting to catch a ball) and when
heavy objects crush the finger.
People usually have pain for some months and then follow with gradual
improvement. Any fractures involving a joint surface will be more complicated
and usually follow with osteoarthritis years later.
Most fractures of the wrist or hand are braced or splinted with metal. Fingers
are often braced to the finger next to it. It is possible that the development of
ideas with respect to management of fractures will evolve in the future,
depending on the development of technology, materials and research
findings. Contents
Meniscal damage
The body uses cartilage meniscus to absorb shock and allow more movement
in some joints. At the lower end of the ulnar bone (on the inside of the wrist if
the palm is pointed forward) a cartilage is present. The end of the ulnar is a
relatively pointy shape, called a styloid. The cartilage in between the styloid
and the wrist / carpal bones increases the movement in this vital structure.
However meniscus can be damaged as well, particularly in falls or where
there is direct impact on this side of the wrist.
Damage to this meniscus is very difficult to determine. A MRI scan or a
radioisotopic bone scan usually is the best methods for determining an injury
to this structure. To some degree these tests are not helpful because an injury
to the meniscus is not easily treated but the pain with this type of injury
usually is mild but relentless and clarity of the diagnosis is sometimes worth
the money spent. The pain is aggravated by direct localized pressure on the
meniscus and rotation of the wrist, particularly rotating the thumb out to the
side from a position of the hand where the thumb is pointing up. Bracing the
wrist, to limit twisting can be the best course of management but this also
limits your ability to do normal things. Contents
Trigger finger
A trigger finger is a small swelling on a tendon that runs down to one of the
fingers. The tendons allow muscles to attach to the bones and create an
action. At the base of each finger there are two tendons. One of the tendons
is split and the second tendon slides through the middle of the other tendon.
The body builds it like this so that the fingers will operate smoothly but if a
swelling occurs in the second tendon (the one that slides through the middle)
it tends to have trouble fitting through the space and a trigger finger occurs.
Most people find that they can bend their affected finger most of the time but
on occasion, or if there is a certain amount of tension in the first tendon, the
finger will tend to flick into a bent position.
There are varying explanations as to why the tendon swells. It appears that
there is an overuse aspect to the tendon becoming enlarged. The problem
tends to occur in people who use their fingers in a forward and back motion
excessively. Typing and using a calculator have been described by patients.
Subsequently, if the activity is ceased or reduced, the swelling appears to
diminish and the problem resolves. There may be a problem where there is
some swelling of the tendon and then an inflammatory response due to
excessive activity produces additional pressure and the inflammation but not
the swelling can reduce if the activity is lessened. Sometimes surgery is
recommended to eliminate the tendon swelling and get function back.
Contents
Dupuytren's contracture
A Dupuytren’s contracture is a condition where the tendons in the palm of the
hand tend to shrink over a long period of time. They will thicken and gradually
become shorter. The eventual effect is that you can’t straighten your finger out
properly. It often occurs in more than one tendon. Surgery is often undertaken
when the use in the hand is dramatically diminished. This condition often
tends to run in families and some have associated Dupuytren’s contracture
with the drinking of alcohol but I have met many people afflicted who do not
touch alcohol.
Theoretically, if you stretch muscle out, you can increase the function of the
hand. In practice, this is difficult to achieve good results. Contents
Chapter 7. Upper arm pain or numbness
Radiculitis, radicular pain
Radicular pain is caused by inflammation and irritation of the nerves as they
exit the spine and start their course into the extremities of the body. The
nerves in this part of their journey are called roots and they can become
inflamed due to a number of reasons; due to compression from tissues in the
area where the nerves emerge (foramen) and inflammation of nearby
structures such as the facet joints. The tissues that can compress the nerves
include the discs in the spine, the encroachment of the foramen by bony spurs
/ enlargement, ligamentous thickening, cysts and tumours that can occur in
the area.
It is normal for the nerves to slide in and out of the foramen during activities of
the spine and extremities. In the neck, the arms will drag the nerves out of the
spinal canal on stretching them down, away and behind the body. Lifting the
arms up above the head will tend to allow the nerves to retract into the canal.
Bending the neck forward or bending the back forward will tend to stretch the
nerves down the spinal canal and stretch the nerves as they arise from the
spine. Therefore the movement of nerves in and out can aggravate the
inflammatory process of the nerve roots.
When nerves are compressed the effect is numbness or pins and needles
(paresthesia). There is no difference between compressing the extremity
nerves and those leaving the spine. Therefore numbness is a sign of nerve
compression. Pain will occur in the region of the inflammation of nerves and
also along their course following a period of constant compression. The
inflammatory process will increase the swelling in the area and therefore the
effects of compression – numbness and pain.
The most common reason for compression of nerve roots are the discs in the
spine. The discs will tend to bulge as they age and lose their hydration. In
addition, if tears occur in the peripheral fibrous layers, soft disc material can
be squeezed out of the disc and place pressure immediately on the nerves as
they travel towards the foramen, ready to leave the spine. You often hear
about discs being removed to decompress the spine. The disc material, in just
about every case, cannot be sucked back into the centre of the disc. The only
way to remove it is by surgical dissection. The disc material will shrink over
months due to dehydration and natural improvement does occur in most
people with a disc prolapse.
So, in some cases, surgery is necessary to remove pressure from the nerves
and to remove some bony enlargement, associated with wear and tear to the
spine over the years. Tumours such as a neurofibroma or a cyst in the spine
may also need to be removed surgically. From a more conservative approach,
the reduction of inflammation of the nerve roots should be beneficial. The
inflammation of nerves in the foramen may be reduced by the limitation of
movements of the arm and neck and by reducing the inflammation in nearby
facet joints in the neck. The inflammation of joints can be reduced by
eliminating trauma to the involved joints, try to eliminate stress by nearby joint
stiffness and ease related muscle tightness and subsequent pain. Contents
Reflex sympathetic dystrophy, regional pain syndrome
There are many poorly understood regional pain syndromes. The brain reacts
to pain in many ways. The reaction occurs immediately in the spinal cord. The
body will retract a limb away from a pain in the extremity. The body will protect
itself by tensing muscles around the painful area. Further up in the brain, the
body reacts to pain by controlling movement of the body. The cortex tries to
ensure that movement restrictions will limit pain and aggravation of an injury.
Centres in the brainstem will initiate an autonomic nervous system reaction.
The sympathetic nervous system will contract peripheral arteries, direct blood
to more vital organs of the body, produce a slowing down of the digestive
tract. These provide body with preparedness to flight or fight.
In addition to this, there are less obvious changes that occur. It has been
identified that when pain occurs over an extended period of time, the brain
remodels itself. The area of the brain that relates to the painful area of the
body becomes enlarged, to the relative diminished size of other nearby
regions represented in the brain. The greater the proportion of the brain that
develops, the greater the impact on reactions to the pain that is experienced.
People then react to chronic pain by a number of phenomenon including
modified behaviour including reduced activities and changes in socialisation
and the increased sensitivity of the skin and other tissues in the painful area.
Reflex sympathetic dystrophy was termed as a result of the changes to the
sympathetic nervous system in the limb where the pain is originated. Regional
pain syndrome is probably more accurate term that is now used. The success
with treating this condition is by removing the source of pain, if possible or still
present and change behaviour to slowly improve the body’s reactions.
Contents
Peripheral neuritis
A peripheral neuritis includes a couple of conditions already spoken about
previously, the ulnar nerve neuritis due to irritation on the inside of the elbow
and carpal tunnel syndrome involving irritation of the median nerve and finally
the irritation of the brachial nerves in the shoulder region, that has not been
spoken about previously.
The irritation of the brachial plexus has been termed a thoracic outlet
syndrome. However, the thorax is generally considered the chest cavity and
the outlet of the thorax is the space between the first ribs, sternum and spine.
The tem thoracic outlet syndrome doesn’t make sense. Perhaps brachial
plexus neuritis could be applied or more localized syndromes associated to
the structures that produce pressure on the nerves running through the
shoulder; scalenus anticus syndrome, pectoralis minor syndrome and
costoclavicular syndrome.
The scalenus anticus syndrome is associated with excessive tension of the
scalenus anticus muscle that places some pressure and irritation on the
plexus running through the base of the neck out towards the shoulder.
Pectoralis minor syndrome is associated with excessive tension of the
pectoralis minor muscle, in the front of the shoulder. The brachial plexus
nerves run underneath this muscle to find access to the upper arm. Excessive
tension can place some pressure on the nerves. The costoclavicular
syndrome is the upper rib(s) are held close to the collar bone / clavicle and
the diminished space can apply pressure.
The condition of brachial plexus neuritis is often a combination of small
(perhaps insignificant) pressure in more than one place. There is perhaps
scalenes muscle hypertonicity and a pectoralis minor muscle hypertonicity
and on top of these some reduction in space in the foramen within the spine.
This combination of sub-clinical pressures is often called a double crush
phenomenon. It can produce signs of nerve pressure such as numbness. The
numbness is usually experienced through the night and on waking for about 5
minutes or until the hand and arm is moved about. It then clears. Contents
Musculoskeletal referral of pain
Pain can be referred from joints and muscles that are producing pain to
nearby areas. Problems in the shoulder will often refer pain down into the
arms. Each tissue has a referral pattern and the pattern can assist with
diagnosing where the pain is referring from. Contents
Chapter 8. Thoracic and Chest pain /
disturbances
Osteoarthritis
Osteoarthritis of any joint in the body tends to occur as the body ages.
However, the deterioration of joints usually is related to factors that either
damage the joint surface or place additional stress or strain on the joints. The
factors or situations that result in damage to the joint surface include a slap on
the back and a compressive injury to the head or fall on the tail. The other
joints in the chest, between the breast bone / sternum and the ribs or between
the spine and ribs can also be damaged. Sometimes the damage can be
caused by a collision with another person or an immoveable object like a tree.
A motor vehicle accident where the car suddenly stops will drive the chest
forward into the immoveable seat-belt and this can also traumatize the joints
between the sternum and the ribs. Injuries to the joints in the thoracic spine
can produce pain that is long term and if the joint surface is damaged,
osteoarthritis will eventually occur.
Stress or strain of joints occurs when more force is applied to a tissue than
what it is designed to take. To some degree a trauma is an excessive and
sudden stress applied to tissue. However it can also be damaging if applied in
lesser force over a sustained period or repeated application. If some of the
joints in the spine are stiff or dysfunctional, increased strain will occur to
nearby joints. The most obvious situation is where the middle of the back
becomes quite hunched. The abnormal position tends to stiffen these joints
and place stress on nearby joints in the spine. The forces then impact on
nearby tissues tends to cause deterioration over many years.
