Clinical Musings (Adolescents) II

We will continue with our discussion of adolescent conditions and injuries that we often see in the clinic.

A year ago a young boy and his father came to the clinic. The boy was 11 years old and was a basketball player. He stated that he plays basketball everyday before and after school. He stated that he was starting to feeling pain in his knees. He stated that this pain is worsening and that running and jumping are extremely painful. His father stated that he holding his son from basketball at this time.

Upon inspection it was seen that the child's knee was indeed swollen at the tibial tuberosity, which can be seen below. This is the structure that anchors your knee cap and the entire quadriceps muscles to the rest lower leg. There is a growth plate at this point and is commonly irritated in growing children. It was also seen that the boy's tibial tuberosity was extremely tender to the touch. He also presented with significant tightening of the quadriceps muscles with testing. What this child was experiencing was Osgood-Schlatter's disease (OS).

http://en.wikipedia.org/wiki/File:Gray345.png

Much like Sever's Disease (Discussed last week), Osgood-Schlatter's disease is a terrible name for a somewhat common condition. Much like Sever's Disease, OS is not a disease at all,  but an apophysitis (please see my last post for more information about apophysitis). Instead of a apophysitis of the heel, OS is an apophysitis of the patella tendon. This condition is also caused by rapid bone growth that muscles and tendons cannot keep up with leading to pulling on the growth plate of the tibial tuberosity. 

If left untreated this condition can lead to progressive bone growth at the tibial tuberosity and eventual deformation of the structure. As seen below, the bone growth will become permanent and could cause life long irritation. 

http://en.wikipedia.org/wiki/File:MaleWithOsgoodSchlatter.jpg

The treatment for this condition holding the patient from all jumping and running activities. In the beginning ice is very important to decrease inflammation because NSAIDS (Advil other OTC anti-inflammatories) are not always safe for adolescents. Progressive stretching of the quadriceps and manual mobilizations should also be done by a therapist. 

This patient was non-compliant with treatment and continued with basketball. He is now 15 and has a permanent deformation at the tibial tuberosity that is painful with most active movements. 

Clinical Musing (Adolescents)

Adolescent kids are sometimes the hardest people to treat. They are usually pretty nervous about being treated and they are terrible symptom reporters. Although it is difficult, they are usually the most fun to interact with once they get comfortable with you.

The next few post I am going to outline some common adolescent conditions that we see in the clinic. 

Sever's Disease

A young girl came into the clinic, with her mother, complaining of heel and ankle pain. She is a soccer player and is very active. She stated that she has felt progressive increase in pain with running walking. She stated that at this point she is unable to run and that she is unable to walk without limping. She said the whole ankle and heel is painful. What this patient was experiencing was Sever's Disease.

Sever's Disease (also Sever's Apophysitis/Calcaneal Apophysitis) is actually a terrible name for a somewhat common dysfunction. From here on out I will refer to it as Sever's Apophysitis (SA) because it is actually a more accurate description of the condition. SA is not a disease but is rather repetitive structural damage at the growth plate of the heel from the Achilles tendon. This usually happens in growing children that participate in sports. Apophysitis is technical description of a tendon pulling on a bone to the point that the bone starts to pull away from the rest of the bone. As you can imagine this can be a severely (pun totally intended) painful condition. 

http://en.wikipedia.org/wiki/File:Gray1241.png

As seen above the Achilles tendon attaches to the heel bone at the posterior foot. In pubescent children, bones tend to grow faster than muscles and this causes increased tension along tendons such as the Achilles  There is a growth plate in the heel bone which can become irritated with this increased tension from the Achilles. This increasing irritation is referred to as Sever's Apophysitis. 

Treatment for this condition is usually manual massage of the calf, gentle and progressive stretching and strengthening activities, possibly bracing and taping techniques. Acutely ice and heat are also helpful. It is also important to hold kids from sports activities in the short run to avoid further injury.

This patient is doing much better and has been able to return to practice recently on a limited program. 

