Because headaches are so common, some people think that getting a headache is just a normal part of life! We have numerous who say, "Oh, I only have the usual headaches... nothing serious, I just take Tylenol or Advil."

Headaches are a sign that something's wrong and chiropractic treatment can be very effective in treating many types of headaches. It is estimated that 20 to 30 percent of adults have more than one episode of tension-type headache a month. Over 17 percent of those with frequent headache meet diagnostic criteria for cervicogenic headache. Headaches result in a significant number of missed work days each year and can have an untold negative impact on the personal lives of headaches sufferers.

A frequent and overlooked cause of headaches is malfunction of the spinal bones in the neck and upper back. When bones of the spine lose their normal position or motion, sensitive nerves and blood vessels to the head can be affected. When spinal nerves and related tissues are stretched or irritated, they can produce throbbing headaches. Aspirin and medications may cover up these warning signs, but do not correct the underlying structural cause.

Migraine vs. Tension Type Headaches There are differences in migraine headaches and tension-type headaches. Migraine headaches are usually severe and sharp, throbbing in nature, and generally affect one side of the head. Tension headaches tend to occur frequently, last a long time and are characterized by a dull, steady pain that feels like a band of pressure around the neck. But despite these differences they are closely related. Chiropractic care has been proven to be extremely effective in treating migraine and tension headaches as well as neck pain and stiffness.

Recent studies link headaches to nerve irritation. One study, conducted at the University of Maryland, found a connection between muscle tension at the base of the neck and headaches. Muscle contractions interfere with the sensitive fibers at the base of the neck that lead to the brain and spinal cord. This muscle tension often plays a contributing factor to headache pain. Another study conducted by Dr. Wright found that the vast majority of migraine headache sufferers have misalignments or joint dysfunction of the spinal vertebrae in the neck that can irritate the spinal nerves.

Neck pain is a common reason people visit their doctor. Neck pain typically doesn't start from a single injury. Instead, the problem usually develops over time from the stress and strain of daily activities. Eventually, the parts of the spine begin to degenerate. The degeneration can become a source of neck pain.

Chiropractic Treatment
Many of the pain-sensing nerves of the spine are in the facet joints, the two interlocking "fingers" at the back of each spinal bone. The normally smooth surfaces on which these joints glide, can become rough, irritated, and inflamed. If you have a joint that doesn't move properly, it maybe "stuck", or the tone of the muscle surrounding the joint may be extremely high. The body tries to prevent normal motion of the joints by having the muscles around the area tighten or even spasm. The chiropractic approach is to help restore a more normal motion and position of affected spinal joints and bones by specific chiropractic adjustments or manipulation. This is often combined with ice, traction, soft tissue massage, electrical muscle stimulation, ultrasound, traction, exercise and stretching. Please see the treatments section for descriptions of each of these procedures.

Often, wear and tear on the parts of the neck is the culprit behind neck pain. For years, this process may not cause any pain. Slowly, as the disc starts collapse, the space between the vertebra narrows and the joints become inflamed. Bone spurs can often develop as the body tries to protect itself in an attempt to stabilize and support the area. Specific chiropractic adjustments can help prevent this from occurring and maintain the normal motion of the joints.

Why do I have neck pain?
There are many causes of neck pain. Doctors are not always able to pinpoint the source of a patient's pain. Your doctor will make every effort to ensure that your symptoms are not from a serious medical cause, such as cancer or a spinal infection. Below is a brief overview of some of the most common causes of neck pain.

Spondylosis
Most neck problems happen after years of wear and tear on the parts of the cervical spine. At first, these small injuries are not painful. But over time they can add up. Eventually they begin to cause neck pain.

Degenerative Disc Disease
The normal aging process involves changes within the intervertebral discs. Repeated stresses and strains weaken the connective tissues that make up a disc. Over time, the nucleus in the center of the disc dries out. When this happens, it loses some of its ability to absorb shock. The annulus also weakens and develops small cracks and tears.

If you are concerned about your neck, please do not hesitate to call us 781-933-5051 so that we can determine if it's time to visit our practice.

Neck pain has many causes. Mechanical neck pain comes from injury or inflammation in the soft tissues of the neck. This is much different and less concerning than symptoms that come from pressure on the nerve roots as they exit the spinal column. People sometimes refer to this problem as a "pinched nerve." Health providers call it cervical radiculopathy.

Cervical radiculopathy is caused by any condition that puts pressure on the nerves where they leave the spinal column. This is much different than mechanical neck pain. Mechanical neck pain is caused by injury or inflammation in the soft tissues of the neck--the disc, the facet joints, the ligaments, or the muscles of the neck.

The symptoms from cervical radiculopathy are from pressure on an irritated nerve. These symptoms are not the same as those that come from mechanical neck pain. Mechanical neck pain usually starts in the neck and may spread to include the upper back or shoulder. It rarely extends below the shoulder. Headaches are also a common complaint of both radiculopathy and mechanical neck pain.

The chiropractic approach is to help restore a more normal motion and position of affected spinal joints and bones by specific chiropractic adjustments or manipulation. This is often combined with ice, traction, soft tissue massage, electrical muscle stimulation, ultrasound, traction, exercise and stretching. Please see the treatments section for descriptions of each of these procedures. We do not always adjust or manipulate the spine in the presence of certain disc and nerve problems in the neck. Depending on your exam findings, more conservative techniques can sometimes be used. Traction can help de-compress the pressure on the discs of your neck. Sometimes, keeping the neck still for a couple of days can help calm the irritated nerves. This is prescribed only when clinically indicated and you should not start wearing a collar prior to being examined by one of the chiropractic doctors. Wearing the collar longer than a couple of days can actually slow the healing process and prolong disability. Electrical muscle stimulation and ice are commonly used to help reduce the inflammation in the muscles and nerves. A thorough exam and history will help in identifying the appropriate treatment for you.

If you are concerned about your arm, please do not hesitate to call us 781-933-5051 so that we can determine if it's time to visit our practice.

The spinal cord is a column of nerve tissue protected by a bony tube in the spinal column. Conditions that narrow the space in this tube put the spinal cord at risk of getting squeezed. This narrowing is called spinal stenosis. Pressure against the spinal cord as a result of spinal stenosis causes myelopathy, a condition that demands medical attention. Myelopathy can cause problems with the bowels and bladder, change the way you walk, and affect your ability to use your fingers and hands.

The bony spinal canal normally has more than enough room for the spinal cord. Typically, the canal is seventeen to eighteen millimeters around, slightly less than the size of a penny. Spinal stenosis occurs when the canal narrows to thirteen millimeters or less. When the size drops to ten millimeters, severe symptoms of myelopathy occur. The symptoms of myelopathy result from pressure against the spinal cord and reduced blood supply in the spinal cord as a result of the pressure.

Cervical spinal stenosis is a serious condition often seen by chiropractors. Treatment is geared toward reducing the inflammation and decreasing pain. Electrical muscle stimulation and ice can calm muscle spasm and pain. Traction can gentle stretch the muscles and decompress the discs in your neck. This usually feels very good. Certain exercises and stretches have been designed to help open the spinal canal, and these will be explained to you by your chiropractic doctor. Ultrasound and heat can also be used. If the condition is severe, referral to a neuro-surgeon or pain clinic may be warranted. Chiropractors are well trained when to refer such cases.

Introduction

The shoulder is a very complex piece of machinery. Its elegant design gives the shoulder joint great range of motion, but not much stability. As long as all the parts are in good working order, the shoulder can move freely and painlessly.

Many people refer to any pain in the shoulder as bursitis. The term bursitis really only means that the part of the shoulder called the bursa is inflamed. Tendonitis is when a tendon gets inflamed. This can be another source of pain in the shoulder. Many different problems can cause inflammation of the bursa or tendons. Impingement syndrome is one of those problems. Impingement syndrome occurs when the rotator cuff tendons rub against the roof of the shoulder, the acromion.

Causes

Why do I have problems with shoulder impingement? Usually, there is enough room between the acromion and the rotator cuff so that the tendons slide easily underneath the acromion as the arm is raised. But each time you raise your arm, there is a bit of rubbing or pinching on the tendons and the bursa. This rubbing or pinching action is called impingement. Impingement occurs to some degree in everyone's shoulder. Day-to-day activities that involve using the arm above shoulder level cause some impingement. Usually it doesn't lead to any prolonged pain. But continuously working with the arms raised overhead, repeated throwing activities, or other repetitive actions of the shoulder can cause impingement to become a problem. Impingement becomes a problem when it causes irritation or damage to the rotator cuff tendons.

Raising the arm tends to force the humerus against the edge of the acromion. With overuse, this can cause irritation and swelling of the bursa. If any other condition decreases the amount of space between the acromion and the rotator cuff tendons, the impingement may get worse. Bone spurs can reduce the space available for the bursa and tendons to move under the acromion. Bone spurs are bony points. They are commonly caused by wear and tear of the joint between the collarbone and the scapula, called the acromioclavicular (AC) joint. The AC joint is directly above the bursa and rotator cuff tendons. In some people, the space is too small because the acromion is oddly sized. In these people, the acromion tilts too far down, reducing the space between it and the rotator cuff.

Symptoms

What does impingement syndrome feel like? Impingement syndrome causes generalized shoulder aches in the condition's early stages. It also causes pain when raising the arm out to the side or in front of the body. Most patients complain that the pain makes it difficult for them to sleep, especially when they roll onto the affected shoulder.

A reliable sign of impingement syndrome is a sharp pain when you try to reach into your back pocket. As the condition worsens, the discomfort increases. The joint may become stiffer. Sometimes a catching sensation is felt when you lower your arm. Weakness and inability to raise the arm may indicate that the rotator cuff tendons are actually torn.

Treatment

Nonsurgical Treatment Your doctor may also prescribe sessions with a physical or occupational therapist. Your therapist will use various treatments to calm inflammation, including heat and ice. Therapists use hands-on treatments and stretching to help restore full shoulder range of motion. Improving strength and coordination in the rotator cuff and shoulder blade muscles lets the humerus move in the socket without pinching the tendons or bursa under the acromion. You may need therapy treatments for four to six weeks before you get full shoulder motion and function back.

Surgery The goal of surgery is to increase the space between the acromion and the rotator cuff tendons. Taking pressure off the tissues under the acromion is called subacromial decompression. The surgeon must first remove any bone spurs under the acromion that are rubbing on the rotator cuff tendons and the bursa. Usually the surgeon also removes a small part of the acromion to give the tendons even more space. In patients who have a downward tilt of the acromion, more of the bone may need to be removed. Surgically cutting and shaping the acromion is called acromioplasty. It gives the surgeon another step to get pressure off (decompress) the tissues between the humerus and the acromion. Please consult your doctor before making a decision.

Introduction

The rotator cuff tendons are key to the healthy functioning of the shoulder. They are subject to a lot of wear and tear, or degeneration, as we use our arms. Tearing of the rotator cuff tendons is an especially painful injury. A torn rotator cuff creates a very weak shoulder. Most of the time patients with torn rotator cuffs are in late middle age. But rotator cuffs tears can happen at any age.

Chiropractic Treatment
Your chiropractic doctor's first goal will be to help control your pain and inflammation. At first, treatments, such as electrical muscle stimulation, ultrasound, heat and ice, focus on easing pain and inflammation. Hands-on treatments and various types of exercises are used to improve the range of motion in your shoulder and the nearby joints and muscles. Gentle joint mobilizations and adjustments are performed to help restore normal biomechanics to the shoulder joint. This is where chiropractic manipulation has an advantage over other specialties. It is important to manipulate and stretch capsular joint restrictions during the treatment phase. Additionally, spinal manipulation to the spine can help remove any joint fixations that can inhibit normal healing and proper motion to the shoulder. Advanced muscle massage and release techniques are used to help restore normal length and elasticity to the muscles, ligaments and tendons. It can also help break down scar tissue and adhesions which in and around the joint and associated soft tissues.

Later, you will do strengthening exercises to improve the strength and control of the rotator cuff and shoulder blade muscles. Your chiropractor will help you retrain these muscles to keep the ball of the humerus in the socket. This will help your shoulder move smoothly during all of your activities. Even if you don't need surgery, you may need to follow a program of rehabilitation exercises set forth by your chiropractic doctor. We will create an individualized program to help you regain shoulder function. This includes tips and exercise for improving posture and shoulder alignment. It is also very important to improve the strength and coordination in the rotator cuff and shoulder blade muscles. Your chiropractor can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems.

Causes
What causes the rotator cuff to tear? The rotator cuff tendons have areas of very low blood supply. The more blood supply a tissue has, the better and faster it can repair and maintain itself. The areas of poor blood supply in the rotator cuff make these tendons especially vulnerable to degeneration from aging. The degeneration of aging helps explain why the rotator cuff tear is such a common injury later in life. Rotator cuff tears usually occur in areas of the tendon that had low blood supply to begin with and then were further weakened by degeneration.

Excessive force can tear weak rotator cuff tendons. This force can come from trying to catch a heavy falling object or lifting an extremely heavy object with the arm extended. The force can also be from a fall directly onto the shoulder. Sometimes injuries that tear the rotator cuff are painful, but sometimes they aren't. Researchers estimate that up to 40 percent of people may have a mild rotator cuff tear without even knowing it.

The typical patient with a rotator cuff tear is in late middle age and has had problems with the shoulder for some time. This patient then lifts a load or suffers an injury that tears the tendon. After the injury, the patient is unable to raise the arm. However, these injuries also occur in young people. Overuse or injury at any age can cause rotator cuff tears.

Symptoms
What does a rotator cuff tear feel like? Rotator cuff tears cause pain and weakness in the affected shoulder. In some cases, a rotator cuff may tear only partially. The shoulder may be painful, but you can still move the arm in a normal range of motion. In general, the larger the tear, the more weakness it causes. In other cases, the rotator cuff tendons completely rupture. A complete tear makes it impossible to move the arm in a normal range of motion. It is usually impossible to raise the arm away from your side by yourself. Most rotator cuff tears cause a vague pain in the shoulder area. They may also cause a "catching" sensation when you move your arm. Most people say they can't sleep on the affected side due to the pain.

If you are concerned about your shoulder, please do not hesitate to call us 781-933-5051 so that we can determine if it's time to visit our practice.

Introduction

Thoracic outlet syndrome (TOS) can cause pain and numbness in the shoulder, arm, and hand. Testing for TOS is difficult. There is no one test to accurately diagnose TOS, and other conditions can have similar symptoms. You will need to go through several tests to find out if TOS is actually the cause of your pain. Making the right diagnosis often takes time and can be a cause of frustration--for both you and your doctor.

Causes
What causes TOS problems? The main cause of TOS is that the nerves and blood vessels going to the arm and hand get squeezed near the thoracic outlet. This can occur for many reasons. Pressure on nerves and vessels can happen in people who have fractured their clavicle. It can also happen in people who have an extra first rib, although this doesn't always result in TOS. Extra muscle or scar tissues in the scalene muscles can put extra pressure on the nerves and arteries. Heavy lifting and carrying can bulk up the scalenus muscles to the point where the nerve and arteries get squeezed.

Traumatic injury from a car accident can also cause problems that lead to TOS. In an accident, the shoulder harness of the seat belt can strain or tear the muscles. As they heal, scar tissue can build up, putting pressure on the nerves and blood vessels at the thoracic outlet. Neck and arm positions used at work and home may contribute to TOS. People who have to hold their neck and shoulders in awkward alignment sometimes develop TOS symptoms. TOS symptoms are also reported by people who have to hold their arms up or out for long periods of time. People with TOS often slouch their shoulders, giving them a "drooped" appearance. The poor body alignment of slouching can compress the nerves and arteries near the thoracic outlet. Being overweight can cause problems with posture, and women who have very large breasts may also use a "droopy" posture. For some reason, TOS affects three times as many women as men.

Symptoms
What problems does TOS cause? TOS causes pain along the top of the clavicle and shoulder. The pain may spread along the inside edge of the arm. Occasionally pain spreads into the hand, mostly into the ring and pinky fingers. Numbness and tingling, called paresthesia, may accompany the pain, especially in the early hours of the morning before it's time to wake up. Symptoms tend to get worse when driving, lifting, carrying, and writing. The arms may also feel tired when held overhead, as when using a blow dryer. It may be harder to hold and grip things, and the hand may feel clumsy.

Symptoms related to the blood vessels are less common. If the blood vessels are causing symptoms, the arm and shoulder may feel heavy and cold. The arm may become somewhat blue (cyanosis), and the constriction of vessels can cause the arm and hand to swell. Problems with the blood vessels that go to the arm are serious. If you experience these symptoms, you should call your doctor right away. TOS symptoms are similar to the symptoms of many other conditions. A herniated disc in the neck, carpal tunnel syndrome in the hand, and bursitis of the shoulder can all cause symptoms very much like those of TOS.

Treatment
Chiropractic doctors will examine and palpate the function and mobility of the first rib and vertebra in the neck to make sure that they are moving properly. Often, if the rib moves upwards or becomes fixated, it can compress the nerves, arteries and veins causing numbness, tingling or pain into the arm. The musculature, such as the anterior scalenes can become overactive an also press on these pain sensitive structures causing the symptoms of TOS. By correcting any functional problems with the ribs and stretching the tightened muscles, the cause of the problem can be eliminated. A home exercise program is essential to the treatment of TOS. This is true even if the cause of your TOS is an abnormality in the bones and muscles. You must consistently do your exercises to get the most benefits.

Chiropractic treatments may begin with exercises to loosen up tight muscles and joints around the compressed nerves and blood vessels. To help restore normal mobility, we may prescribe stretching for the joints, muscles, and nerves. Chiropractors can also help you find ways to manage your pain and avoid future problems. Deep muscle work is sometimes performed to help breakdown scar tissue and adhesions which form in the muscles and tendons.