The symptoms of osteoarthritis tends to occur decades following trauma or
after a significant period of increased strain. Usually stiffness will be noticed
first and at times the degenerating joints can become inflamed and painful.
The inflamed joints can be solitary or multiple. There are commonly very slow
fluctuations of pain. The fluctuations can last weeks and months and are
affected by activity. However gentle activity is often the best thing to assist
with pain control. Sometimes the pain can ease completely and at other times
the pain can continue for many months or years.
The strategies to help revolve around management that can ease the
inflammatory processes in the joints and strategies to relieve pain or manage
pain. Keeping busy is often a useful strategy. In addition, breathing deeply will
exercise the joints in the spine and joints between the ribs and the spine and
ribs and sternum in a very gentle fashion. Contents
Thoracic facet joint and costal joint sprains
Thoracic facet joint sprains / mid back sprain are quite common. They can
occur with substantial trauma such as a collision on a football field or due to
very minor trauma that is frequently due to everyday life activities. The causes
of injury to the joints in this region include; a slap on the back, by a collision
with another person or an immoveable object like a tree or a motor vehicle
accident where the car suddenly stops will drive the chest forward into the
immoveable seat.
The minor injury occurs when the pain is first felt. It is likely that in many
cases the injury occur undertaking a minor twisting of the trunk. Following a
sustained period of relative inactivity, the muscles and joints do not function
always as they should. If the joints are moved by muscles due to a lack of
coordination that occurs after inactivity, small injuries can occur. Twisting to
grab the seat belt in the morning is another common activity that can result in
minor injury.
A small injury can produce incredibly severe pain. The torn tissues are
exquisitely sensitive and when stretched give you a sharp / knife like pain.
The stretching will occur when bending away from the painful side at times but
consistently when compressing the involved joint. Swelling accompanies all
sprained joints. The swelling / fluid in the joint will bulge and stretch the
sensitive tissues when the joint surfaces are squashed together.
The first step in assisting a patient with a mid back or chest sprain is
identifying where the problem is and how many joints are affected. The
management that helps is all associated with reducing the inflammatory
swelling in the joint. Ice has been advocated for swollen joints and may be
successful in the first 24 hours. Most of the joints in this region are close to
the skin and therefore can be assisted by the application of ice. Heat may be
useful in some people. The forces in the joints of the mid-back need to be
widely distributed. Stiffness due to transient or more permanent reasons can
increase the strain on inflamed joints. Removing the stiffness can be of great
assistance to healing. Muscle tension can also localise the forces in the area
of the injury. Heat, which helps muscles lose some of their tension, can be a
great help. Contents
Sternocostal joint sprain, malposition
The joints between the breast-bone / sternum and the ribs can be damaged
(joint sprain) and subsequently become misaligned. There are a couple of
possible problems with misalignment; firstly the joint could be stiff (unable to
return to its correct position) and secondly, may be unstable due to the
previous injury and so therefore cannot be maintained in a normal position. In
this second case, it can be pushed into normal alignment but it will just fall out
again.
Where the joint is stiff, often manipulation will correct this problem very quickly
and rapid relief can be gained. In the second situation where instability is
present, misalignment is something that will be present indefinitely. The joints
cannot be strengthened because there is insufficient muscle crossing the
joint, to build up. The joints can be wired together, as happens with open
heart surgery. However, following a sprain, this is never / rarely undertaken.
Most people deal with a little instability in this joint, without discomfort.
Contents
Thoracic spine or costal joint dysfunction, stiffness
Thoracic spine joint dysfunction or stiffness can occur in many different
conditions in the back. Some can be long-term and others transient.
Osteoarthritis and disc degeneration can produce long term stiffness. Muscle
spasm and transient stiffness of the joints in the spine can frequently be
relieved quickly and easily by manipulation and massage techniques in the
spine and of costovertebral joints (just beside the spine).
The problem with dysfunction and stiffness is the localisation of increased
stress on some areas in the spine. It is usually nearby joints that are most
commonly adversely affected. The adverse effects can be pain, degenerative
changes and osteoarthritis. Contents
Inflammatory arthritis
Inflammatory arthritis is different to osteoarthritis in its cause and also
associated symptoms and signs. There are many causes of inflammatory
arthritis but all are associated with systemic / widespread symptoms of
disease such as rheumatoid arthritis.
Rheumatoid arthritis can affect multiple joints, causing destruction and
pathological fusion. It can be associated with inflamed tendons, contracture of
muscles and significant distortions of the body including the wrist and hand
and softening of bone. The severity of the damage in Rheumatoid arthritis is
often severe and the damage to the joints can be so severe that the natural
processes of osteoarthritis can take over and completely fuse the two bones
together.
The other forms of inflammatory arthritis are different in their unique ways.
This includes psoriatic arthritis that affects usually less than 5 joints in an
irregular pattern. Lupus can be severe producing dramatic effects on the
hands and may have the characteristic butterfly rash over the cheeks and
nose. Gout is a condition that presents fairly commonly and usually the
presentation is sudden onset of severe pain and swelling. The joints are
usually solitary or few in number and will settle over some time until the next
episode.
Each form of inflammatory arthritis has a different pattern usually and while
the diagnosis of these arthritides is often difficult, the patterns can often be
helpful to narrow down the possibilities. Blood tests, including anti-bodies to
specific tissue types have been gaining greater and greater value.
Inflammatory arthritis is thought to be an auto-immune condition in most
cases (except gout and pseudogout) and therefore antibodies will be present
in the blood, that for some reason attack its own tissue.
In the thoracic spine and chest gout will never occur. The tissues are too
warm for crystals of uric acid to form and then provide attacks of irritation to
the joints. In the thoracic spine ankylosing spondylitis may be important. The
effects may be increasing stiffness of both the spine and rib cage. Some
forms of inflammatory arthritis can be associated with changes in the eyes
and organs such as the heart. Other forms of inflammatory arthritis can affect
the junctions between parts of the sternum and be as a result of a systemic
infection.
The pain associated with inflammatory arthritis is similar in characteristics to
inflammatory osteoarthritis. The joints are extremely sensitive, producing a
sharp pain on compressing the joint surfaces. There are normally acute
limitations of movement of the mid back arching back due to pain. The main
challenge with inflammatory conditions of the mid back and chest is to find out
what is the cause and therefore what the future has install? Contents
Myofascial pain from overuse, shoulder or coughing strain
Muscle pain can occur in the thoracic spine as a result of excessive activity or
as a reaction to pain in the area. Many of the muscles of the shoulder run
down and attach to the lower part of the spine and shoulder blade that sits on
the thoracic cage. These muscles can develop an assortment of local and
widespread problems that can be treated effectively.
The muscles in between the ribs are called intercostal muscles. They can
often cause considerable pain. In probably 30% of all people that attend
hospital with suspected heart attack are found to have musculoskeletal pain
and most of this would be the intercostal muscles. They are upset by many
things but the most common causes are coughing / sneezing, pain in the
vicinity such as spinal pain, rib fracture, GORD (gastro-oesophageal reflux
disease) and shoulder myofascial pain. It has been found that poor sleep and
anxiety can cause or aggravate this intercostal muscle pain.
With any muscle pain, heat, gentle stretching, gentle activity and massage
techniques are the most effective. Intercostal muscles can improve quickly
over a couple of days with localized treatment. Muscles that are related to
either shoulder can take a long time to improve and will often re-establish,
once they have improved. Contents
Thoracic disc disruption, herniation
The discs in the spine consist of a flexible combination of a fibrous perimeter
and relatively soft centre. They are built this way to enable flexibility but cope
with the axial forces down through the body. It could be said that people were
not supposed to live as long as they do. Even as recently as a 100-150 years
ago, you were quite unusual to live beyond 50 years of age and many people
did not reach 40 years of age. The discs in the spine deteriorate over the
decades of life. They start off fresh and functional. By the time you get to thirty
years of age, the fibrous perimeters of the disc have usually deteriorated,
developing cracks and defects that can produce significant problems. It is
often in one’s thirties that disc prolapses occur, where the soft centre can be
forced out through the cracks in the fibrous perimeter and push back toward
the nerves arising from the thoracic spine.
When the soft centre loses some of its vitality or fluid, the whole disc structure
tends to lose height and the fibrous perimeter will bulge. The body copes with
this usually but it can reduce the space for nerves to sit without interference.
When the disc continues to lose hydration, it becomes more like gristle than
soft jelly and a prolapse of disc material is unusual following your 50th year of
life. As the disc narrows and perhaps associated with some inherent
instability, the body reacts by creating bony bridges between vertebrae in the
spine (“spurs”). Eventually the vertebra in the spine, where the disc has
deteriorated, will fuse together but this process takes years. If we only lived to
50 years of age, we would in most cases have little problems.
What causes the discs to deteriorate? In many cases the deterioration is
initiated by trauma. Damage to the bone on either side of the disc will affect
the supply of nutrients to the disc and deterioration will occur. Sometimes the
perimeter of the disc can be damaged by severe impact such as in a whiplash
injury. The other factors include deterioration of the nearby spinal joints,
pressure on the discs due to curved shapes in the spine and stiffness of
nearby joints. Exercise of the discs tends to increase the supply of nutrients to
the disc and reduce the likelihood of disc disease. The thoracic spine has a
significant curve, concave to the front, placing pressure on the discs in the
spine.
While the prolapsed disc will tend to shrink via becoming dehydrated over
time, a prolapsed or herniated disc is only able to be corrected by surgical
intervention. The soft centre has been described as being like toothpaste in
young people. You know how difficult it is to suck toothpaste back into a tube.
The only way to get the toothpaste away is by using your finger or a
toothbrush. However, if there is no herniation, the disc can be assisted by
strategies to increase nutrients supplied to the disc. Contents
Notalgia Paresthetica
Notalgia paresthetica is a condition of sensory change / numbness / tingling
sensation. It occurs in a patch, not far from the midline where the spine is at
the back. This condition is described in the mid back area and the patch is
often 6-15 cm in an oval shape. The nerves that supply this area of the skin
come from the nerves that exit the spine. They travel up towards the head a
little, penetrate through the muscle of the back and then change direction,
heading down towards the tail before innervating the skin.
This “V” shaped course appears to be what causes the problem. Some people
have a more significant angle on the change of direction than others. The
more significant the turn, the more likely someone will be affected. Often
when someone experiences this sensory change / loss, it will persist for some
weeks. It is not painful but very irritating. It is possible that the greater the
tension in the muscles in the back, through which the nerves penetrate, the
more problem is experienced.
