The Science of Back Pain

Back pain is a worldwide and personal problem. It is currently estimated over 85% of people will have back pain at some point in their lives. If you join that group with a back injury you have a 70% likelihood of reinjuring your back. Few topics in healthcare can be more controversial than back care depending upon your source of information. The spine is amazingly complicated and intricate in how it was created. And unfortunately, there is no automatic or "one size fits all" cure for back pain.

People frequently have progressive an more frequent episodes that can become dibilatating. This may lead to chronic pain and specialized techniques which we are also able to help them manage or cure.

What can I do with my back pain?

There are an infinite number of opinions and a wide variety of treatment options available to someone suffering from back pain. The problem is opinions won't necessarily help you heal and just because a particular treatment worked for one person doesn't mean it will work for you. The truth is most of the so called "treatments" promoted today are the modern day equivalents of the Wild West Snake Oil Salesman.

Many treatments may look effective but in reality time is a great healer. Many scientific studies known as randomized controlled trials (RCT's) have demonstrated that the pain symptoms with a back injury will start to go away in about 6-8 weeks. The true measurement of a back treatment's effectiveness is not just if your pain goes away but if your back pain comes back a few weeks or months later. For many people their pain symptoms clear up in about 6-8 weeks but that doesn't mean the problem is gone. These same type of studies show that many back pain sufferers have constant, recurrent problems month after month.

Research is the key: Randomized controlled trials (RCT's)

RCT's answer the question of: Is one treatment better than another?

So what is a back pain sufferer to do? Dealing with back pain is bad enough without having to get a degree in research to figure out what's really going to help and what isn't. This is where RCT's come in. These are the gold standard used in medicine to determine what works and what doesn't. The RCT offers the highest proof of effectiveness that a treatment really works. The information and treatment techniques used at Spine & Sport are supported by this type of research.

RCT's are at the heart of almost all medical research especially in the use of medications. You probably wouldn't want to use a medication unless it had been properly tested first. This brings up another interesting point with RCT's. There should be multiple RCT's done by different groups to give a treatment validity. Some examples of poor science are some of the recent weight loss drugs that have been discovered to have a number of bad side effects. These drugs had only a small number of RCT's supporting their use. They had not been studied thoroughly enough and the results were disastrous.

Unfortunately the same problem plagues people with back pain. For some reason, medical professionals will often promote a treatment for back pain without first properly demonstrating that it actually works. As a matter of fact there are hundreds of RCT's demonstrating that many common treatment methods DON'T WORK for the majority of people.

Muscles and back pain, the heart of the matter

This is where we will finally discuss the new science of back pain. You've been exposed to a little bit of research and now have an idea of how back pain treatments are scientifically proven to be effective. Let's apply that knowledge to some little known (and often neglected) muscles in your body: the multifidus and the transverse abdominus.

The focus on muscles in the treatment of back pain is nothing new. Hundreds of treatments such as massage, stretching, acupuncture and strengthening have all been used. Many times these do feel good and for many people these treatments provide temporary relief but the key word is temporary. The main problem is most of these treatments are focused on the wrong muscles. To better explain this let's look at some anatomy.

Three muscular layers of the back (there are a lot of moving parts back there!)

• Outer Layer: Erector spinae
• Middle Layer: multifidus, transverse abdominus, quadratus lumborum.
• Inner Layer: spine, discs, ligaments, joints

Many of the treatments people have tried for back pain have focused on the outer layer of muscles. Although these may be sore and there is often moderate to severe guarding or spasm this is often just a symptom of a deeper underlying problem. The focus on outer layer muscles for rehabilitation is why traditional back exercise programs have failed.

Surgeons have often focused their attention on the inner layers of the back. There are many surgical techniques to address problems in the inner layer discs, joints and the spine itself. Common procedures include:

• Discectomy, in which a portion of the disc is actually removed to remove pressure on a nerve.
• Laminectomy, in which a portion of bone is removed to create space and reduce pressure on a nerve.

Spinal fusion in which the disc is removed and the two vertebrae are fused together forming one bone. Currently there is significant controversy over new studies questioning the effectiveness of spinal fusion in terms of cost and relief of symptoms. There are also numerous studies looking at the long term effectiveness of spinal fusion vs. intense focused spinal exercises and they are finding both give similar long term results, although the specific exercise group cost is only a fraction of a spinal fusion.

Why do we care about these middle layer muscles?

In the past few years more and more research is demonstrating that the middle layer of muscles plays a significant role in low back pain. Numerous studies have demonstrated that the multifidus muscle goes into a state of "shock" immediately after a back injury. This muscle is of particular importance as it is one of the main stabilizers of the vertebrae in the spine. It is a highly active muscle used during almost every movement of the back.

The outer layer muscles are the "movers." These are the powerful muscles that actually move the spine and trunk. There are multiple multifidus muscles in many layers (as shown in picture) and they have two functions. One is to support the spine during all of the movements we do on a daily basis. The second is to detect movement and subtle changes in the spinal joints. This "position sense" which we call proprioception, is of utmost importance as it allows the nervous system to make ongoing adjustments in muscle tension which are necessary to stabilize and protect our spinal joints, discs and ligaments. This position sense is happening subconsciously in all of the joints of the body and is what allows us to have balance and move in a coordinated fashion.

