Sunday, February 22, 2009

Aggravating activities in chronic low back ache are not specifically directional !!!

Classifiable self reported aggravating activities in chronic low back ache are: aggravation in flexion, extension or unilateral bending. Wand BM et al tried to find do the self-reported aggravating activities of people with chronic non-specific low back pain move the spine in a consistent direction? In an observational study they found there is no evidence for the existence of a consistent direction of spinal movement during the self-reported aggravating activities of people with chronic non-specific low back pain. Participants in this study were described as demonstrating a directional pattern if all three self-reported aggravating activities moved the spine in the same direction.

Result of the study by Wand BM et al:
In their study over 148 participants with three classifiable aggravating activities they found:
1. Only 47 (32%) demonstrated a directional pattern. And out of them
2. 46 (98%) demonstrated a flexion pattern and
3. 1 (2%) an extension pattern.
They have also asserted the observed incidence of a directional pattern in the three self-reported aggravating activities of the 148 participants (32%) was no different from what would have been expected by chance.

The self-reported aggravating activities of people with chronic non-specific low back pain do not involve consistent directions of spinal movement: an observational study. Wand BM et al, Aust J Physiother. 2009;55(1):47-51.

Friday, February 20, 2009


See the sagittal image downloaded from google image:

My comments on the image:

1. The slice taken is passing through mid way between two vertebral bodies i.e. passing through the middle of the transverse foramina.
2. look at the inverted triangle- that is the TS of spinal cord.
3. look at the two arms of the triagle- they are the two spinal roots.
4. look at the angle of the triangle from which the roots are coming you can see black dots on a white back ground. That portion is the area that shows TS of roots that are going to exit on levels below.

Mixed nerves carrying all fibers i.e. sensory, motor & autonomic fibers can be entrapped here by posterior or posterior-lateral disc prolapses.

Automomic fibers control many visceral functions. At lumbar level they control functions of bowel & bladder. Autonomic inputs to control peripheral vascular tone in the lower limb also pass through the lumbar spine.

There are evidences that tell us that; by graded mobilizations the mechanical impacts of local venous congestion caused by discogenic or spondylogenic pathology are reduced. And many more neurophysiological effects occur (I have described in one of my priious blogs). The question is as physios do we influence autonomic nervous system functioning by spinal mobilization technique? Physiotherapeutic management of lumbar disorders often utilises specific segmental joint mobilisation techniques; however, there is only limited evidence of any neurophysiological effects and much of this has focused on the cervical spine and upper limbs.

A randomized placebo controlled trial carried out by Jo Perry and Ann Green was published in Manual Therapy, 2008, 13(6), 492-499. This study aims to extend the knowledge base underpinning the use of a unilaterally applied lumbar spinal mobilisation technique by exploring its effects on the peripheral sympathetic nervous system (SNS) of the lower limbs. SNS activity was determined by recording skin conductance (SC) obtained from lower limb electrodes.

Their findings indicated that there was a significant change in skin conductance from baseline levels (13.5%) that was specific to the side treated for the treatment group during the intervention period (compared to placebo and control conditions).

This study provides preliminary evidence that a unilaterally applied postero-anterior mobilisation technique performed, at a rate of 2 Hz, to the left L4/5 lumbar zygopophyseal joint results in side-specific peripheral SNS changes in the lower limbs.


Manual Therapy, 2008, 13(6), 492-499

How clinical tests are tested:

The clinical tests are tested on the following criteria:

1. Generally accepted criteria for reproducibility (inter- and intra-observer reliability and agreement).

2. Construct validity.

3. Responsiveness.

4. Feasibility.

Thursday, February 19, 2009

5-cervical clinimetric tests:

1. Muscle endurance of short neck flexors

This test was first described by Grimmer, and several modifications have been described since then.
Test position: The patient in supine position. The modified test position is crook lying.
Subjects are instructed to "tuck in their chins" (craniocervical flexion) and then to raise their heads. The time between assuming the test position until the chin begins to thrust is measured in seconds with a stopwatch.
Modification of the original test by Grimmer: In these modifications, the starting position for the test is different (crook lying) and the examiners monitor the chin tuck and occipital position.

2. Manual muscle testing

Test position: Test is performed without head support, prone for extensors and supine for flexors. Manual resistance is applied and strength is graded.
Grade 1= enable to maintain position against gravity. ……..
Grade 5= maintaining position against full manual resistance.

3. Craniocervical flexion test

Patient position: patient in a supine position.
Upper cervical flexion is measured with an inflatable pressure biofeedback unit placed behind the neck, with the patient in a supine position.
The subject slowly performs an upper cervical flexion without flexion of the mid and lower cervical spine. The test can be scored in two ways. Activation score is the maximum pressure achieved and held for 10 seconds.
A performance index is calculated by multiplying pressure increases from baseline (20 mm Hg) by the number of successfully completed 10-second holds.