Treatment then requires relaxing the muscles in the spine, using massage,
stretching and manipulation. Once the tension is taken away from the nerves
supplying the skin on the back, it takes awhile for the sensation to improve.
There is often improvement over about 1-3 weeks. Contents
Thoracic spine fracture, tumor
Thoracic vertebra tends to fracture in the vertebral body at the front. The
curve in the mid back requires the body of the vertebra to bear most of the
compressive forces and sometimes the load becomes too great and the bone
collapses into itself. Fractures like this tend to occur with sudden compressive
forces including a fall onto your backside / tail, a headfirst collision (perhaps
diving into shallow water), a seizure or spasm of muscles in the trunk or
where there is a predisposing condition such as osteoporosis or an existing
tumour.
The pain from such a fracture is usually significant but often not severe. It
tends to be enduring or long-lasting over many weeks or many months. This
type of fracture tends to be relatively safe because the debris often collapses
into itself or spreads out away from the nerves at the back of vertebral body.
This is most helpful. If someone has well established DISH or multiple fusion
of vertebra in the spine and substantial force is applied to the spine, the
fracture can occur from front to back and this is an emergency situation. Care
is needed with respect to adventuring if you have this type of bony spinal
stiffness.
The challenge with a fracture of the thoracic spine is to find out whether there
is a fracture and how recent it is. People are often x-rayed and found to have
fractures of their spine without recalling a trauma. It is often the case where a
fracture can produce some pain, that then eases and a fracture is never
recognized.
Tumours of the spine often cause minimal symptoms. Some people have a
relentless, aching pain and others have acute pain following a fracture in the
tumour site, but many have no pain at all. The important thing here is to
identify the tumour and determine what treatment is available to assist.
Contents
Costochondral inflammation, costochondritis
Costochondral inflammation or costochondritis is infrequent in the chest. Most
ribs in the chest have a bony component and a cartilage component. The
cartilage is more flexible than bone and the chest needs to be flexible to
breathe and bend with compressive forces applied at times. Otherwise the
bony / osseous ribs would just break. The junctions between the bony and
cartilage ribs in most people is unremarkable. They are there but you would
never know.
Occasionally, due small traumas to the junctions or due
to an inflammatory condition / arthritis in the body, they
can become irritable or inflamed. The result is chest
pain. It tends to be persistent and can be associated
with pains elsewhere in other joints.
The important thing is to identify whether costochondritis is the cause of the
chest pain. Contents
Rib fracture, tumor
Rib fractures usually occur as a result of trauma. It could be from a fall, an
impact to the chest which can include a whiplash injury, where the chest is
stopped by the seatbelt, an assault where you are kicked or punched. In some
people with tumours or osteoporosis, coughing or sneezing can result in bone
fractures. Bone fractures can be dangerous because the broken rib can act
like a spear and deflate your lungs. The lungs work due to a vacuum type
action of the diaphragm and accessory muscles around the chest. However, if
the lung has a hole in it, the pressure in the lung cannot suck air into it.
If the fracture is not dangerous to your lungs, most rib fractures are left to heal
naturally without splinting. Contents
Sternal fracture, tumor
Fractures of the sternum / breast bone are also as a result of trauma; some
kind of impact to the chest. You may sometimes obtain a fracture of the
sternum though a whiplash type injury or fall. The sternum is usually able to
heal without treatment. The pain can be significant and last weeks or months.
Contents
Xiphoid process misalignment, manubriosternal inflammation
The sternum / breast-bone has three parts; the body (the large part in the
middle), the manubrium (the shapely lump at the top) and the xiphoid process
(the bit at the bottom that tapers down to a point. Normally these three parts
join without problems but rarely the join between the manubrium and body
can develop an inflammation that produces sustained midline chest pain. This
inflammatory process is usually part of a systemic problem, where more than
one joint is inflamed.
The xiphoid process can be misaligned. It occurs commonly but is rarely of
significance. It has been suspected that the process can be forced so that the
point tends to angle towards the lower back. From my experience, there is
rarely a recollected trauma attached and it is not clear why it takes on this
shape. Contents
Atherosclerosis, myocardial infarction / heart attack
Angina and myocardial infarction / heart attack are critically serious conditions
to differentiate. Chest pain can occur with both conditions. The character can
be described as squeezing or pressure. The pain can refer to the left shoulder
and down into the left arm. In many people pain is not present with a heart
attack. Particularly diabetics and more elderly people. The other symptoms
associated with a heart attack are often a change of colour of the face, feeling
unwell, sweating and breathlessness, particularly while undertaking activity.
Angina may only have pain and last for lesser duration BUT they need to be
differentiated. You may be diagnosed with angina and have a heart attack so,
if you have some of these symptoms, call an ambulance and be seen at an
emergency department of a hospital.
The cause of a heart attack is blockage of the coronary arteries. Surgery can
be undertaken, using stents or bypass surgery, to allow blood to flow through
these arteries again. Blood tests can be used to check for heart damage but
an angiogram or scan for blood perfusion of the heart will better check for
artery occlusion. See your Medical Doctor if you have any concerns.
Contents
Coronary artery spasm, Angina
The coronary arteries can become partially occluded due to spasm of the
smooth muscle within their walls. This has been proposed as the cause of
angina. Angina is a partial restriction of blood supplying the heart and pain
results. Nitroglycerin under the tongue is effective with angina pectoris and
can be used to differentiate angina from myocardial infarction. With angina
and a heart attack, you may not get a second chance. Please see your
medical Doctor or present to the Emergency Department of a hospital.
Contents
Myocarditis, Pericarditis
The myocardium is the muscle of the heart. The suffix, “itis”, refers to
inflammation of. Therefore myocarditis is the inflammation of the heart
muscle. It is usually due to infection. Pericarditis is an inflammation of the
periphery of the heart and is often due to infection as well. When the
surrounds of the heart swell with inflammation, the heart cannot pump
because it cannot expand enough to get blood into its chambers. Both of
these conditions can quickly become a medical emergency.
Many people waiting for heart transplants are in the cue due to myocardial
damage. Please see a cardiologist or present to an Emergency Department if
you experience pain in the chest, breathlessness, pallor of the face or
unexplained perspiration. Contents
Pleurisy, Pneumonia, Pulmonary embolism, Bronchitis,
pneumothorax
There are many conditions of the chest cavity and lungs. Pleurisy is the
inflammation of the lung membranes surrounding the lungs. Usually following
a chest infection, pleurisy can be encountered. If swelling occurs, associated
with a fairly diffuse pain on breathing, the lungs will become crowded with fluid
taking up some of the room in the chest cavity. Antibiotics may be used to
help the body eliminate the infection.
Pneumonia can also result in chest pain and breathlessness. The infection
occurs in the lobes of the lungs and fills the air sacs so that there is less
opportunity for the blood to absorb the oxygen from the air. Sometimes you
may hear a gurgling of air bubbling through the passageways in the lung
fields. This condition can be fatal and needs to be attended to. If you
experience these symptoms, please visit your Medical practitioner.
A pulmonary embolism is a clot or debris that has lodged in the small arteries
of the lungs. It usually occurs in older people or people who have been forced
to lie down or are recuperating. Clots can also occur in some medical
conditions such as heart arrhythmia, deep vein thrombosis, polyarteritis or
some clotting disorders. When the small artery gets a clot lodged in its lumen,
the blood cannot get past. Swelling occurs at the site and typically some of
the lung past the clot will die. These clots can eventually be reabsorbed by the
body but it may also cause death, depending on the extent of the damage.
The symptoms can be vague, including chest pain. Sometimes the symptoms
can be quite minor. A chest x-ray will normally be quite helpful.
Bronchitis is an inflammation of the bronchi, at the base (top) of the lung
airway tree. These large airways can become inflamed due to infection,
perhaps due to allergy or aspiration of fluids including stomach acids.
Breathing is normally quite a noisy process with bronchitis and it may continue
for months; chronic bronchitis.
A pneumothorax is a condition where air gets into the chest cavity and then
causes the lung to collapse because the air that gets in, is at greater pressure
than the inhaled air. Sometimes a pneumothorax can be trauma induced, with
a sharp object introduced to the chest cavity or spontaneous (just happens)
where a leak allows air to escape from the sacs of inhaled air into the chest
cavity. This will quickly become a crisis. It can also involve severe pain. If you
have significant difficulty in breathing and no explanation, call an ambulance.
Contents
Gastro-esophageal reflux disease (GORD), Barrett's
esophagus, achalasia
GORD (gastro-oesophageal reflux disease) occurs when some contents
(gastric juices) of the stomach reflux into the esophagus (tube that carries
food into the stomach). The acidic fluids of the stomach tend to erode the
lower end of the esophagus / oesophagus and pain results. There are several
explanations as to why reflux occurs.
Commonly it is suggested that the valve that stops fluid from back flowing into
the esophagus, fails to work properly. It is often suggested that the acidity in
the stomach may be elevated and thus when reflux occurs, injury or irritation
occurs. Others believe that the acidity within the stomach is insufficient and so
food is unable to be digested adequately. Reflux may be a disturbance of
poorly digested food within the stomach. There is a condition called a hiatus
hernia, where part of the stomach is drawn up through the diaphragm,
producing part of the mechanism to keep fluids in the stomach. This facilitates
the irritation to lower esophageal walls.
There are many strategies for limiting reflux. It is best to avoid lying down
within a couple of hours after eating. It is best to eat your evening meal early.
Some medications may assist to keep fluids within the stomach or reduce the
acidity and thus irritation.
If the irritation occurs to the lower part of the esophagus over an extended
period of time, Barrett’s esophagus can result. This is a cancer of the lower
esophagus and it is difficult to treat. It is far better to attend to the reflux than
have to worry about treatment for cancer.
Achalasia is a dilation of the lower end of the esophagus. This can cause
significant problems in getting the food down into the stomach. If swallowing
of food becomes a problem, your Medical Doctor can run tests to illuminate
what is causing the problem. Contents
Aortic aneurysm, thrombophlebitis
The aorta is the main artery that takes blood from the heart down into the
abdomen (supplying organs) and further onto the legs. An aneurysm is a
dilation of an artery. The dilation usually involves an extended, thinning
arterial wall and the possibility is that the artery can rupture. Blood is irritating
to tissues unless it is located in the circulatory system. Blood in the chest or
abdomen, outside the blood vessels produces an inflammatory reaction and
pain. In addition, if the aorta bursts, blood pressure drops almost immediately
and death is rapid.