Clinical Musings II

A few weeks ago a patient came into the office complaining of shoulder pain with most shoulder movements that woke her up in the night. When asked where the pain was located she stated that the pain was in the lateral shoulder. She then started to rub the outside of her arm. When asked if she feels pain when she rubs her arm in the area that usually hurts with shoulder movement, she stated the she does not.  This is an extremely common presentation for shoulder pain.

What this patient was experiencing was referral pain from the rotator cuff. Lateral shoulder pain that occurs with movement but does not hurt with palpation is usually referral pain from the infraspinatus tendon of the rotator cuff.

The rotator cuff (RTC) is a term that is thrown out there a lot and is usually referred to without much knowledge of what it actually is. The RTC is actually a group of 4 muscles: The infraspinatus, subscapularis, supraspinatus and the teres minor. 

http://www.creativerehab.net/

These four muscles are the primary movers and stabilizers of the shoulder. People think that you only injure your RTC by playing sports, but most often times we can injure these structures by poor posture and repetitive habits. 

The patient I was seeing was an avid exerciser that just finished knee surgery. During that time she was exercising her upper body exclusively and thus caused irritation to her RTC. This is what was causing her pain. More specifically, she was presenting with infraspinatus tendinitis (inflammation of the tendon). 

Treatment for this condition is usually trigger point release techniques (either dry needling or deep massage), Ultrasound, RTC strengthening, and shoulder mobilizations. This patient has been seen for 3 weeks and is showing vast improvements. Unfortunately, physical therapy is not always helpful and more aggressive treatment maybe necessary. 

Clinical Musings

Recently I saw a young patient that plays in several sports that require ballistic shoulder movements. She stated that while pitching in fast pitch softball she felt severe pain in her shoulder and that the pain has not improved in the past few weeks. She stated that the shoulder was tender to the touch and with movement above shoulder height.

Many orthopedist and therapist would suspect only ONE thing… rotator cuff injury. Although this is a perfectly logical assumption one must always be thorough in their examination.

Upon inspection, one thing was immediately noticeable. There was a significant difference in shoulder height (painful shoulder was lower). With this it was important to see if the scapulas are winging. Upon inspection it was seen that her affected shoulder was in fact “winging”.

There are varying degrees of winging and illustrated below is an example of a severely winging scapula. A winging scapula could be more subtle and less noticeable.  

http://muscletesting.com/blog/2011/08/12/experiments-in-muscle-testing-episode-02-the-problem-with-bicep-curls/rhomboids-3/

These signs should raise a little red flag in a good diagnostician for a possible long thoracic nerve injury.

The long thoracic nerve innervated that serratus anterior (SA). The SA is a muscle that looks much like the serrated end of a knife thus its name the serratus anterior.

http://conornordengren.com/category/anatomy/

The SA is only of the primary stabilizer for the shoulder complex in conjunction with the RTC therefore a long thoracic nerve palsy could be misdiagnosed as a  rotator cuff injury. The primary way of differentiating the two is to look for the winging scapula. 

Working on stabilization of the shoulder and using functional electric stimulation to cause activation of the SA has been very effective in treating this patient. In just two weeks she has improved 70% and is now able to raise her shoulder above her head with no pain. 

Ouch My Knee Hurts!!! [Part 6] Posterior Knee Pain

Posterior knee pain is very common and can be very limiting to ones daily life. Posterior knee pain could mean many things but it is important to narrow down the most likely causes. One of the most common causes of posterior knee pain are the hamstrings. 

The hamstrings are one of the biggest and most important muscles in the legs. Due to its anatomical structure the hamstrings are somewhat vulnerable to injury. The hamstring is the main muscle responsible for bending the knee. The hamstrings come from the hip and attaches to the posterior knee, making the hamstring one of the longest muscles in the body. Not only are the hamstrings very long but they are also very thin. This structure makes the hamstrings vulnerable to injury in a way that we do not see in larger more bulky muscles.  A hamstring strain to this insertion of the hamstrings (Zone 1) could cause pretty significant posterior knee pain.

The posterior knee also contains the origin of the calf (Zone 4), the gastrocnemius.  The calf is the muscle that is used to push the foot down and is integral to jumping. The calf is a very powerful muscle that is strained less often at the origin.