4. Dynamometry

Isometric cervical muscle strength measurements can be measured with dynamometric instruments that use integrated strain gauges or a load cell and microprocessor. Results are presented in Newton.
These instruments can measure neck flexion and rotation, using three different kinds of instruments, a Penny and Giles hand-held myometer, a portable dynamometer and a modified Sphygmomanometer dynamometer.

5. Functional lifting tests

There are two different performance tests, the PILE test and the timed weighted overhead test.
PILE test:
In the PILE test, subjects are instructed to lift weights in a plastic box from waist to shoulder (0.76–1.37 m). After four lifting movements, the weight is increased.
Timed weighted overhead test:
In the timed weighted overhead test, subjects are asked to raise their arms above their heads. They are then instructed to thread a rope with their hands through links of a chain with 5-pound cuff weights attached to each wrist.

Clinimetric evaluation of methods to measure muscle functioning in patients with non-specific neck pain

Panjabi et al estimated that the neck musculature contributes about 80% to the mechanical stability of the cervical spine, while the osseoligamentous system contributes the remaining 20%.
Evidences suggest that patients with neck pain have
1. Reduced maximal isometric neck strength and endurance capacity.
2. Further in patients with chronic neck pain jerky and irregular cervical movements and poor position sense acuity have been found.

Exercises are commonly used to improve neck muscle function and thereby decrease pain or other symptoms. Evaluating the progress of neck muscle function during treatment requires tests which can be carried out easily and meet certain standards for clinimetric properties.

Chantal HP de Koning et al of Netherlands did a review to provide information for researchers and clinicians to facilitate choices amongst existing instruments to measure neck muscle functioning in patients with neck pain. Following are their conclusions:

1. The choice of a test (or instrument) depends on the kind of muscle function to be evaluated.
2. The muscle endurance of the short neck flexors and the cervical PILE test were found to have sufficient reliability.

They recommend using the muscle endurance for short neck flexors, that is patients are instructed to raise their head in a crook-lying position with monitoring of the chin tuck by the musculoskeletal practitioner, and using the cervical PILE test as a performance test.

What is PILE test: PILE is the short form of progressive iso-inertial lifting evaluation (PILE) test.
About the research carried out by Chantal HP de Koning et al:
Chantal HP de Koning et al did a critical analysis of the research literature on the clinimetric properties of tests to measure neck muscle strength or endurance in patients with non-specific neck pain, which can be used in daily practice.
How they did it?
They did a literature search of Medline, CINAHL and Embase databases from 1980 to January 2007. Two reviewers independently assessed the clinimetric properties of identified measurement methods, using a checklist of generally accepted criteria for reproducibility (inter- and intra-observer reliability and agreement), construct validity, responsiveness and feasibility.
The search identified a total of 16 studies.
What are clinimetric tests: The tests that measure something in clinical settings. In this particular instance i.e. in this paper by Chantal HP de Koning et al cervical muscle function tests are discussed.
The instruments or tests included were:
1. muscle endurance tests for short neck flexors,
2. craniocervical flexion test with an inflatable pressure biofeedback unit,
3. manual muscle testing of neck musculature,
4. dynamometry
5. functional lifting tests (the cervical progressive iso-inertial lifting evaluation (PILE) test and the timed weighted overhead test).

Wednesday, February 18, 2009

Frozen Shoulder Update

Various stretches have been introduced for the posterior shoulder; however, little quantitative analysis to measure stretching of the posterior capsule has been performed. Which further implies the biomechanical impacts of the stretching on the joints would vary. That further implies that the out comes on joint mobility of a stiff joint are different.

In clinical setting we want quick and more importantly less painful techniques that are easy to administer by the therapist. I personally have utilized the cyriax’s capsular stretching methods for a decade now. I am currently working on modified techniques of my own. To improve the hand behind the back my personal favorite is mulligan’s technique. However I have modified that too in my own way.

Currently I am treating 7-8 frozen shoulders a day in my clinic. Personal satisfaction is what I cherish most. But with satisfaction there comes dissatisfaction; I hope that’s true for any clinician who understands his patient’s plethora of suffering. I feel dissatisfaction also sometime erupts out of failure to provide adequate relief in few patients wihich acts as an impetus for furthering my current clinical knowledge. So I am in the constant look out for such papers that have a immediate clinical application.

I found one paper by Tomoki Izumi et al titled “Stretching Positions for the Posterior Capsule of the Glenohumeral Joint Strain Measurement Using Cadaver Specimens” published in AMERICAN JOURNAL OF SPORTS MEDICINE.

The summery of that paper is as follows:

According to the authors hypothesis, the current shoulder stretching program is not sufficient to stretch the entire posterior capsule.

Hence a controlled laboratory study using cadaver specimens was designed by the authors. They used 8 fresh-frozen cadaver shoulders (average age, 82.4 years), 8 stretching positions for the posterior capsule were simulated by passive internal rotation.