So, if you feel a significant pulsation in your abdomen or hear a gushing
sound at night, when everything is quiet, have the arteries checked.
Occasionally you may experience a whooshing sound in your ear at night.
This condition is harmless but a whooshing sound in other places may be very
serious.
Sometimes the veins can become inflamed. If a deep vein within the leg
develops a clot, a level of inflammation will occur as a result of the
obstruction. In other smaller veins, an inflammatory state, usually related to a
clot, can occur. These can occur anywhere in the body but the pain and
tenderness (tender to touch) will be quite localized. The vein will often be felt
to have a small, tender lump within it. Thrombophlebitis needs to be checked
by a Doctor. In some places in the body, you do not need to worry. In other
areas, where the clots are larger, drugs may be required to avoid the clots
lodging in arteries after travelling through the heart. Contents
Direct trauma, wound to the chest
Direct trauma to the chest can create a wound, bruising or a puncture of the
chest wall. A wound needs to be treated with antiseptic and possibly
antibiotics or a tetanus vaccination. Bruising can be treated using a topical
hirudoid cream or fingers of stretch adhesive tape. Puncture wounds can
result in an atelectasis or pneumothorax. Please refer to the description of
these lesions earlier. Contents
Mastitis, Pregnancy related breast pain
Mastitis is a condition often experienced by breast-feeding Mothers. It is
incredibly painful and reportedly due to poor breast hygiene following feeding
the baby. A medical opinion is needed quickly with respect to this type of
infection. Contents
Chapter 9. Lower back pain
Osteoarthritis
Osteoarthritis of any joint in the body tends to occur as the body ages.
However, the deterioration of joints usually is related to factors that either
damage the joint surface or place additional stress or strain on the joints. The
factors or situations that result in damage to the joint surface include a
situation where someone jumps onto the lower back with a pointed knee or
perhaps lifting a very heavy weight. These injuries tend to produce pain that is
long term and if the joint surface is damaged, osteoarthritis will eventually
occur.
Stress or strain of joints occurs when more force is applied to a tissue than
what it is designed to take. In the lower back it is more common that damage
occurs when the force is applied less severely over a sustained period or
repeated application. The most common strain on the joints in the lower back
arises from poor posture (an increased arch in the lower back). Pregnancy is
the classic situation but a beer gut will accomplish the same strain to the
joints. If some of the joints in the spine are stiff or dysfunctional, increased
strain will occur to nearby joints. The most obvious situation is where some
joints in the lower back have been fused or the disc removed, either naturally
or surgically. The forces then impacted on nearby tissues tends to cause
deterioration over many years.
While the symptoms of stress on the joints in the lower back is felt at the time
(pregnant ladies often experience lower back pain), the symptoms of
osteoarthritis tends to occur decades following trauma or after a significant
period of increased strain. Usually stiffness will be noticed first and at times
the degenerating joints can become inflamed and painful. The inflamed joints
can be solitary or multiple. There are commonly very slow fluctuations of pain.
The fluctuations can last weeks and months and are affected by activity.
However gentle activity is often the best thing to assist with pain control.
Sometimes the pain can ease completely and at other times the pain can
continue for many months or years.
The strategies to help revolve around management that can ease the
inflammatory processes in the joints and strategies to relieve pain or manage
pain. Keeping busy is often a useful strategy. Contents
Lumbar facet syndrome
The most common strain / stress on the joints in the lower back arises from
poor posture (an increased arch in the lower back). Pregnancy is the classic
situation but a beer gut will apply the same types of stress to the facet joints in
the lower back. A lumbar facet syndrome is a condition where the facet
irritation is consistent over a period of time. There is every chance that
osteoarthritis will develop if the stress to the joints is ongoing.
However, you can change your posture in the lower back, removing the sway
back look and tucking your tail under. There are many strategies for reducing
the strain on your joints. Contents
Lower back facet joint sprain
The majority of patients that present to my Clinic with lower back pain have
experienced a facet joint sprain. Lumbar facet joint sprains / Lower back
sprain will present as an acute / sharp pain involving the lower back. They can
occur with substantial trauma such as a lifting injury or due to very minor
trauma that is frequently due to everyday life activities.
Often it is associated with getting up out of a chair following lounging for an
hour or more and activities immediately following sitting are the most
dangerous. Following a sustained period of relative inactivity, the muscles and
joints do not function always as they should. If the joints are moved by
muscles due to a lack of coordination that occurs after inactivity, small injuries
can occur. The tissues of the joints in the back have very delicate
membranes, a thicker capsule and fairly strong ligaments supporting them. If
the more delicate tissue tears, perhaps on twisting to reach something behind
you, an inflammatory response will begin. The injury occurs when the pain is
first felt.
A small injury can produce incredibly severe pain. The torn tissues are
exquisitely sensitive and when stretched give you a sharp / knife like pain.
The stretching will occur usually when bending forward, away from the injured
tissues but consistently when compressing the involved joint (leaning back or
arching your back). Swelling accompanies all sprained joints. The swelling /
fluid in the joint will bulge and stretch the sensitive tissues when the joint
surfaces are squashed together.
The first step in assisting a patient with a lower back sprain is identifying
where the problem is and how many joints are affected. The management that
helps is all associated with reducing the inflammatory swelling in the joint. Ice
is usually useful for swollen joints in the lower back and may be successful in
the first 24 hours. Following this initial 24 hours, benefit is usually gained from
the application of heat. The forces in the joints of the lower back are spread
out amongst all the joints. Stiffness due to transient or more permanent
reasons can increase the strain on inflamed joints. Removing the stiffness via
manipulation can be of great assistance and is safe with this type of injury as
long as the injured tissues are protected. Muscle tension can also localise the
forces in the area of the injury. Heat and massage, that helps muscles lose
some of their tension, can be a great help. Contents
Lower back joint dysfunction, stiffness
Lumbar / Lower back joint dysfunction or stiffness can occur in many different
conditions in the neck. Some can be long-term and others transient.
Osteoarthritis and disc degeneration can produce long term stiffness. Muscle
spasm and transient stiffness of the joints in the spine can frequently be
relieved quickly and easily by manipulation and massage techniques in the
spine.
The problem with dysfunction and stiffness is the localisation of increased
stress on some areas in the spine. It is usually nearby joints that are most
commonly adversely affected. The adverse effects can be pain, degenerative
changes and osteoarthritis. Contents
Inflammatory arthritis, Ankylosing spondylitis
Inflammatory arthritis is different to osteoarthritis in its cause and also
associated symptoms and signs. There are many causes of inflammatory
arthritis but all are associated with systemic / widespread symptoms of
disease such as rheumatoid arthritis.
Rheumatoid arthritis can affect multiple joints, causing destruction and
pathological fusion. It can be associated with inflamed tendons, contracture of
muscles and significant distortions of the body including the wrist and hand
and softening of bone. The severity of the damage in Rheumatoid arthritis is
often severe and the damage to the joints can be so severe that the natural
processes of osteoarthritis can take over and completely fuse the two bones
together.
The other forms of inflammatory arthritis are different in their unique ways.
This includes psoriatic arthritis that affects usually less than 5 joints in an
irregular pattern. Lupus can be severe producing dramatic effects on the
hands and may have the characteristic butterfly rash over the cheeks and
nose. Gout is a condition that presents fairly commonly and usually the
presentation is sudden onset of severe pain and swelling. The joints are
usually solitary or few in number and will settle over some time until the next
episode.
Each form of inflammatory arthritis has a different pattern usually and while
the diagnosis of these arthritides is often difficult, the patterns can often be
helpful to narrow down the possibilities. Blood tests, including anti-bodies to
specific tissue types have been gaining greater and greater value.
Inflammatory arthritis is thought to be an auto-immune condition in most
cases (except gout and pseudogout) and therefore antibodies will be present
in the blood, that for some reason attack its own tissue.
In the lumbar spine or lower back gout will never occur. The tissues are too
warm for crystals of uric acid to form and then provide attacks of irritation to
the joints. In the lower back ankylosing spondylitis may be important. The
sacroiliac joints in early adult years tend to be the first affected in ankylosing
spondylitis. Some forms of inflammatory arthritis can be associated with
changes in the eyes (such as Reiter’s Disease) and organs such as the heart.
The pain associated with inflammatory arthritis is similar in characteristics to
inflammatory osteoarthritis. The joints are extremely sensitive, producing a
sharp pain on compressing the joint surfaces. There are normally acute
limitations of movement of the legs due to the stress placed on the sacroiliac
joints and arching the lower back due to pain. The main challenge with
inflammatory conditions of the lower back is to find out what is the cause and
therefore what the future has install? Contents
Myofascial pain from overuse, postural strain
Muscles in the lower back and hips produce a considerable amount of the
pain in people that present for treatment. Muscles often produce a pain that is
relatively dull or without spikes of more intense pain. There is an exception,
where this characteristic pain does become sharp, and it is associated with a
tearing of muscle. Muscle tears can occur in the lower back but are fortunately
uncommon.
The factors that contribute to the presence of aching muscular pain are a
reaction to pain in the region, postural strain producing a facet syndrome,
occupational stress (particularly lifting) and less commonly, mental stress and
anxiety. Muscles will always react to pain in the vicinity, whatever the source.
Muscles will eventually react to ongoing use, by becoming tighter and
eventually painful. Some occupations are commonly affected by this
condition. Carpenters, plumbers, people undertaking home duties such as
vacuuming and sweeping, Nurses and motor mechanics for a start. In all of
these situations it is not the extreme of the forces involved but the consistency
of the muscular recruitment that is important.
One of the best things to do about tension of muscles in the lower back and
hips is to change the way you use your spine and reduce the strain to joints
and muscles. The Alexander technique describes this particularly well. When
you stand, following sitting, tuck your feet underneath yourself (you may need
to edge forward on the chair) and rise up with your head above your lower
back. Contents
Lumbar disc disruption, herniation
The discs in the spine consist of a flexible combination of a fibrous perimeter
and relatively soft centre. They are built this way to enable flexibility but cope
with the axial forces down through the body. It could be said that people were
not supposed to live as long as they do. Even as recently as a 100-150 years
ago, you were quite unusual to live beyond 50 years of age and many people
did not reach 40 years of age. The discs in the spine deteriorate over the
decades of life. They start off fresh and functional. By the time you get to thirty
years of age, the fibrous perimeters of the disc have usually deteriorated,
developing cracks and defects that can produce significant problems. It is
often in one’s thirties that disc prolapses occur, where the soft centre can be
forced out through the cracks in the fibrous perimeter and interfere with the
nerves arising from the neck.