The popliteus is a small muscle in the posterior knee (Zone 2) which helps to “unlock” the knee during walking and running activities. This muscle can become irritated and cause some pain with knee bending and straightening. 

All of these issues are soft tissue issues that will improve with therapy and rest. Ice is also very helpful in reducing pain and irritation in the short run.  Hamstring strains could be more problematic depending on the severity of the injury. See a physical therapist for more information about your knee pain. 

Ouch My Knee!! [Part 5] From Joe Shmo to Joe DiMaggio

Knee pain in Zone 4a and 4b could mean a few things but the main thing we want to rule out is a meniscus tear. If you watch ESPN or listen to sports radio I am sure you have heard of a professional athlete be sidelined for months because of this issue. I also want to make it clear that you do not have to be a professional athlete to suffer from a meniscus tear; this can affect everyone from Joe Shmo to Joe DiMaggio.

 

What is the Meniscus?

The meniscus is the cartilage in the knee that acts as a cushion and a guide for the knee while it bends and straightens. The meniscus is integral for the structure and function of the knee. If you think of the meniscus as both the shocks and the struts of your car, you could imagine how important they are. The meniscus is made up of two C shaped pieces of cartilage that face each other. This creates a deeper surface for the femur (which is the thigh bone) to connect to the tibia (shin bone).

The front and back of the meniscus are delineated into two different sections; therefore there are actually 4 parts of the meniscus that can be damaged. There is the anterior medial meniscus (AMm), posterior medial meniscus (PMm), anterior lateral meniscus (ALm) and the posterior lateral meniscus (PLm). Each one of these parts of the meniscus can be torn or injured. Please note that all drawings of anatomy are incredibly crude and were done by yours truly. Please look up images online if you are confused by my drawings.

What does a meniscus tear feel like?

• Pain with jumping, running and sometimes walking
• Possible clicking or popping in the knee when putting weight on the knee
• Pain feels like stiffness that you can’t shake off
• Feels like the knee is stuck and won’t unlock
• Knee sometimes buckles
• Pain when bending the knee

What causes a meniscus tear?

A meniscus tear is usually caused by more traumatic means such as slipping or getting your foot stuck while performing a cutting maneuver, performing deep heavy squats with improper form, planting the foot while turning the hips at high speeds. More mundane activities could also result in meniscus tears such as, slipping and falling, stepping down a stair incorrectly.

What is another condition that can be confused for a meniscus tear?

• Patella femoral syndrome (See past posts)
• Patella tendinitis (See past posts)
• ACL,MCL,LCL tear (See future posts)

What are some treatments?

Treatment options depend mostly on injury severity. Minor and moderate tears are usually treated with Physical therapy and conservative care. More severe tears could possibly require surgery if physical therapy is ineffective. Please consult with a professional before running to get an MRI or into surgery. Many times physical therapy can help to restore full function without the need for surgery.  

Ouch My Knee!! [Part 4]

Pain in Zone 3 could possibly be caused by quadriceps tendinitis. Quadriceps tendinitis is not as common as some other conditions, however, this condition could cause some serious pain while running and jumping.

The quadriceps are a very large muscle group which are made up of four different heads (illustrated below). 

 The quadriceps are primarily used to extend the knee into a straight position, but are used in basically all standing or dynamic movements (like jumping, sprinting, running, walking). The quadriceps are literally the most important muscles in the leg. This huge muscle group that is so important to all movement of the knee attaches to a very small bone called the patella. 

We have talked about the patella at length in other blogs so I encourage you to read parts 1-3 of this series. One interesting part of the patella tendon is that it is what is called a “floating bone” meaning that the patella or “knee cap” has no ligamentous connection to any other bone. Most bones are connected to other bones through ligaments but the patella actually just "floats" on top of the knee connected to the body only though tendons [Just as a side, tendons connect bone to muscle, whereas, ligaments  generally connect bone to bone].

Because the patella does not have any ligamentous connection it is a very unstable bone that is affected by outside forces such as the quadriceps. The attachment of the quadriceps on the patella is called the patella tendon (muscle to bone).  

What does quad tendinitis feel like?

• Pain right above the patella with running, jumping, squatting
• Swelling in the area above patella
• Pain when rubbing quad tendon

What causes quad tendinitis?