You will be given exercises to strengthen the muscles of your shoulder and upper back and to stretch the muscles in the front of the chest and shoulders. Swimming can help some patients, but the backstroke and full breaststroke may worsen the condition. Your exercise program will focus on helping you sit and stand with good posture. Good posture is critical to managing TOS symptoms. Therefore, postural corrective exercises are crucial for a timely recovery. We will also give you tips to help avoid TOS pain. For example, you should limit the length of time the arms are used in outstretched or overhead positions, and don't do heavy carrying and lifting. Simple things like taking frequent breaks, changing positions, stretching, or using a hand truck or cart can bring relief. Patients usually start doing resistive exercise and activities. Chiropractic treatments help improve motion in the shoulder blade and arm. Posture and strengthening exercises help prevent future TOS problems. We will give special attention to the type of work you do. We will make suggestions to help you avoid work postures and activities that could cause problems. You'll be shown strategies to take care of any future symptoms and avoid further problems.

If you are concerned about your arm, please do not hesitate to call us 781-933-5051 so that we can determine if it's time to visit our practice.

Introduction

Lateral epicondylitis, commonly known as tennis elbow, is not limited to tennis players. The backhand swing in tennis can strain the muscles and tendons of the elbow in a way that leads to tennis elbow. But many other types of repetitive activities can also lead to tennis elbow--painting with a brush or roller, running a chain saw, and using many types of hand tools. Any activities that repeatedly stress the same forearm muscles can cause symptoms of tennis elbow.

Causes
Why did I develop tennis elbow? Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop tennis elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition. Hammering nails, picking up heavy buckets, or pruning shrubs can all cause the pain of tennis elbow.

However, tennis elbow often does not involve inflammation. Rather, the problem is within the cells of the tendon. Doctors call this condition tendonosis. In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers. Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue. No one really knows exactly what causes tendonosis. Some doctors think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

Symptoms
What does tennis elbow feel like? The main symptom of tennis elbow is tenderness and pain that starts at the lateral epicondyle of the elbow. The pain may spread down the forearm. It may go as far as the back of the middle and ring fingers. The forearm muscles may also feel tight and sore. The pain usually gets worse when you bend your wrist backward, turn your palm upward, or hold something with a stiff wrist or straightened elbow. Grasping items also makes the pain worse. Just reaching into the refrigerator to get a carton of milk can cause pain. Sometimes the elbow feels stiff and won't straighten out completely.

Treatment
Chiropractic treatment is usually only needed for four to six weeks. Chiropractic manipulation can help restore the normal alignment and motion of the elbow joint. This is sometimes called closed reduction manipulation. This is where chiropractic manipulation has an advantage over other specialties. It is important to manipulate and stretch capsular joint restrictions during the treatment phase. Chiropractic care focuses on not just relieving the symptoms, but correcting the underlying problem. Before any treatment can begin, you will begin a standard chiropractic examination of the head, neck and upper back and entire upper extremity to check for any nervous system interference to the group of nerves called the brachial plexus. Research studies have shown that spinal manipulation/adjustments to the neck are effective in treating tennis elbow.

When symptoms are from tendonosis, you can expect healing to take longer, usually up to three months. If your tendonosis is severe, it may take at least six months for complete healing. If the problem is caused by acute inflammation, sometimes anti-inflammatory medications such as ibuprofen may give you some relief, but it will not correct the problem.

Dr. Zohn and Dr. Kane will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. We may apply tape to take some of the load off the elbow muscles and tendons. You may need to wear an elbow strap that wraps around the upper forearm in a way that relieves the pressure on the tendon attachment.

Ice and electrical stimulation to ease pain and improve healing of the tendon. Deep muscle work is sometimes performed to help breakdown scar tissue and adhesions which form in the muscles and tendons. Treatment sessions may also include iontophoresis, which uses a mild electrical current to "push" anti-inflammatory medicine to the sore area. Exercises are used to gradually stretch and strengthen the forearm muscles. Because tendonosis is often linked to overuse, your chiropractor will work with you to reduce repeated strains on your elbow. When symptoms come from a particular sport or work activity, we will observe your style and motion with the activity. You may be given tips about how to perform the movement so the elbow is protected. We can check your sports equipment and work tools and suggest how to alter them to keep your elbow safe.

Introduction

Medial epicondylitis is commonly known as golfer's elbow. This does not mean that only golfers have this condition. But the golf swing is a common cause of medial epicondylitis. Many other repetitive activities can also lead to golfer's elbow--throwing, chopping wood with an ax, running a chain saw, and using many types of hand tools. Any activities that stress the same forearm muscles can cause symptoms of golfer's elbow.

Causes
Why did I develop golfer's elbow? Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop golfer's elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition. Shoveling, gardening, and hammering nails can all cause the pain of golfer's elbow. Swimmers who try to pick up speed by powering their arm through the water can also strain the flexor tendon at the elbow.

In some cases, the symptoms of golfer's elbow are due to inflammation. In an acute injury, the body undergoes an inflammatory response. Special inflammatory cells make their way to the injured tissues to help them heal. Conditions that involve inflammation are indicated by "-itis" on the end of the word. For example, inflammation in a tendon is called tendonitis. Inflammation around the medial epicondyle is called medial epicondylitis. However, golfer's elbow often is not caused by inflammation. Rather, it is a problem within the cells of the tendon. Doctors call this condition tendonosis. In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.

Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue. No one really knows exactly what causes tendonosis. Some doctors think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

Symptoms
What does golfer's elbow feel like? The main symptom of golfer's elbow is tenderness and pain at the medial epicondyle of the elbow. Pain usually starts at the medial epicondyle and may spread down the forearm. Bending your wrist, twisting your forearm down, or grasping objects can make the pain worse. You may feel less strength when grasping items or squeezing your hand into a fist.

Treatment
Chiropractic treatment is usually only needed for four to six weeks. Chiropractic manipulation can help restore the normal alignment and motion of the elbow joint. This is sometimes called closed reduction manipulation. This is where chiropractic manipulation has an advantage over other specialties. It is important to manipulate and stretch capsular joint restrictions during the treatment phase. Chiropractic care focuses on not just relieving the symptoms, but correcting the underlying problem. Before any treatment can begin, you will begin a standard chiropractic examination of the head, neck and upper back and entire upper extremity to check for any nervous system interference to the group of nerves called the brachial plexus. Research studies have shown that spinal manipulation/adjustments to the neck are effective in treating golfer's elbow.

When symptoms are from tendonosis, you can expect healing to take longer, usually up to three months. If your tendonosis is severe, it may take at least six months for complete healing. If the problem is caused by acute inflammation, sometimes anti-inflammatory medications such as ibuprofen may give you some relief, but it will not correct the problem.

Dr. Zohn and Dr. Kane will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. We may apply tape to take some of the load off the elbow muscles and tendons. You may need to wear an elbow strap that wraps around the upper forearm in a way that relieves the pressure on the tendon attachment.

Ice and electrical stimulation are used to ease pain and improve healing of the tendon. Deep muscle work is sometimes performed to help breakdown scar tissue and adhesions which form in the muscles and tendons. Treatment sessions may also include iontophoresis, which uses a mild electrical current to "push" anti-inflammatory medicine to the sore area. Exercises are used to gradually stretch and strengthen the forearm muscles. Because tendonosis is often linked to overuse, your chiropractor will work with you to reduce repeated strains on your elbow. When symptoms come from a particular sport or work activity, we will observe your style and motion with the activity. You may be given tips about how to perform the movement so the elbow is protected. We can check your sports equipment and work tools and suggest how to alter them to keep your elbow safe.

Introduction

de Quervain's tenosynovitis is a condition that causes pain on the inside of the wrist and forearm just above the thumb. It is a common problem affecting the wrist and is usually easy to diagnose.

Causes
How did this condition develop? Repeatedly performing hand and thumb motions such as grasping, pinching, squeezing, or wringing may lead to the inflammation of tenosynovitis. This inflammation can lead to swelling, which hampers the smooth gliding action of the tendons within the tunnel. Arthritic diseases that affect the whole body, such as rheumatoid arthritis, can also cause tenosynovitis in the thumb. In other cases, scar tissue from an injury can make it difficult for the tendons to slide easily through the tunnel.

Symptoms
What problems does this condition cause? At first, the only sign of trouble may be soreness on the thumb side of the forearm, near the wrist. If the problem isn't treated, pain may spread up the forearm or further down into the wrist and thumb. As the friction increases, the two tendons may actually begin to squeak as they move through the constricted tunnel. This noise is called crepitus. If the condition is especially bad, there may be swelling along the tunnel near the edge of the wrist. Grasping objects with the thumb and hand may become increasingly painful.

Treatment
If at all possible, you must change or stop all activities that cause your symptoms. Chiropractic care focuses on not just relieving the symptoms, but correcting the underlying problem. Chiropractic manipulation can help restore the normal alignment and motion of the thumb and carpal bones in the wrist joint. This is sometimes called closed reduction manipulation. Take frequent breaks when doing repeated hand and thumb actions. Avoid repetitive hand motions, such as heavy grasping, wringing, or turning and twisting movements of the wrist. Keep the wrist in a neutral alignment. In other words, keep it in a straight line with your arm, without bending it forward or backward. We may recommend a special forearm and thumb splint called a thumb-spica splint. This splint keeps the wrist and lower joints of the thumb from moving. The splint allows the APL and EPB tendons to rest, giving them a chance to begin to heal.

Your chiropractor may check your workstation and the way you do your work tasks. Suggestions may be given about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems.

Introduction

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of carpal tunnel syndrome.



This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

Causes
What causes carpal tunnel syndrome? Any condition that makes the area inside the carpal tunnel smaller or increases the size of the tissues within the tunnel can lead to symptoms of carpal tunnel syndrome (CTS). For example, a traumatic wrist injury may cause swelling and extra pressure within the carpal tunnel. The area inside the tunnel can also be reduced after a wrist fracture or dislocation if the bone pushes into the tunnel. Any condition that causes abnormal pressure in the tunnel can produce symptoms of CTS. Various types of arthritis can cause swelling and pressure in the carpal tunnel. Fractured wrist bones may later cause CTS if the healed fragments result in abnormal irritation on the flexor tendons.

Other conditions in the body can produce symptoms of CTS. Pregnancy can cause fluid to be retained, leading to extra pressure in the carpal tunnel. Diabetics may report symptoms of CTS, which may be from a problem in the nerve (called a neuropathy) or from actual pressure on the median nerve. People with low thyroid function (called hypothyroidism) are more prone to problems of CTS. In other instances, CTS can start when the tenosynovium thickens from irritation or inflammation. This thickening causes pressure to build inside the carpal tunnel. But the tunnel can't stretch any larger in response to the added swelling, so the median nerve starts to squeeze against the transverse carpal ligament. If the pressure continues to build up, the nerve is eventually unable to function normally.

When pressure builds on the median nerve, the blood supply to the outer covering of the nerve slows down and may even be cut off. The medical term for this is ischemia. At first, only the outside covering of the nerve is affected. But if the pressure keeps building up, the inside of the nerve will start to become thickened. New cells (called fibroblasts) form within the nerve and create scar tissue. This is thought to produce the feelings of pain and numbness in the hand. If pressure is taken off right away, the symptoms will go away quickly. Pressure that isn't eased right away can slow or even stop the chances for recovery.

Symptoms
What does CTS feel like? One of the first symptoms of CTS is gradual numbness in the areas supplied by the median nerve. This is quickly followed by pain where the nerve gives sensation in the hand. The hand may begin to feel like it's "asleep," especially in the early morning hours after a night's rest. Pain may spread up the arm to the shoulder and even to the side of the neck. If the condition progresses, the thenar muscles of the thumb can weaken, causing the hand to be clumsy when picking up a glass or cup. If the pressure keeps building in the carpal tunnel, the thenar muscles may begin to shrink (atrophy). Touching the pad of the thumb to the tips of the other fingers becomes difficult, making it hard to grasp items such as a steering wheel, newspaper, or telephone.



Treatment
In each hand, eight bones, called carpal bones, come together at the wrist. The carpal tunnel is approximately the width of your index finger. The median nerve runs through this carpal tunnel. However, when the carpal bones become misaligned, the tendons become compressed. This leads to entrapment and compression of the median nerve against the flexor retinaculum, and a reduction in the blood supply with the resulting pain, numbness and tingling. Carpal bones become misaligned through injury, such as a fall or through repetitive motion, such as … typing and hammering which shocks and overstretch the wrist.

Chiropractic manipulation can help restore the normal alignment and motion of the carpal bones, thus taking pressure off of the tendons and median nerve. This is sometimes called closed reduction manipulation. Chiropractic care focuses on not just relieving the symptoms, but correcting the underlying problem. Before any treatment can begin, you will begin a standard chiropractic examination of the head, neck and upper back and entire upper extremity to check for any nervous system interference to the group of nerves called the brachial plexus.

As you progress, we have you start strengthening your hand by squeezing and stretching special putty. There is a specific protocol which uses a series of "fist" positions to encourage the finger tendons to slide within the carpal tunnel. Additional exercises to help strengthen and stabilize the muscles and joints in the hand will also be incorporated. Other exercises are used to improve fine motor control and dexterity. Some of the exercises you'll do are designed to get your hand working in ways that are similar to your work tasks and sport activities. We will help you find ways to do your tasks that don't put too much stress on your hand and wrist. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Activities that are causing your symptoms need to be changed or stopped if at all possible. Avoid repetitive hand motions, heavy grasping, holding onto vibrating tools, and positioning or working with your wrist bent down and out. If you smoke, talk to your doctor about ways to help you quit. Lose weight if you are overweight. Reduce your caffeine intake.

A wrist brace will sometimes decrease the symptoms in the early stages of CTS. A brace keeps the wrist in a resting position--not bent back nor bent down too far. When the wrist is in this position, the carpal tunnel is as big as it can be, so the nerve has as much room as possible inside the carpal tunnel. A brace can be especially helpful for easing the numbness and pain felt at night because it can keep your hand from curling under as you sleep. The wrist brace can also be worn during the day to calm symptoms and rest the tissues in the carpal tunnel.

If chiropractic treatment is successful, you should see improvement in four to six weeks. You may need to continue with chiropractic treatments and with wearing your wrist splint at night to control symptoms and keep your wrist from curling under as you sleep. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions, heavy grasping, and vibration in the hand.

Introduction

Lateral epicondylitis, commonly known as tennis elbow, is not limited to tennis players. The backhand swing in tennis can strain the muscles and tendons of the elbow in a way that leads to tennis elbow. But many other types of repetitive activities can also lead to tennis elbow--painting with a brush or roller, running a chain saw, and using many types of hand tools. Any activities that repeatedly stress the same forearm muscles can cause symptoms of tennis elbow.

Causes
Why did I develop tennis elbow? Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop tennis elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition. Hammering nails, picking up heavy buckets, or pruning shrubs can all cause the pain of tennis elbow.

However, tennis elbow often does not involve inflammation. Rather, the problem is within the cells of the tendon. Doctors call this condition tendonosis. In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers. Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue. No one really knows exactly what causes tendonosis. Some doctors think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

Symptoms
What does tennis elbow feel like? The main symptom of tennis elbow is tenderness and pain that starts at the lateral epicondyle of the elbow. The pain may spread down the forearm. It may go as far as the back of the middle and ring fingers. The forearm muscles may also feel tight and sore. The pain usually gets worse when you bend your wrist backward, turn your palm upward, or hold something with a stiff wrist or straightened elbow. Grasping items also makes the pain worse. Just reaching into the refrigerator to get a carton of milk can cause pain. Sometimes the elbow feels stiff and won't straighten out completely.

Treatment
Chiropractic treatment is usually only needed for four to six weeks. Chiropractic manipulation can help restore the normal alignment and motion of the elbow joint. This is sometimes called closed reduction manipulation. This is where chiropractic manipulation has an advantage over other specialties. It is important to manipulate and stretch capsular joint restrictions during the treatment phase. Chiropractic care focuses on not just relieving the symptoms, but correcting the underlying problem. Before any treatment can begin, you will begin a standard chiropractic examination of the head, neck and upper back and entire upper extremity to check for any nervous system interference to the group of nerves called the brachial plexus. Research studies have shown that spinal manipulation/adjustments to the neck are effective in treating tennis elbow.

When symptoms are from tendonosis, you can expect healing to take longer, usually up to three months. If your tendonosis is severe, it may take at least six months for complete healing. If the problem is caused by acute inflammation, sometimes anti-inflammatory medications such as ibuprofen may give you some relief, but it will not correct the problem.

Dr. Zohn and Dr. Kane will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. We may apply tape to take some of the load off the elbow muscles and tendons. You may need to wear an elbow strap that wraps around the upper forearm in a way that relieves the pressure on the tendon attachment.

Ice and electrical stimulation to ease pain and improve healing of the tendon. Deep muscle work is sometimes performed to help breakdown scar tissue and adhesions which form in the muscles and tendons. Treatment sessions may also include iontophoresis, which uses a mild electrical current to "push" anti-inflammatory medicine to the sore area. Exercises are used to gradually stretch and strengthen the forearm muscles. Because tendonosis is often linked to overuse, your chiropractor will work with you to reduce repeated strains on your elbow. When symptoms come from a particular sport or work activity, we will observe your style and motion with the activity. You may be given tips about how to perform the movement so the elbow is protected. We can check your sports equipment and work tools and suggest how to alter them to keep your elbow safe.

Introduction

Medial epicondylitis is commonly known as golfer's elbow. This does not mean that only golfers have this condition. But the golf swing is a common cause of medial epicondylitis. Many other repetitive activities can also lead to golfer's elbow--throwing, chopping wood with an ax, running a chain saw, and using many types of hand tools. Any activities that stress the same forearm muscles can cause symptoms of golfer's elbow.

Causes
Why did I develop golfer's elbow? Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop golfer's elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition. Shoveling, gardening, and hammering nails can all cause the pain of golfer's elbow. Swimmers who try to pick up speed by powering their arm through the water can also strain the flexor tendon at the elbow.