When the soft centre loses some of its vitality or fluid, the whole disc structure
tends to lose height and the fibrous perimeter will bulge. The body copes with
this usually but it can reduce the space for nerves to sit without interference.
When the disc continues to lose hydration, it becomes more like gristle than
soft jelly and a prolapse of disc material will be very unusual following your
50th year of life. As the disc narrows and perhaps associated with some
inherent instability, the body reacts by creating bony bridges between
vertebrae in the spine (“spurs”). Eventually the vertebra in the spine, where
the disc has deteriorated, will fuse together but this process takes years. If we
only lived to 50 years of age, we would in most cases have little problems.
What causes the discs to deteriorate? In many cases the deterioration is
initiated by trauma. Damage to the bone on either side of the disc will affect
the supply of nutrients to the disc and deterioration will occur. Sometimes the
perimeter of the disc can be damaged by severe load such as in a lifting
injury. The other factors include deterioration of the nearby spinal joints,
pressure on the discs due to curved shapes in the spine and stiffness of
nearby joints. Exercise of the discs tends to increase the supply of nutrients to
the disc and reduce the likelihood of disc disease.
While the prolapsed disc will tend to shrink via becoming dehydrated over
time, a prolapsed or herniated disc is only able to be corrected by surgical
intervention. The soft centre has been described as being like toothpaste in
young people. You know how difficult it is to suck toothpaste back into a tube.
The only way to get the toothpaste away is by using your finger or a
toothbrush. However, if there is no herniation, the disc can be assisted by
strategies to increase nutrients supplied to the disc. Contents
Meralgia Paresthetica
Meralgia paresthetica is a condition of sensory change / numbness / tingling
sensation. It occurs in a patch, incorporating part of the outside and front of
the thigh. This condition can involve numbness / sensory loss that extends a
little below the knee and the patch is often 10-40 cm long and 5-10 cm wide.
The nerves that supply this area of the skin come from the nerves that exit the
spine in the upper part of the lower back. They travel around the back of the
abdomen, side of the pelvis, penetrate through tissues and between muscles
in the groin before travelling down through the thigh and innervating the skin.
The path of these nerves appears to be what causes the problem. Some
people can experience some nerve pressure as the nerves passes close to
muscles in the trunk, penetrates through tissues in the groin as it emerges
underneath the tops of a patients trousers (belt) and then moves into the
thigh. Tight trousers, tight belts and other pressures applied to the nerve, as it
exists the pelvis, appears to cause the problem. Often when someone
experiences this sensory change / loss, it will persist for some weeks. It is not
painful but very irritating.
Treatment then requires relaxing the muscles in the abdominal and pelvic
regions, using massage, stretching and manipulation and releasing the
pressure applied by tight pants and tight belts. Once the tension is taken away
from the nerves supplying the skin on the thigh, it takes awhile for the
sensation to improve. There is often improvement over about 1-3 weeks.
Contents
Lumbar spine fracture, Sacrum fracture, Pelvic fracture, tumor
Lumbar vertebra tends to fracture in the vertebral body at the front. The curve
in the lower back protects the bodies from most of the compressive forces but
sometimes the load becomes too great and the bone collapses into itself.
Fractures like this tend to occur with sudden compressive forces including a
fall onto your backside / tail. There can be predisposing conditions such as
osteoporosis or an existing tumour that increase the chance of a fracture
occurring.
The pain from such a fracture is usually significant and can be severe. It tends
to be enduring or long-lasting over many weeks or many months. This type of
fracture tends to be relatively safe because the debris often collapses into
itself or spreads out away from the nerves at the back of vertebral body.
Fractures can occur from front to back through the lumbar vertebra in an
automobile accident and this is very serious. Anything that makes the spine
unstable will raise the potential for nerve damage.
The challenge with a fracture of the lumbar spine is to find out whether there
is a fracture and how recent it is. People can be x-rayed and found to have
fractures of their spine without recalling a trauma. It is sometimes the case
where a fracture can produce some pain, that then eases and a fracture is
never recognized.
Pelvic fractures vary in position and clinical significance. Often the trauma is
significant such as a car accident or a fall. These fractures can be lifethreatening if the sharp edges of the fracture damage vital organs. If you
experience significant trauma to the pelvic region, you should investigate the
extent of the injuries dutifully.
Tumours of the spine and pelvis often cause minimal symptoms. Some
people have a relentless, aching pain and others have acute pain following a
fracture in the tumour site, but many have no pain at all. The important thing
here is to identify the tumour and determine what treatment is available to
assist. Contents
Lumbar spinal stenosis, Hemivertebra, Transitional vertebra
Lumbar spinal stenosis is a narrowing of the lumen of the spinal canal. This
can be due to degenerative changes to the spine, where spurs encroach upon
the space where the nerves travel down. Stenosis can also be due to due
bulges, tumours and cysts. Apart from a disc prolapse, all of these conditions
occur slowly. However the symptoms may occur all of a sudden. A narrowing
of the spinal canal can be without symptoms until something changes to
increase the compression of nerves or demand for blood.
Increases in compression may be due to further disc herniation, swelling
associated with an inflammation of nearby joints or tissues or perhaps a
compression fracture of the vertebral body. The nerves in the spinal canal are
supplied with blood from blood vessels in the canal. The more activity the
more blood is required to allow them to function. When there is a narrowed
space in the spine, the blood vessels cannot dilate enough to supply the
nerves with sufficient blood. The result is usually leg pain. This is not sciatica
but a temporary pain in the legs, called a claudication. If the spine is flexed
forward, the canal’s dimensions increase and the claudication usually goes
quickly. The main challenge with leg pain is to know what its cause is.
A hemivertebra can occur in any part of the spine, including the lower back.
The vertebra has two halves, developmentally, and on occasion one half does
not develop, creating a triangular shaped vertebra. This results in a scoliosis
and in some cases needs to be attended to surgically.
In the bottom of the lumbar spine there is individual lumbar vertebra and a
naturally fused sacrum, made up of 5 fused / joined vertebra. The lowest
individual vertebra can be totally or partially stuck to the sacrum and the top
sacral vertebra can be totally or partially independent to the other 4 sacral
fused vertebrae. While, most of the time, the confusion in whether a vertebra
is a lumbar vertebra or sacral vertebra is not particularly important, at times it
can be significant. If the lowest lumbar vertebra is attached to the top sacral
vertebra, then it becomes part of the sacrum. All fused joints in the spine will
place some additional strain on nearby joints. An additional fused joint will
potentially place extreme stress on the now lowest movable joints in the lower
back. They will frequently deteriorate rapidly as a result of this structure.
Contents
Chapter 10. Hip pain
Osteoarthritis
Osteoarthritis of any joint in the body tends to occur as the body ages.
However, the deterioration of joints usually is related to factors that either
damage the joint surface or place additional stress or strain on the joints. The
factors or situations that result in damage to the joint surface include a fall
from a height or a car accident where the knees hit the dashboard of the car.
Some occupations such as carpet layers will suffer damage to the hip joints
when they stretch the carpet out. These injuries tend to produce pain that is
long term and if the joint surface is damaged, osteoarthritis will eventually
occur.
Stress or strain of joints occurs when more force is applied to a tissue than
what it is designed to take. To some degree a trauma is an excessive and
sudden stress applied to tissue. However it can also be damaging if applied in
lesser force over a sustained period or repeated application. If some of the
joints in the lower back are stiff or dysfunctional, increased strain will occur to
nearby joints including the hip joints. The hip consists of one large ball (at the
top of the leg) and a deep cup called the acetabulum. Osteoarthritis can occur
also if the hip is not well formed prior to birth (hip dysplasia).
The symptoms of osteoarthritis tends to occur decades following trauma or
after a significant period of increased strain. Usually stiffness will be noticed
first and at times the degenerating joints can become inflamed and painful.
The hip joints can become inflamed due to osteoarthritis. There are commonly
fluctuations of pain. The fluctuations can last days and weeks and be
aggravated by activity. Frequently sleeping on the affected hip will aggravate
the pain in osteoarthritis. Keeping busy is often the best thing to assist with
pain control. Sometimes the pain can ease completely and at other times the
pain can continue for many months or years.
The strategies to help revolve around treatment that can ease the
inflammatory processes in the joints and strategies to relieve pain or manage
pain. The first thing to try is to avoid sleeping on the bad side. Sewing a small
object on the bad side of night-wear can help to prompt you to move if you
unconsciously choose the wrong side to lie on. Contents
Acetabular labrum tear
The acetabular labrum is a small ring of cartilage that creates a deeper cup on
the cup side of the hip joint. The labrum, made of a type of cartilage is
attached strongly to the acetabulum but if excessive force is applied, can be
torn or detached from the acetabulum. The result is pain. The pain is usually
striking, sharp pain. The pain is aggravated by compressing the labrum by
bringing the thigh toward the labrum that is torn.
A tear in a labrum does not repair easily. It is possible that it will never actually
join back together. Apparent healing may be observed by a reduction or
resolution in the inflammatory process and pain but the tear may still remain.
It is possible that scarring may re-attach a detached labrum. In this type of
lesion advanced scanning such as a MRI may demonstrate the lesion but
good clinical testing is often effective. Normally, to enable the problem to
resolve avoidance of further aggravation is the most effective strategy.
Contents
Myofascial pain, muscle tear
Muscles in the lower back and hips produce a considerable amount of the
pain in people that present for treatment. Muscles often produce a pain that is
relatively dull or without spikes of more intense pain. There is an exception,
where this characteristic pain does become sharp, and it is associated with a
tearing of muscle. Muscle tears can occur in the area of the hip and thigh.
The factors that contribute to the presence of aching muscular pain are a
reaction to pain in the region; including hip joint osteoarthritis, lower back
osteoarthritis, trochanteric bursitis and fracture. Muscles will always react to
pain in the vicinity, whatever the source. Muscles will eventually react to
ongoing use, by becoming tighter and eventually painful. Some occupations
are commonly affected by this condition. Carpenters, plumbers, people
undertaking home duties such as vacuuming and sweeping, Nurses and
motor mechanics for a start. In all of these situations it is either degeneration
of the lower back or hip that is important with respect to the incidence of hip
muscle tightness.