The multifidus muscles allow for fine control of the spine which keeps the joints and bones moving properly. About two-thirds of the total stiffness that all the back muscles can provide for support through muscle contraction comes from the multifidus muscles. For many years the spine by itself was thought to be incredibly stable and strong but recent studies have demonstrated that the spine, although very mobile, is actually very weak. It can only support about 20 pounds before it collapses. Dynamic muscular support is of utmost importance. One can now see how a multifidus muscle not functioning properly can have great potential to cause back problems.

Studies have shown that the multifidus muscle will atrophy, or waste away, 25% within the first 24 hours of back pain. To make matters worse the multifidus does not recover on its own in most people. This has been difficult to explain until recently. Researchers discovered that the multifidus muscles have only 1 level of nerves (think of nerves like an electrical cord) coming from the spine. Most muscles in the body have multiple layers of nerve supply so if one is damaged another can compensate. This makes the multifidus more susceptible to injury because it has no backup.

Strengthen your stomach to help your back: another old wives tale bites the dust

The transverse abdominus also undergoes a similar "shock." Its purpose is to brace the trunk during movement. Everyone has heard the old adage "Strengthen your stomach to help your back." Although the advice had good intentions it is not entirely accurate.

Most people are not exercising the correct stomach muscle. The universal stomach strengthening exercise that most people think of is the "sit up" or "crunch." This works the rectus abdominus muscle, which may look good at the beach, but does not do a lot to support your back. As a matter of fact many people with back pain have tried this exercise only to find their back pain worsens. This is most likely due to having weak multifidus muscles which are not properly stabilizing the spine during the sit up exercise. This means the discs and joints of the spine are not supported properly and are undergoing excessive strain and stress.

Clinical Spinal Instability

(what's with all the fancy terms, all I know is my back hurts and I want it to go away!)

Now that we've discussed these particular muscles what does it all mean? The bottom line is this, research has shown with almost any back injury, regardless of how it happened, these muscles atrophy and do not work properly. This has been proven with herniated or bulging discs, during pregnancy, after back surgery, car accidents and any other way you can think of to hurt your back. This deterioration caused by loss of nerve control (neurological problem) combined with inability to keep the spine stable (mechanical problem) leads to what we term Clinical Spinal Instability. In summary nearly all back pain leads to three interrelated problems:

• Increased motion will develop at the spinal joints leading to increased wear and tear.
• At the same time, protective stabilizing muscles of the trunk's middle layer will fail to work correctly as the nervous system cannot properly activate them.
• Outer layer muscles are then substituted for the middle layer muscles in an attempt by the nervous system to provide some support at the injured area, this is commonly referred to as spasm.

Spine & Sport has the solution to your back pain (great, I was hoping you would get to the point eventually!!!!!!)

At this point you may be thinking exactly what hundreds of our patients have wondered before: "Great, I've learned a lot but what do I do now?" Let's start by telling you more about what doesn't work. Unfortunately we've discovered that the muscles we have been discussing, multifidus and transverse abdominus, do not get better on their own. As a matter of fact, once they've been injured they tend to get worse.

We've also discovered that most traditional exercise routines, even those taught by physical therapists, doctors and chiropractors are not specific enough to isolate and properly rehabilitate these muscles. The good news is they can be strengthened but it requires very specific. Some people have suggested that retraining these muscles is easy and can be done on your own. Simply put, it doesn't work.

The reality of the situation is these exercises are difficult to do correctly on your own and require the guidance and supervision of a properly trained Physical Therapist. It will be worth the time and effort spent as it is so much more effective then other treatment methods. The techniques and equipment to permanently rehabilitate your back is available exclusively at Spine & Sport

To read about some of our specific methods of treatment please click on the links below. But if you really want to understand how your back functions and how it can feel good again please call us or email us and schedule an appointment for an evaluation.

At Spine & Sport we treat many different types of hip pathologies. The hip is surrounded by large bones, muscle groups and ligaments that can lead to hip pain of multiple origins.

Bones
The hip joint is made up of two large bones: the pelvis and the femur (the thighbone). It is the largest ball-and-socket joint in your body. The "ball" is the rounded end of the femur called the femoral head. The "socket" is a concave depression in the pelvis called the acetabulum. The femoral head fits into the acetabulum to form the hip joint. This anatomy allows for a lot of motion within the joint yet provides great stability — for activities like walking, running, jumping and climbing.

The femoral head attaches by way of the femoral neck to the rest of the femur. At the top of the femur there is another bump on the outside of your hip called the greater trochanter. Many muscles attach at this location. Cartilage is a shock absorber and helps prevent friction between the femoral head and the acetabulum-- hip pain can occur if your cartilage begins to wear down or is damaged.

Muscles and Tendons
The motion of the ball-and-socket is controlled by several very powerful muscles which attach to the bones. The muscles you probably know the best are your “glutes” (gluteal muscles), the large, strong muscles that attach to the back of your hip bones, otherwise known as your “buttocks”.

The glutes attach to your greater trochanter; those muscles help hold your pelvis and your body up so you don’t fall over, they also help you walk. On top of that layer of muscle is the iliotibial band, which starts at the rim of your pelvis outside the hip joint and runs down the outside of your leg to the knee.