Stretching positions of 0°, 30°, 60°, and 90° of elevation in the scapular plane; 60° of flexion; 60° of abduction; 30° of extension; and 60° of flexion and horizontal adduction were adopted. Strain was measured in the upper, middle, and lower parts of the capsule.
They found:
1. Increase in strains of the upper, middle, and lower capsule with internal rotation at 0°, 30°, and 60° of elevation were statistically significant, respectively (P < .01). Other shoulder positions demonstrated no positive strain values.

2. Based on the results of this cadaver study, large strains on the posterior capsule of the shoulder were obtained at a stretching position of 30° of elevation in the scapular plane with internal rotation for the middle and lower capsule, while a stretching position of 30° of extension with internal rotation was effective for the upper and lower capsule.

Tuesday, February 17, 2009

rotator cuff update

An investigation of supraspinatus tendon samples obtained from patients undergoing arthroscopic repair of a rotator cuff tear revealed:

1. Cartilage-like changes in rotator cuff. According to the researchers stress-shielded and transversely-compressed side of the enthesis of the rotator cuff has a distinct tendency to develop cartilage-like or atrophic changes in response to the lack of tensile load. The formation of cartilage-like changes in the enthesis in many ways can be considered a physiological adaptation to the compressive loads.

2. Rotator cuff tendons also show frequently marked changes on articular side of the rotator cuff under arthroscopic vision.
3. Over a long period, this process (described above) may develop into a primary degenerative lesion in that area of the tendon.

4. According to the authors these above 3 points explains well why the tendinopathy is not always clearly activity related, and can be strongly correlated with age.

5. The authors due to above said reason authors have emphasized rotator cuff injuries to be considered as an ”underuse” injury rather than an overuse injury as a result of stress-shielding.

6. The authors also revealed another grave picture in rotator cuff tendon tears. According to them, tendon changes are not only localized at the site of rupture, but also in the macroscopic intact tendon portion.

7. Finally authors have found a correlation of plasma glucose levels in non diabetic patients with rotator cuff tear. Normal, but in the high range of normal, increasing plasma glucose levels may be a risk factor for rotator cuff tear.

Comments of Karim Khan in British journal of sports medicine

Fatness affects the overall oxygen delivery to working tissues but not fitness

I have grown up as a sports physiotherapist reading clinical sports medicine by Brukner & Khan. Till now this book is sort of bible to me. i am fascinated by the book and more by the author's ability to express terse subjects in explicit yet digestible manner.

when i saw a article by Karim Khan in British journal of sports medicine, i was quite eager to know what is it all about. it was fitness of fat people. Few important points are as follows:

1. changes in fitness & changes in fatness may not go side by side:
Aerobic fitness is the overall ability of the cardio-respiratory system to transport litres of oxygen to the working tissues. Any accumulation of body fat reduces the utility of this transport in terms of daily activities (including treadmill running).

To take a practical example, a man with a body mass of 70 kg and an aerobic fitness of 3.5 l/min has a relative VO2max of 50ml/[kg.min]. If that same person accumulates an extra 14 kg of body fat, the aerobic fitness may remain at 3.5 l/min. but the relative VO2max decreases to 41.7 ml/[kg.min].

Hence Units of oxygen transport can not be used to distinguish the importance of changes in fitness relative to changes in fatness.
To my experience changes in fitness precedes changes in fatness in many people under my weight loss regime especially in long term weight loss modules. Even there is non-significant weight loss there is significant changes in fitness parameters especially in aerobic fitness parameters both at physiological & biochemical fronts.

2. weight loss may not be the factor that is responsible for change in BP in a hypertensive overweight or obese going through exercises.
Exercises is prescribed as anti-hypertensive therapy. Many physicians prefer to prescribe exercises to overweight & obese hypertensive patients. However is important to determine whether an improvement of condition following exercise prescription is due to an increase in aerobic fitness, or whether it simply reflects a reduction in body fat content.

A review of 61 studies of training-induced changes in resting blood pressure concluded that any reduction in resting pressures could not be attributed to concomitant weight loss, since the changes in systolic and diastolic readings showed very small and statistically non-significant correlations with changes in body mass.

I have vividly discussed issues like this in my book "A concise text book for the management of the overweight & obese". This book was released this republic day (Jan 26) in a state level program. please have a look. for further inquiry contact:

0091-0674-2436217 (9 am-12 noon, 6pm-8pm on working days only)

Monday, February 16, 2009

The way I treat my Bell's Palsy cases

Bells palsy is a LMN type of lesion of facial nerve. usually theere is a compressive pathology i.e. a oedema withing the outlet of facial nerve in the mastoid canal. the muscles of one side of the face are flaccid.