One of the best things to do about tension of muscles in the lower back and
hips is to change the way you use your spine and reduce the strain to joints
and muscles. You may gain some benefit from walking with your feet tracking
on lines that are 10-15cm apart. Contents
Apophysitis
A traction apophysitis involves the muscles that attach to the bone that you sit
on and some that attach to the pelvis. An apophysitis is where the tendon at
the point where it attaches to the bone is irritated and becomes inflamed due
to overuse. This can be strenuous use of these muscle groups over a short
period of time or extended periods of time with less significant strain involved.
The causes for a traction apophysitis of the bone that you sit on (ischial
tuberosity) is usually due to regular / repeated stretching of the hamstrings.
Other places involving a traction apophysitis occur due to overuse or over
stretching of the muscles and tendons attaching to these locations.
A tendonitis and apophysitis may be treated by using ice when recently
aggravated, using heat on the muscle tension, stretching and massaging the
tight muscle and tendinous attachments. Contents
Inflammatory arthritis
Inflammatory arthritis is different to osteoarthritis in its cause and also
associated symptoms and signs. There are many causes of inflammatory
arthritis but all are associated with systemic / widespread symptoms of
disease such as rheumatoid arthritis.
Rheumatoid arthritis can affect multiple joints, causing destruction and
pathological fusion. It can be associated with inflamed tendons, contracture of
muscles and significant distortions of the body including the wrist and hand
and softening of bone. The severity of the damage in Rheumatoid arthritis is
often severe and the damage to the joints can be so severe that the natural
processes of osteoarthritis can take over and completely fuse the two bones
together.
The other forms of inflammatory arthritis are different in their unique ways.
This includes psoriatic arthritis that affects usually less than 5 joints in an
irregular pattern. Lupus can be severe producing dramatic effects on the
hands and may have the characteristic butterfly rash over the cheeks and
nose. Gout is a condition that presents fairly commonly and usually the
presentation is sudden onset of severe pain and swelling. The joints are
usually solitary or few in number and will settle over some time until the next
episode.
Each form of inflammatory arthritis has a different pattern usually and while
the diagnosis of these arthritides is often difficult, the patterns can often be
helpful to narrow down the possibilities. Blood tests, including anti-bodies to
specific tissue types have been gaining greater and greater value.
Inflammatory arthritis is thought to be an auto-immune condition in most
cases (except gout and pseudogout) and therefore antibodies will be present
in the blood, that for some reason attack its own tissue.
In the hip gout will never occur. The tissues are too warm for crystals of uric
acid to form and then provide attacks of irritation to the joints. In the hip
rheumatoid arthritis can be a devil. Some forms of inflammatory arthritis can
be associated with changes in the eyes (such as Reiter’s Disease) and
organs such as the heart (such as with rheumatic fever).
The pain associated with inflammatory arthritis is similar in characteristics to
inflammatory osteoarthritis. The joints are extremely sensitive, producing a
sharp pain on compressing the joint surfaces. There are normally acute
limitations of movement of the legs due to the stress placed on the hip joints
and due to pain. The main challenge with inflammatory conditions of the hip is
to find out what is the cause and therefore what the future has install?
Contents
Bursitis
There are bursas in many places within the hip region and other parts of the
body. The trochanteric bursa is commonly identified as being the cause of hip
pain. The inflammation of a bursa can be due to excessive compression of the
bursa from overlying muscles and tendons. The harder the muscles are
working, the more irritation the bursa will suffer. Invariably, if you have an
inflamed trochanteric bursitis, you will have tense muscles on the side of the
hip that have caused it to be inflamed.
Other bursas in the hip region mainly occur within the groin. With respect to
gluteus minimus and the iliotibial band, massage and stretching of the
muscles that go over the top of the trochanteric bursa can make a real
difference. Contents
Fracture, bone pathology
Fractures certainly can occur of bones that make up the hip. The most
common are fractures of the neck of the femur. The femoral neck fracture
usually occurs in older people following a fall. It is possible younger people
may have a fracture of the hip if they have osteopenia / osteoporosis due to
taking cortisone or poor eating (anorexia as an example). People may have
pain for some months and then it slowly improves. Most people with femoral
neck fractures have metal braces or a hip prosthesis surgically installed
because walking with a hip fracture is almost impossible.
The acetabulum (bone of the pelvis that the femur articulates in) can fracture.
The head of the femur will collapse right through into the pelvic basin. This is
a major problem and emergency treatment is required. It is possible that the
development of ideas with respect to management of fractures will evolve in
the future, depending on the development of technology, materials and
research findings. Contents
Polymyalgia Rheumatica
Polymyalgia rheumatica can also affect the hip and thigh as well as or instead
of the neck and shoulder region, with pain extending into the leg. It usually
affects the older person (> 60 years) on one side and the pain is usually
significant, aching and has a tendency to be more disabling in the morning
before 11am. After this time of day, the pain eases a little but does continue.
The issues relevant in this condition are; whether this condition is present and
what can you do about the problem? Blood tests are quite helpful with respect
to treating this condition and cortisone can resolve symptoms very quickly.
However, with cortisone there are some risks and complications. For
example, the heart does not cope well with increased blood pressure and
corticosteroids do tend to increase blood pressure. Contents
Inguinal and Femoral hernias
Hernias may occur in the groin. In ladies a femoral hernia can occur, with
abdomen tissue pushing down into the space where blood vessels enter the
front of the thigh. Coughing or sneezing will tend to push abdominal contents
down further into the space and lying down will often cause the herniated
abdominal tissue to fall back into the abdominal cavity.
Men’s anatomy is different to ladies in the area of the groin. Their weakest
point is where the seminal vessels travel from the scrotum and penetrate into
the abdominal cavity. This is where the hernia in men tends to occur. Men can
have a direct or indirect inguinal hernia, but as in women, coughing and
sneezing or carrying heavy items tends to push the abdominal tissue further
into harm’s way. Reclining may temporarily reduce the hernia.
The important thing with a hernia is to identify the problem, gain clarification
as to the extent of the problem and surgery can eliminate the problem quite
successfully. Contents
Hematoma / Corked Thigh
The thigh is a common place for bruising to occur. A pool of blood is termed a
hematoma and in the thigh, it can be referred to as a “corked thigh”. The
strategy to take with a hematoma is to apply hirudoid cream or stretchable
adhesive tape in a finger like pattern over the top of the bruising. Sometimes
the bruising will tend to descend down the leg. This can look very strange.
Contents
Chapter 11. Knee pain
Osteoarthritis
Osteoarthritis of any joint in the body tends to occur as the body ages.
However, the deterioration of joints usually is related to factors that either
damage the joint surface or place additional stress or strain on the joints. The
factors or situations that result in damage to the joint surface include a fall on
a bent knee or a condition where a defect occurs in the articular cartilage and
bone (osteochondritis). The result is both a hole in the articular cartilage and a
loose body in the joint that can cause damage. These injuries tend to produce
pain that is long term and if the joint surface is damaged, osteoarthritis will
eventually occur.
Stress or strain of joints occurs when more force is applied to a tissue than
what it is designed to take. Lesser forces applied over a sustained period or
repeated application can also produce osteoarthritis. If some of the joints in
the ankle and foot are positioned so that it creates a relative position of being
knock kneed, increased strain will occur to knee joints. The knee consists of
two joints; a large irregular joint (at the bottom of the femur) and the small
strut style joint called the tibiofibular joint. Both can develop osteoarthritis.
The symptoms of osteoarthritis tends to occur decades following trauma or
after a significant period of increased strain. Usually stiffness will be noticed
first and at times the degenerating joints can become inflamed and painful.
Both the tibiofemoral and tibiofibular joints can become inflamed due to
osteoarthritis. There are commonly fluctuations of pain. The fluctuations can
last days and weeks and be aggravated by activity. Frequently getting up from
the floor, squatting down and running will aggravate the pain in osteoarthritis,
whether it affects the large or small joint. Keeping busy is often the best thing
to assist with pain control. Sometimes the pain can ease completely and at
other times the pain can continue for many months or years.
The strategies to help revolve around treatment that can ease the
inflammatory processes in the joints and strategies to relieve pain or manage
pain. The first thing to try is heat and some kind of support. A brace
(particularly heat retaining brace) can feel better and provide the knee with
some support. There are numerous therapeutic applications that can be
rubbed onto the knee. Contents
Inflammatory arthritis
Inflammatory arthritis is different to osteoarthritis in its cause and also
associated symptoms and signs. There are many causes of inflammatory
arthritis but all are associated with systemic / widespread symptoms of
disease such as rheumatoid arthritis.
Rheumatoid arthritis can affect multiple joints, causing destruction and
pathological fusion. It can be associated with inflamed tendons, contracture of
muscles and significant distortions of the body including the wrist and hand
and softening of bone. The severity of the damage in Rheumatoid arthritis is
often severe and the damage to the joints can be so severe that the natural
processes of osteoarthritis can take over and completely fuse the two bones
together.
The other forms of inflammatory arthritis are different in their unique ways.
This includes psoriatic arthritis that affects usually less than 5 joints in an
irregular pattern. Lupus can be severe producing dramatic effects on the
hands and may have the characteristic butterfly rash over the cheeks and
nose. Gout is a condition that presents fairly commonly and usually the
presentation is sudden onset of severe pain and swelling. The joints are
usually solitary or few in number and will settle over some time until the next
episode.
Each form of inflammatory arthritis has a different pattern usually and while
the diagnosis of these arthritides is often difficult, the patterns can often be
helpful to narrow down the possibilities. Blood tests, including anti-bodies to
specific tissue types have been gaining greater and greater value.
Inflammatory arthritis is thought to be an auto-immune condition in most
cases (except gout and pseudogout) and therefore antibodies will be present
in the blood, that for some reason attack its own tissue.
In the knee gout will rarely occur as the tissues are usually too warm for
crystals of uric acid to form and then provide attacks of irritation to the joints.
Some forms of inflammatory arthritis can be associated with changes in the
eyes (such as Reiter’s Disease) and organs such as the heart (such as with
rheumatic fever).
The pain associated with inflammatory arthritis is similar in characteristics to
inflammatory osteoarthritis. The joints are extremely sensitive, producing a
sharp pain on compressing the joint surfaces. Compression of the joint
surfaces may be undertaken by bending the knee to 5 degrees and then
applying gentle pressure to either side of the knee. There are normally acute
limitations of movement of the legs due to the stress placed on the hip joints
and due to pain. The main challenge with inflammatory conditions of the
knees is to find out what is the cause and therefore what the future has
install? Contents
Myofascial pain, muscle tear
Muscles in the area above and below the knee produce a considerable
amount of the pain in people that present for treatment. Muscles often
produce a pain that is relatively dull or without spikes of more intense pain.