In some cases, the symptoms of golfer's elbow are due to inflammation. In an acute injury, the body undergoes an inflammatory response. Special inflammatory cells make their way to the injured tissues to help them heal. Conditions that involve inflammation are indicated by "-itis" on the end of the word. For example, inflammation in a tendon is called tendonitis. Inflammation around the medial epicondyle is called medial epicondylitis. However, golfer's elbow often is not caused by inflammation. Rather, it is a problem within the cells of the tendon. Doctors call this condition tendonosis. In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.

Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue. No one really knows exactly what causes tendonosis. Some doctors think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

Symptoms
What does golfer's elbow feel like? The main symptom of golfer's elbow is tenderness and pain at the medial epicondyle of the elbow. Pain usually starts at the medial epicondyle and may spread down the forearm. Bending your wrist, twisting your forearm down, or grasping objects can make the pain worse. You may feel less strength when grasping items or squeezing your hand into a fist.

Treatment
Chiropractic treatment is usually only needed for four to six weeks. Chiropractic manipulation can help restore the normal alignment and motion of the elbow joint. This is sometimes called closed reduction manipulation. This is where chiropractic manipulation has an advantage over other specialties. It is important to manipulate and stretch capsular joint restrictions during the treatment phase. Chiropractic care focuses on not just relieving the symptoms, but correcting the underlying problem. Before any treatment can begin, you will begin a standard chiropractic examination of the head, neck and upper back and entire upper extremity to check for any nervous system interference to the group of nerves called the brachial plexus. Research studies have shown that spinal manipulation/adjustments to the neck are effective in treating golfer's elbow.

When symptoms are from tendonosis, you can expect healing to take longer, usually up to three months. If your tendonosis is severe, it may take at least six months for complete healing. If the problem is caused by acute inflammation, sometimes anti-inflammatory medications such as ibuprofen may give you some relief, but it will not correct the problem.

Dr. Zohn and Dr. Kane will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. We may apply tape to take some of the load off the elbow muscles and tendons. You may need to wear an elbow strap that wraps around the upper forearm in a way that relieves the pressure on the tendon attachment.

Ice and electrical stimulation are used to ease pain and improve healing of the tendon. Deep muscle work is sometimes performed to help breakdown scar tissue and adhesions which form in the muscles and tendons. Treatment sessions may also include iontophoresis, which uses a mild electrical current to "push" anti-inflammatory medicine to the sore area. Exercises are used to gradually stretch and strengthen the forearm muscles. Because tendonosis is often linked to overuse, your chiropractor will work with you to reduce repeated strains on your elbow. When symptoms come from a particular sport or work activity, we will observe your style and motion with the activity. You may be given tips about how to perform the movement so the elbow is protected. We can check your sports equipment and work tools and suggest how to alter them to keep your elbow safe.

Introduction

Thoracic outlet syndrome (TOS) can cause pain and numbness in the shoulder, arm, and hand. Testing for TOS is difficult. There is no one test to accurately diagnose TOS, and other conditions can have similar symptoms. You will need to go through several tests to find out if TOS is actually the cause of your pain. Making the right diagnosis often takes time and can be a cause of frustration--for both you and your doctor.

Causes
What causes TOS problems? The main cause of TOS is that the nerves and blood vessels going to the arm and hand get squeezed near the thoracic outlet. This can occur for many reasons. Pressure on nerves and vessels can happen in people who have fractured their clavicle. It can also happen in people who have an extra first rib, although this doesn't always result in TOS. Extra muscle or scar tissues in the scalene muscles can put extra pressure on the nerves and arteries. Heavy lifting and carrying can bulk up the scalenus muscles to the point where the nerve and arteries get squeezed.

Traumatic injury from a car accident can also cause problems that lead to TOS. In an accident, the shoulder harness of the seat belt can strain or tear the muscles. As they heal, scar tissue can build up, putting pressure on the nerves and blood vessels at the thoracic outlet. Neck and arm positions used at work and home may contribute to TOS. People who have to hold their neck and shoulders in awkward alignment sometimes develop TOS symptoms. TOS symptoms are also reported by people who have to hold their arms up or out for long periods of time. People with TOS often slouch their shoulders, giving them a "drooped" appearance. The poor body alignment of slouching can compress the nerves and arteries near the thoracic outlet. Being overweight can cause problems with posture, and women who have very large breasts may also use a "droopy" posture. For some reason, TOS affects three times as many women as men.

Symptoms
What problems does TOS cause? TOS causes pain along the top of the clavicle and shoulder. The pain may spread along the inside edge of the arm. Occasionally pain spreads into the hand, mostly into the ring and pinky fingers. Numbness and tingling, called paresthesia, may accompany the pain, especially in the early hours of the morning before it's time to wake up. Symptoms tend to get worse when driving, lifting, carrying, and writing. The arms may also feel tired when held overhead, as when using a blow dryer. It may be harder to hold and grip things, and the hand may feel clumsy.

Symptoms related to the blood vessels are less common. If the blood vessels are causing symptoms, the arm and shoulder may feel heavy and cold. The arm may become somewhat blue (cyanosis), and the constriction of vessels can cause the arm and hand to swell. Problems with the blood vessels that go to the arm are serious. If you experience these symptoms, you should call your doctor right away. TOS symptoms are similar to the symptoms of many other conditions. A herniated disc in the neck, carpal tunnel syndrome in the hand, and bursitis of the shoulder can all cause symptoms very much like those of TOS.

Treatment
Chiropractic doctors will examine and palpate the function and mobility of the first rib and vertebra in the neck to make sure that they are moving properly. Often, if the rib moves upwards or becomes fixated, it can compress the nerves, arteries and veins causing numbness, tingling or pain into the arm. The musculature, such as the anterior scalenes can become overactive an also press on these pain sensitive structures causing the symptoms of TOS. By correcting any functional problems with the ribs and stretching the tightened muscles, the cause of the problem can be eliminated. A home exercise program is essential to the treatment of TOS. This is true even if the cause of your TOS is an abnormality in the bones and muscles. You must consistently do your exercises to get the most benefits.

Chiropractic treatments may begin with exercises to loosen up tight muscles and joints around the compressed nerves and blood vessels. To help restore normal mobility, we may prescribe stretching for the joints, muscles, and nerves. Chiropractors can also help you find ways to manage your pain and avoid future problems. Deep muscle work is sometimes performed to help breakdown scar tissue and adhesions which form in the muscles and tendons.

You will be given exercises to strengthen the muscles of your shoulder and upper back and to stretch the muscles in the front of the chest and shoulders. Swimming can help some patients, but the backstroke and full breaststroke may worsen the condition. Your exercise program will focus on helping you sit and stand with good posture. Good posture is critical to managing TOS symptoms. Therefore, postural corrective exercises are crucial for a timely recovery. We will also give you tips to help avoid TOS pain. For example, you should limit the length of time the arms are used in outstretched or overhead positions, and don't do heavy carrying and lifting. Simple things like taking frequent breaks, changing positions, stretching, or using a hand truck or cart can bring relief. Patients usually start doing resistive exercise and activities. Chiropractic treatments help improve motion in the shoulder blade and arm. Posture and strengthening exercises help prevent future TOS problems. We will give special attention to the type of work you do. We will make suggestions to help you avoid work postures and activities that could cause problems. You'll be shown strategies to take care of any future symptoms and avoid further problems.

If you are concerned about your arm, please do not hesitate to call us 781-933-5051 so that we can determine if it's time to visit our practice.

Introduction

de Quervain's tenosynovitis is a condition that causes pain on the inside of the wrist and forearm just above the thumb. It is a common problem affecting the wrist and is usually easy to diagnose.

Causes
How did this condition develop? Repeatedly performing hand and thumb motions such as grasping, pinching, squeezing, or wringing may lead to the inflammation of tenosynovitis. This inflammation can lead to swelling, which hampers the smooth gliding action of the tendons within the tunnel. Arthritic diseases that affect the whole body, such as rheumatoid arthritis, can also cause tenosynovitis in the thumb. In other cases, scar tissue from an injury can make it difficult for the tendons to slide easily through the tunnel.

Symptoms
What problems does this condition cause? At first, the only sign of trouble may be soreness on the thumb side of the forearm, near the wrist. If the problem isn't treated, pain may spread up the forearm or further down into the wrist and thumb. As the friction increases, the two tendons may actually begin to squeak as they move through the constricted tunnel. This noise is called crepitus. If the condition is especially bad, there may be swelling along the tunnel near the edge of the wrist. Grasping objects with the thumb and hand may become increasingly painful.

Treatment
If at all possible, you must change or stop all activities that cause your symptoms. Chiropractic care focuses on not just relieving the symptoms, but correcting the underlying problem. Chiropractic manipulation can help restore the normal alignment and motion of the thumb and carpal bones in the wrist joint. This is sometimes called closed reduction manipulation. Take frequent breaks when doing repeated hand and thumb actions. Avoid repetitive hand motions, such as heavy grasping, wringing, or turning and twisting movements of the wrist. Keep the wrist in a neutral alignment. In other words, keep it in a straight line with your arm, without bending it forward or backward. We may recommend a special forearm and thumb splint called a thumb-spica splint. This splint keeps the wrist and lower joints of the thumb from moving. The splint allows the APL and EPB tendons to rest, giving them a chance to begin to heal.

Your chiropractor may check your workstation and the way you do your work tasks. Suggestions may be given about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems.

Introduction

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of carpal tunnel syndrome.



This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

Causes
What causes carpal tunnel syndrome? Any condition that makes the area inside the carpal tunnel smaller or increases the size of the tissues within the tunnel can lead to symptoms of carpal tunnel syndrome (CTS). For example, a traumatic wrist injury may cause swelling and extra pressure within the carpal tunnel. The area inside the tunnel can also be reduced after a wrist fracture or dislocation if the bone pushes into the tunnel. Any condition that causes abnormal pressure in the tunnel can produce symptoms of CTS. Various types of arthritis can cause swelling and pressure in the carpal tunnel. Fractured wrist bones may later cause CTS if the healed fragments result in abnormal irritation on the flexor tendons.

Other conditions in the body can produce symptoms of CTS. Pregnancy can cause fluid to be retained, leading to extra pressure in the carpal tunnel. Diabetics may report symptoms of CTS, which may be from a problem in the nerve (called a neuropathy) or from actual pressure on the median nerve. People with low thyroid function (called hypothyroidism) are more prone to problems of CTS. In other instances, CTS can start when the tenosynovium thickens from irritation or inflammation. This thickening causes pressure to build inside the carpal tunnel. But the tunnel can't stretch any larger in response to the added swelling, so the median nerve starts to squeeze against the transverse carpal ligament. If the pressure continues to build up, the nerve is eventually unable to function normally.

When pressure builds on the median nerve, the blood supply to the outer covering of the nerve slows down and may even be cut off. The medical term for this is ischemia. At first, only the outside covering of the nerve is affected. But if the pressure keeps building up, the inside of the nerve will start to become thickened. New cells (called fibroblasts) form within the nerve and create scar tissue. This is thought to produce the feelings of pain and numbness in the hand. If pressure is taken off right away, the symptoms will go away quickly. Pressure that isn't eased right away can slow or even stop the chances for recovery.

Symptoms
What does CTS feel like? One of the first symptoms of CTS is gradual numbness in the areas supplied by the median nerve. This is quickly followed by pain where the nerve gives sensation in the hand. The hand may begin to feel like it's "asleep," especially in the early morning hours after a night's rest. Pain may spread up the arm to the shoulder and even to the side of the neck. If the condition progresses, the thenar muscles of the thumb can weaken, causing the hand to be clumsy when picking up a glass or cup. If the pressure keeps building in the carpal tunnel, the thenar muscles may begin to shrink (atrophy). Touching the pad of the thumb to the tips of the other fingers becomes difficult, making it hard to grasp items such as a steering wheel, newspaper, or telephone.



Treatment
In each hand, eight bones, called carpal bones, come together at the wrist. The carpal tunnel is approximately the width of your index finger. The median nerve runs through this carpal tunnel. However, when the carpal bones become misaligned, the tendons become compressed. This leads to entrapment and compression of the median nerve against the flexor retinaculum, and a reduction in the blood supply with the resulting pain, numbness and tingling. Carpal bones become misaligned through injury, such as a fall or through repetitive motion, such as … typing and hammering which shocks and overstretch the wrist.

Chiropractic manipulation can help restore the normal alignment and motion of the carpal bones, thus taking pressure off of the tendons and median nerve. This is sometimes called closed reduction manipulation. Chiropractic care focuses on not just relieving the symptoms, but correcting the underlying problem. Before any treatment can begin, you will begin a standard chiropractic examination of the head, neck and upper back and entire upper extremity to check for any nervous system interference to the group of nerves called the brachial plexus.

As you progress, we have you start strengthening your hand by squeezing and stretching special putty. There is a specific protocol which uses a series of "fist" positions to encourage the finger tendons to slide within the carpal tunnel. Additional exercises to help strengthen and stabilize the muscles and joints in the hand will also be incorporated. Other exercises are used to improve fine motor control and dexterity. Some of the exercises you'll do are designed to get your hand working in ways that are similar to your work tasks and sport activities. We will help you find ways to do your tasks that don't put too much stress on your hand and wrist. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Activities that are causing your symptoms need to be changed or stopped if at all possible. Avoid repetitive hand motions, heavy grasping, holding onto vibrating tools, and positioning or working with your wrist bent down and out. If you smoke, talk to your doctor about ways to help you quit. Lose weight if you are overweight. Reduce your caffeine intake.

A wrist brace will sometimes decrease the symptoms in the early stages of CTS. A brace keeps the wrist in a resting position--not bent back nor bent down too far. When the wrist is in this position, the carpal tunnel is as big as it can be, so the nerve has as much room as possible inside the carpal tunnel. A brace can be especially helpful for easing the numbness and pain felt at night because it can keep your hand from curling under as you sleep. The wrist brace can also be worn during the day to calm symptoms and rest the tissues in the carpal tunnel.

If chiropractic treatment is successful, you should see improvement in four to six weeks. You may need to continue with chiropractic treatments and with wearing your wrist splint at night to control symptoms and keep your wrist from curling under as you sleep. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions, heavy grasping, and vibration in the hand.

Introduction


A rise in the use of MRI (magnetic resonance imaging) has led to the discovery that many people, perhaps as many as fifteen percent of Americans, have a thoracic disc herniation. Seeing a herniated thoracic disc on MRI is often "incidental," meaning it shows up when the person has MRI testing for another problem.

Few people with a herniated thoracic disc feel any symptoms or have any problems as a result of this condition. In rare cases when symptoms do arise, the main concern is whether the herniated disc is affecting the spinal cord.

Although people often refer to a thoracic disc herniation as a "slipped disc," the disc doesn't actually slip out of place. Rather, the term "herniation" means that the material in the center of the disc has squeezed out of the normal space. In the thoracic spine, this condition mostly affects people between forty and sixty years old.

Causes

Why do I have this problem? Thoracic disc herniations are mainly caused by wear and tear in the disc. This wear and tear is known as degeneration. As a disc's annulus ages, it tends to crack and tear. These injuries are repaired with scar tissue. Over time the annulus weakens, and the nucleus may squeeze (herniate) through the damaged annulus. Spine degeneration is common in T11 and T12. T12 is where the thoracic and lumbar spine meet. This link is subject to forces from daily activity, such as bending and twisting, which lead to degeneration. Not surprisingly, most thoracic disc herniations occur in this area.

Less commonly, a thoracic disc may herniate suddenly (an acute injury). A thoracic disc may herniate during a car accident or a fall. A thoracic disc may also herniate as a result of a sudden and forceful twist of the mid-back. Diseases of the thoracic spine may lead to thoracic disc herniation. Patients with Scheuermann's disease, for example, are more likely to suffer thoracic disc herniations. It appears these patients often have more than one herniated disc, though the evidence is not conclusive.

The spinal cord may be injured when a thoracic disc herniates. First, the spinal canal of the thoracic spine is narrow, so the spinal cord is immediately in danger from anything that takes up space inside the canal. Second, most disc herniations in the thoracic spine squeeze straight back, rather than deflecting off to either side. As a result, the disc material is often pushed directly toward the spinal cord. Third, a herniated disc can cut off the blood supply to the spinal cord. Discs that herniate into the "critical zone" of the thoracic spine (T4 to T9) can shut off blood from the one and only blood vessel going to the front of the spinal cord in this section of the spine. This can cause the nerve tissues in the spinal cord to die, leading to severe problems of weakness or paralysis in the legs.

Symptoms

What does the condition feel like? Symptoms of thoracic disc herniation vary widely. Symptoms depend on where and how big the disc herniation is, where it is pressing, and whether the spinal cord has been damaged. Pain is usually the first symptom. The pain may be centered over the injured disc but may spread to one or both sides of the mid-back. Also, patients commonly feel a band of pain that goes around the front of the chest. Patients may eventually report sensations of pins, needles, and numbness. Others say their leg or arm muscles feel weak. Disc material that presses against the spinal cord can also cause changes in bowel and bladder function.

Disc herniations can affect areas away from the spine. Herniations in the upper part of the thoracic spine can radiate pain and other sensations into one or both arms. If the herniation occurs in the middle of the thoracic spine, pain can radiate to the abdominal or chest area, mimicking heart problems. A lower thoracic disc herniation can cause pain in the groin or lower limbs and can mimic kidney pain.



Treatment

The chiropractic approach is to help restore a more normal motion and position of affected spinal joints and bones by specific chiropractic adjustments or manipulation. This is often combined with ice, traction, soft tissue massage, electrical muscle stimulation, ultrasound, traction, exercise and stretching. Please see the treatments section for descriptions of each of these procedures. We do not always adjust or manipulate the spine in the presence of certain disc and nerve problems in the mid-back or thoracic spine. Depending on your exam findings, other techniques can sometimes be used. There are very specific therapeutic exercises which have been proven very effective in reducing disc problems in the thoracic spine. These will be discussed at length and demonstrated in the office. Traction can help de-compress the pressure on the discs of mid-back. Electrical muscle stimulation and ice are commonly used to help reduce the inflammation in the muscles and nerves. Longstanding poor posture is a common cause of disc problems in the thoracic spine. Therefore, postural corrective exercises will be prescribed. A thorough chiropractic examination and history will help in identifying the appropriate treatment for you.