If the iliotibial band becomes too tight or overused, it can contribute to hip and knee pain. Some of the other muscles in the hip are:

• Adductor (or groin) on the inside of your thigh.
• Iliopsoas muscle, a hip flexor muscle that originates in the lumbar spine and attaches to the upper thigh bone.
• Rectus femoris muscle, one of the quadriceps muscles on the front of your thigh.

Muscles play an important role in the health and well-being of your hip. All these muscles work together to provide you with range of motion in your hip while keeping your body stable and upright. An underlying recommendation for preventing hip pain is to maintain flexibility and muscle tone.

Pain Sources
General causes of hip pain include:

• Muscle strain
• Bone fracture (such as a fracture of the femoral neck)
• Tendinitis
• Arthritis
• Bone spurs or other malformations of the hip

Physical therapists often see a lot of patients with bursitis of the hips. This condition is caused when bursae, small fluid-filled sacks that act as cushions where there is friction between muscles, bones, and tendons, become inflamed or damaged from injury.

One of the most common forms of bursitis is trochanteric bursitis (pain on the outside of your hip), but there are bursae in other parts of your hip as well. For example, there is one under the iliopsoas muscle in the front of your hip.

The hip is a complicated mechanism and therefore hip pain can originate in many different parts of the joint. Learning the anatomy of your hip will better enable you to pinpoint your pain and work with your therapist to keep it from limiting your life.

Arthritis is a frequent cause of hip pain and hip replacement. Yet the term arthritis actually covers a number of different conditions including osteoarthritis and rheumatoid arthritis.

Hip Pain and Osteoarthritis
The most common type of arthritis is osteoarthritis, the so-called ‘wear and tear arthritis’. Osteoarthritis is caused by the gradual wearing down of cartilage in a joint, which can lead to inflammation of joint lining. It can also be due to an injury to the joint, sometimes referred to as “traumatic arthritis.”

Risk factors for osteoarthritis include:

• Aging
• Obesity
• Damage or trauma to the joint
• Structural problems with the joint
• Having rheumatoid arthritis

Symptoms of osteoarthritis develop slowly, beginning with stiffness or soreness in your hip and eventually becoming painful enough to prevent you from doing normal activities, such as walking or climbing stairs. Working with your physical therapist to maximize your range of montion and strength can greatly reduce symptoms of osteoarthritis.

Look out for any of these symptoms:

• Pain in the inner thigh, buttock, or groin area
• Pain in your outer thigh down to your knee
• Tendency to limp

Hip Pain and Rheumatoid Arthritis
There are other conditions like rheumatoid arthritis in which inflammation rather than the wear and tear instigates pain. It may be an immune system response that causes the deterioration characteristic of this kind of joint pain, this is often seen at its most extreme in children who have juvenile rheumatoid arthritis.

The cause of RA is not fully understood, although researchers believe that an abnormal response of the body’s immune system contributes to the disease. Research also points to the possibility that RA’s cause lies in your genes or even infections. Symptoms of RA include:

• Pain developing in joints on both sides of the body, like the same knuckle on the right hand as on the left
• Swelling of the affected joints
• Tiredness
• Morning stiffness
• Soreness after sitting for a long time
• Weakness
• Muscle pain
• Anemia
• Unusual lumps, especially on elbows, called rheumatoid nodules

Early diagnosis of RA is critical to preserving your quality of life. Your physical therapist will coordinate care with your physician and together, along with you, protect the health of your joints.

Tendinitis occurs when a muscle is overused and irritates the tendon that attaches it to the bone. In your hip tendons perform an important role by keeping strong muscles attached to the femur (thigh bone) as your legs move.

One kind of tendinitis that occurs as a result of overuse is called iliopsoas tendinitis. The iliac muscle, which starts at your hip bone, and the psoas muscle, which starts in your lower spine, are used when lifting the leg toward the chest to keep you stable (this muscle is active in most activities). They come together in a tendon at the top of the femur, and that is the point where tendinitis occurs. Physical therapists will work with you to alleviate these symptoms and return the spring in your step.

Hip Pain and Tendinitis: Who Is at Risk
Damage is most likely to occur from an activity that requires repeatedly lifting the leg while turning it out at the hip, as in ballet or gymnastics. Athletes in sports that require a lot of high kicking or squatting and lifting weights may also put strain on this area.

This injury occurs often in hockey, soccer, football and track athletes, yet is seen consistently in occupations involving repetitive iifting.

This can also occur if you have a snapping hip, a condition in which the tendon repeatedly “pops” over a boney projection, gradually wearing down the tendon.

Hip Pain and Tendinitis: Symptoms
It is important to be as detailed as possible in describing your hip pain so your therapist can make an accurate diagnosis. You should make note of the activity or activities that trigger the pain, where the pain occurs in your body, and anything that you can do to relieve the pain (such as resting). In essence, knowing what makes the symptoms better or worse.

Tendinitis tends to feel sore in specific areas. Iliopsoas tendinitis causes pain in the front of your hip, and you may also experience some tenderness due to swelling in the area. The pain will increase gradually if left untreated, as your tendons continue to be worn. Make sure you talk to your therapist about a course of treatment for your tendinitis.