However, where the pain does become sharp, and it is associated with a
tearing of muscle. Muscle tears can occur in the lower leg and thigh. The calf
muscles (especially gastrocnemius) and hamstrings appear to more
commonly receive tears.
The factors that contribute to the presence of aching muscular pain are a
reaction to pain in the region; including knee osteoarthritis, cartilage tears in
the knee and ligamentous sprain. Muscles will always react to pain in the
vicinity, whatever the source. Muscles will eventually react to ongoing use, by
becoming tighter and eventually painful. Some occupations are commonly
affected by this condition. Labourers and gardeners for a start.
One of the best things to do about tension of muscles in the lower leg and
thighs is to reduce pain in your lower back and reduce the strain to joints and
muscles in your legs. The muscles will respond to heat, massage and
stretching. Contents
Infrapatellar tendonitis, tendon tear
The strongest action of your knee is to extend / straighten it. You use this
when you are lifting things, using your body to push hard, run and walk. If your
quadriceps are strong, you will have power in your legs. If your Infrapatellar
tendon has a tear or develops a tendonitis / inflammation of the tendon, the
whole mechanism breaks down and your strength dissipates. A fracture of the
patella will accomplish the same disabling result.
Pain will occur on using the muscles at the front of the thigh or trying to
straighten your knee if you have a tendonitis of the Infrapatellar tendon. If you
develop a tear in the tendon, it will be amazing that you can walk around. The
important thing clinically is to know what is causing the problem and what can
be done. Ultrasound can be useful to distinguish what the problem is.
Contents
Cruciate ligament, Collateral ligament tear
Each knee has two cruciate ligaments and two collateral ligaments that
support the knee. To some degree, a major tear of one of these ligaments and
you will affect the strength and stability of the knee greatly. The two cruciate
ligaments cross each other near the centre of the knee joint. One attaches to
the front of the femur and back of the tibia and the other to the back of the
femur and front of the tibia. Together, they give the joint much of its integrity.
A tear of the anterior cruciate ligament will often cause a sudden giving way of
the knee. Coming down stairs appears to be very troublesome with this injury.
An anterior cruciate ligament can be ruptured by an impact to the inside of the
knee and an impact on the top of the tibia, within the lower leg.
Surgically the cruciate ligaments can be replaced (knee reconstruction) and a
knee brace (preferably with a hinged mechanism) may hold it satisfactorily
together.
The collateral ligaments in the knee hold the knee on the outside and the
inside of the knee. The ligaments on either side of the knee provide support
for the knee from a sideways buckling. These ligaments provide much stability
but tearing is often partial and healing can be successful with sufficient
support during the process of healing. Contents
Patella dislocation, Patella tracking dysfunction
A knee cap / patella dislocation can occur in people of any age, where the
ridge that keeps the knee cap normally located is insufficient to maintain its
position. The knee cap can dislocate out to the side. The initial episode is
often very painful but subsequently the pain is less noticeable. Some people,
if they can relax their quadriceps, will be able to relocate the patella
themselves. When the patella dislocates, the appearance of the knee is
extremely bent. It looks as though the whole knee has lost its normal position.
The patient will not be able to use their leg because the knee cap cannot slide
in its normal groove.
A patellar tracking dysfunction / chondromalacia patellae is a condition where
the muscles on the outside of the quadriceps pull the knee cap over towards
the outside (not enough to dislocate).However, the result is the abnormal
strain to the surfaces of the bottom of the knee cap and the articular cartilage
of the femur at the knee. Pain, swelling and heat can occur in the knee.
Patella tracking dysfunction is one of the most common problems that affect
the knee. The most effective strategy is to strengthen the muscles on the
inside of the quadriceps, so that they will balance the strength of the
quadriceps on the outside. This takes time and the more painful the knee is,
the greater the loss of strength of the muscles on the inside of the quadriceps.
Contents
Bursitis, Baker’s cyst
The knee has its share of bursa, helping to enable tendons to slide over
nearby bone. The infrapatellar tendon usually has a bursa that lies beneath it.
If the quadriceps muscles work hard, the tension / strain over the infrapatellar
bursa will be increased and a bursitis may result.
A baker’s cyst is a swelling of the knee joint’s fluid. An inflammation of the
knee joint will expand into a number of typical locations; above the patella at
the front, below the knee cap on the front and at the back of the knee. A
Baker’s cyst may be due to an infection, inflammatory arthritis, due to a
trauma or injury and for reasons that are difficult to explain. Contents
Osgood Schlatters disease, Osteochondritis Dissecans
Osgood Schlatters disease is a traction apophysitis of the place where the
Infrapatellar tendon attaches below the patella (knee cap). This site is called
the tibial tuberosity. The tuberosity is a prominent bump at the front and top of
the tibia. With an apophysitis of the tuberosity, the prominence becomes even
more obvious. The site becomes tender and swollen due to the inflammation.
On x-ray, the site becomes patchy instead of uniform. This apophysitis only
occurs in teenagers who are active. It is the activity that causes the reaction
on the bone. After a considerable period of time, the inflammatory process
settles, leaving a more prominent bump and often some tenderness.
In osteochondritis dissecans, a defect occurs in the articular cartilage and
bone (osteochondritis). This is often seen as being a fracture. The name
osteochondritis dissecans has been dismissed by some as being misleading.
An osteochondral defect has been termed and is perhaps more accurate. The
result is both a hole in the articular cartilage and a loose body in the joint that
can cause damage. The symptoms of someone with a defect like this are
sudden bursts of severe, sharp pain if the loose body gets caught between
the joint surfaces. In addition swelling is common. Surgical removal is usually
best in the hope of preserving as much of the joint surface as possible.
Contents
Fracture, Tumor
Fractures occur near the bones of the knee at times. The bones on either side
of the knee are very strong and do not break often. You can obtain a fracture
of the top of the fibula (strut like bone on the outside of the lower leg),
particularly when there is a fracture to the ankle. The stress to the top of the
fibula is great if the ankle is either twisted or landed on during a fall.
People, who suffer a fracture of the top of the fibula, can improve reasonably
quickly with a brace because the bone is not weight bearing. Pain may occur
for some weeks and then follow with gradual improvement. Any fractures
involving a joint surface will be more complicated and usually follow with
osteoarthritis years later. There is a joint between the tibia and fibula.
Contents
Shin splints / Traction apophysitis
There are a few muscles that come up from the foot and attach to the front of
the tibia. Their role is to support the arches in the foot. If someone does a lot
of physical activity where they are on their feet, these muscles can apply a
traction force to the shin, where they attach. The result in some people is shin
splints. Shin splints is really a traction apophysitis of the muscle tendons,
attaching to the front of the leg.
In most people, tapering off the activity, massage and heat are helpful to
resolve shin splints. Teenagers often are the victims of this condition because
they are more active than most adults. However, it can occur at any age as
long as they are ambulant. Contents
Chapter 12. Ankle and Foot pain
Osteoarthritis
Osteoarthritis of any joint in the body tends to occur as the body ages.
However, the deterioration of joints usually is related to factors that either
damage the joint surface or place additional stress or strain on the joints. The
factors or situations that result in damage to the joint surfaces of joints in the
foot and ankle include a fall onto the foot or ankle, stubbing the toe, landing
on the feet from a height or a badly sprained ankle. These injuries tend to
produce pain that is long term and if the joint surface is damaged,
osteoarthritis will eventually occur.
Stress or strain of joints occurs when more force is applied to a tissue than
what it is designed to take. To some degree a trauma is an excessive and
sudden stress applied to tissue. However it can also be damaging if a lesser
force is applied over a sustained period or repeated application. If some of the
joints in the ankle or foot are stiff or dysfunctional, increased strain will occur
to nearby joints in the foot or ankle. The foot and ankle contains plenty of
joints, 14 in the toes, 10 in the foot and another two in the ankle. All can
develop osteoarthritis.
The symptoms of osteoarthritis tends to occur decades following trauma or
after a significant period of increased strain. Usually stiffness will be noticed
first and at times the degenerating joints can become inflamed and painful.
The ankle that is made up of the union of the talus and tibia and fibula above
can become inflamed due to osteoarthritis. In addition the subtalar joints,
between the talus and calcaneus, talus and navicular, talus and cuboid and
cuneiform bones can become inflamed with osteoarthritis.
The joints between metatarsal bones and the phalanges at the base of the
toes are commonly affected by osteoarthritis. An example of long-term strain
on a joint is the large toe, bent towards the little toe and forming a bunion. The
strain on the metatarso-phalangeal joint at the base of the large toe will often
end with the joint developing osteoarthritis. There are commonly fluctuations
of pain. The fluctuations can last days and weeks and be aggravated by
activity. Wearing inappropriate shoes can aggravate the pain of osteoarthritis.
Keeping busy is often the best thing to assist with pain control. Sometimes the
pain can ease completely and at other times the pain can continue for many
months or years.
The strategies to help revolve around treatment that can ease the
inflammatory processes in the joints and strategies to relieve pain or manage
pain. The first thing to try is orthotics or a different pair of shoes. For some
people, wearing a number of different shoes each day helps enormously on
spreading the forces through different places in the foot. Contents
Inflammatory arthritis
Inflammatory arthritis is different to osteoarthritis in its cause and also
associated symptoms and signs. There are many causes of inflammatory
arthritis but all are associated with systemic / widespread symptoms of
disease such as rheumatoid arthritis.
Rheumatoid arthritis can affect multiple joints, causing destruction and
pathological fusion. It can be associated with inflamed tendons, contracture of
muscles and significant distortions of the body, especially the wrist and hand
and softening of bone (particularly the hip). The severity of the damage in
Rheumatoid arthritis is often severe and the damage to the joints can be so
severe that the natural processes of osteoarthritis can take over and
completely fuse the two bones together.
The other forms of inflammatory arthritis are different in their unique ways.
This includes psoriatic arthritis that affects usually less than 5 joints in an
irregular pattern. Reiter’s disease tends to affect the heel, creating persistent
pain at the back of the heel. Gout is a condition that presents fairly commonly
and usually the presentation is sudden onset of severe pain and swelling. The
joints are usually solitary or few in number and will settle over some time until
the next episode. The most commonly affected joint with gouty arthritis is the
base of the large toe. The swelling and redness of this joint can be very
striking and the pain unbelievable.