Introduction


Although people often refer to a disc herniation as a "slipped disc," the disc doesn't actually slip out of place. Rather, the term "herniation" means that the material at the center of the disc has squeezed out of its normal space. This condition mainly affects people between thirty and forty years old.

Causes
Why do I have this problem? Herniation occurs when the nucleus in the center of the disc pushes out of its normal space. The nucleus presses against the annulus, causing the disc to bulge outward. Sometimes the nucleus herniates completely through the annulus and squeezes out of the disc. Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand this pressure. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. This process is known as degeneration. Over time, the annulus weakens, and the nucleus may begin to squeeze (herniate) through the damaged annulus. At first, the pressure bulges the annulus outward. Eventually, the nucleus may herniate completely through the outer ring of the disc.

Vigorous, repetitive bending, twisting, and lifting can place abnormal pressure on the shock-absorbing nucleus of the disc. If great enough, this increased pressure can injure the annulus, leading to herniation. A lumbar disc can also become herniated during an acute, or sudden, injury. Lifting with the trunk bent forward and twisted can cause a disc herniation. A disc can also herniate from a heavy impact on the spine, such as falling from a ladder and landing in a sitting position. Herniation causes pain from a variety of sources. It can cause mechanical pain. This is pain that comes from the parts of the spine that move during activity, such as the discs and ligaments. Pain from inflammation occurs when the nucleus squeezes through the annulus. The nucleus normally does not come in contact with the body's blood supply. However, a tear in the annulus puts the nucleus at risk for contacting this blood supply. When the nucleus herniates into the torn annulus, the nucleus and blood supply meet, causing a reaction of the chemicals inside the nucleus. This produces inflammation and pain. A disc herniation may also put pressure against a spinal nerve. Pressure on an irritated or damaged nerve can produce pain that radiates along the nerve. This is called neurogenic pain.



Symptoms
What does the condition feel like? Many cases of lumbar disc herniation result from degenerative changes in the spine. The changes that eventually lead to a disc herniation produce symptoms gradually. At first, complaints may only include dull pain centered in the low back, pain that comes and goes over a period of a few years. Doctors think this is mainly from small tears in the annulus. Larger cracks in the annulus may spread pain into the buttocks or lower limbs. When the disc herniates completely through the annulus, it generally causes immediate symptoms, with sharp pain that starts in one hip and shoots down part or all of the leg. Commonly, patients no longer feel their usual back pain, only leg pain. This is likely because painful tension on the annulus releases when the nucleus pushes completely through.

Disc herniations produce inflammation when the nucleus comes in contact with the body's blood supply (mentioned earlier). The inflammation can be a source of throbbing pain in the low back and may spread into one or both hips and buttocks. A herniated disc can press against a spinal nerve, producing symptoms of nerve compression. Nerve pain follows known patterns in the lower limbs. It can be felt on the side of the upper thigh, in the calf, or even in the foot and toes. Pressure on the nerve can also cause sensations of pins, needles, and numbness where the nerve travels down the lower limbs. If this happens, a person's reflexes slow. The muscles controlled by the nerve weaken, and sensation in the skin where the nerve goes is impaired.

Rarely, symptoms involve changes in bowel and bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder. The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder. This is an emergency. If the pressure isn't relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Doctors recommend immediate surgery to remove pressure from the nerves.

Treatment
First, surgery is the last option for disc problems in the lower back. In fact, 95% of patients with lower back pain with and without disc involvement do not require surgery. For these 95% of patients, conservative treatment is the recommended approach. Spinal misalignments, often painless at first, eventually lead to wear on the discs in the spine. The chiropractic approach to disc problems is to help restore better motion and position to the spinal joint. Besides reducing the disc bulging, better spinal function helps reduce inflammation and begin the slow process of healing the surrounding soft tissues. This is often combined with ice, traction, soft tissue massage, electrical muscle stimulation, ultrasound, traction, exercise and stretching. We do not always adjust or manipulate the spine in the presence of certain disc and nerve problems in the spine. Depending on your exam findings, other techniques can sometimes be used, although manipulation is usually very helpful.

The spine is made up of a series of connected bones called "vertebrae". The disc is a combination of strong connective tissues which hold one vertebra to the next, and acts as a cushion or shock absorber between the vertebrae. The disc is made of a tough outer layer called the "annulus fibrosis" and a gel-like center called the "nucleus pulposus." When healthy, discs allow normal turning and bending. As you get older, the center of the disc may start to lose water content, making the disc less effective as a cushion. This may cause a displacement of the disc's center (called a herniated or ruptured disc) through a crack in the outer layer. Most disc herniations occur in the bottom two discs of the lumbar spine, at and just below the waist.

A herniated lumbar disc can press on the nerves in the spine and may cause pain, numbness, tingling or weakness of the leg. Similarly, a herniated or bulging disc in the neck may cause numbness, tingling or pain into the arm or hand. Herniated or bulging discs may also cause localized back or neck pain, although neck and back pain alone (without leg pain or arm pain) can have many causes other than a herniated disc.

Since spinal discs have a very poor blood supply, they depend upon the circulation of joint fluids to bring in nutrients and expel waste. If a spinal joint loses its normal motion and this pumping action is impaired, the health of the disc deteriorates. Like a wet sponge, a healthy disc is flexible. A dry sponge is hard, stiff, and can crack easily. This is how many disc problems begin.

Because of the way each disc is attached to the vertebra above and below it, a disc cannot "slip" as commonly thought. However, trauma or injury to the spine can cause discs to bulge, herniate, or worse, rupture. This can be quite painful, putting pressure on the spinal cord and nerve roots, interfering with their function. Disc problems are one of the most common conditions seen at the Winchester Hospital Chiropractic Center. Specially designed tables, called Flexion/Distraction tables are designed for treating such conditions.

Specific therapeutic exercises proven extremely effective in reducing disc problems in the lumbar spine will be demonstrated and performed in the office. These are called Mckenzie exercises or McKenzie Therapy. Traction can help de-compress the pressure on the discs of mid-back. Electrical muscle stimulation and ice are commonly used to help reduce the inflammation in the muscles and nerves. Longstanding poor posture is a common cause of disc problems in the low back. Therefore, postural corrective exercises will be prescribed. A thorough chiropractic examination and history will help in identifying the appropriate treatment for you. Chiropractic doctors see lumbar disc problems quite often in daily practice and have excellent results.

Introduction

Low back pain is one of the main reasons Americans visit their doctor. For adults over forty, it ranks third as a cause for doctor visits, after heart disease and arthritis. Eighty percent of people will have low back pain at some point in their lives. And nearly everyone who has low back pain once will have it again. Very few people who feel pain in their low back have a serious medical problem. Ninety percent of people who experience low back pain for the first time get better in two to six weeks. Only rarely do people with low back pain develop chronic back problems. Your doctor will evaluate your condition to make sure that no serious problems exist. Certainly, in some cases the problem can be serious and require more aggressive treatment--even surgery.

A definite cause of the pain cannot be determined in a large portion of cases. The spine changes as we age. Like skin that can become dry and wrinkled with age, the spine may also show normal signs of aging. These are natural changes that happen with the passing of time. Some people may experience pain from these changes; others don't. Changes in the spine that happen over time are referred to as degeneration or degenerative disc disease. Degeneration can be thought of as wear and tear that occurs each day as we use our spine for normal activities. Low back pain does not mean that you are destined to become disabled.

Causes
Why do I have low back pain? There are many causes of low back pain. Doctors are not always able to pinpoint the source of a patient's pain. But your doctor will make every effort to ensure that your symptoms are not from a serious medical cause, such as cancer or a spinal infection. The vast majority of back problems are a result of wear and tear on the parts of the spine over many years. This process is called degeneration. Over time, the normal process of aging can result in degenerative changes in all parts of the spine. Injuries to the spine, such as a fracture or injury to the disc, can make the changes happen even faster. There is strong evidence that cigarette smoking also speeds up degeneration of the spine. Scientists have found links among family members, showing that genetics plays a role in how fast these changes occur.

Degenerative Model The intervertebral disc changes over time. At first, the disc is spongy and firm. The nucleus pulposus portion in the center of the disc contains a great deal of water. This gives the disc its ability to absorb shock and protect the spine from heavy and repeated forces. The first change that occurs is that the annulus around the nucleus weakens and begins to develop small cracks and tears. The body tries to heal the cracks with scar tissue. But scar tissue is not as strong as the tissue it replaces. The torn annulus can be a source of pain for two reasons. First, there are pain sensors in the outer rim of the annulus. They signal a painful response when the tear reaches the outer edge of the annulus. Second, like injuries to other tissues in the body, a tear in the annulus can cause pain due to inflammation.



With time, the disc begins to lose water, causing it to lose some of its fullness and height. As a result, the vertebra begin to move closer together. As the disc continues to degenerate, the space between the vertebra shrinks. This compresses the facet joints along the back of the spinal column. As these joints are forced together, extra pressure builds on the articular cartilage on the surface of the facet joints. This extra pressure can damage the facet joints. Over time, this may lead to arthritis in the facet joints. These degenerative changes in the disc, facet joints, and ligaments cause the spinal segment to become loose and unstable. The extra movement causes even more wear and tear on the spine. As a result, more and larger tears occur in the annulus.

The nucleus may push through the torn annulus and into the spinal canal. This is called a herniated or ruptured disc. The disc material that squeezes out can press against the spinal nerves. The disc also emits enzymes and chemicals that produce inflammation. The combination of pressure on the nerves and inflammation caused by the chemicals released from the disc cause pain.

As the degeneration continues, bone spurs develop around the facet joints and around the disc. No one knows exactly why these bone spurs develop. Most doctors think that bone spurs are the body's attempt to stop the extra motion between the spinal segment. These bone spurs can cause problems by pressing on the nerves of the spine where they pass through the neural foramina. This pressure around the irritated nerve roots can cause pain, numbness, and weakness in the low back, buttocks, and lower limbs and feet.

A collapsed spinal segment eventually becomes stiff and immobile. Thickened ligaments and facet joints, scarred and dried disc tissue, and protruding bone spurs prevent normal movement. Typically, a stiff joint doesn't cause as much pain as one that slides around too much. So this stage of degeneration may actually lead to pain relief for some people.

Mechanical Pain Mechanical back pain is caused by wear and tear in the parts of the lumbar spine. This type of pain is similar in nature to a machine that begins to wear out. Mechanical pain usually starts from degenerative changes in the disc. As the disc begins to collapse and the space between the vertebrae narrows, the facet joints may become inflamed. Mechanical pain typically gets worse after activity due to strain on the moving parts of the spine. Mechanical pain is usually felt in the back, but it may spread into the buttocks, hips, and thighs. The pain rarely goes down past the knee. Mechanical back pain usually doesn't cause weakness or numbness in the leg or foot, because the problem is not from pressure on the spinal nerves.

Neurogenic Pain Neurogenic pain means "pain from nerve injury." Neurogenic pain occurs when spinal nerves are inflamed, squeezed, or pinched. This can happen when a disc herniates or when a nerve gets pinched where it leaves the spine. Recently it has also become known that when a disc ruptures, chemicals are released that inflame the nerves even if there is no pressure directly on the nerve. Neurogenic symptoms concern doctors more than mechanical pain because it can damage the nerves and lead to weakness or numbness in the lower extremities. The nerve pressure causes symptoms in the areas where the nerve travels, rather than in the low back. This happens because pressure on the spinal nerve affects structures away from the spine, such as the muscles energized by the nerves. As a result, a person's back may not hurt, yet the person feels pain, numbness, or weakness in his or her leg or foot. This indicates there's a problem with the body's electrical wiring. The pressure on the nerve affects how the body functions. Muscles weaken. Reflexes slow. Sensations of pins, needles, and numbness may be felt where the nerve travels.

Annular Tears Our intervertebral discs change with age, much like our hair turns gray. Perhaps the earliest stage of degeneration occurs due to tears that occur in the annulus. These tears can result from wear and tear over a period of time. They can also be the result of a sudden injury to the disc due to a twist or increased strain on the disc that overpowers the strength of the annulus. These annular tears may cause pain in the back until they heal with scar tissue.

Internal Disc Disruption Multiple annular tears can lead to a disc that becomes weak. The disc starts to degenerate and collapse. The vertebrae begin to compress together. The collapsing disc can be the source of pain because it has lost the ability to be a shock absorber between the vertebrae. This condition is sometimes referred to as internal disc disruption. This type of problem causes primarily mechanical back pain due to inflammation of the disc and surrounding structures.

Herniated Disc A disc that has been weakened may rupture, or herniate. If the annulus ruptures, or tears, the material in the nucleus can squeeze out of the disc, or herniate. A disc herniation usually causes compressive problems if the disc presses against a spinal nerve. The chemicals released by the disc may also inflame the nerve root, causing pain in the area that the nerve root travels down the leg. This type of pain is referred to as sciatica. Even a normal disc can rupture. Heavy, repetitive bending, twisting, and lifting can place too much pressure on the disc, causing the annulus to tear and the nucleus to rupture into the spinal canal.

Facet Joint Arthritis The facet joints along the back of the spinal column link the vertebrae together. They are not meant to bear much weight. However, if a disc loses its height, the vertebra above the disc begins to compress toward the one below. This causes the facet joints to press together. Articular cartilage covers the surfaces where these joints meet. Like other joints in the body that are covered with articular cartilage, the facet joints can develop osteoarthritis as the articular cartilage wears away over time. Extra pressure on the facet joints, such as that from a collapsing disc, can speed the degeneration in the facet joints. The swelling and inflammation from an arthritic facet joint can be a source of low back pain.

Segmental Instability Segmental instability also includes conditions in which a vertebral body begins to slip over the one below it. When a vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, this extra movement in the bones of the spine can create problems. It can lead to mechanical pain simply because the structures of the spine move around too much and become inflamed and painful. The extra movement can also cause neurogenic symptoms if the spinal nerves are squeezed as a result of the segmental instability.

Spinal Stenosis Stenosis means "closing in." Spinal stenosis refers to a condition in which the tissues inside the spinal canal are "closed in," or compressed. The spinal cord ends at L2. Below this level, the spinal canal contains only spinal nerves that travel to the pelvis and legs. When stenosis narrows the spinal canal, the spinal nerves are squeezed inside the canal. The pressure from the condition can cause problems in the way the nerves work. The resulting problems include pain and numbness in the buttocks and legs and weakness in the muscles supplied by the nerves. Because these nerves travel to the bladder and rectum, weakness in the these muscles can cause problems with control of the bladder and bowels.

Foraminal Stenosis Spinal nerves exit the spinal canal between the vertebrae in a tunnel called the neural foramen. Any thing that causes this tunnel to become smaller can squeeze the spinal nerve where it passes through the tunnel. This condition is called foraminal stenosis, meaning the foramen is narrowed. As the disc collapses and looses height, the vertebral body above begins to collapse toward the one below. The opening around the nerve root narrows, squeezing the nerve. Arthritis of the facet joints causes bone spurs to form and point into the foramen, causing further nerve compression and irritation. Foraminal stenosis can cause a combination of mechanical pain and neurogenic pain from the irritated nerve root.

Symptoms

What are some of the symptoms of low back problems? Symptoms from back problems vary. They depend on a person's condition and which structures are affected. Some of the more common symptoms of low back problems are low back pain, pain spreading into the buttocks and thighs, pain radiating from the buttock to the foot, back stiffness and reduced range of motion, muscle weakness in the hip, thigh, leg, or foot, sensory changes (numbness, prickling, or tingling) in the leg, foot, or toes.

Rarely, symptoms involve changes in bowel or bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder. The pressure may cause symptoms of low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder. This is an emergency. If the pressure isn't relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Doctors recommend immediate surgery to remove pressure from the nerves.



Treatment

Low back pain is the number one reason patients seek care at the Winchester Hospital Chiropractic Center. We see hundreds of patients a week for this condition alone. Manual treatments such as spinal manipulation have been shown to be the most effective in treating people with lower back pain. Chiropractic doctors are the experts in spinal adjustments and manipulation. In fact, chiropractors perform 94% of all spinal manipulations in the United States. The remaining 6% are made up of physical therapists, medical doctors and osteopathic doctors. The chiropractic doctors at Winchester Hospital are trained in the latest adjusting techniques. You will also be taught neutral spinal postures aimed at decreasing pain, improving mobility, strength and function. Patients are taught how to protect their spines and prevent the problems from returning again. Strengthening exercises are also incorporated. Treatments are often combined with electrical muscle stimulation, ice, ultrasound, exercises, exercise balls, soft tissue massage, and traction. All of these are designed to help decrease pain and inflammation and improve function and mobility. Please see treatment sections to read further about these procedures.

Aerobic exercises may include walking on a treadmill, riding a stationary bike, or swimming. These activities can relieve the stress of low back pain, and they can cause your body to release endorphins into the blood stream. Endorphins are the body's own natural painkillers. An active approach to treatment helps patients attain better muscle function, so they can get their activities done easier. Active chiropractic rehabilitation speeds recovery, reducing the possibility that back pain will become a chronic problem. Along with active exercise, this format is used to help patients resume normal activity as swiftly as possible. Though patients are cautioned about trying to do too much, too quickly, they are guided toward returning to their activities. Pain is used to gauge the upper limits of activity. This approach gives patients a greater sense of control. They take an active role in learning how to care for their back pain. Treatment sessions focus on reassuring patients that getting back to work and other normal activities swiftly won't cause harm and can actually help them get better faster.

When needed, patients are encouraged to take certain actions to improve their spine health. Patients who smoke are encouraged to get help to quit. Because of the limited blood supply in the tissues of the low back, smoking speeds the degenerative process and impairs healing. Patients who are out of shape are encouraged to get fit. This strategy makes it less likely that back pain or injury will strike again in the future.