Hip Pain and Tendinitis: Treatment
Your therapist will work with you to:

• Stretch specific muscles of your hip for flexiblity
• Adjust activities to allow function yet remove irritation to the tendons
• Strengthen complementary muscle groups
• “release” tender spots in the muscle that may hinder your ability to heal otherwise
• create a return to sport/activity timeline and progression

Hip Pain and Tendinitis: Prevention
Athletes in all sports should warm up before leaping into hearty exercise. It is also important to enhance strength and flexibility of all the muscles in your hips and legs so that pressure is not isolated in any one spot.

Understanding how your muscles and tendons work together to keep your hips in motion can help you take care of your body and respond to hip pain before it progresses.

Knee Basics
At Spine & Sport we treat many different kinds of knee pathologies and injuries. Injuries can range from acute traumatic injuries to overuse injuries. The following information includes the anatomy of the knee and the multiple injuries that one may face.

a) Femur (femoral bone).
b) Medial femoral condyle.
c) Lateral femoral condyle.
d) Intercondylar fossa.
e) Tibia.
f) Lateral condyle of tibia.
g) Medial condyle of tibia.
h) Fibula.
i) Fibula, head.
1) lateral semilunar cartilage (meniscus).
2) medial semilunar cartilage (meniscus).
3) anterior cruciate ligament.
4) posterior cruciate ligament.
5) tibial collateral ligament.
6) head of fibula, capsular ligament.
7) Interosseous ligament of leg.

Ligament Injuries: Your knee contains four major ligaments (ligaments attach bone to bone), that connect your femur to your tibia and fibula. You have two collateral ligaments; one on the inside of your knee called you medial collateral ligament (MCL) and one on the outside called your lateral collateral ligament (LCL). The other two ligaments are inside you knee and cross each other as they stretch diagonally from the bottom of your femur to the top of your tibia. These ligaments are named the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). The most severe injury of these ligaments and the most common include the ACL, where reconstructive surgery and physical therapy is usually the most common course of treatment. The following are some signs and symptoms of ligament injuries.

• Immediate pain that worsens as you stand or try to walk
• A “popping” sound
• Inability to bear weight
• Feeling of buckling or giving way
• May have significant swelling

Tendon Injuries: Tendonitis is irritation and inflammation of one or more tendons. A tendon is what attaches the muscles to bones. Acute tendonitis or chronic tendonitis of the patellar tendon, which connects the quadriceps muscle on the front of the thigh to the tibia at the tibial tuberosity, may occur. Some of the signs and symptoms of tendonitis include:

• Pain in one or both knees
• Swelling in the front of the knee or just below the knee cap
• Worsening pain when you walk, jump, run or climb stairs
• Inability to completely extend or straighten your knee
• Pain initially, then improves with activity, and worsens at the end of activity

Meniscus Injuries: The meniscus is a piece of cartilage that curves within your knee joint that assists with shock absorption, gives joint contour and reduces bone to bone contact. The medial meniscus (inside portion of the knee) is larger and shaped like a C with the lateral meniscus being smaller and shaped more like an O. The outer 1/3 of the meniscus has proper blood flow, the middle 1/3 has 50/50 blood flow, and the inner 1/3 of the meniscus has poor blood flow. So, the healing effect of the tear will depend on the location of the tear. Meniscus injuries involve tears in the cartilage, which can occur in various places and configurations. Signs and symptoms of this type of injury include:

• Pain along the joint line
• Mild to moderate swelling that occurs slowly, as long as 36 hours after the injury
• Inability to straighten the knee completely
• May experience “clicking”, “catching”, or “locking” characteristics

Bursitis: Some knee injuries cause inflammation in the bursae, the small sacs of fluid that cushion the outside of your knee joint so that tendons and ligaments glide smoothly over the joint. Bursitis can lead to:

• Warmth, swelling, redness
• Pain even at rest
• Aching/stiffness with walking and considerable pain with kneeling or ascending/descending stairs
• Tender to touch

Iliotibial Band Syndrome: This occurs when the ligament that extends from the outside of our pelvic bone to the outside of your tibia (iliotibial band) becomes so tight that it rubs against the outer portion of your femur. Distance runners are especially susceptible to iliotibial band syndrome, which generally causes:

• A sharp burning discomfort usually along the outside of the knee and is usually present after a long distance run
• Pain that usually goes away with rest, but may return when commencing running again
• May have “snapping” along the outer knee
• Usually normal range of motion, but most likely loss of flexibility of muscles

Osteoarthritis: Sometimes called degenerative arthritis. This is the most common type of arthritis. It’s a wear and tear condition that occurs when the cartilage in your knee deteriorates with use and age. As bone continues to rub against bone a process of calcification occurs, this is where our body lays down additional bone, therefore causing arthritis to be present. Osteoarthritis usually develops gradually and tends to cause:

• Swelling
• Pain usually with standing or walking
• “Popping” sounds likely
• Loss of flexibility in the knee
• Stiffness

Chondromalacia of the patella, or patellofemoral pain: This is a general term that refers to pain arising between your patella and the underlying femur. It’s common in young adults, especially those who have a slight misalignment of the kneecap; in athletes; and in older adults, who usually develop the condition as a result of arthritis of the kneecap. Chondromalacia of the patella causes:

• Pain and tenderness in the front of the knee that worsens when you sit for long periods of time
• Pain with getting up from a chair
• Pain with ascending/descending stairs
• Grinding sensation may be present when extending your knee

Other knee pathologies may include, but not limited to: rheumatoid arthritis, loose bodies, hyper-extended knee, contusions, and muscle strains. In addition, please understand that many symptoms in the knee can be referred from your lumbar spine (low back). If you have any of these symptoms you may want to consider being evaluated by a medical provider who is knowledgeable in orthopedic conditions.

