MONTHLY HEALTH UPDATE
Is Your Foot Causing Your Knee Pain?
Chad Abramson, D.C.
Whole Body Health
The Importance of the Cervical Curve
When looking at the neck from the left side, the cervical curve should look "C-shaped",
or lordotic. This develops when infants learn to lift and hold their head up while laying on their stomach and continues to progress when a child starts moving around on all fours. When we bend our head forward and backward, the most active cervical vertebrae are the C4, C5, and C6 vertebrae that make up the mid-lower cervical spine. Therefore, this region normally “wears out” first, resulting in degenerative joint disease (DJD) and degenerative disk disease (DDD). This is part of the normal, natural aging process, and can flatten and/or reverse one’s cervical curve. However, trauma can significantly accelerate degeneration. Among some practitioners and researchers, there has been speculation that abnormal cervical curvature may result in altered blood flow from the heart to the back of the brain. A 2015 study looked specifically at the hemodynamics (the dynamics of blood flow) through the vertebral arteries in individuals with a normal vs. a flat or reversed cervical curve.
The research team found an association between the loss of the normal cervical curvature and an alteration of the normal blood flow through the vertebral arteries that travel through small holes in the cervical vertebrae. In their conclusion, they commented on the importance of correcting the cervical curve in order to restore the altered flow of blood.
Altered blood flow through the vertebral arteries has also been implicated AS A risk FACTOR IN vertebral-basilar insufficiency (VBI) stroke. In addition, a flat or reversed cervical curve can increase tension on the vertebral arteries which may lead to weakening of the arterial wall making them more susceptible to injury and inflammation, which can cause the arteries to narrow, limiting blood flow to the back part of the brain. One of the goals of chiropractic is to improve posture, which can include restoring the cervical lordotic curve. To accomplish this, your doctor of chiropractic may utilize several in- office and home-based therapies; however, please be patient as cervical lordosis retraining can take time!
The "Many Faces" of Whiplash
Whiplash typically involves an injury to the neck, but it can often include symptoms
outside of the cervical region, which is why the term “whiplash associated disorder” (WAD) may
be a more appropriate description for the condition. WAD is most commonly associated with car
accidents, but other forms of trauma, such as a slip and fall, can also result in WAD. So what
makes WAD so unique?
Researchers have divided WAD into three primary classes: WAD I is basically pain with negative examination findings; WAD II includes pain with examination findings such as loss of motion; and WAD III includes the WAD II findings plus neurological losses (altered sensation and/or strength in the arm). There is also a WAD IV that includes fractures and dislocations. Whiplash associated disorder may include a constellation of symptoms that are often wide ranging —from nothing to minor, short-term discomfort to chronic, permanent, disabling problems that greatly affect the rest of the patient’s life. Studies have shown that recovery is more likely in patients with a WAD I injury than those with a WAD II injury. Likewise, the chance of recovery is higher among those with WAD II than those with WAD III.
But the controversy in any classification system include the “outliers”, or those that don’t get better when the physical factors involved and the WAD class suggests they should. This is what has perplexed researchers and healthcare professionals since this injury was first described in 1928 among those injured in train accidents (under the term “railroad neck”).
A 2017 review of past studies suggests that physical factors may play a smaller role in recovery prediction than psychosocial factors, or how the injured person deals with the injury emotionally or mentally. The review found the risk of pain becoming a chronic issue (lasting longer than three months) is elevated in patients with greater post-injury pain intensity and disability, whiplash grades (WAD III > WAD II > WAD 1), cold hyperalgesia (more sensitive to cold sensation), post-injury anxiety, catastrophizing (thinking things are worse than they are), and how long a patient waited to seek treatment.
Doctors of chiropractic are trained to assess and treat patients with WAD as well as provide them with exercises and other self-help management strategies to better enable them to recover from their injury.
Neck Pain / Headaches
Neck Pain and the Facet Joints
Neck pain is one of those conditions that virtually everyone has had at some point in
time. The degree of how it can affect one's life is highly variable—from minimal functional
limitations to total disability. So where does neck pain come from and why are the "facet joints"
The anatomy of a vertebrae in the spine is quite unique. There are seven vertebrae that make up the cervical spine. The top vertebra in the neck is called the atlas (C1), which basically swivels around the axis (C2). The atlas and axis allow us to rotate our head, such as when checking traffic or looking over our shoulder. The top two vertebrae (c1 and c2) are uniquely shaped, while the remaining cervical vertebrae (c3-7) are very similar in appearance with a vertebral body in the front and a bony ring with spinous process on the back that protects the spinal cord.