Dr. Kane and Dr. Zohn will show you how to keep your spine safe during routine activities. You'll learn about healthy posture and how posture relates to the future health of your spine. And you'll learn about body mechanics, how the body moves and functions during activity. Chiropractors teach safe body mechanics to help you protect the low back as you go about your day. This includes the use of safe positions and movements while lifting and carrying, standing and walking, and performing work duties. If indicated, your chiropractic doctor will work closely with your medical doctor and employer to help you get back on the job as quickly as reasonably possible. You may be required to do lighter duties at first, but as soon as you are able, you'll begin doing your normal work activities. Your chiropractor can do a work assessment to make sure you'll be safe to do your job. Dr. Kane and Dr. Zohn may suggest changes that could help you work safely, with less chance of re-injuring your back.

If you are concerned about your back, please do not hesitate to call us 781-933-5051 so that we can determine if it's time to visit our practice.

Introduction


The intervertebral discs in the lower spine are commonly blamed for low back pain. Yet low back pain has many possible causes, and doctors aren't always certain why symptoms occur. During an office visit for low back pain, your doctor may describe how changes in the discs can lead to back pain. When talking about these changes, your doctor may use the terms "degeneration" or "degenerative disc disease." Although the parts of the spine do change with time and in some sense degenerate, this does not mean a person's spine is deteriorating and that he or she is headed for future pain and problems. These terms are simply a starting point for describing what occurs in the spine over time and how the changes may explain the symptoms people feel.

Causes

Why do I have this problem? Our intervertebral discs change with age, much like our hair turns gray. Conditions such as a major back injury or fracture can affect how the spine works, making the changes happen even faster. Daily wear and tear and certain types of vibration can also speed up degeneration in the spine. In addition, strong evidence suggests that smoking speeds up degeneration of the spine. Scientists have also found links among family members, showing that genetics plays a role in how fast these changes occur.

Disc degeneration follows a predictable pattern. First, the nucleus in the center of the disc begins to lose its ability to absorb water. The disc becomes dehydrated. Then the nucleus becomes thick and fibrous, so that it looks much the same as the annulus. As a result, the nucleus isn't able to absorb shock as well. Routine stress and strain begin to take a toll on the structures of the spine. Tears form around the annulus. The disc weakens. It starts to collapse, and the bones of the spine compress.

Symptoms

What does the condition feel like? Pain in the center of the low back is often the first symptom patients feel. It usually starts to affect patients in their twenties and thirties. Pain tends to worsen after heavy physical activity or staying in one posture for a long time. The back may also begin to feel stiff. Resting the back eases pain. At first, symptoms only last a few days. This type of back pain often comes and goes over the years. Doctors call this recurring back pain. Each time it strikes, the pain may seem worse than the time before. Eventually the pain may spread into the buttocks or thighs, and it may take longer for the pain to subside.

Treatment

Surgery People with degenerative disc problems tend to gradually improve over time. Most do not need surgery. In fact, only one to three percent of patients with degenerative disc problems typically require surgery. Doctors prefer to try nonsurgical treatment for a minimum of three months before considering surgery. If after this period nonsurgical treatment hasn't improved symptoms, the doctor may recommend surgery. The main types of surgery for degenerative disc problems include lumbar laminectomy, discectomy, fusion.

Lumbar Laminectomy The lamina forms a roof-like structure over the back of the spinal column. When the nerves in the spinal canal are squeezed by a degenerated disc or by bone spurs pushing into the canal, a laminectomy removes part or all of the lamina to release pressure on the spinal nerves.

Discectomy Surgery to take out part or all of a problem disc in the low back is called discectomy. Discectomy is done when the degenerated disc has ruptured (herniated) into the spinal canal, putting pressure on the spinal nerves. Surgeons generally perform this operation through an incision in the low back. Traditional methods involve chipping a small part of the lamina bone off the back of the spinal column. This is called laminotomy. It leaves greater room for the surgeon to remove the disc. Laminotomy differs from laminectomy (described above) in that laminectomy involves removing most or all of the lamina. Many doctors now do procedures that require only small incisions in the low back. Categorized as "minimally invasive surgeries," these procedures are used to remove damaged portions of the problem disc. Advocates believe that this type of surgery is easier to perform. They also believe it prevents scarring around the nerves and joints and helps patients recover more quickly. Examples include percutaneous lumbar discectomy, laser discectomy, and microdiscectomy.

Fusion Fusion surgery joins two or more bones into one solid bone. This prevents the bones and joints from moving. The procedure is sometimes done with a disc excision. Mechanical pain is eased because the fusion holds the moving parts steady, so they can't cause irritation and inflammation. The main types of fusion for degenerative disc problems include anterior lumbar interbody fusion, posterior lumbar fusion, combined fusion.

Anterior Lumbar Interbody Fusion This surgery is done through the abdomen, allowing the doctor to work on the front (anterior) of the lumbar spine. Removing the disc (discectomy) leaves a space between the pair of vertebrae. This "interbody" space is filled with a bone graft. One method is to take a graft from the pelvic bone and tamp it into place. Another method involves inserting two hollow titanium screws packed with bone, called fusion cages, into the place where the disc was taken out. The bone graft inside the cages fuses with the adjacent vertebrae, forming one solid bone.

Posterior Lumbar Fusion A posterior lumbar fusion is done though an incision in the back. In this procedure, the surgeon lays small grafts of bone over the problem vertebrae. Most surgeons will also apply metal plates and screws to hold the vertebrae in place while they heal. This protects the graft so it can heal better and faster.

Combined Fusion As its name suggests, this procedure involves fusing the anterior (front) and posterior (back) surfaces of the problem vertebrae. By locking the vertebrae from the front and back, some doctors believe the graft stays solid and is prevented from collapsing. Results do show improved fusion of the graft, though patients seem to fare equally well with other methods of fusion.

Introduction



Arthritis of the lumbar facet joints can be a source of significant low back pain. Aligned on the back of the spinal column, the facet joints link each vertebra together. Articular cartilage covers the surfaces where these joints meet. Like other joints in the body that are covered with articular cartilage, the lumbar facet joints can be affected by arthritis.

Causes
Why do I have this problem? Normally, the facet joints fit together snugly and glide smoothly, without pressure. If pressure builds where the joint meets, the cartilage on the joint surfaces wears off, or erodes. Each segment in the spine has three main points of movement: the intervertebral disc and the two facet joints. Injury or problems in any one of these structures affects the other two. As a disc thins with aging and from daily wear and tear, the space between two spinal vertebrae shrinks. This causes the facet joints to press together.



Facet joints can also become arthritic due to a back injury earlier in life. Fractures, torn ligaments, and disc problems can all cause abnormal movement and alignment, putting extra stress on the surfaces of the facet joints. The body responds to this extra pressure by developing bone spurs. As the spurs form around the edges of the facet joints, the joints become enlarged. This is called hypertrophy. Eventually, the joint surfaces become arthritic. When the articular cartilage degenerates, or wears away, the bone underneath is uncovered and rubs against bone. The joint becomes inflamed, swollen, and painful.

Facet joint arthritis develops slowly over a long period of time. This is partly because spinal degeneration in later life is the main cause of facet joint arthritis. Symptoms rarely develop immediately when degeneration is causing the problems. However, rapid movements, heavy twisting, or backward motions in the low back can injure a facet joint, leading to immediate symptoms.

Symptoms
What does the condition feel like? Pain from facet joint arthritis is usually worse after resting or sleeping. Also, bending the trunk sideways or backward usually produces pain on the same side as the arthritic facet joint. For example, if you lie on your stomach on a flat surface and raise your upper body, you hyperextend the spine. This increases pressure on the facet joints and can cause pain if there is facet joint arthritis. Pain may be felt in the center of the low back and can spread into one or both buttocks. Sometimes the pain spreads into the thighs, but it rarely goes below the knee. Symptoms of nerve compression--numbness or tingling--are usually not felt because facet arthritis generally causes only mechanical pain. Mechanical pain is pain from abnormal movement in the spine.

However, symptoms of nerve compression can sometimes occur at the same time as the facet joint pain. The arthritis can cause bone spurs at the edges of the facet joint. These bone spurs may form in the opening where the nerve root leaves the spinal canal. This canal is called the neural foramen. If the bone spurs rub against the nerve root, the nerve can become inflamed and irritated. This nerve irritation can cause symptoms where the nerve travels. These symptoms may include numbness, tingling, slowed reflexes, and muscle weakness.

Treatment
Patients are usually seen a few times a week for about 4-6 weeks. In severe and chronic cases, additional treatment may be warranted. Low back pain is the number one reason patients seek care at the Winchester Hospital Chiropractic Center. Facet joint pain and inflammation is one of the common causes of pain in the lower back. Manual treatments such as spinal manipulation have been shown to be one of the most effective in treating people with facet joint pain which causes lower back pain. Chiropractic doctors are the experts in spinal adjustments and manipulation. In fact, chiropractors perform 94% of all spinal manipulations in the United States. Spinal manipulation is one of the only ways to induce motion at specific vertebra in the spine. Chiropractic adjustments help restore normal motion to the joints, reduce pain and inflammation and relieve irritation to the sensitive nerves. Additionally, you will also be shown neutral spinal postures aimed at decreasing pain, improving mobility, strength and function.

Patients are taught how to protect their spines and prevent the problems from returning again. Strengthening exercises are also incorporated. Treatments are often combined with electrical muscle stimulation, ice, ultrasound, exercises, exercise balls, soft tissue massage, and traction. All of these are designed to help decrease pain and inflammation and improve function and mobility. Nutritional recommendations may be prescribed. For example, glucosamine sulfate has been proven effective in not only reducing pain, but in reversing some of the wear in cartilage and actually stimulating new growth of the cartilage. Ginger extract has been shown to have the same clinical effects on pain as does Celebrex.

Introduction



Stenosis means "closing in." Spinal stenosis describes a condition in which the nerves in the spinal canal are "closed in," or compressed. The spinal canal is the hollow tube formed by the bones of the spinal column. Anything that causes this bony tube to shrink can squeeze the nerves inside. As a result of many years of wear and tear on the parts of the spine, the tissues nearest the spinal canal sometimes press against the nerves. This helps explain why lumbar spinal stenosis (stenosis of the low back) is a common cause of back problems in adults over fifty-five years old.

Causes
Why do I have this problem? In the lumbar spine, the spinal canal usually has more than enough room for the spinal nerves. The canal is normally seventeen to eighteen millimeters around, slightly less than the size of a penny. Spinal stenosis develops when the canal shrinks to twelve millimeters or less. When the size drops below ten millimeters, severe symptoms of lumbar spinal stenosis occur. There are many reasons why symptoms of spinal stenosis develop. Some of the more common reasons include congenital stenosis (being born with a small spinal canal), spinal degeneration, spinal instability, disc herniation.

Congenital stenosis: Some people are born with a spinal canal that is narrower than normal. They may not feel problems early in life. However, having a narrow spinal canal puts them at risk for stenosis. Even a minor back injury can cause pressure against the spinal cord. People born with a narrow spinal canal often have problems later in life, because the canal tends to become narrower due to the effects of aging.

Degeneration: Degeneration is the most common cause of spinal stenosis. Wear and tear on the spine from aging and from repeated stresses and strains can cause many problems in the lumbar spine. The intervertebral disc can begin to collapse and the space between each vertebrae shrinks. Bone spurs may form that stick into the spinal canal and reduce the space available to the spinal nerves. The ligaments that hold the vertebrae together may thicken and also push into the spinal canal. All of these conditions cause the spinal canal to narrow.

Spinal instability: Spinal instability can cause spinal stenosis. Spinal instability means that the bones of the spine move more than they should. Instability in the lumbar spine can develop if the supporting ligaments have been stretched or torn from a severe back injury. People with diseases that loosen their connective tissues may also have spinal instability. Whatever the cause, extra movement in the bones of the spine can lead to spinal stenosis.

Disc herniation: Spinal stenosis can occur when an intervertebral disc in the low back herniates. Normally, the shock-absorbing disc is able to handle the downward pressure of gravity and the strain from daily activities. However, if the pressure on the disc is too strong, such as landing from a fall in a sitting position, the nucleus inside the disc may rupture through the outer annulus and squeeze out of the disc. This is called a disc herniation. If an intervertebral disc herniates straight backward, it can press against the nerves in the spinal canal, causing symptoms of spinal stenosis.

Symptoms
What does the spinal stenosis feel like? Spinal stenosis usually develops slowly over a long period of time. This is because the main cause of spinal stenosis is spinal degeneration in later life. Symptoms rarely develop quickly when degeneration is the source of the problem. A severe injury or a herniated disc may cause symptoms to develop immediately. Patients with stenosis don't always feel back pain. Primarily, they have pain and weakness in their legs--usually in both legs at the same time. Some people say they feel that their legs are going to give out on them.

Symptoms mainly affect sensation in the lower limbs. Nerve pressure from stenosis can cause a feeling of pins and needles in the skin where the spinal nerves travel. Reflexes become slowed. Some patients report "charleyhorses" in their leg muscles. Others report strange sensations like water trickling down their legs.

Symptoms change with the position of the low back. Bending forward (flexion) widens the spinal canal and usually eases symptoms. That's why people with stenosis tend to get relief when they sit down or curl up to sleep. Activities such as reaching up, standing, and walking require the spine to straighten or even bend back slightly (extension). This position of the low back makes the spinal canal smaller and often worsens symptoms.

Treatment
Manual treatments such as spinal manipulation and lumbar spinal traction have been shown to be effective in reducing the symptoms associated with lumbar spinal stenosis. Patients often find that curling up to sleep or lying on their back with their knees bent and supported gives them relief. These positions flex the spine forward, which widens the spinal canal and can give the spinal cord some more room to breath. You will be shown specific spinal postures aimed at decreasing pain, improving mobility, strength and function. Patients are taught how to protect their spines. Treatments are often combined with electrical muscle stimulation, ice, ultrasound, soft tissue massage, and traction. All of these are designed to help decrease pain and inflammation and improve function and mobility. Please see treatment sections to read further about these procedures.

Another technique performed only by chiropractic doctors is called manual flexion/distraction which is an advanced and specific form of traction. It involves the use of a specially designed traction table which can help open and widen the spinal canal, taking pressure off of the spinal cord. Patients often feel immediate relief after the first treatment! On rare occasions, bracing may be indicated to help keep the spine in a semi-flexed position, widening the spinal canal.

Aerobic exercises may include walking on a treadmill, riding a stationary bike, or swimming. Stationary biking is a good exercise because it keeps the spine slightly bent forward, opening the spinal canal. These activities can also relieve the stress of low back pain, improve heart and lung health, endurance and can cause your body to release endorphins into the blood stream. Endorphins are the body's own natural painkillers.

When needed, patients are encouraged to take certain actions to improve their spine health. Patients who smoke are encouraged to get help to quit. Because of the limited blood supply in the tissues of the low back, smoking speeds the degenerative process and impairs healing. Patients who are out of shape are encouraged to get fit. This strategy makes it less likely that back pain or injury will strike again in the future.

Dr. Kane and Dr. Zohn will show you how to keep your spine safe during routine activities. You'll learn about healthy posture and how posture relates to the future health of your spine. You'll learn about body mechanics, how the body moves and functions during activity. Chiropractors teach safe body mechanics to help you protect the low back as you go about your day. This includes the use of safe positions and movements while lifting and carrying, standing and walking, and performing work duties.

Introduction



Normally, the bones of the spine (the vertebrae) stand neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine. In this condition, one of the spine bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful.

Causes

Why do I have this problem? In younger patients (under twenty years old), spondylolisthesis usually involves slippage of the fifth lumbar vertebra over the top of the sacrum. There are several reasons for this. First, the connection of L5 and the sacrum forms an angle that is tilted slightly forward, mainly because the top of the sacrum slopes forward. Second, the slight inward curve of the lumbar spine creates an additional forward tilt where L5 meets the sacrum. Finally, gravity attempts to pull L5 in a forward direction.

Facet joints are small joints that connect the back of the spine together. Normally, the facet joints connecting L5 to the sacrum create a solid buttress to prevent L5 from slipping over the top of the sacrum. However, when problems exist in the disc, facet joints, or bony ring of L5, the buttress becomes ineffective. As a result, the L5 vertebra can slip forward over the top of the sacrum.

A condition called spondylolysis can also cause the slippage that happens with spondylolisthesis. Spondylolysis is a defect in the bony ring of the spinal column. It affects the pars interarticularis, mentioned above. This defect is most commonly thought to be a "stress fracture" that happens from repeated strains on the bony ring. Participants in gymnastics and football commonly suffer these strains. Spondylolysis can lead to the spine slippage of spondylolisthesis when a fracture occurs on both sides of the bony ring. The back section of the bony ring separates from the main vertebral body, so the injured vertebra is no longer connected by bone to the one below it. In this situation, the facet joints can't provide their normal support. The vertebra on top is then free to slip forward over the one below.

A traumatic fracture in the bony ring can lead to slippage when the fracture goes completely through both sides of the bony ring. The facet joints are no longer able to provide a buttress, allowing the vertebra with the crack in it to slip forward. This is similar to what happens when spondylolysis (mentioned earlier) occurs on both sides of the bony ring, but in this case it happens all at once.

Degenerative changes in the spine (those from wear and tear) can also lead to spondylolisthesis. The spine ages and wears over time, much like hair turns gray. These changes affect the structures that normally support healthy spine alignment. Degeneration in the disc and facet joints of a spinal segment causes the vertebrae to move more than they should. The segment becomes loose, and the added movement takes a additional toll on the structures of the spine. The disc weakens, pressing the facet joints together. Eventually, the support from the facet joints becomes ineffective, and the top vertebra slides forward. Spondylolisthesis from degeneration usually affects people over 40 years old. It mainly involves slippage of L4 over L5.