The joints of the lower leg, ankle, and foot act as a functional group and not necessarily isolated joints. The primary function of the ankle and foot is to distribute and decrease various forces acting on the body through contact of the foot and ankle with the ground. This becomes particularly evident with walking and running. The movement in each individual joint of the foot and ankle is minimal, but when combined, there is enough range of motion (ROM) in the complex to allow functional movement along with functional stability. Typically the foot is divided into rearfoot, midfoot, and forefoot. The rearfoot consists of the tibiofibular joint, talocrural (ankle) joint, and the subtalar joint. The rearfoot is primarly innervated by the peroneal and the tibial nerves. There are many supportive ligaments in the rearfoot, and there are many anatomy and functional anatomy texts available with full descriptions. The midfoot consists of all of the mid tarsal joints that allow collectively the foot to adapt to many positions without putting any undue stress on a specific joint or muscle/tendon group. The forefoot consists of all of the joints distal to the midfoot including tarsometatarsals (TMT), intermetatarsals (IMT), metatarsophalangeal (MTP), and interphalangeal (IP) joints.

Since a minimum of 80 percent of the general population has foot or ankle problems, a thorough history, examination, assessment, and treatment of the foot and ankle by your physical therapist will lead to correct diagnosis and intervention to return you to all activities in the most appropriate manner. Make the call to our office today!

The subcranial spine is made up of the base of the occiput, C1, or the atlas, and C2, or the axis. Right now, if you nod your head yes in an up-and-down direction, the majority of that motion should take place between the base of the skull and the atlas. If the motion does not take place here, it is passed down through the lower cervical spine. If you now shake your head no, if you do not agree, most of that motion should take place normally between C1 and C2. Over 50 percent of the motion typically takes place between C1 and C2, yet again, if it does not take place here, it is passed down to the (more angled at 45o) facet joints of the mid to lower cervical spine. Coupled movements are common in the subcranial spine with typically the atlas sliding to the opposite side of a rotation movement. Because of the coupled movements, complex ligamentous system, proximity of the throat and swallowing anterior, and the brain and brain stem with the spinal cord exiting the skull in the subcranial region, symptoms here can be focal, vague, or widespread. Injuries in the subcranial region can include headache, fatigue, dizziness, decreased concentration, elevated sympathetic nervous system, irritability, and symptoms not only in the upper extremities but also in the lower extremities. Frequently headaches due to poor posture and sustained muscular tension are frequently found in this area.

Physical therapists utilize many techniques including soft-tissue and joint mobilization; perhaps modalities of heat, cold, or ultrasound; trigger-point dry needling (TDN); postural retraining; spinal stabilization; and home exercise programs to address and improve all of the above.

The subcranial spine does interact with the head, the lower cervical spine, and really the entire body. To see if a subcranial fault is creating some of your symptoms or problems, call your physical therapist for an evaluation today!

Cervical spine
The cervical spine is the uppermost part of the spine, also called the neck. There are seven vertebrae within the cervical spine. They are numbered C1 to C7, from top to bottom. The first two vertebrae of the cervical spine are shaped differently from the rest and are specialized in their movements compared to the rest of the neck. A normal curve in the neck would be toward the front. This forward curve is called a lordotic curve.

Vertebrae (bone)
Each vertebra consists of the following parts.

• Body. The body is the front portion and the main weight-bearing structure of the vertebra with the spinal discs between the vertebra in this area.
• Spinous process is the rear portion of the vertebra. It is the bony ridge you can feel down your back.
• Laminae are two small plates of bone that join in the back of the vertebra.
• Pedicles are short, thick bumps that project backward from the upper part of the vertebral body.
• Transverse processes are the bony projections on either side of the vertebra where the laminae join the pedicles. Muscles and ligaments attach to the spine on the transverse processes.
• Facet joints are the spinal joints, with 2 at each level of the spine, one on the right and one on the left.

In the center of each vertebra is a large opening, called the spinal canal, through which the spinal cord and nerves pass. The vertebrae are held together by groups of ligaments, fibrous tissues that connect bone to bone.

Intervertebral discs
Intervertebral discs are flat, round cushioning pads that sit between the vertebrae (inter means "between" or "within") and act as shock absorbers. Each intervertebral disc is made of very strong tissue, with a soft, gel-like center, called the nucleus pulposus, surrounded by a tough outer layer called the annulus. When a disc changes shape, usually through unusual of sustained pressures, some of the soft nucleus pulposus may bulge or even protrude through a tear in the annulus. This bulging of the nucleus pulposus can result in pain from the disc itself and if further bulging occurs, pressure a nerve root causing other symptoms such as numbness, tingling, weakness burning, and others.

Facet joints
A joint is the area where two or more bones connect. Joints allow for movement, since bones themselves are too hard to bend without being damaged. Facet joints are the specialized joints that connect the vertebrae. The facet joints allow the vertebrae to move against each other, providing stability and flexibility. These joints allow us to twist, to bend forward and backward and from side to side.

Each vertebra has two sets of facet joints. One pair faces upward to connect with the vertebra above and the other pair faces downward to join with the vertebra below.