• Lack of stretching of the quadriceps
• Lack of warming up of said muscle group
• Inappropriate progression of exercise program

What is another condition that could be confused with quad tendinitis?

 A quad strain could be confused with quadriceps tendinitis. A quadriceps strain will cause pain in the thigh could be located anywhere along the quadriceps muscles.

What are some treatments?

Resting and ice are a good first step, but all painful activities should be stopped. Stretching and modification to exercise should be considered when returning to exercise routine. Of course physical therapy is a good option if pain does not improve in 3 weeks. 

Ouch My Knee!! [Part 3]

Knee pain in Zone 2 is very common and can possibly mean patella femoral syndrome. Now this might sound really scary but it’s a very common and benign condition (if you are inactive). For those of you that exercise regularly this can be a very difficult condition to deal with.

What is Patella femoral syndrome?

The patella is your “knee cap” is that bone that sort of floats on top of your knee. This “floating bone” is connected to your body by muscle, tendon, and fascia (or tissue). The patella is supposed to move in a predictable and set “tract” that should not deviate. The patella sort of glides along set grooves that dictate where it should go, this occurs when you bend and straighten the knee.  If you ever have seen floats during the Thanksgiving Day parade you will notice that the balloons are being controlled by several different ropes pulling in different direction. The people pulling the ropes are controlling the tract of the balloon.

When you have Patella femoral syndrome is it caused by an imbalance pulling of the patella to one side or another, this causes undo pulling and rubbing on the grooves that the knee cap glides in. So if you imagine that the parade balloon is like the patella, it means that something is pulling on the balloon too hard and it deviate to one side more than another. You could imagine that during a parade this would cause a problem.  I could envision a 50 foot Snoopy taking out the north side of Macy’s.  The patella is supposed to glide up and down the knee in a way that it doesn’t rub the sides of the grooves; much like the 50 foot Snoopy is not supposed to rub the sides of Columbus Circle.

What does Patella femoral syndrome feel like?

• Pain with jumping, running and sometimes walking
• Pain when sitting for prolonged periods
• Pain feels like stiffness that you can’t shake off
• Pain persisted after sitting down

What causes Patella femoral syndrome?

• Tightness of ITBand (iliotibial band) which is the band of tissue on the outside of your thigh. It’s the thing that hurts when someone gives you a “dead leg”.
• Tightness of the tendons and fascia pulling on your patella
• Imbalance of muscles pulling on your knee cap
• Poor running mechanics
• Poor exercise form

What is another condition that can be confused for Patella femoral syndrome?

• Chondromalacia patella – This is mild arthritis on the bottom surface of your knee cap which causes grinding and pain.

What are some treatments?

Of course, physical therapy is suggested. A physical therapist would be able to best assess what limitations are causing your condition and would address them appropriately. Patella femoral syndrome does not often go away on its own so early treatment is important. If you suspect that you have patella femoral syndrome please discontinue painful activities until cleared by a physical therapist. 

Ouch My Knee Hurts!!! [Part 2]

Knee pain in Zone 1 could indicate a couple of things but most often times leads to patella tendinitis.

What is patella tendinitis?

Patella tendinitis is inflammation of the patella tendon. The patella tendon extends from the patella (knee cap) and attaches to the tibial tuberosity.  This tendon connects the entire muscle group of the quadriceps to the body. The patella tendon is therefore placed under significant force during running and jumping activities. Imagine a shoe lace holding a 100lb bucket from a pulley system; this is just a fraction of the forces placed of the patella tendon. Although the patella tendon is incredibly strong and can handle these forces sometimes these incredible forces can take its toll and can cause injury.

What does patella tendinitis feel like?

• Pain with jumping, running and sometimes walking
• Pain when rubbing the patella tendon
• Pain feels like burning and sometimes throbbing.
• Pain persisted after sitting down (not aways)

What causes patella Tendinitis?

• Repetitive jumping activities such as volleyball and basketball
• Not warming up before activity
• Tight quadriceps and a lack of stretching of said muscles

What are some treatments?