In many of my patients i found the following history:

Travel in bus or car for a long journey, with cold air hitting the affeted side face. i few cases patients repot of taking icecream & ear-ache.

some common suspected causes are:

- virus

- compression of nerve

- bacteria

- drugs

- cold temperature

- trauma of the facial nerve

- Pressure of facial nerve due to tumor

As a physical therapist i recommend a 21 day physical therapy course consising of following treatment modalities (i dont how many of these modalities are evidence based but i have been using them for at least 10 years now):

1. Facial Massage for 5-10 minutes twice a day in a chin - forehead direction to maintain the tone.

2. Infrared on the affected side to increase the blood supply and decrease skin resistance before ES application/ i many cases i chose monode SWD in subthermal doses.

3. Electrical Nerve Stimulation application to the nerve and muscle (i go for galvanic stimulation rather than faradic stimulation 5-10 mins with rectangular pulses).

4. Patient Education and advice. Patient should lie down at intervals to reduce the effects of gravity upon the paralyzed muscle. The eye should be blinked regularly because the blink reflex is lost.

5. The most important of all is Facial Exercise. following are some facial exercises i tell my patients:

- Closing eyelids

- Frowning

- Expression of surprise

- Wrinkling of the nose

- Pursing of the lips

- Compresses the cheek against the teeth

- Blowing

- Smiling

- uttering vowels in loud voice.

That’s it.. My patient was just treated for 3 weeks.

Sunday, February 15, 2009

A Simple Review of Shin Splint

MTSS is the short form of medial tibial stress syndrome which is an advanced medical terminology used to describe a group of exercise induced leg pain. Shin splint is one of the exercise induced leg pain. In the following article we will discuss about shin splints.
Ways shin splint presents:
1. Compartment Syndrome: Where an increase in pressure in certain muscles can cause extreme pain and decreases in circulation to the leg.
2. Tendonitis/Periostitis: Abnormal strain placed on the muscles, tendons, and on the covering around the bone that the tendon is attached to.
3. Stress Fractures: When exposed to increased strain and fatigue, minute fractures may result in the bones of the lower leg.
Contributing factors:
• Poor walk/run mechanics
• Inadequate calf flexibility
• Inadequate strength of the dorsi-flexors (muscles of the front of the lower leg)
• A rapid increase in mileage or frequency of aerobic classes
• Poor or worn out footwear
Symptoms include:
• Pain – usually on the inside of the shin bone (tibia) extending over a length of 10-20cm. The pain is usually of gradual onset, and worst with running.
• If you have focal pain (i.e. all the pain is over a 1-2cm area) then it is possible you have a stress fracture, rather than periostitis.
• If your pain is concentrated in the muscles rather than the bone-muscle junction, then it is possible you have compartment syndrome.
Signs include:
• Tenderness – along a 10-20cm length of the inner border of the tibia if it is periostitis. Focal tenderness where a tender spot can be located to one palpating finger on the sore spot is suggestive of a stress fracture. Diffuse muscle tenderness is present in the case of compartment syndrome.
• Hopping on the injured leg is relatively pain free in the case of periostitis, but is very painful if a stress fracture is present.
• Over-pronating flat feet (pronated calcanium) are commonly seen in those who complain of shin splint pain.
Usually none are required. If a stress fracture is suspected, then an x-ray may confirm this if symptoms have been present for longer than a month. Otherwise, a bone scan is needed. Compartment pressure studies can help confirm a diagnosis of compartment syndrome.
• First aid – an ice pack or ice massage can be helpful after painful activity.
• Mechanical correction of over-pronating feet is essential. A podiatry referral is recommended.
• Physiotherapy, including myofascial release and a muscle rehabilitation problem is useful.
• Surgery is only required for confirmed compartment syndrome or very severe cases of periostitis lasting many months.
A special sports medicine treatment prospective:
1. Proper shoe selection
2. Laser/Ultrasound
3. Ice
4. Rest
5. Elevation
6. Cross training (ie.if you are in a running sport try rollerblading, cycling, swimming for your fitness to give the running muscles a break
7. Gait or Running analysis (seek help from a Physiotherapist or orthotist who has a specialized training in looking for biomechanical faults in your running technique)
8. Physiotherapy/Massage
9. After the symptoms have decreased a slow build-up of strength of the muscles of the front of the shin especially in their lengthened position is imperative for preventing a reoccurrence
10. Although a difficult muscle to stretch, the muscles can be stretched at the front of the shin by kneeling on the top of the affected foot for a 30 second hold repeating three times (see diagram). Simple ankle circles can also be very helpful for warming up the shin. Calf stretches are important to decrease the resistance to contracting for the muscles on the front of the shin.
11. Tennis requires a lot of stopping and starting and change of direction which results in rapid lengthening and shortening of the muscles and structures on the front of the shin. In the off season it is beneficial to set up a little obstacle course in your gym. It should include a variation of forward, backward, and sideways running and cutting gradually increasing speed and the duration of the work-out. This type of training requires a good warm-up and at least 48 hours recovery time between sessions
ALWAYS seek medical care within 5 days of onset if not resolving with mileage reduction, ice, and stretching.