Nerves
The spinal cord, the column of nerve fibers responsible for sending and receiving messages from the brain, runs through the spinal canal. It is through the spinal cord and its branching nerves that the brain influences the rest of the body, controlling movement and organ function.

As the spinal cord runs through the spinal canal, it branches off into 31 pairs of nerve roots, which then branch out into nerves that travel to the rest of the body. The nerve roots leave the spinal cord through openings called foramen, which are found between the vertebrae at each level on both sides of the spine. The nerves of the cervical spine control the upper chest and arms. The nerves of the thoracic spine control the chest and abdomen, and the nerves of the lumbar spine control the legs, bowel, and bladder.

Trigger Points
Trigger points are dysfunctional areas of muscle that occur in response to any irritation of the muscle or in reaction to a pain stimulus from a different problem. As the area of the muscle contracts in response to the irritant, the tension in the muscle during contraction compresses the blood vessels that run through the area limiting the flow of blood (and therefore oxygen, nutrition etc). This results in an increase in inflammation and further irritation of the tissue. Increased pain and other symptoms are the result including referred symptoms to distant areas of the body. Trigger points occur in all areas of the body and spread to adjacent muscles over time if not properly diagnosed and treated.

Referred Symptoms
Referred symptoms from muscles occur frequently and often include pain, numbness, tingling, pressure, burning, weakness, and others. These muscular symptoms are sometimes incorrectly assumed to be nerve entrapments or irritations leaving the patient with a poor outcome in their treatment. The literature reports many modern diagnoses that are often used that in reality are sometimes a trigger point problem including arthritis, tendonitis, bursitis, herniated disc, plantar fasciitis, carpal tunnel syndrome, thoracic outlet syndrome, migraine headaches, fibromyalgia, and others. When the trigger point problem is properly diagnosed and the appropriate releases performed, patients typically recover regardless of the duration of the pain or dysfunction. If the trigger points are not properly released, attempts at stretching or strengthening often fail and result in increased pain as the tissue cannot stretch or contract to perform the activity.

As we consider a cervical (neck) problem, the upper back and upper extremities are included as areas of referral are often involved. For example, shoulder, arm, and hand problems often involve problems more centrally located in the spine or shoulder blade areas. Headaches are often a result of a problem in the upper back or neck areas. For these reasons the level of experience of the therapist if vital. At Spine and Sport Physical Therapy, our therapists are experienced and certified in orthopedic techniques to insure you the best possible outcome and return you to the lifestyle you desire.

Shoulder Blade
The scapula, or shoulder blade, is the anchoring sitefor many muscles including those of the rotator cuff. It serves as the platform of the ball and socket (glenohumeral) joint of the shoulder. As upper arm bone, or humerus, lifts, the scapula must move through a coordinated pattern to both support and assist the arm. If this rhythm is off, shoulder pain, impingement syndrome, and upper back pain can be a result. This is often treated in physical therapy by identifying faulty movement patterns and restoring optimal motion through selective stretching, strengthening, and postural exercises. See your Spine & Sport therapists to help your scapula and shoulder joint be happy and healthy!

Frozen Shoulder
Adhesive capsulitis, or frozen shoulder, is a condition involving extreme stiffness of the ball and socket joint of the shoulder. While it is not a common condition, it can affect anyone, typically those between the ages of 40-60. Symptoms include a progressive loss of shoulder range of motion and increased shoulder irritability and pain. There is a possible connection between frozen shoulder and other medical conditions such as diabetes and thyroid disorders, but it can also occur after lengthy immobilization of the shoulder, an injury, or surgery. Physical therapy can be beneficial for reduction in pain and to increase mobility in the joint through stretching and mobilization techniques. Let the therapists at Spine & Sport get your shoulder back in motion and you back to your life!

Arthritis
Arthritis,is a progressive degenerative process that occurs as a result of wear and tear to a joint. Normal activity can result in arthritis later in life, and injury can hasten the process. While arthritis itself cannot be reversed without joint replacement surgery, physical therapy can help increase mobility in the joint and improve your strength and function. The therapists at Spine & Sport will be happy to help you restore motion and strength in your shoulders!

Other Conditions
Various muscular strains and tears, shoulder instability or dislocations, postural syndromes, as well as referred pain from the back or neck can all cause shoulder pain and/or dysfunction. A thorough evaluation, as done by the therapists at Spine & Sport, can determine the source of your symptoms and help restore optimal function.

Basics
The shoulder is commonly regarded as the most versatile joint in the body. It has a high degree of mobility in multiple directions which allow humans to complete a vast array of movements. However, the shoulder sacrifices stability in order to gain mobility, thus making it prone to injury. The ball and socket joint of the shoulder is not very stable, picture a golf ball sitting on a golf tee. The high demands placed on the shoulder in various activities such as sports, heavy lifting or vibration encounter in many trades, or repetitive motions such as on an assembly line or with computer work, are all risk factors for acquiring a shoulder injury. The full shoulder “girdle” is a complex structure composed of at least 3 major bones, more than a dozen muscles, as well as blood vessels, nerves, and connective tissues. All of these components must be functioning well in order for the system to work.