Symptoms

What does the condition feel like? An ache in the low back and buttock areas is the most common complaint in patients with spondylolisthesis. Pain is usually worse when bending backward and may be eased by bending the spine forward. Spasm is also common in the low back muscles. The hamstring muscles on the back of the thighs may become tight. The pain can be from mechanical causes. Mechanical pain is caused by wear and tear on the parts of the spine. When the vertebra slips forward, it puts a painful strain on the disc and facet joints.

Slippage can also cause nerve compression. Nerve compression is a result of pressure on a nerve. As the spine slips forward, the nerves may be squeezed where they exit the spine. This condition also reduces space in the spinal canal where the vertebra has slipped. This can put extra pressure on the nerve tissues inside the canal. Nerve compression can cause symptoms where the nerve travels and may include numbness, tingling, slowed reflexes, and muscle weakness in the lower body.

Nerve pressure on the cauda equina, the bundle of nerve roots within the lumbar spinal canal, can affect the nerves that go to the bladder and rectum. The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle.

Treatment

Nonsurgical Treatment When the vertebra hasn't slipped very far, doctors begin by prescribing nonsurgical treatments. In some cases, the patient's condition is simply monitored to see if symptoms improve. Your doctor may ask that you rest your back by limiting your activities. This is to help decrease inflammation and calm muscle spasm. You may need to take time away from sports or other strenuous activities to give your back a chance to heal. If you still have symptoms after a period of rest, your doctor may have you wear a rigid back brace or cast for two to three months. Keeping the spine from moving can help ease pain and inflammation. Patients often work with a physical therapist. After evaluating your condition, your therapist can assign positions and exercises to ease your symptoms. Your therapist can design an exercise program to improve flexibility in your low back and hamstrings and to strengthen your back and abdominal muscles.

Nonsurgical Rehabilitation Nonsurgical treatment for spondylolisthesis commonly involves physical therapy. Your doctor may recommend that you work with a physical therapist a few times each week for four to six weeks. In some cases, patients may need a few additional weeks of care. The first goal of treatment is to control symptoms. Your therapist works with you to find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used to calm pain and muscle spasm. Patients are shown how to stretch tight muscles, especially the hamstring muscles on the back of the thigh.

As patients recover, they gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these "core" muscles helps patients move easier and lessens the chances of future pain and problems. A primary purpose of therapy is to help you learn how to take care of your symptoms and prevent future problems. You'll be given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist will also describe strategies you can use if your symptoms flare up.

Introduction



Spondylolysis happens when a crack forms in the bony ring on the back of the spinal column. Most commonly, this occurs in the low back. In this condition, the bone that protects the spinal cord fractures as a result of excessive or repeated strain. The area affected is called the pars interarticularis, so doctors sometimes refer to this condition as a "pars defect."

This condition appears in six percent of children. It mainly affects young athletes who participate in sports in which the spine is repeatedly bent backwards, such as gymnastics, football, and karate. Although spondylolysis can affect people of any age, children and adolescents are most susceptible. This is because their spines are still developing, and the pars is the weakest part of the vertebra. Placing extra strain on this area of the spine during childhood increases the chance that a pars defect will occur.

Causes

Why do I have this problem? Spondylolysis is thought to be caused by repeated strains that damage the lower spine over time. The repeated strains can eventually lead to an "overuse injury" in the pars interarticularis. The most common location for this to occur is in the lowest vertebra of the spine, L5. This vertebra connects the spine to the pelvis. However, a problem with the pars can occur in any lumbar vertebra. It rarely happens in more than one vertebra at a time. The vertebra initially responds to the abnormal strain by adding new bone cells around the injured area. But if the injuries happen faster than the body can keep up with needed repairs, a crack may form in the weakened bone. This is called a stress fracture. This type of fracture occurs in the pars, the area of bony ring between the pedicle and lamina.

The crack may affect only one side of the bony ring. However, it is equally common for the defect to occur on both sides. When this happens, the vertebra above is no longer connected by bone, allowing the vertebra on top to slide forward over the one below. The vertebra is no longer held firmly in place by the facet joints on the back of the ring. As a result, the vertebra is free to slip forward over the one below. This slippage, which is closely related to spondylolysis, is called spondylolisthesis.

Spondylolysis commonly occurs in young gymnasts who regularly practice backbends as part of their routines. Football linemen and dancers are also prone to spondylolysis. Symptoms sometimes appear when an athlete quickly ramps up his or her training intensity, applies incorrect technique, or uses poor equipment.

Symptoms

What does the condition feel like? People with spondylolysis may feel pain and stiffness in the center of the low back. Bending fully backward increases pain. Symptoms typically get worse with activity and go away with rest. Doctors refer to this type of back pain as mechanical pain because it most likely comes from excess movement between the vertebrae.

Individuals may eventually experience pain that radiates down one or both legs. This pain may come from pressure and irritation on the nerves that exit the spinal canal near the fracture. When nerve pressure in the low back causes leg pain, doctors refer it as compressive pain.

The cause of this nerve compression is a result of the body's attempt to heal the stress fracture. Over time, the healing process may cause a bump of extra cartilage to grow at the site where the bones are trying to heal the overuse injury. If too much cartilage builds up, this bump may intrude into the opening where the nerves exit the spine. The bump may squeeze the nerve. This can produce pain and weakness in the leg. Reflexes become slowed. The person may also notice a "pins and needles" sensation in the skin where the spinal nerve travels.

Treatment

Nonsurgical Treatment Doctors often begin by prescribing nonsurgical treatment for spondylolysis. This is because symptoms from these stress fractures often resolve with rest or bracing. In some cases, doctors simply monitor their patients' condition to see if symptoms improve. An X-ray may be taken every few months to check how well the area is healing.

If the doctor feels that the problem is due to a recent fracture, you may be placed in a rigid back brace or cast for three to four months. Keeping the spine from moving can help ease pain and inflammation. It can also improve the chances the bones will grow back together. Most people who require a brace or cast overcome symptoms and are able to eventually get back to activities free of pain. This can happen even when follow up tests show that the bones haven't completely healed. Your doctor may ask that you rest your back by limiting your activities. The purpose of this is to help decrease inflammation and calm muscle spasm. You may need to take some time away from your sport, especially if it requires repeated back bending. This gives your back a chance to heal. Most patients who follow these measures get better. Patients are rarely counseled to completely discontinue participating in their sport and only in severe cases.

Patients often work with a physical therapist. After evaluating your condition, a therapist can assign positions and exercises to ease your symptoms. The therapist may design an exercise program to improve the strength and control of your back and abdominal muscles. By watching you perform your sport activity, your therapist can suggest style, technique, or equipment changes to improve your performance and prevent future problems.

Nonsurgical Rehabilitation Recovery from this condition is much like nonsurgical treatment mentioned earlier. Once you have rested your back to allow it to heal, your doctor may recommend that you work with a physical therapist a few times each week for four to six weeks. In severe cases, patients may need a few additional weeks of physical therapy.

The first goal of treatment is to control symptoms. The therapist works with you to find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used to calm pain and muscle spasm. As you recover, you will gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these "core" muscles helps patients begin moving easier and lessens the chances of future pain and problems. When needed, a therapist can work closely with a sports coach on strategies for a patient's safe return to his or her sport. The two may provide suggestions on technique, equipment, and training frequency and intensity.

A primary purpose of therapy is to help patients learn how to take care of their symptoms and prevent future problems. Patients are given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist also describes strategies you can use if your symptoms flare up.

Most adolescents get better after wearing a brace or cast for three months. Even then, a CT scan sometimes shows an unhealed fracture. In these cases, however, symptoms often go away completely, allowing a safe return to sports. Patients do best when guided in a gradual manner with the supervision of a therapist and sports coach. When a fracture does not heal and causes pain that is severe, surgery may be needed.

Introduction

A painful sacroiliac joint is one of the more common causes of mechanical low back pain. Sacroiliac (SI) joint dysfunction is a term that is used to describe the condition - because it is still unclear why this joint becomes painful and leads to low back pain. Sacroiliac joint dysfunction can be a nuisance but it is seldom dangerous and rarely leads to the need for surgery. Most people who suffer from this problem can reduce the pain and manage the problem with simple methods.

Causes

Why do I have this problem? There are many different causes of SI joint pain. Pregnancy may be a factor in the the development of SI joint problems later in life. Also, if a person has one leg is shorter that the other, the abnormal alignment may end up causing SI joint pain and problems. Often, an exact cause leading to a painful SI joint condition can't be found. The joint simply gets painful, and the patient and provider don't have an answer as to why the joint has become painful.

The SI joint is a synovial joint, similar to all joints such as the knee, hip and shoulder. Because of this, different types of arthritis that affect all the joints of the body will also affect the sacroiliac joint. This includes conditions such as rheumatoid arthritis, gout and psoriasis. The joint can be infected when bacteria that travel in the blood settle in the joint causing a condition called septic arthritis. This is perhaps the most worrisome cause of SI joint pain and may well require surgery to drain the infection.



Injury to the SI joint is thought to be a common cause of pain. Injury can occur during an automobile accident. One common pattern of injury occurs when the driver of a vehicle places one foot on the brake before a collision. The impact through the foot on the brake is transmitted to the pelvis causing a twisting motion to this side of the pelvis. This can injure the SI joint on that side resulting in pain. A similar mechanism occurs with a fall on one buttock. The force again causes a twisting motion to the pelvis and may injure the ligaments around the joint.

Symptoms

What does the condition feel like? The most common symptoms from SI joint dysfunction are low back and buttock pain. The pain may affect one side or both SI joints. The pain can radiate down the leg all the way to the foot and may be confused with a herniated disc in the lumbar spine. The pain may radiate into the groin area. People often feel muscle spasm in one or both of their buttocks muscles. Problems with the SI joint may make sitting difficult. Pain in one SI joint may cause a person to sit with that buttock tilted up. It is usually uncomfortable to sit flat in a chair.

Treatment

Nonsurgical Treatment Doctors often begin by prescribing nonsurgical treatment for SI joint dysfunction. In some cases, doctors simply monitor the patient's condition to see if symptoms improve. Anti-inflammatory medications, such as ibuprofen and naproxen, are commonly used to treat the pain and inflammation in the joint. Acetominiphen (for example, Tylenol) can be used to treat the pain, but it will not control the inflammation. Your doctor may ask that you rest your back by limiting your activities. The purpose of this is to help decrease inflammation and calm the muscle spasm. Some patients benefit from wearing a special brace called a sacroiliac belt. This belt wraps around the hips to hold the sacroiliac joint tightly together, which may ease your pain.

Patients often work with a physical therapist. After evaluating your condition, a therapist can assign positions and exercises to ease your symptoms. The therapist may design an exercise program to improve the strength and control of your back and abdominal muscles. Some therapists are trained in manipulative techniques that attempt to treat the pain in this manner. You may be able to learn how to adjust your SI joint yourself and ease the symptoms. If your physical therapist is not trained in manipulation, he/she may be able to suggest a chiropractic physician or osteopathic physician in your area who can provide this treatment.

If conservative treatment is unsuccessful, injections may be suggested by your doctor. As described above, injections are used primarily to confirm that the pain is coming from the SI joint. A series of cortisone injections may be recommended to try to reduce the inflammation in and around the SI joint. Cortisone is a powerful anti-inflammatory medication that is commonly used to control pain from arthritis and inflammation. Other medications have been injected into the joint as well. A chemical called hyaluronic acid has been used for years to treat osteoarthritis of the knee. This chemical is thought to reduce pain due to its lubricating qualities and the fact that it nourishes the articular cartilage in the synovial joints. The true mechanism of action remains unknown, but it has been used with some success in the SI joint. All of these injections are temporary and are expected to last several months at the most.

Another procedure that has been somewhat successful is called radiofrequency ablation. After a diagnostic injection has confirmed that the pain is coming from the SI joint, the small nerves that provide sensation to the joint can be "burned" with a special needle called a radiofrequency probe. In theory, this destroys any sensation coming from the joint, making the joint essentially numb. This procedure is not always successful. It is temporary but can last for up to two years. It can be repeated if needed.



Surgery Surgery may be considered if other treatments don't work. Surgery consists of fusing the painful SI joint. A fusion is an operation where the articular cartilage is removed from both ends of the bones forming the joint. The two bones are held together with plates and screws until the two bones grow together, or fuse, into one bone. This stops the motion between the two bones and theoretically eliminates the pain from the joint. This is a big operation and is not always successful at relieving the pain. The operation is not commonly performed unless the pain is debilitating. SI joint pain is seldom this severe.



Nonsurgical Rehabilitation Doctors often recommend physical therapy for patients with SI joint dysfunction. Patients are normally seen a few times each week for four to six weeks. In severe and chronic cases, patients may need a few additional weeks of care. When movement of a joint is limited, the pain and symptoms of SI joint dysfunction may worsen. Getting more motion can give you the relief you need for daily activities. If you don't have full range of motion, your therapist has several ways to help you get more movement including joint manipulation, stretching, and exercises. Active movement and stretching as part of a home program can also help restore movement and get you better faster. Therapists commonly prescribe a set of stretches to improve flexibility in the muscles of the trunk, buttocks, and thighs. In addition to the treatment you receive by your therapist, you may be given ways to help your own SI joint if your pain returns. These exercises usually require that you position your hip and pelvis in a certain way and either stretch or contract and relax specific muscles. Follow the instructions of your therapist when doing these exercises.

If the SI joint has too much mobility and problems keep coming back, you may need extra help to stabilize the SI joint. You may be issued a SI belt to stabilize the joint. A belt like this can often ease pain enough to let you exercise comfortably. You'll learn some exercises to help you build strength, muscle control, and endurance in the muscles that attach around the SI joint. Unfortunately, few muscles actually connect to both the sacrum and the pelvis. Key muscles to work are the gluteus maximus, as well as the abdominal and low back muscles.

After Surgery You will normally need to wait at least six weeks before beginning a rehabilitation program after having SI joint fusion surgery. You should plan on attending therapy sessions for six to eight weeks. Expect full recovery to take up to six months. During therapy after SI joint surgery, your therapist may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm your pain and muscle spasm. Then you'll begin learning how to move safely with the least strain on the healing area.

As your rehabilitation program evolves, you'll begin doing more challenging exercises. The goal is to safely advance your strength and function. As your therapy sessions come to an end, your therapist helps you get back to the activities you enjoy. Ideally, you'll be able to resume your normal activities. You may need guidance on which activities are safe or how to change the way you go about your activities. When treatment is well under way, regular visits to your therapist's office will end. Your therapist will continue to be a resource. But you'll be in charge of doing your exercises as part of an ongoing home program.

Introduction

Osteoarthritis (OA) is a common problem for many people after middle age. OA is sometimes referred to as degenerative, or wear and tear, arthritis. OA commonly affects the hip joint. In the past, little was done for the condition. Now doctors have many ways to treat hip OA so patients have less pain, better movement, and improved quality of life.



Causes

How does OA develop? OA of the hip can be caused by a hip injury earlier in life. Changes in the movement and alignment of the hip eventually lead to wear and tear on the joint surfaces. The alignment of the hip can be altered from a fracture in the bones around or inside the hip. If the fracture changes the alignment of the hip, this can lead to excessive wear and tear--just like the out-of-balance tire that wears out too soon on your car. Cartilage injuries, infection, or bleeding within the joint can also damage the joint surface of the hip.

Not all cases of OA are related to alignment problems or a prior injury, however. Scientists believe genetics makes some people prone to developing OA in the hip. Scientists also believe that problems in the subchondral bone may trigger changes in the articular cartilage. Normally, the articular cartilage protects the subchondral bone. But some medical conditions can make the subchondral bone too hard or too soft, changing how the cartilage normally cushions and absorbs shock in the joint.

Avascular necrosis (AVN) is another cause of degeneration of the hip joint. In this condition, the femoral head (the ball portion of the hip) looses a portion of its blood supply and actually dies. This leads to collapse of the femoral head and degeneration of the joint. AVN has been linked to alcoholism, fractures and dislocations of the hip, and long term cortisone treatment for other diseases.

Symptoms

What does OA of the hip joint feel like? The symptoms of hip OA usually begin as pain while putting weight on the affected hip. You may limp, which is the body's way of reducing the amount of force that the hip has to deal with. The changes that happen with OA cause the affected hip to feel stiff and tight due to a loss in its range of motion. Bone spurs will usually develop, which can also limit how far the hip can move. Finally, as the condition becomes worse, pain may be present all the time and may even keep you awake at night.

Treatment

Chiropractic plays a critical role in the treatment of hip OA. Hands-on treatments and various types of exercises are used to improve the range of motion in your hip and the nearby joints and muscles. Chiropractic adjustments/manipulations are performed to help restore normal biomechanics to the hip joint. This is where chiropractic manipulation has an advantage over other specialties. It is important to manipulate and stretch capsular joint restrictions during the treatment phase. A primary goal is to help you learn how to control symptoms and maximize the health of your hip. You will learn ways to calm pain and symptoms, which might include the use of rest, heat, electrical muscle stimulation, ultrasound or topical rubs. Range-of-motion and stretching exercises will be used to improve hip motion. You will be shown strengthening exercises for the hip to steady the joint and protect it from shock and stress. We can also suggest tips for getting your tasks done with less strain on the joint.

Many Practitioners frequently overlook the feet when examining the hip. The feet should always be checked for poor or faulty biomechanics. The feet are the foundation of the body and many foot conditions eventually contribute to knee, hip and lower back problems. Orthotics for your shoes and sneakers will have a significant effect in reducing excessive biomechanical forces on the hip. At the Winchester Hospital Chiropractic Center, we can take molds of your feet and fit you for custom made orthotics.

Medical studies have shown that glucosamine and chondroitin sulfate can also help people with OA. These supplements seem to have nearly the same benefits as anti-inflammatory medicine with fewer side affects. Many doctors feel the research supports these supplements and are encouraging their patients to use them.