Recovery time:
Average recovery time is 2-4 weeks for periostitis, 6-8 weeks for stress fracture and several months for compartment syndrome.
Recovery sequence:
• Step 1 Ice packs, pain relief, felt or orthotic footwear correction.
• Step 2 Myofascial release and muscle rehabilitation.
• Step 3 Continue swimming and cycling, and only restart running after at least two weeks when symptoms have settled. Start on grass initially.
• Step 4 Build up pace and add stop-start routines.
• Step 5 Run figure eights.
• Step 6 Perform cutting and turning exercises.
• Step 7 Team training and skill sessions.
• Step 8 Resume playing, half a game at first.

Saturday, February 14, 2009

The place of Physioanatomic Imaging Approach in treatment of LS spine disorders:

The following should be an algorithmic approach of clinicians working with LS spine disorders.

1. Patient symptoms and history must be evaluated by use of a pain drawing and information sheet.
2. The patient's pain pattern is categorized into a nonspecific pattern or into one of four recognizable pathway patterns (radicular, dorsal ramus, polyneuropathy, and sympathetic). Because each spinal lesion is typically manifested primarily via one of the four symptom pathways, the distribution of expected symptoms from each pathologic feature can be compared with the patient's pain drawing.
3. The patient's presenting symptoms are also used to determine the most cost-effective and efficacious use of initial diagnostic imaging evaluation.
4. In a minority of patients the findings on noninvasive imaging either will not correlate with the patient's symptoms or will demonstrate multiple abnormalities that could account for the patient's symptoms. In these patients, invasive techniques are extremely helpful in defining a pain generator or pain generators.
5. Finally an assessment of the significance of imaged lesions can be made.
What is Physioanatomic (noninvasive and invasive) imaging evaluation?
The goal of physioanatomic (both noninvasive and invasive) imaging evaluation is to increase specificity by differentiating pain generators from asymptomatic underlying pathologic conditions.
Noninvasive Physioanatomic imaging:
1. computed tomography,
2. single-photon emission-computed tomographic bone scan, and
3. magnetic resonance imaging
The above said 3 tests have sigificant diagnostic accuracy in detecting pathologic conditions.
Invasive Physioanatomic imaging:
1. diskography-enhanced computed tomography
2. nerve root block
3. facet block
The physioanatomic imaging approach:
The physioanatomic imaging approach attempts to correlate pathologic changes demonstrated by noninvasive imaging modalities or invasive modalities with the patient's symptoms to evaluate whether the symptoms and the pathologic lesion are concordant or discordant.
The outcome of physioanatomic imaging approach
When used with intensive conservative management and psychologic testing, this physioanatomic approach has been reported to result in much better treatment outcomes.
Impact on disease detection physioanatomic imaging approach:
1. Identification of a 50% prevalence of underlying abnormalities in patients between 20 and 60 years old who have no symptoms.
2. When such patients (as above) have a back injury, subsequent imaging show 50% of population studied abnormalities that are not related to an acute injury.
3. Degeneration of the spine progresses in all patients throughout their lifetime, and nearly all of the population will have back discomfort at some time.
Luers PR; Curr Probl Diagn Radiol. 1992 Sep-Oct;21(5):151-213. Lumbosacral spine imaging: physioanatomic method.

will you succeed in treating a cervical redicuopathy?

while a patent is under your care (physiotherapy) you can know with certain conviction whether the patient is going to improve or not.

variable for the prediction:

According to Cleland, J.A et al the following cluster of variables as most significant:

  • Age of less than 54 years
  • Dominant arm not affected
  • Looking down does not worsen symptoms
  • Multimodal treatment (manual therapy, cervical traction, deep neck flexor strengthening for at least 50% of visits)


1. Having three of the four variables present led to an 85% posttest probability the patient would experience short-term success.

2. Having all four variables present were associated with a 90% post-test probability.

8- Clinical tests for testing rotator cuff tears

3 most encountered rotator cuff pathology are: bursitis, partial-thickness rotator cuff tear, and full-thickness rotator cuff tear. The following eight clinical tests were examined:

* Neer impingement sign
* Hawkins-Kennedy impingement sign
* Painful-arc sign
* Supraspinatus muscle strength test
* Infraspinatus muscle strength test
* Speed test
* Cross-body adduction sign
* Drop-arm sign

watch the following site for details:

Thursday, February 12, 2009

Sports Shoes. Elementary considerations of sports shoes: part I

Different sports have different shoes. For example horse riding & ballet dance shoes are different that of running or football shoes. This following topic is written with reference to running & sports requiring similar shoes.
Athletic running sports shoes bring automatically an idea that they are soft on feet & absorb shock. However, Withnall R et al studying on army recruits reported similar rates of lower limb injuries were for all insoles (shock absorbing and non-shock absorbing) in a randomized controlled trial. The trial provides no support for a change in policy to the use of shock absorbing insoles for military recruits (4).
To clarify this ambiguity we found an opportunity to write an article is to assist in understanding athletic footwear. In addition, the various components of a typical athletic shoe are described, including the upper, the midsole/outsole. Hence let us review the parts of a sports shoe.
Parts of a sports shoe:

1. Upper
2. Insert
3. Midsole
4. Outsole

The upper: hold the midsole and outsole to the bottom of the foot. Upper provides upper as well as enhancing the flexibility, stability and support functions.
The insert: It influences the overall fit since it helps position the arch support. The need for, placement and inclusion of arch support systems varies greatly relative to gender, age, foot size, and arch type. It also is dependent on the sport and activity level of the athlete. An important modification of the insert is a shoe orthotics. This is a custom made insert that is designed to make up for structural problems in the foot. These structural problems might be genetic, or the result of chronic injuries.
The midsole: The midsole is the shoe's cushioning system. In early athletic shoes, especially in running shoes, midsoles didn't really exist. Not until an athlete with an interest in shoe design started thinking about running shoes and how they could be improved to reduce injuries and allow for more training did the invention of the midsole as we know it exist. We see today midsole "innovations" in every type of shoe from walking to basketball. The innovations range from improved foam midsoles to complicated air and fluid systems. Hence as a whole the midsole provides stability, flexibility, cushioning & durability.
The outsole: The main function of the outsole is to provide traction as well as to reduce wear on the midsole thereby increasing the overall durability of the shoe. Early outsole units were made of leather or rubber. They were later modified according to the athlete's need. For example, early running shoes used for track events could best be described as leather shoes with nails driven through them. Today, the outsoles for track shoes have plastic plates molded into them that allow a runner to change the spikes.Traction relative to specific movements in sports like basketball is provided by running vs. pivoting, type of surface as frictional needs differ, depending on the movement, in different areas of the outsole. An improved understanding of shoe-surface interactions remains a critical need to improve the design of shoe-surface combinations with the goal of meeting player needs while minimizing injury potential (3).

There are various models of athletic shoes & it is extremely difficult for the clinician to maintain a database of current shoe models and features. McPoil TG has stressed the importance of the clinician providing the athlete a list of footwear features and components based on their particular foot classification or problem, rather than attempting to recommend a specific model of athletic shoe. A detailed explanation of these features is provided to assist the practitioner in helping the athlete select the most appropriate shoe (1).

According to Reinschmidt C et al many investigations in the area of sport shoe research have shown that subject-specific responses can be expected. Different groups of athletes may require different types of shoes. The definition of these grouping characteristics and their design needs seem to be the most important challenge for the sport shoe researchers and manufacturers for the near future.


1. McPoil TG; J Sci Med Sport. 2000 Sep;3(3):260-7.
3. Livesay GA; Am J Sports Med. 2006 Mar;34(3):415-22. Epub 2006 Jan 6
4. Withnall R et al ; J R Soc Med. 2006 Jan;99(1):32-7.

Sports Shoes. Prominent injuries by sports shoes (Evidences only): part II

Though improper sports shoes could have a direct relationship with sports injuries, there are not many direct evidences that link sports shoes to a particular kind of sports injuries. We analyzed the recent evidences from the year 1994-2008 from PUBMED with the key word “sports shoes” AND “sports injuries”. In a recent research it was found no increased incidence of ankle sprains is associated with shoe design in collegiate basketball players (2). How ever this finding is hard to believe in every sporting scenario. Taunton JE et al found running shoe age were associated with injury. Knee was the most injured joint found in the study however the sports shoes are not incriminated in all cases of injuries(3). Similarly according to Milburn PD et al literature related to footwear design and injury prevention in most sports played on natural turf is limited (5).

Following are few direct evidence we found in above said search criteria:

According to Van Mechelen there are many associations between running injuries and many factors such as warm-up and stretching exercises, body height, malalignment, muscular imbalance, restricted range of motion, running frequency, level of performance, stability of running pattern, shoes and inshoe orthoses and running on 1 side of the road remains unclear or is backed by contradicting or scarce research findings (9).

Wilk BR et al reported in a single case study that defective running shoes as a incriminating contributing factor in plantar fasciitis of a triathlete. They found manufacturing defect which possibly contributed to the development of plantar fasciitis.

According top Frey C causal factors associated with stress fractures include training errors, exercise surfaces, footwear, and anatomic abnormalities. It is only logical to think that footwear can play an important role in the development and treatment of stress fractures because it plays a important role in foot loading, structure, and stability which have a significant impact on the development of stress fractures (6).