Rotator Cuff
This commonly-affect structure is a group of four small muscles that originate on the shoulder blade (scapula) and whose tendons form a supporting “cuff” for the ball and socket (glenohumeral) joint of the shoulder. The supraspinatus originates from the top of the shoulder blade, the infraspinatus and teres minor start on the back of the shoulder blade, and the subscapularis originates from the undersurface of the shoulder blade.

These muscles, most often the supraspinatus, can become damaged due to trauma, overuse, or due to individual differences in shoulder structure. The early stage of injury is often known as “impingement syndrome.” This is when the tendons are getting pinched between bones during movement. Typically, this has the same effect as a rope rubbing over a rough edge for an extended period: eventually the rope shreds and tears!

Pain with lifting your arm above your shoulder or with lying on the shoulder, as well as a sense of “looseness” in the shoulder can all be signs of a rotator cuff problem.

Physical therapy can benefit the health of the rotator cuff both as a preventative measure and following a surgical repair. Restoring healthy movement patterns between the scapula and the shoulder joint, balancing out muscle tension and strength, stretching tight structures, and posture re-education are all ways Spine & Sport therapists can help get you off of the sidelines and back in the game of life!

The elbow is a complex set of joints made up of predominantly the ulnohumeral or trochlear joint, the radiohumeral joint, and the radioulnar joint. The elbow is frequently an area that is particularly influenced by the art of physical therapy. The treatments are typically geared toward the pathology or the condition of the elbow because the joint can respond poorly to trauma, or incorrect or harsh treatment.

The elbow joints themselves work together to functionally position the hand with the elbow bending up and down (flexion and extension) and rotating the hand in what is called pronation and supination. The primary goal of physical therapy initially is to gain back full extension of the elbow as soon as possible with techniques including stretching, contract/relax, and use of modalities including heat, ice, and ultrasound. Joint manipulation and soft-tissue mobilization are also utilized appropriately around the elbow. Frequent problems around the elbow include lateral epicondylitis, (tennis elbow); medial epicondylitis, (golfer's elbow); and occasionally nerve entrapments including the ulnar, median, and radial nerves as they innervate the hand. Any sensory, motor, or functional use problem of the elbow, wrist, and hand can be thoroughly evaluated, treated, or referred appropriately by your physical therapist. Call us now to set up an appointment for an initial evaluation or a screen.

Both of our forearms, wrists, and hands can be considered the most active and intricate parts of our bodies with the daily work they do. They are vulnerable to injury which can impact function long term, as they do not respond well to serious trauma. There are 28 bones, many articulations, and 19 intrinsic with 20 extrinsic muscles of the wrist and hand. This combination provides a tremendous variability of movement and function. The hand functionally is an expressive organ we use for nonverbal communication, and it frequently senses our surroundings in both a motor and sensory roll while acting in a protective roll. They frequently provide information to temperature, thickness, depth, width, shape, and sensory input or motion of objects. As physical therapists, we would have a very difficult time without our hands in examining and feeling in our occupation. The joints, muscles, ligaments, and nerves function as a group, and they do not act in isolation. Each joint depends on balanced forces on all sides of it for proper positioning and control. If the balance is not present due to injury or for some other reason, the loss of counterbalancing forces can result in deformities that can be very obvious. As a functional kinetic chain the shoulder, elbow, and wrist joints allow the hand to be placed on nearly any area of the body.

Basic anatomical findings in the forearm include the radius and the ulna which link to the eight carpal bones of the wrist. In general, there are four carpal bones in the proximal wrist and four in the distal wrist. The capitate is the major fulcrum and larges bone of the wrist. From the distal carpals, we go into the metacarpal region which includes the first metacarpal that allows most of our unique oppositional movements as humans.

At Spine & Sport, we work with many common hand and finger injuries, deformities, and functional problems. We do see post-surgical cases of muscle and tendon injuries. This does include some basic splinting with full, comprehensive rehabilitation and return of motion, strength, and function. For complex splinting, we do refer appropriately to our certified hand therapist colleagues. In fact, we are always looking for great professionals, and a certified hand therapist could be a welcome addition to our team.

The thoracic spine is identified as the area between the cervical and lumbar spines consisting of two paired ribs from each of 12 thoracic vertebra segments. Ribs one, 10, 11, and 12 articulate with a single vertebra, and rights two through nine articulate with the two adjacent vertebra and intervening vertebral disc of the adjacent vertebra. Ribs one through 10 also have costotransverse joints with are synovial joints found between the ribs in the transverse processes of the vertebra of that level. Anteriorly the costochondral joints are between the ribs and the costal cartilage. Ribs joints two through six are synovial, but the first costal cartilage is united with the sternum in what is called a synchondrosis.

In the thoracic spine, two facet joints on each segment make up the primary tri-joint complex along with the disc between the vertebrae. With these 12 vertebrae and their 12 ribs, the thoracic spine is predominantly stable and can become hypomobile or hypermobile. Motion assessment by your physical therapist with active and passive movements is necessary in differentiating motion problems of the thoracic spine. Due to the 12 vertebrae, even an increase of one or two degrees of movement, each one can yield a 10o-20o improvement in the case of hypomobile segments. Many direct and indirect soft-tissue and joint manipulations and mobilizations can be used in the thoracic region, as it is a highly stable area. Increasing movement in the thoracic spine can decrease stress on the lumbar and cervical spines which tend to be more mobile areas. In particular the transitional zones between the cervicothoracic (C/T) junction and the thoracolumbar (T/L) junction can be areas of fault and very important in effective treatment and outcomes for patients. Where there is a specific sproblem with the thoracic spine or utilizing the thoracic spine you can call your physical therapist today.