Introduction

In many areas of the body, muscles and tendons must slide over and against one another during movement. At each of these places, a small sac of lubricating fluid helps the muscles and tendons move properly. Usually these sacs of fluid, called bursae, function to reduce friction, but if they become swollen and irritated they can cause pain.

One common area where this occurs is in the bursa on the outside of the hip, called the trochanteric bursa. This creates a condition known as trochanteric bursitis. This condition is common in older individuals. It may also occur in younger patients who are extremely active in exercises such as walking, running, or biking.



Causes

Why do I have this problem? Sometimes a bursa can become inflamed (swollen and irritated) because of too much friction or because of an injury to the bursa. An inflamed bursa can cause pain because movement makes the structures around the bursa rub agaisnt it. Friction can build in the bursa during walking if the long tendon on the side of the thigh is tight. It is unclear what causes this tightening of the tendon. The gluteus maximus attaches to this long tendon. As you walk, the gluteus maximus pulls this tendon over the greater trochanter with each step. When the tendon is tight, it rubs against the bursa. The rubbing causes friction to build in the bursa, leading to irritation and inflammation. Friction can also start if the outer hip muscle (gluteus medius) is weak, if one leg is longer than the other, or if you run on banked surfaces.

Most cases of trochanteric bursitis appear gradually with no obvious underlying injury or cause. Trochanteric bursitis can occur after artificial replacement of the hip joint or other types of hip surgery. The cause may be a combination of changes in the way the hip works, the way it is aligned, or the way scar tissue has formed from the healing incision.

A fall on the hip can cause bleeding into the bursa. The bleeding is not serious, but the bursa may react to the blood by becoming inflamed. The inflammation causes the bursa to become thickened over time. This thickening, constant irritation, and inflammation may result in the condition becoming chronic, or long lasting.

Symptoms

What does the condition feel like? The first symptom of trochanteric bursitis is usually pain. The pain can be felt in the area of the hip right over the bump that forms the greater trochanter. Eventually the pain may radiate down the outside of the thigh. As the problem progresses, the symptoms include development of a limp when walking and stiffness in the hip joint. Eventually, the pain will also be present at rest and may even cause a problem with sleeping.

Treatment

Trochanteric bursitis is often treated successfully with chiropractic care. Chiropractic adjustments/manipulations are performed to help restore normal biomechanics to the hip joint. This is where chiropractic manipulation has an advantage over other specialties. It is important to manipulate and stretch capsular joint restrictions during the treatment phase. Chiropractors use hands on treatment and stretching to help restore full hip range of motion. Improving strength and coordination in the buttock and hip muscles also enables the femur to move in the socket smoothly and can help reduce friction on the bursa. You may need chiropractic treatments for four to six weeks before full motion and function return.

Younger patients who have this condition because of overuse can usually be treated by reducing their activity or changing the way they do their activity. Combining this with an exercise program of stretching and strengthening and various modalities such as ice, electrical muscle stimulation, heat and ultrasound.

Many Practitioners frequently overlook the feet when examining the hip. The feet should always be checked for poor or faulty biomechanics. The feet are the foundation of the body and many foot conditions eventually contribute to knee, hip and lower back problems. Orthotics for your shoes and/or sneakers will have a significant effect in reducing excessive biomechanical forces on the hip. At the Winchester Hospital Chiropractic Center, we can take molds of your feet and fit you for custom made orthotics.

Introduction

Pain in the buttock that radiates down the leg is commonly called sciatica. The most common cause for sciatica is irritation of the spinal nerves in or near the lumbar spine. Sometimes the nerve irritation is not in the spine but further down the leg. One possible cause of sciatica is piriformis syndrome. Piriformis syndrome can be painful, but it is seldom dangerous and rarely leads to the need for surgery. Most people with this condition can reduce the pain and manage the problem with simple methods, such as physical therapy.



Causes

What causes this problem? The symptoms of sciatica come from irritation of the sciatic nerve. It's still a mystery why the piriformis muscle sometimes starts to irritate the sciatic nerve. Many doctors think that the condition begins when the piriformis muscle goes into spasm and tightens against the sciatic nerve, squeezing the nerve against the bone of the pelvis.



In some cases, the muscle may be injured due to a fall onto the buttock. Bleeding in and around the piriformis muscle forms a hematoma. A hematoma describes the blood that has pooled in that area. The piriformis muscle begins to swell and put pressure on the sciatic nerve. Soon the hematoma dissolves, but the muscle goes into spasm.



The sciatic nerve stays irritated and continues to be a problem. Eventually the muscle heals, but some of the muscle fibers inside the piriformis muscle are replaced by scar tissue. Scar tissue is not nearly as flexible and elastic as normal muscle tissue. The piriformis muscle can tighten up and put constant pressure against the sciatic nerve.

Symptoms

What does the condition feel like? Piriformis syndrome commonly causes pain that radiates down the back of the leg. The pain may be felt only on one side, though it is sometimes felt on both sides. The pain can radiate down the leg all the way to the foot and may be confused for a herniated disc in the lumbar spine. Changes in sensation and weakness in the leg or foot are rare. Some people say they feel a sensation of vague tingling down the leg. Sitting may be difficult. Usually people with piriformis syndrome do not like to sit. When they do sit down, they tend to sit with the sore side buttock tilted up rather than sitting flat in the chair.

Treatment

What treatment options are available? Doctors often begin by prescribing nonsurgical treatment for piriformis syndrome. In some cases, doctors simply monitor their patients' condition to see if symptoms improve. Anti-inflammatory medications, such as ibuprofen and naproxen, are commonly used to treat the pain and inflammation caused by the irritation on the nerve. Acetaminophen (for example Tylenol®) can be used to treat the pain but will not control the inflammation. You'll probably work with a physical therapist. After evaluating your condition, the therapist uses treatments to ease spasm and pain in the piriformis muscle. Exercises, particularly stretching exercises, are given to try and relieve irritation on the sciatic nerve.

If you still have pain after trying these treatments, your doctor may suggest injections.The main use of injections is to see if your pain is from piriformis syndrome. An injection of local anesthetic such as lidocaine can be injected into the muscle to temporarily relax it. This loosens up the muscle and reduces the irritation on the sciatic nerve. Other medications have also been injected into the piriformis muscle. Cortisone, for example, may be mixed with the anesthetic medication to reduce the inflammation on the sciatic nerve. Cortisone is a potent anti-inflammatory medication that is commonly used both in pill form and in injections to treat inflammation.



Botulism injection therapy (also known as Botox® injections) can be used to actually paralyze the piriformis muscle. This makes the muscle relax, which helps take pressure off the sciatic nerve. The effect of the Botox® injection isn't permanent; it generally only lasts a few months. In the meantime, however, it is hoped that a stretching program can be used to fix the problem. In other words, when the injection wears off, the muscle may have been stretched enough so that the symptoms do not return.

Surgery may be considered but usually only as a last resort. There are two procedures in use. The first is to cut the piriformis tendon where it attaches on the greater trochanter (the bump on the side of your hip). The other method is to cut through the piriformis muscle to take pressure off the sciatic nerve. These procedures are usually done on an outpatient basis, meaning that you will be able to go home the same day as the surgery. In some cases, you may need to stay in the hospital for one night. Both procedures can be done under general anesthesia or under a spinal type of anesthetic. The surgeon begins by making a small incision, usually about three inches long, in the buttock. The fibers of the gluteus maximus, the largest buttock muscle, are split. This gives the surgeon a way to see deep into the buttock and locate the piriformis muscle. When the piriformis muscle and tendon can be seen, the surgeon then cuts (releases) the tendon where it connects to the greater trochanter. If more room is needed to release the pressure on the nerve, a portion of the piriformis muscle may be removed. This usually doesn't cause problems with strength because there are several much stronger muscles that help turn the leg outward.



Nonsurgical Rehabilitation Most patients with piriformis syndrome work with a physical therapist. Plan to attend physical therapy sessions two to three times each week for six to eight weeks. Your therapist begins by evaluating your condition. This includes attention to the low back, as well as the sacroiliac and hip joints. Physical therapy treatments for piriformis syndrome often begin with heat applications. Heat is used to help the piriformis muscle relax, easing spasm and pain. Your physical therapist may place a hot pack over your buttocks muscle.

Ultrasound is another treatment choice that can be set for deep heating in the buttock area. Ultrasound uses high frequency sound waves that are directed through the skin. The deep heating effect of ultrasound is ideal for preparing the piriformis muscle for hands- on forms of treatment and for getting the muscle to stretch out.

Hands-on treatments such as deep massage and specialized forms of soft-tissue mobilization may be used initially. Your therapist may also position your hip and leg in a way that helps to relax nerve signals to the piriformis. The keystone treatment for piriformis treatment is stretching. Stretching is especially effective following heat and hands on treatments. Your therapist will position you in ways that help you get a good stretch on the piriformis muscle. Along with the stretches you'll do in the clinic, you'll be shown several ways to stretch the muscle on your own. You need to do your stretches every few hours. Be gentle and cautious as you stretch to avoid overdoing it. As your symptoms ease, your therapist will gradually advance your program to include posture training, muscle strengthening, and general conditioning.

Introduction

Sciatica sufferers often have severe pain along the sciatic nerve path, usually in the back of the leg and thigh, sometimes to the ankle, foot, and toe(s). There may be searing, sharp pain but also paresthesias or strange nerve feelings such as pins and needles, burning, tingling, prickling, sensations or tenderness--that may be felt. Ironically, with all the pain and nerve sensations, the leg might feel numb! To complicate matters, the location of sciatic pain may vary. It is usually in the back of the legs or thighs, in some individuals pain is in the front or side of the legs. This may mean your lower disc has been damaged or become inflammed. The sciatic nerve itself may also be inflamed or irritated.

Generally, in the initial stage of this condition the first thing to develop is back pain. Often, a minor stretch or bend in the wrong direction will bring on the "attack". Usually, this is a movement that is just the "straw that breaks the camel's back". In other words, you have a pre- existing problem that is suddenly made serious by this improper motion. Not all leg pain is sciatica, but most all sciatica involves leg pain.

Causes

Like most other conditions, sciatica has a wide variety of causes. Unlike most other conditions, however, this health problem's link to the spinal column is often very obvious. A misaligned spine, a bulging, inflamed or protruded disc, can irritate the sciatic nerve which may result in sciatica. Often, spasm of a small muscle in the gluteal area (the piriformis) due to overstretching or abnormal posture will cause sciatica.

Symptoms

The quality of the pain may vary as well. There may be constant pain but then it may let up for hours or even days. The intensity may vary, it may ache, or be knife-like. Sometimes postural movements like lying down or changing positions, affect the pain and sometimes they don't. In this way, sciatica is like a toothache or earache, always there no matter what you do. In severe cases, sciatica causes a loss of reflexes or even a shrinking of the calf and or thigh muscles. To sciatica sufferers, a good night's sleep may be a thing of the past. Simple things like walking, bending, turning, sitting, or standing can be difficult or impossible.

Introduction

Osteoarthritis (OA) is a common problem for many people after middle age. OA is sometimes referred to as degenerative, or wear and tear, arthritis. OA commonly affects the knee joint. In fact, knee OA is the most common cause of disability in the United States. In the past, people were led to believe that nothing could be done for their problem. Now doctors have many ways to treat knee OA so patients have less pain, better movement, and enhanced quality of life.



Causes

How does OA develop? OA of the knee can be caused by a knee injury earlier in life. It can also come from years of repeated strain on the knee. Fractures of the joint surfaces, ligament tears, and meniscal injuries can all cause abnormal movement and alignment, leading to wear and tear on the joint surfaces. Not all cases of knee OA are related to a prior injury, however. Scientists believe genetics makes some people prone to developing degenerative arthritis. Obesity is linked to knee OA, and losing only ten pounds can reduce the risk of future knee OA by 50 percent.

Scientists believe that problems in the subchondral bone may trigger changes in the articular cartilage. Normally, the articular cartilage protects the subchondral bone. But some medical conditions can make the subchondral bone too hard or too soft, changing how the cartilage normally cushions and absorbs shock in the joint.

Symptoms

What does OA of the knee feel like? OA develops slowly over several years. The symptoms are mainly pain, swelling, and stiffening of the knee. Pain is usually worse after activity, such as walking. Early in the course of the disease, you may notice that your knee does fairly well while walking, then after sitting for several minutes your knee becomes stiff and painful. As the condition progresses, pain can interfere with simple daily activities. In the late stages, the pain can be continuous and even affect sleep patterns.

Treatment

Chiropractic treatment plays a critical role in the treatment of knee OA. A primary goal is to help you learn how to control symptoms and maximize the health of your knee. You will learn ways to calm pain and symptoms, which might include the use of rest, heat, or topical rubs. Chiropractic adjustments/manipulations are performed to help restore normal biomechanics to the knee joint. This is where chiropractic manipulation has an advantage over other specialties. It is important to manipulate and stretch capsular joint restrictions during the treatment phase. This helps improve normal motion and keeps the joint lubricated. Modalities such as ice, electrical muscle stimulation, ultrasound and heat may also be used to decrease pain and inflammation.

Range-of-motion and stretching exercises will be used to improve knee motion. You will be shown strengthening exercises for the hip and knee to help steady the knee and give additional joint protection from shock and stress. People with knee OA who have strong leg muscles enjoy fewer symptoms and prolong the life of their knee joint. Your therapist will also suggest tips for getting your tasks done with less strain on the joint.

You will learn ways to calm pain and symptoms, which might include the use of rest, heat, ice or topical rubs. Range-of-motion and stretching exercises will be used to improve hip motion. You will be shown strengthening exercises for the hip to steady the joint and protect it from shock and stress. We can also suggest tips for getting your tasks done with less strain on the joint.

Many Practitioners frequently overlook the feet when examining the hip. The feet should always be checked for poor or faulty biomechanics. The feet are the foundation of the body and many foot conditions eventually contribute to knee, hip and lower back problems. Orthotics for your shoes and sneakers will have a significant effect in reducing excessive biomechanical forces on the hip and the shock-absorbing component will reduce impact and protect the joint. People who walk regularly are encouraged to choose a soft walking surface, such as a cinder or grass track. At the Winchester Hospital Chiropractic Center, we can take molds of your feet and fit you for custom made orthotics. OA can't be cured, but therapies are available to ease symptoms and to slow down the degeneration. Recent information shows that mild cases of knee OA may be maintained and in some cases improved without surgery. Medical studies have shown that glucosamine and chondroitin sulfate can also help people with OA. These supplements seem to have nearly the same benefits as anti-inflammatory medicine with fewer side affects. Many doctors feel the research supports these supplements and are encouraging their patients to use them.

Dr. Zohn and Dr. Kane will teach their patients how to protect the arthritic knee joint. This starts with tips on choosing activities that minimize impact and twisting forces on the knee. People who modify their activities can actually slow down the affects of knee OA. For instance, people who normally jog might decide to walk, bike, or swim to reduce impact on their knee joint. Sports that require jumping and quick starts and stops may need to be altered or discontinued to protect the knee joint.

A new type of knee brace, called a knee unloading brace, can help when OA is affecting one side of the knee joint. For example, a bowlegged posture changes the way the knee joint lines up. The inside (medial) part of the knee joint gets pressed together. The cartilage suffers more damage, and greater pain and problems occur. The unloading brace pushes against the outer (lateral) surface of the knee, causing the medial side of the joint to open up. In this way, the brace shares the pressure and unloads the arthritic medial side of the joint. A knee unloading brace can help relieve pain and allow people to do more of their usual activities. For some cases of knee OA, you may be given a heel wedge to wear in your shoe. By tilting the heel, the wedge alters the way the knee lines up, which works like the unloading brace mentioned above to take pressure off the arthritic part of the knee.

Introduction

Iliotibial band (ITB) syndrome is an overuse problem that is often seen in bicyclists, runners, and long-distance walkers. It causes pain on the outside of the knee just above the joint. It rarely gets so bad that it requires surgery, but it can be very bothersome. The discomfort may keep athletes and other active people from participating in the activities they enjoy.



Causes

How does ITB syndrome develop? The ITB glides back and forth over the lateral femoral condyle as the knee bends and straightens. Normally, this isn't a problem. But the bursa between the lateral femoral condyle and the ITB can become irritated and inflamed if the ITB starts to snap over the condyle with repeated knee motions such as those from walking, running, or biking.

People often end up with ITB syndrome from overdoing their activity. They try to push themselves too far too fast and end up running, walking, or biking more than their body can handle. The repeated strain causes the bursa on the side of the knee to become inflamed. Some experts believe that the problem happens when the knee bows outward. This can happen in runners if their shoes are worn on the outside edge, or if they run on slanted terrain. Others feel that certain foot abnormalities, such as foot pronation, cause ITB syndrome. (Pronation of the foot occurs when the arch flattens).

Recently, health experts have found that runners with a weakened or fatigued gluteus medius muscle in the hip are more likely to end up with ITB syndrome. This muscle controls outward movements of the hip. If the gluteus medius isn't doing its job, the thigh tends to turn inward. This makes the knee angle into a knock-kneed position. The ITB becomes tightened against the bursa on the side of the knee. This is also called a valgus deformity of the knee. People with bowed legs may also be at risk of developing ITB syndrome. The outward angle of the bowed knee makes the lateral femoral condyle more prominent and can make the snapping worse. This condition is also called a varus deformity of the knee.



Symptoms

What does ITB syndrome feel like? The symptoms of ITB syndrome commonly begin with pain over the outside of the knee, just above the knee joint. Tenderness in this area is usually worse after activity. As the bursitis grows worse, pain may radiate up the side of the thigh and down the side of the leg. Patients sometimes report a snapping or popping sensation on the outside of the knee.