Each form of inflammatory arthritis has a different pattern usually and while
the diagnosis of these arthritides is often difficult, the patterns can often be
helpful to narrow down the possibilities. Blood tests, including anti-bodies to
specific tissue types have been gaining greater and greater value.
Inflammatory arthritis is thought to be an auto-immune condition in most
cases (except gout and pseudogout) and therefore antibodies will be present
in the blood, that for some reason attack its own tissue.
Some forms of inflammatory arthritis can be associated with changes in the
eyes (such as Reiter’s Disease) and organs such as the heart (such as with
rheumatic fever). Children and teenagers can suffer from juvenile arthritis. It is
a cruel condition that affects many joints, usually symmetrically. The ankles
are commonly affected and the swelling and inability to stand up is upsetting.
The pain associated with inflammatory arthritis is similar in characteristics to
inflammatory osteoarthritis. The joints are extremely sensitive, producing a
sharp pain on compressing the joint surfaces. The ankle joint can be checked
for inflammation by applying gentle pressure to the front of the joint. There are
normally acute limitations of movement of the joints of the feet and ankles due
to the inflammation and pain. The main challenge with inflammatory
conditions of the feet and ankles is to find out what is the cause and therefore
what the future has install? Contents
Myofascial pain, muscle tear
Muscles in the area of the foot and ankle produce a considerable amount of
the pain in people that present for treatment. Muscles often produce a pain
that is relatively dull or without spikes of more intense, sharp pain. However,
where the pain does become sharp, and it is often associated with a tearing of
muscle. Muscle tears can occur in the lower leg and back of the ankle in the
achilles tendon. The achilles tendon, when it ruptures, is often described like
being shot and has an accompanying loud noise.
The factors that contribute to the presence of aching muscular pain are a
reaction to pain in the region; including foot and ankle osteoarthritis, fractures
in the foot and ligamentous sprain. Muscles will always react to pain in the
vicinity, whatever the source. Muscles will eventually react to ongoing use, by
becoming tighter and eventually painful. Some occupations are commonly
affected by this condition. Labourers and gardeners for a start.
One of the best things to do about tension of muscles in the lower leg and foot
is to reduce pain in the region and reduce the strain to joints and muscles in
your feet. They will respond to massage, heat and stretching usually.
Contents
Tendonitis, Traction spur / Heel spur
Like everywhere else in the body, tendons around the foot and ankle can
become inflamed if they are overworked. A tendonitis is a regular occurrence
in the achilles tendon at the back of the ankle. Sometimes it can become so
painful and tender that you are unable to wear shoes. There appears to be a
relationship between the tension and irritation of the calf muscles and achilles
tendon and the tension of the plantar fascia. The plantar fascia or muscles of
the feet are commonly tight and painful. There are many layers of muscles at
the bottom of the foot and most attach to the bottom of the heel. If they
become over-zealous with their work or the body demands too much of them
a traction apophysitis will occur and eventually a heel spur will arise.
It is likely that the relationship between the achilles tendon and the plantar
muscles is the heel bone / calcaneus that join the two together. If one of these
structures are tight, it will tend to pull on the calcaneus and therefore tend to
stretch the other muscles. They then react and so a tug-a-war ensues. The
back of the heel can also develop a heel spur and both can be painful. So,
with respect to finding a solution, massage and stretching are important,
having sensible shoes and treatment of any muscles tears or tendonitis are
important. Orthotics can be useful. Contents
Plantar fasciitis
Plantar fasciitis is a condition of inflammation of the fascia and muscles at the
bottom of the foot. The more tension there is in the plantar muscles, the more
likely a heel spur will occur. Please refer to heel spurs previously. Contents
Medial and lateral ankle ligament tear / Sprain
The ligaments on the inside (medial) and outside (lateral) of the ankle are
exposed to great forces, particularly in walking and running on uneven
ground. A sprained ankle happens to most people some time in their life and
to many it is a recurrent injury. The ligaments are extensive and strong,
particularly on the outside (lateral) side of the joint. These tough bands
succeed in most cases in retaining normal position of the ankle joint / mortise.
However, the strain on the ligaments if you roll your ankle (more commonly
stretching the outside of the ankle) is often too great for them to cope with and
they will tear.
A sprained ankle usually becomes swollen, painful to move and although
bearing weight on the joint may be possible, the swelling and sensitivity of
tissues surrounding the injured joint often makes this impossible due to pain.
In most cases the swelling will occur mainly on the injured side but in some
people the pain feels to be everywhere and swelling is diffuse.
Treatment for a sprained ankle is traditionally Rest, Ice, Compression &
Elevation (R.I.C.E). Rest is essential. The torn ligaments and capsule need to
repair and further injury will delay what is needed. Rest may involve not
undertaking activity but it may also involve crutches and popular recently, an
orthopedic boot. Ice is effective usually due to the fact it is a relatively
superficial joint. Compression and elevation are used to keep the swelling
down. This makes good sense because healing will occur more quickly if
there is no swelling. The healing requires the mobilisation of blood cells and
inflammatory fluids that mop up damaged tissue, supply the basic elements of
scar tissue that will eventually knit together the injured tissues. Swelling just
dilutes the effect and slows down the process.
As healing occurs, it is useful to apply some controlled strain to the injured
tissues. Too much may cause a further tear. Too little is wasting your time.
Contents
Osteochondrosis, Sever’s disease
Osteochondrosis is a term that is perhaps limited in its value. Sever’s disease
is a process where the pulling attachment of the achilles tendon initiates an
inflammatory process of decay in the back of the heel. The people most
commonly affected are children between 7 – 15 years of age that are very
active. Many children find the same problem on both sides.
The process of repair may take awhile and often involves restriction of activity.
The heel that is tender and it is usually aggravated by running. This may
support the parent’s recommendation to the child to stop running around.
Contents
Bursitis, Osteochondral defect
The ankle has a bursa behind the achilles tendon. It can become inflamed as
a result of increased activity or irritation to the tendon (tendonitis). Stretching
and massage of the calf muscles may help to reduce the tension and irritation
to the tendon.
An osteochondral defect begins as a small defect within the articular cartilage
in the ankle joint. It often happens in runners, dancers or athletes who jump.
While in many cases no injury is remembered, it is possible that trauma
causes a small cleft in the cartilage covering the bone. When a cleft occurs,
the bone underneath the defect in the cartilage can be eroded away. It is seen
to die and becomes soft. Once it becomes soft the articular cartilage overlying
the bone starts to break up, leaving a hole in the joint surface and debris in
the joint. The result is sudden onset of pain, when debris finds itself in
between the joint surfaces. Sometimes it is short lived and often the pain will
start after the joint is relaxed. Swelling will usually be present in the ankle.
Usually the pain is sufficient that walking is impossible.
The major goal in this process is to preserve as much of the joint surface as
possible. Any debris in the joint has the potential for causing further damage
and needs to be removed surgically. Contents
Fracture, Tumor
Fractures occur near the bones of the ankle often. The bones on either side of
the ankle are very strong but are exposed to severe forces particularly if you
fall onto it or if your foot becomes caught and you keep moving. Fractures can
occur to the bottom of the tibia and / or fibula from rolling your ankle and the
ligament pulls off a bit of the bone. Fractures can occur in the calcaneus (heel
bone) landing after falling from a height and in any of the toes due to things
dropping on your foot, kicking objects intentionally or unintentionally.
People, who suffer fractures of the foot and ankle, usually improve slowly due
to the weight that this part of the body has to carry with each step. A brace
may assist with mobility once healing has occurred. Rehabilitation is important
to gain most function back following a fracture. Pain may occur for some
months and then follow with gradual improvement. Any fractures involving a
joint surface will be more complicated and usually follow with osteoarthritis
years later.
Tumours occur in the foot and ankle, like in other parts of the body. They can
be metastases and primary tumours. If ongoing pain occurs or the foot and
ankle looks strange, investigation may be worthwhile. Contents
Chapter 13. Abdominal and Pelvic pain
Gastroenteritis
Gastroenteritis is an inflammation of the gastrointestinal tract, usually due to
an infectious etiology. Gastroenteritis is normally contracted due to
contaminated foodstuffs or objects that enter the mouth. The usual symptoms
include abdominal pain, vomiting, diarrhea and nausea. The body is
particularly good at expelling the organism but in some cases the organism
can result in massive dehydration and death. Contents
Celiac disease, Fructose and Lactose malabsorption
Celiac disease is an inflammation of the small intestine as a result of eating
gluten. Gluten is protein that gives elasticity to bread and binds together other
foodstuffs. Gluten is found in wheat and other grains such as barley and rye.
In Celiac disease the gluten is so offensive to the duodenum (start of the
small bowel) that it becomes inflamed and the normal hills and trough contour
of the wall of the small intestine become smooth and irritated. It significantly
reduces the absorption of nutrients in this part of the bowel including some
that are essential for health. Celiacs MUST avoid gluten. Even traces of
gluten can perpetuate or worsen the problem.
Fructose malabsorption is a very common problem. It is a condition that
appears to have been identified in the last 10 years or so. In these people,
fructose (commonly referred to as Fruit Sugar) cannot be broken down due to
a lack of an enzyme that allows the sugar to be digested. Fructose then
proceeds through to the small intestine where organisms that are native to the
small intestine thrive on the Fructose sugar. They live and thrive and in
response, give off hydrogen gas. This results in a full, gaseous and
uncomfortable feeling, often much pain and irregular toileting habits.
Now fructose is found in all fruit. Fruit contains both fructose and glucose
sugar types. In some fruit there is more fructose and in others there is more
glucose. Some fruit start off with more glucose and when they ripen, it is
converted to fructose. Fructose appears to be sweeter than glucose. If the
fruit contains more fructose than glucose, people with a fructose
malabsorption need to avoid it. This includes all the stone fruit, apples, pears
etc. Berries, pineapple, bananas (particularly less ripe bananas), kiwi fruit are
tolerated reasonably well in small portions. Fructose molecules make up a
larger structure called Fructans. Fructans are found in many vegetables,
wheat, corn syrup, artificial sweeteners etc. It is possible to have some
fructose but too much and you will feed those organisms that make you feel
very unwell.
Lactose malabsorption is similar to fructose malabsorption. Lactose is a sugar
type (milk sugar). If it is not digested due to a lack of an enzyme to break it
down, the organisms within the small intestine will flourish and produce gas in
the same way. It is possible to purchase lactose-free cow’s milk, cream,
yoghurt and mature cheese has no lactose within it. You may need to have
gelato instead of ice-cream but there is a lot to offer someone with a lactose
malabsorption. Contents