Technically the abdomen is the part of the body between the pelvis and the thorax in the front and the sides of the body. Anatomically the abdomen stretches from the thoraic diaphragm to the pelvis at the pelvic brim or iliac crest. The pelvic rim runs from the intervertebral discs between L5 and S1 anteriorly to the pubic symphysis at the edge of the pelvic inlet. The region between the pelvic inlet and the thoracic diaphragm is the abdominal cavity which contains the majority of the vital organs including the liver, kidneys, spleen, and pancreas along with the alimentary tract which is predominantly for nutritional absorption and digestion of food and ridding of post-consumer waste. In the scope of neuromusculoskeletal physical therapy, we will talk predominantly about the muscular components of the abdomen which include the tranversus abdominus, rectus abdominus, and the pyramidalis muscle.

The transversus abdominus lays anterior and lateral in the abdominal wall which is deep to the internal oblique muscle. It may be considered a major muscle of the functional core or core of the human body, but in reality it functions with the remainder of the muscles across the entire abdominal sheath including the internal/external obliques and the effects of the latissimus dorsi along with the thoracolumbar fascia.

For movement and health, it is the function of all of these muscle groups from the posterior or dorsal spine along with the abdomen working together the thorax and the pelvis to be successful with movement and function. Physical therapists have the training and expertise to adequately test and diagnose problems in the core region. Likewise they have techniques including soft-tissue mobilization and releases, trigger-point dry needling (TDN), proprioceptive neuromuscular facilitation (PNF) techniques, and many other techniques not only to treat this region but to follow up with independent home exercise programs to develop, maintain, and exceed to prevent future problems in this region. Exercising abdominal muscles is very important to contribute to proper posture, balance, and support while decreasing potential for back pain. Movement disciplines such as pilates, yoga, Tai Chi, and jogging can be utilized as prevention for those without symptoms. However, before utilizing any gym equipment or outside forces, the individual needs to be able to move and lift their own body weight. Specific exercises could include front and side planks, knees to forearm or full length. Have you been instructed in how to properly do an abdominal lift versus a sit-up? Guess what, sit-ups can hurt your back. Call your physical therapist today.

The two illia (look kind of like elephant ears) come together posteriorly at the sacrum and anteriorly at the pubic symphysis. The sacroiliac (SI) joints posteriorly can be considered the "key" as the forces of locomotion and transfer of weight from the spine to the lower limbs to provide elasticity to the pelvic ring. These joints buffer the forces and jars to the spine in the upper body that can be caused as the lower limbs strike the ground. This shock-absorbent function and energy transfer system of the SI and pubic symphysis depend on the joints being predominantly stable, yet there is a degree of mobility in pelvic function with activities such as gymnastics, and they obviously need to move and open for childbirth. In general, mobility is relatively high in young people through the SI joints and pelvis, and can decrease mobility with progressive stiffness upon aging. The stability inherent in the joints and pelvis is largely through several strong and supportive ligaments including posterior SI ligaments, interosseus ligaments, and anterior SI ligament. Sacrotuberous ligaments and sacrospinous ligaments typically limit anterior and posterior movement of the sacrum and pelvis relative to the fixed versus the moving segment.

The muscle systems around the pelvis actively stabilize the joints and contribute to load transfer and shock absorption during gait and pelvic rotational activities with the largest muscles in the body. The muscles can be supported into an inner group, primarily of deep muscles, and an outer group with four subgroups that act primarily in crossing or diagonal patterns of force in pelvic stabilization. The inner group consists of the deep muscles of the tranverse abdominus, diaphragm, multifidus, and pelvic floor musculature. The outer group consists of the deep longitudinal system, superficial posterior oblique system, anterior oblique system, and lateral system. The deep longitudinal system is made up of the erector spinae, thoracolumbar fascia, and the hamstring muscles along with their continued functional attachments through the sacrotuberous ligament. The superficial posterior oblique system includes the latissimus dorsi, glute max, and the intermingled thoracolumbar fascia. The anterior oblique system includes the internal and external obliques, contralateral adductors, and the abdominal fascia that is between. The lateral system consists of the glute medius and minimus and the contralateral adductors.

As always, the initial physical therapy examination includes many tests and measures that look for clusters of symptoms to fully diagnose the movement dysfunction that may be occurring in the pelvis, hips, low back, or lower extremities. There is still a significant art to the diagnosis and treatment of pelvic dysfunction, as there are not a lot of tests that have a high reliability of validity, specificity, and/or sensitivity in the current literature. However, many times clusters of diagnostic tests coupled with subjective history and examination findings including muscular tone and various tests and measures will result in appropriate diagnosis, treatment, and intervention with a thorough home exercise program to correct, discourage recurrence and/or to provide preventative measures. Typically thorough examination and clinical treatment intervention with home exercise can be sufficient for the majority of pelvic dysfunction. Diagnostic tests and further workup can yield important information for things that do not resolve within a 2-4 week period of time. Call today for an appointment with your physical therapist if you need to have your pelvis evaluated. As always, you can talk with our client-patient services on all the details.