Of course, Physical therapy is suggested. In the short term, avoid painful activities, ice and resting. Taping and patella straps are sometimes beneficial. Talk to a professional before purchasing braces.

Other Possible diagnoses

• Patellofemoral syndrome
• Chondromalacia patella
• Knee arthritis
• Osgood Schlatters disease (NOTE: If you are complaining of pain similar to patella tendinitis but you are younger than 17 it is possible that you are experiencing another condition. Individuals that participate in repetitive jumping activities, that have yet to go through puberty, could have this condition) This is a condition where the patella tendon starts to pull away from its boney attachment (Tibial tuberosity). 

Ouch! My Knee Hurts!!! [Part 1]

This Blog is going to be one of a series of blogs. The next few weeks we will be discussing the knee and the variety of diagnoses and treatments related to it.

Among athletes and non-athletes one of the most common complaints I hear is of knee pain. The knee probably seems to be a straight forward joint compared to other joints of the body.  Although the knee may seem less complicated than a shoulder or the back, the knee is extremely dynamic and can pose several different problems.  The key to figuring out how to fix the problem, is to ask the right questions. Answering these questions accurately is the imperative to being able to accurately diagnosis any knee issue.

Where is the pain located?

It is important to note where the pain is located when you experiencing knee pain.

1. Patella tendon – Possible patella tendinitis
2.  Either side of the patella tendon – Possible patella femoral syndrome
3. Quad tendon – Possible Quad tendinitis
4. Joint line– Possible  medial meniscus (a), lateral meniscus (b)
5. Posterior knee – Possible Hamstring strain, popliteal tendinitis
6. Whole anterior knee – Possible L4 peripheral symptoms, arthritis, internal tear (ACL, PCL)
7. Inside joint line – Possible MCL issue
8. Outside joint line – Possible LCL Issue

What causes pain?

•  Is the pain caused when standing?
•  Is the pain caused by sitting?
• Does it hurt to run?
• Does it hurt to turn?

What does the pain feel like? What Else are you feeling?

• Burning?
• Tingling?
• Throbbing?
• Sharp?
• Stabbing?
• Was there a pop or a snap?

In the next few weeks we will go over each possible diagnosis. We will review the possible causes, treatments and how to avoid these issues. 

Fitness FAQ’s from your resident CSCS

How do I lose my arm or stomach flab?

I think I get asked this question more than any other question in my professional career! My wife alone has asked me this question about fifty times and she is always dissatisfied with the answer. It’s a simple answer to a simple question that people usually don’t want to hear. This is my fat loss golden rule:  To lose fat anywhere, you must lose fat everywhere! It really is that simple. It’s physically impossible to lose fat locally without total body fat loss. You can do 1,000 crunches a day and you will not see any stomach fat loss unless your calorie intake is less than your calorie output. Meaning, that what you eat (calorie intake) has to be less than what you put out during your daily life and exercise (calorie output). A recent study has shown that it is not just about exercise but that diet contributes most to weight loss.

[Small tangent: Women have a tendency to pool fat in certain areas of their body in subcutaneous fat (below the skin). These areas are the upper arms, stomach, thighs and buttocks. Men have a tendency to pool fat viscerally (below the muscle, around organs in the abdomen) Subcutaneous fat is harder to lose than visceral fat… Sorry, ladies.]

How do I lose weight?

So let’s get one thing straight. You should not just aim to “lose weight.” Instead, you should aim to lose fat mass in relation to lean body mass (muscle). There are plenty of very, very unhealthy “skinny” people. Take for example, an anorexic female that has very low fat mass but also has critically low muscle mass and is malnourished. Although the anorexic female may be skinny, she is also incredibly unhealthy. Your focus should be on being fit and healthy—NOT skinny!

Losing fat mass and gaining muscle mass is critical to achieving health and fitness. Losing fat mass and gaining muscle mass does not only improve your aesthetics,  but also improves blood chemistry, reduces the risk of certain heart conditions, improves bone density, and increases overall strength, along with a whole laundry list of other benefits. Therefore, exercise is critical to overall health—although your diet is most important factor in losing weight.  With that said, I think it’s important to note that you should not just cut your calorie intake by eating less or simply not eating.