Between each vertebral body is a spinal disk and the processes are connected to the processes of the vertebrae above and below by facet joints. The facet joints are a major source of neck pain, and injuries to the facet joints are commonly referred as "cervical facet syndrome." Biomechanical studies show that the capsules that surround the facet joints have many nerve endings and can become highly strained when large amounts of force are applied to the body, such as during a motor vehicle collision. When this occurs, the combination of inflammation and capsular deformation can lower the threshold in various pain producing receptors in the facet joint. This results in persistent neck pain which can increase with normal movement.
There are many treatment approaches available for persistent neck pain arising from the facet joints, such as spinal manipulation and joint mobilization performed by a doctor of chiropractic.
Home-based self-care recommendations may include specific exercises to stretch and strengthen the cervical spine, nutritional advice, home cervical traction units, a cervical pillow, and cervical curve-retaining techniques.
The Relationship of the Hip, the Low Back, and Knee
The hip is a very unique joint. The depth of the socket, the strength of the muscles and ligaments
surrounding it, and the way it functions in weight bearing activities is unlike any other joint in the body.
The focus this month is on the relationship between the hip and the rest of the body. The hip joint is a synovial joint, meaning it moves freely. It is a ball-and- socket joint that is made up of the femoral head (the “ball”) and the acetabulum (the “socket”). The ball is largely contained within the cup or socket, though there are genetic and cultural differences with regards to the depth and shape of the hip joint in any one individual.
The relationship between the hip and the surrounding joints is intimate in that each joint affects the next. For instance, ankle pronation—or the inward rolling of the foot and ankle—results in a knocked knee, which can then shift the hip outwards. The pelvis then drops down on that side, the tailbone or sacrum becomes unleveled or sloped, and the lower spine curves to compensate with the ultimate goal of keeping your eyes level. Hence, when your hip hurts, your doctor of chiropractic will examine and treat the ENTIRE lower kinetic chain—the foot, ankle, knee, hip, pelvis, and spine—as ALL are so closely related to each other. When it comes to managing you and your hip pain, be prepared for management of any of the following:
- Ankle pronation: This is the inward rolling of the ankle often associated with a flat foot. When viewing someone with ankle pronation from behind, the angle from the Achilles tendon to the ground will lean inward when it normally should be perpendicular. A valgus correction in a “rear foot post”—a heel wedge thicker on the inside—of a foot orthotic (customized arch support) is needed to correct this.
- Knocked-knees: Ankle pronation can result in “knocked-knees” (genu valgus) which overloads or jams the outer knee joint, over-stretching the inner knee joint and ligaments. The knee cap (patella) then rides excessively hard on the outer surface of the femoral groove in which it glides as one bends and straightens their knee, causing knee cap pain.
- Hip inward angulation (or coxa vera): As the knee shifts inward or knocks, the head of the femur moves outward, leaving the joint less stable. Leg length deficiency (LLD)—or a short leg—occurs when the pelvis drops on that side further destabilizing the lower kinetic chain.
Once ankle pronation is properly corrected with a rear foot post and the hind foot is repositioned
back to neutral (if LLD persists) a heel lift can be placed under the foot orthotic to corrective this
imbalance. ONLY then will the pelvis become level and stable so it can properly serve as a strong
foundation for the spine the rest of the body to rest on!
We haven't touched the subject of muscle imbalance, strengthening of commonly weak hip extensor muscles, or stretching of overly tight hip flexors and adductor muscles—topics for another day! The good news—doctors of chiropractic can help you with this common problem!