Treatment

Most cases of ITB syndrome respond very well to chiropractic treatment and usually require only 4-6 weeks of care. Chiropractic doctors will make sure the joints in the entire lower extremity are functioning and moving properly. This includes checking your feet, ankles, knee and hip. We want to identify the cause of you pain, not just treat the symptoms. Chiropractic adjustments/manipulations are performed to help restore normal biomechanics to the feet, ankles, hips and knee joint. This is where chiropractic manipulation has an advantage over other specialties. It is important to manipulate and stretch capsular joint restrictions during the treatment phase. This helps improve normal motion and promotes proper biomechanics as well as keeping the joint lubricated. Modalities such as ice, electrical muscle stimulation, ultrasound and heat may also be used to decrease pain and inflammation.

Stretching and strengthening exercises may be used in combination with a knee brace, kneecap taping, or shoe inserts to improve muscle balance and joint alignment of the hip and lower limb. We will ask you about your sport activities and may give you tips on your warm up and training schedule, footwear, and choices of terrain. You should be able to return to normal activity within four to six weeks. You may will most likely need to be working with your chiropractor during this time. A key element of treatment is your training schedule. We can work with you to adjust the distance you run, your footwear, and the running surfaces you choose.

Foot orthotics may be recommended to improve foot and lower limb alignment. Wearing orthotics in your shoes may be allow you to resume normal walking immediately, but you should probably cut back on more vigorous activities for several weeks to allow the inflammation and pain to subside. Strengthening and stretching exercises are chosen to correct muscle imbalances, such as weakness in the gluteus medius muscle or tightness in the iliotibial band. Treatments such as ultrasound, friction massage, and ice may be used to calm inflammation in the ITB. Chiropractic treatment sometimes includes iontophoresis, which uses a mild electrical current to "push" anti-inflammatory medicine to the sore area.

Introduction

Prepatellar bursitis is the inflammation of a small sac of fluid located in front of the kneecap. This inflammation can cause many problems in the knee.



Causes

How does prepatellar bursitis develop? Bursitis is the inflammation of a bursa. The prepatellar bursa can become irritated and inflamed in a number of ways. In some cases, a direct blow or a fall onto the knee can damage the bursa. This usually causes bleeding into the bursa sack, because the blood vessels in the tissues that make up the bursa are damaged and torn. In the skin, this would simply form a bruise, but in a bursa blood may actually fill the bursa sack. This causes the bursa to swell up like a rubber balloon filled with water. The blood in the bursa is thought to cause an inflammatory reaction. The walls of the bursa may thicken and remain thickened and tender even after the blood has been absorbed by the body. This thickening and swelling of the bursa is referred to as prepatellar bursitis.

Prepatellar bursitis can also occur over a longer period of time. People who work on their knees, such as carpet layers and plumbers, can repeatedly injure the bursa. This repeated injury can lead to irritation and thickening of the bursa over time. The chronic irritation leads to the same condition in the end--prepatellar bursitis.

The prepatellar bursa can also become infected. This may occur without any warning, or it may be caused by a small injury and infection of the skin over the bursa that spreads down into the bursa. In this case, instead of blood or inflammatory fluid in the bursa, pus fills it. The area around the bursa becomes hot, red, and very tender.

Symptoms

What does prepatellar bursitis feel like? Prepatellar bursitis causes pain and swelling in the area in front of the kneecap and just below. It may be very difficult to kneel down and put the knee on the floor due to the tenderness and swelling. If the condition has been present for some time, small lumps may be felt underneath the skin over the kneecap. Sometimes these lumps feel as though something is floating around in front of the kneecap, and they can be very tender. These lumps are usually the thickened folds of bursa tissue that have formed in response to chronic inflammation.

The bursa sack may swell and fill with fluid at times. This is usually related to your activity level, and more activity usually causes more swelling. In people who rest on their knees a lot, such as carpet layers, the bursa can grow very thick, almost like a kneepad in front of the knee. Finally, if the bursa becomes infected, the front of the knee becomes swollen and very tender and warm to the touch around the bursa. You may run a fever and feel chills. An abscess, or area of pus, may form on the front of the knee. If the infection is not treated quickly, the abscess may even begin to drain, meaning the pus begins to seep out.

Treatment

Chronic prepatellar bursitis is can be a real nuisance. Chronic prepatellar bursitis will usually improve over a period of time from weeks to months with proper treatment. The fluid-filled sack is not necessarily a problem, and if it does not cause pain, it is not always a cause for alarm or treatment. The sack of fluid may come and go with variation in activity. This is normal. The swelling and tenderness often gets in the way of kneeling and causes pain. For people who do things requiring kneeling, this creates a hardship both in their occupation and recreational activities. Treatment usually starts by trying to control the inflammation and determining what has caused the problem in the first place. This may include a short period of rest or possibly a brace to immobilize the knee. A knee pad may be useful in making it easier to kneel on the affected knee. People with jobs that require them to be on their knees frequently should probably consider knee pads before the problem starts.

Chiropractors will often use heat, ice, and ultrasound to help calm the pain and swelling. We may also instruct you in specialized stretching and strengthening exercises used in combination with a knee brace, taping of the patella, or shoe inserts. These exercises and aids are used to improve muscle balance and joint alignment of the hip and lower limb, easing pressure and problems in the bursa. The feet should always be checked for poor or faulty biomechanics. The feet are the foundation of the body and many foot conditions eventually contribute to knee, hip and lower back problems. Orthotics for your shoes and sneakers will have a significant effect in reducing excessive biomechanical forces on the knee. At the Winchester Hospital Chiropractic Center, we can take molds of your feet and fit you for custom made orthotics.

It is imperative that we make sure that there is no infection. If an infection is found to be causing the prepatellar bursitis, the bursa will need to be drained with a needle--perhaps several times over the first few days. If this is the case, we will refer you to an orthopedist for drainage and possible antibiotics. The body will absorb the some of the blood in the bursa over several weeks, and the bursa should return to normal.

Introduction

The big group of muscles and tendons in the back of your thigh are commonly called the hamstrings. Injuries in this powerful muscle group are common, especially in athletes. Hamstring injuries happen to all types of athletes--from Olympic sprinters to slow-pitch softball players. Though these injuries can be very painful, they will usually heal on their own. But for an injured hamstring to return to full function, it needs special attention and a specially designed rehabilitation program.

Causes

How do hamstring injuries occur? Hamstring injuries happen when the muscles are stretched too far. Sprinting and other fast or twisting motions with the legs are the major cause of hamstring injuries. Hamstring injuries most often occur in running, jumping, and kicking sports. Water skiing, dancing, weight lifting, and ice-skating also cause frequent hamstring injuries. These sports are also more likely to cause avulsions.

The major factors in hamstring injuries are low levels of fitness and poor flexibility. Children very seldom suffer hamstring injuries, probably because they are so flexible. Muscle fatigue and not warming up properly can contribute to hamstring injuries. Imbalances in the strength of different leg muscles can lead to hamstring injuries. The hamstring muscles of one leg may be much stronger than the other leg, or the quadriceps muscles on the front of the thigh may overpower the hamstrings.

Symptoms

What does a hamstring injury feel like? Hamstring injuries usually occur during heavy exercise. In especially bad cases, an athlete may suddenly hear a pop and fall to the ground. The athlete may be able to walk with only mild pain even in a severe injury. But taking part in strenuous exercise will be impossible, and the pain will continue.

In less severe cases, athletes notice a tight feeling or a pulling in their hamstring that slows them down. This type of hamstring injury often turns into a long-lasting problem. The hamstring may be pulled, partially torn, or completely torn. The injury can happen at the musculotendinous junction (mentioned earlier), within the muscle, or where the tendon connects on the ischial tuberosity (avulsion). In the rare case of a complete tear, the pain is excruciating. The torn tissues may form a hard bunch in the back of the thigh when the leg is bent. The skin may also bruise, turning purple from bleeding under the skin. This is not necessarily dangerous but can look somewhat alarming.



Treatment

Chiropractors who treat a lot of athletes see may patients with hamstring injuries. For minor muscle pulls, you may need two to four weeks to safely get back to your activities. For more severe muscle tears, you may need chiropractic rehabilitation for two to three months, with complete healing occurring by four to six months. It is very important to treat and rehabilitate your hamstring injury correctly. Incomplete or improper healing makes re-injury much more likely. For the first three to five days after the injury, the main goal of treatment is to control the swelling, pain, and hemorrhage (bleeding). Hamstring injuries are initially treated using the RICE method. RICE stands for rest, ice, compression, and elevation.

A good chiropractic doctor will examine the entire kinetic chain that is look at your feet, knees, hips, pelvis and lower back. Small muscle imbalances, poor posture, faulty running biomechanics, joint restrictions at the knee and hip can all contribute to hamstring injuries. If these are not corrected, the problem will keep returning.

Chiropractic adjustments/manipulations are performed to help restore normal biomechanics to these areas. This is where chiropractic manipulation has an advantage over other specialties. Research has shown that after a spinal manipulation is performed at to the low back, there is an increase of strength of the quadriceps and hamstrings. This is due to stimulation of the nerve supply to those muscles. Custom made orthotics may also be prescribed for your shoes to help support the arches of your feet and correct poor biomechanics.

RICE - Rest, Ice, Compression, Elevation Rest is critical. Your chiropractic doctor may recommend a short period (up to one week) of immobilization. Severe tears may require a longer period of rest. This may mean you spend most of your time lying down. You may need to use crutches to get around. If you put too much weight on your hamstring after an injury, more damage may occur and more scar tissue may form. Ice applied to the injured hamstring controls swelling and pain but doesn't stop it completely. This is important because your body's inflammatory response actually helps your muscles heal. Cold treatments slow the metabolism and blood flow in the area. Cold also reduces your sensations of pain by numbing the nerves. And experiencing less pain helps you relax, reducing muscle spasms. A plastic bag full of ice cubes or crushed ice, held on with an elastic bandage, is the most effective type of cold treatment. The ice should be kept on the injury for twenty to thirty minutes. You can also use cold gel packs, chipped ice, or cold sprays. Cold treatments should be repeated at least four times a day for the first two to three days. They can be done as often as every two hours if needed. Compression can help reduce the bleeding in your muscle to limit swelling and scarring. To apply compression, your doctor may suggest that you wrap your hamstring firmly in an elastic bandage. It is unclear exactly how effective compression is in hamstring injuries, but patients often report having less pain with the wrap. Elevation can help reduce swelling. It also keeps your leg immobilized. The key to elevation is to raise and support the injured body part above the level of the heart. In the case of a hamstring injury, this requires lying down and supporting the leg up on pillows.

As your hamstrings begin to heal, it is critical that you follow an exercise program to regain your strength and mobility. Specially designed exercises encourage your body to rebuild muscle instead of scar tissue. The exercises also help prevent re-injury. Rehabilitation can be slow, so you will need to be patient and not push yourself too hard or too fast.

Early in your chiropractic rehabilitation, exercises may be done in a swimming pool or on a stationary bike set to low resistance. These exercises allow you to take your hamstrings through a range of motion without having to hold up your weight. When you can walk without a limp and feel very little tenderness, you can start a walking program. Eventually you can work up to jogging.

Stretching will be a key feature of your rehabilitation program. You will be shown how to stretch. Plan to continue these stretches even after you heal, because a re injury of the same hamstring is common. Increasing your flexibility may help you avoid another hamstring injury in the future. It is important that you maintain good flexibility to keep your hamstrings healthy.

Strengthening exercises usually begin with isometric exercises. These exercises involve contracting the muscles without moving your leg joints. As your hamstrings get stronger, light weights are used. It is important that you feel no pain during these exercises.

You should maintain your general level of fitness throughout your rehabilitation. We can suggest workouts that don't stress your hamstrings. Most hamstring injuries get better with treatment. Even world-class athletes with severe hamstring injuries are usually able to return to competition. By keeping the hamstrings flexible and giving the body time to heal, you should be able to return to the activities you enjoy.

Introduction

The patella, or kneecap, can be a source of knee pain when it fails to function properly. Alignment or overuse problems of the patella can lead to wear and tear of the cartilage behind the patella. This produces pain, weakness, and swelling of the knee joint. Several different problems can affect the patella and the groove it slides through in the knee joint. These problems can affect people of all ages.



Causes

How do these problems develop? Problems commonly develop when the patella suffers wear and tear. The underlying cartilage begins to degenerate, a condition sometimes referred to as chondromalacia patella. Wear and tear can develop for several reasons. Degeneration may develop as part of the aging process--like putting a lot of miles on a car. The patellofemoral joint is usually affected as part of osteoarthritis of the knee. One of the more common causes of knee pain is a problem in the way the patella tracks within the femoral groove as the knee moves. The quadriceps muscle helps control the patella so it stays within this groove. If part of the quadriceps is weak for any reason, a muscle imbalance can occur. When this happens, the pull of the quadriceps muscle may cause the patella to pull more to one side than the other. This in turn causes more pressure on the articular cartilage on one side than the other. In time, this pressure can damage the articular cartilage.

A similar problem can happen when the timing of the quadriceps muscles is off. There are four muscles that form the quadriceps muscle group. As mentioned earlier, the vastus medialis oblique (VMO) is one of these four muscles. The VMO is the section of muscle on the inside of the front of the thigh. The vastus lateralis (VL) runs down the outside part of the thigh. People with patellofemoral problems sometimes have problems in the timing between the VMO and the VL. The VL contracts first--before the VMO. This tends to pull the patella toward the outside of edge of the knee. The result is abnormal pressure on the articular surface of the patella.

Another type of imbalance may exist due to differences in how the bones of the knee are shaped. These differences, or anatomic variations, are something people are born with. Some people are born with a greater than normal angle where the femur and the tibia (shinbone) come together at the knee joint. Women tend to have a greater angle here than men. The patella normally sits at the center of this angle within the femoral groove. When the quadriceps muscle contracts, the angle in the knee straightens, pushing the patella to the outside of the knee. In cases where this angle is increased, the patella tends to shift outward with greater pressure. This leads to a similar problem as that described above. As the patella slides through the groove, it shifts to the outside. This places more pressure on one side than the other, leading to damage to the underlying articular cartilage.

Finally, anatomic variations in the bones of the knee can occur such that one side of the femoral groove is smaller than normal. This creates a situation where the groove is too shallow, usually on the outside part of the knee. People who have a shallow groove sometimes have their patella slip sideways out of the groove, causing a patellar dislocation. This is not only painful when it occurs, but it can damage the articular cartilage underneath the patella. If this occurs repeatedly, degeneration of the patellofemoral joint occurs fairly rapidly.

People who have a high-riding patella are also at risk of having their patella dislocate. In this condition, called patella alta, the patella sits high on the femur where the groove is very shallow. Here the sides of the femoral groove provide only a small barrier to keep the high-riding patella in place. A strong contraction of the quadriceps muscle can easily pull the patella over the edge and out of the groove, leading to a patellar dislocation. Patella alta is most common in girls, especially those who have generalized laxity (looseness) in their joints.

Symptoms

What do patellar problems feel like? When people have patellofemoral problems, they sometimes report a sensation like the patella is slipping. This is thought to be a reflex response to pain and not because there is any instability in the knee. Others report having pain around the front part of the knee or along the edges of the kneecap. These symptoms may be due to problems with the way the patella lines up in the femoral groove. But symptoms of patellar pain can happen even when the patella appears to be lined up properly.

Patellofemoral problems exist when there is damage to the articular cartilage underneath the patella. This does not necessarily mean that the knee will be painful. Some people never have problems. Others experience vague pain in the knee that isn't centered in any one spot. Sometimes pain is felt along the inside edge of the patella, though it may be felt anywhere around or behind the patella. Typically, people who have patellofemoral problems experience pain when walking down stairs or hills. Keeping the knee bent for long periods, as in sitting in a car or movie theater, may cause pain.

The knee may grind, or you may hear a crunching sound when you squat or go up and down stairs. If there is a considerable amount of wear and tear, you may feel popping or clicking as you bend your knee. This can happen when the uneven surface of the underside of the patella rubs against the femoral groove. The knee may swell with heavy use and become stiff and tight. This is usually because of fluid accumulating inside the knee joint, sometimes called water on the knee. This is not unique to problems of the patella but sometimes occurs when the knee becomes inflamed.

Treatment

The initial treatment for a patellar problem begins by decreasing the inflammation in the knee. Chiropractic treatment can help in the early stages by decreasing pain and inflammation. We may use ice massage, electrical muscle stimulation, patellar mobilization maneuvers and ultrasound to limit pain and swelling.

A good chiropractic doctor will examine the entire kinetic chain, that is, look at your feet, knees, hips, pelvis and lower back. Small muscle imbalances, poor posture, faulty running biomechanics, joint restrictions at the knee and hip can all contribute to patellofemoral problems. If these are not corrected, the problem will keep returning. Chiropractic adjustments/manipulations are performed to help restore normal biomechanics to these areas. This is where chiropractic manipulation has an advantage over other specialties.

Bracing or taping the patella can help you to do exercises and activities with less pain. Most braces for patellofemoral problems are made of soft fabric, such as cloth or neoprene. You slide them onto your knee like a sleeve. A small buttress pads the side of the patella to keep it lined up within the groove of the femur. An alternative to bracing is to tape the patella in place. The chiropractor applies and adjusts the tape over the knee to help realign the patella. The idea is that by bracing or taping the knee, the patella placed in better alignment within the femoral groove. This in turn is thought to improve the pull of the quadriceps muscle so that the patella stays lined up in the groove. Patients report less pain and improved function with these forms of treatment. As the pain and inflammation become controlled, your chiropractic doctor will work with you to improve flexibility, strength, and muscle balance in the knee.

Patients with patellofemoral problems may benefit from four to six weeks of chiropractic care. The aim of treatment is to calm pain and inflammation, to correct muscle imbalances, and to improve function of the patella. Muscle imbalances are commonly treated with stretching and strengthening exercises. Flexibility exercises are often designed for the thigh and calf muscles. Guided exercises are used to maximize control and strength of the quadriceps muscles.

Your chiropractor may issue a knee brace or instruct you how to apply tape to your knee. We may also cast your foot for special shoe inserts, called orthotics, to improve knee alignment and function of the patella. This will help reduce some of the excessive forces being transmitted to the knee and knee cap (patella).