Injury to the anterior tibial tendon, extensor hallucis longus, extensor communis tendons, or dorsalis pedis artery, vein, and nerve are known as "boot-top" injuries. Boot-top tendon lacerations in ice hockey are common. But it is not clear that "boot-top" injuries are caused by shoes. However, according to Simonet WT "boot-top" injuries should be preventable if equipment is worn properly.

According to Robbins et al athletic footwear are associated with frequent injury that are thought to result from repetitive impact. No scientific data suggest they protect well. Expensive athletic shoes are deceptively advertised to safeguard well through "cushioning impact", yet account for 123% greater injury frequency than the cheapest ones (2).

Comments of Tancred B in the following article is unavailable in PUBMED
“Footwear: the hidden component in sporting injuries? A commentary”.

1. Wilk BR; J Orthop Sports Phys Ther. 2000 Jan;30(1):21-8; discussion 29-31.
2. Robbins S; J Athl Train. 2008 May-Jun;43(3):230-3
3. Taunton JE et al; Br J Sports Med. 2003 Jun;37(3):239-44.
4. Robbins S et al; Br J Sports Med. 1997 Dec;31(4):299-303.
5. Milburn PD et al ; Sports Med. 1998 May;25(5):319-27.
6. Frey C; Clin Sports Med. 1997 Apr;16(2):249-57.
7. Tancred B; Am J Phys Med Rehabil. 1996 Jan-Feb;75(1):66-7.
8. Simonet WT et al; J Trauma. 1995 Jan;38(1):30-1.
9. Van Mechelen; Sports Med. 1992 Nov;14(5):320-35.

Sports Shoes. Protective aspect of sports shoes & current concepts: part III

1. The protective function of sports shoes.
The shoe can be thought of as a powerful tool for controlling human movement. A well-designed shoe can assist in reducing the number of lower limb injuries arising from sport and training activities (9).
Barnes RA et al reviewed the types of injury acquired by sportsmen in both training and playing is then followed by a discussion of aspects of footwear design and their role in both contributing to and preventing lower limb injury. Finally, the paper considers support and shock absorption techniques in the context of footwear design (9).
Working on hip injuries Paluska recommends; coaches, trainers and medical personal who care for runners should advocate running regimens, surfaces, shoes, technique and individualised conditioning programmes that minimise the risk of initial or recurrent hip injuries (5). Running shoes are designed specifically for different foot types in order to reduce injuries. Running in the correct footwear matched for foot type may have a greater influence on mechanics when runners become exerted (4).
Butler RJ et al evaluated changes in kinematics and kinetics over the course of a prolonged run when low (LA) and high (HA) arched runners wear motion control and cushioning shoes. They found, in LA runners, MC shoes decreased tibial internal rotation compared to CT shoes over the course of a prolonged run. In HA runners, running in the CT shoes reduced tibial shock compared to the MC shoes (4).
A study by Larsen et al shows that it may be possible to prevent certain musculoskeletal problems in the back or lower extremities among military conscripts by using custom-made biomechanic shoe orthoses (6).
According to Thecker et al the most encouraging evidence for effective prevention of shin splints involves the use of shock-absorbing insoles (7).
van der Putten EP et basing on a biomechanical analysis, came up with a different approach to shoe design specifically for mountain climbing. They recommended
1. Regional thinning of the sole, which allows easy flexion and extension of the toes.
2. That the form of the shoe should conform to the natural form of the foot & the shoe closure should provide a close fit for feet with width differences of up to 20 mm. Further they developed a shoe-sizing system.
After testing the prototypes they concluded that the new shoe design can contribute to the prevention of foot injuries and deformations in sport climbing (8).
Lake MJ reviewed the typical biomechanical approaches used to identify protection offered by sports footwear during dynamic activities
Lake MJ recommended
1. Subject tests should be used in combination with standard mechanical techniques to evaluate footwear protection.
2. Impact attenuation characteristics of footwear during sporting activities were most distinguished by analysis of tibial shock signals in the frequency and joint time-frequency domains.
3. Lateral stability and traction properties of footwear are better assessed using game-like manoeuvres of subjects on the actual sporting surface.
Advances in tools allowing measurement of dynamic foot function inside the shoe also aid our assessment of shoe protective performance. In combination, these newer approaches should provide more information for the design of safer sports footwear (1).