How should I diet?

Crash diets will work in the short run but will always fail! I do not say “always” lightly. The reason why these diets always ultimately fail is because the body is designed to require nutrition and will always seek it out. If you think of an engine, it is designed to require several elements to run. The engine requires gasoline, air, a spark, coolant and oil among other things. If any of these elements are eliminated, the engine will not run correctly or fail to run at all. The same goes for the human body. If you’re not eating correctly and you’re lacking elements of nutrition, your body will not run correctly. Likewise, if you’re consuming all the necessary elements but you’re not consuming them in the correct ratios, your body will not run correctly. These elements at the basic levels are the following: Protein, Carbohydrates, Fat and Fatty Acids, Minerals, Vitamins, and the most often forgotten—WATER!!! (Coffee and diet coke DO NOT COUNT.)  If you’re finding that you’re lacking in some of these areas, a good place to start is our Maven Shake, which combines the basics with a little extra something that’ll give you an extra boost. (Note: This isn’t just a shameless plug. I started drinking the Maven Shake every morning and I notice a legit difference.) 

My Achilles Heel! Is my Achilles heel…?

So as the weather warms I am seeing an influx of Achilles related injuries. So I wanted to shed some light onto what the Achilles is and what injuries are associated with it. 

What is the Achilles tendon?

-          The Achilles tendon (calcaneal tendon) is the common tendon of the ankle that attaches the calf to the foot. The “calf” muscle is comprised of 2 major muscle groups of the gastrocnemius (gastroc) and the soleus. These two muscles are in charge of flexing the foot down towards the floor or technically referred to as plantarflexion. You can feel your Achilles tendon by touching the back of your ankle and feeling for the large cord like tendon that extends down to the heel.

Why is the Achilles often injured?

-          

     The tricky part about Achilles issues is that it can caused by many things. The Achilles plays a major function in all weightbearing movement from standing to sprinting. Any issue with the Achilles will drastically affect ones function throughout a normal day. Some problems with the Achilles are the following:

o   Located in a vulnerable area susceptible to injury from outside forces such as a slide tackle.

o   Takes the majority of the load during jumping activities.

o   Used constantly throughout day and exercise.

o   Relatively small tendon for girth of muscle it attaches to.

o   Tendon attaches to calcaneus (heel) but also shares tissue with bottom of heel and effects plantar fascia.

What are some common injuries?

-           Some common injuries sustained to the Achilles tendon and possibly associated with the Achilles tendon are:

o   Achilles tendinitis or tendinosis – Inflammation of Achilles tendon. This is indicated by pain when touching the Achilles and pain with all running and jumping activities. May see slight swelling of tendon.

o   Achilles rupture – Tendon ruptures are very painful and require immediate medial attention. Full Achilles ruptures are immensely painful and require surgical repair and can be diagnosed by use of the Thompson test. The Thompson test is when the effected calf is squeezed and a positive finding is when the foot does not flex down (plantarflex).  Partial tears can be seen when a dip in the actual tendon (looks like a pothole in the tendon).

o   Achilles apophysitis (mostly just children) – Also called Severs Disease, Achilles apophysitis is when the Achilles tendon pulls away from the heel causing pain and swelling. Much care must be taken to avoid over stretching.

o   Heels Spurs (secondary) – Tight Achilles will sometimes contribute to heels spurs which are boney growths are an attachment of a plantar fascia.

o   Plantar fasciitis (secondary) – Inflammation of the plantar fascia of the foot (arch of the foot). Tightness of the Achilles will contribute to plantar fasciitis by placing the foot in poor alignment and causing increases stress across the plantar fascia.

What are some causes for injury?

-          Some causes for Achilles injuries are often preventable

o   Over use – Weekend warriors and avid runners with poor running technique will sometimes develop Achilles tendinitis.  See my last post about running technique.

o   Tight calves – Stretching is very important. One way you can tell if your calfs are tight is if you are unable to flex your foot towards your head >90 degrees. Be sure to warm up >10mins before stretching any muscles.

o   Improper footwear – High heeled shoes and flip flops do not support your foot properly and could eventually cause Achilles injuries.