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome, Inflammation, & Treatment Options
Carpal tunnel syndrome (CTS) belongs to a group of disorders called "entrapment
neuropathies" and as the name implies, it is caused by the trapping of the median nerve in the carpal
tunnel of the wrist. There are MANY ways to treat CTS, with some of the most effective focused on
Inflammation (from the Latin inflammatio) is commonly referred to as “swelling” and is a sequence of biological responses to harmful stimuli that include pathogens such as bacteria and viruses, damaged cells, and other irritants. It is a protective response to something abnormal that has occurred and involves our immune cells, blood supply, and more. Inflammation helps to eliminate the cause of cell injury, clean up necrotic or dead cells from area, and initiate the tissue repair process.
The hallmarks of inflammation include heat, redness, swelling, pain, and loss of function. With CTS, inflammation can arise from multiple causes. One common cause is from the rapid, repetitive rubbing together of the nine tendons that travel through the already tight carpal tunnel. This "mechanical" cause can be managed by modifying the activity by slowing down, taking breaks to allow the tissues to rest, and decreasing the force required by the job or task.
The inflammation associated with CTS can also arise from other causes that are less obvious and common than trauma or overuse. Some of these include (but are not limited to) rheumatoid arthritis (and other autoimmune forms of arthritis) and hormonal changes such as an overactive pituitary gland, an underactive thyroid, diabetes, taking birth control pills, or pregnancy.
Women are three times more likely to develop CTS than men. While hormones may play a role, women also have different shaped carpal tunnels and smaller wrists. Either way, the underlying cause must be dwelt with AS SOON AS POSSIBLE to reduce the pain, numbness, tingling, and loss of function. So how can we reduce inflammation?
An ice massage applied directly over the carpal tunnel/wrist is both easy to perform and very effective. Modifying activities that may be causing or irritating CTS is important but not always available. Night splints help to prevent extreme flexion or extension of the wrist and reduces sleep interruptions common with CTS. Chiropractic utilizes all the above plus manual therapies, like joint mobilization, and exercises/stretches that can be done at home.
As the Western diet may promote inflammation, your doctor may also recommend the Paleo diet, Mediterranean diet, or a gluten-free diet to aid in the recovery process.
Low Back Pain
Exercises on a Swiss Ball Help Back Pain Patients!
In previous articles, we’ve explored how to individualize an exercise program for those with
back pain. This month, we’ll look at why utilizing a Swiss ball may be more helpful for the back pain
patient than simply doing floor-based exercises.
In a 2015 study published in the Journal of Sports Science and Medicine, researchers assigned twelve chronic (more than three months) low back pain (cLBP) patients to perform either floor- or ball-based exercises three times a week for eight weeks using four different motions or exercises.
Though subjects in both groups experienced improvements, the gains were much greater for those in the Swiss/gym ball group regarding functional improvement. CT scans of the participants in the ball group also revealed an increase in the cross-sectional area of the deep low back stabilizing multifidus (MF) muscles.
So why did the swiss ball patients fare better? A strong possibility is that the use of unstable devices such as a gym or Swiss ball forces the neuromuscular system to work harder to maintain balance. This process not only improves propropception— the body & ability to sense where its various parts are in relation to one another for purposes of movement and balance—but it also works out additional muscle groups that are involved in normal everyday movement that may not be activated when exercising from the floor or another stable surface.
The four Swiss ball exercises included in the study:
- Bridge-1: Lay supine (on your back) with the ball under your upper back and bring one knee toward the chest to a 90/90° hip/knee angle; hold ten seconds and repeat five times with each leg.
- Bridge-2: Lay supine with your upper back on the floor with the ball under the pelvis; push down into the ball with the pelvis for ten seconds and repeat five times.
- Bird-dog (kneel on all-fours—quadruped position): Place a small ball (4-6”) under one knee (kneel on it) and slowly lift and straighten the opposite leg and balance for ten seconds and repeat ten times with each leg.
- "See-Saw:" Lay on your stomach with the ball under the pelvis/hips, balance on the forearms, raise the legs, and do a scissors-kick (as if swimming) for ten seconds ten times with each leg.
We encourage proper form and working safely within "reasonable pain boundaries" that YOU define. Gradually increase reps and sets as you improve, modify the methods, and most important, HAVE FUN!
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Abramson Family Chiropractic
10222 19 th Ave SE, Suite 103, Everett, WA 98208
This information should not be substituted for medical or chiropractic advice. Any and all health care concerns, decisions, and actions must be done through the advice and counsel of a health care professional who is familiar with your updated medical history.