Current issues in the design of running and court shoes:
2. a. Energy aspects:
Sport shoes can have an influence on the energetics of human movement. The two main aspects where sport shoes can play a role are in maximizing the energy which is returned to the athlete and minimizing the energy which is lost by the athlete. Maximum values of energy storage in a shoe sole are on the order of 10 J. However, not all of this energy is returned to the athlete as shoe midsoles lose approximately 30% of the energy input (2).
Strategy to minimize energy loss include (1) reducing the mass of the shoe, (2) using appropriate midsole materials which dissipate unwanted vibrations, (3) implementing constructions which improve the stability of the ankle joint and (4) increasing the bending stiffness of shoe midsoles which reduces the energy lost at the metatarso-phalangeal joint (2).
b. Performance aspects:
Depending on the movement, energy return form the sports shoe sometimes occurs at the wrong time, frequency, location and in the wrong direction which compromises the ultimate influence on improving performance. As a result, the actual influence that energy return has on performance is probably minimal (2).
Energy that has not been lost for tasks not directly related to the actual performance may be applied to the movement and may result in an increase of athletic performance. Stefanyshyn DJ et al have proposed that athletic footwear can have a much larger influence on performance by minimizing the energy which is lost as opposed to maximizing the energy which is returned.
3. Current concepts of sports shoe design:
Three most important functional design factors for sport shoes: injury prevention, performance and comfort. For running shoes, pronation control and cushioning are still considered to be the key concepts for injury prevention despite the fact that conclusive clinical and epidemiological evidence is missing to show the efficacy of these design strategies. Several design features have been proposed to be effective in controlling the amount of pronation. However, the kinematic effects of such features seem to be subject-specific and rather small especially when looking at the actual skeletal motion.
Recent running shoe research suggests that cushioning may not or only marginally be related to injuries and that cushioning during the impact phase of running may be more related to aspects such as comfort, muscle tuning or fatigue.
For court shoes, lateral stability, torsional flexibility, cushioning and traction control appear to be important design strategies to decrease the risk of injury. For court shoes, optimal traction seems to be the key factor for performance. Research in the area of shoe comfort is still sparse.
With respect to running performance, the shoe concepts of weight reduction, efficiency and energy return are important (as discussed above). The concept of energy return does not seem to be a feasible concept whereas concepts which aim to minimize energy loss appear to be more promising and successful, e.g. weight reduction, reduction of muscle energy required for stabilization.
Cushioning, fitting and climate concepts appear to improve the comfort of both running and court shoes.
1. Lake MJ; Ergonomics. 2000 Oct;43(10):1610-21.
2. Stefanyshyn DJ et al; Sportverletz Sportschaden. 2000 Sep;14(3):82-9.
3. Reinschmidt C; Sportverletz Sportschaden. 2000 Sep;14(3):71-81.
4. Butler RJ; Gait Posture. 2007 Jul;26(2):219-25. Epub 2006 Oct 20.
5. Paluska SA; Sports Med. 2005;35(11):991-1014.
6. Larsen K; J Manipulative Physiol Ther. 2002 Jun;25(5):326-31.
7. Thecker SB; Med Sci Sports Exerc. 2002 Jan;34(1):32-40.
8. van der Putten EP et al; Appl Ergon. 2001 Aug;32(4):379-87.
9. Barnes RA; J Sports Sci. 1994 Aug;12(4):341-53.

Monday, February 9, 2009

Review of Labral Tears of shoulder

The glenoid labrum of the shoulder has extensive anatomic variation but appears to be important for contributing to shoulder stability and for increasing the depth of contact between the glenoid labrum and the humeral head. Tears of the labrum are commonly seen in association with other pathologic entities, such as instability and rotator cuff tears, and treatment of the labral pathology may be incidental to treatment of the other more significant pathology. However, conditions isolated to the labrum do occur and can be a significant source of shoulder problems. Effective treatment of these lesions may result in significant improvement in the patient's symptoms (4).
Labral lesions are difficult to diagnose, and special diagnostic studies and, frequently, arthroscopy are required. How much we can rely on clinical tests is a question. Shoulder complaints are frequently recurrent. Instability might cause some of these complaints (3). History taking and clinical tests are commonly used to diagnose shoulder pain. It is unclear, whether tests and history accurately diagnose instability or intra-articular pathology (IAP) (3).
3 different tests designed specifically to detect superior labral anterior posterior lesions (the resisted supination external rotation test, the crank test, and the active compression test) (2).
Luime JJ et al analyzed the accuracy of clinical tests and history taking for shoulder instability or IAP. They suggested, best evidence supports the value of the relocation and anterior release tests. Symptoms related to IAP (labral tears) remain unclear. Most promising for establishing labral tears are currently the biceps load I and II, pain provocation of Mimori, and the internal rotation resistance strength tests (3).

The resisted supination external rotation test (RSER), helps for the diagnosis of superior labral anterior posterior lesions of the shoulder. RSER test by re-creating the peel-back mechanism, the resisted supination external rotation test is more accurate than 2 other commonly used physical examination tests designed to diagnose superior labral anterior posterior tears in overhead-throwing athletes (2).
The SLAP test: (SLAP apprehension test) is performed by suddenly internally rotating the shoulder as the shoulder is adducted 300 in 900 of forward flexion. A positive test is noted with clicking in the shoulder and/or pain radiating down the biceps tendon or in the posterior aspect of the joint.
Crank Test: To identify a labral tear, Liu and colleagues described the crank test, executed by internal and external rotation of the shoulder in maximum forward flexion, with an axial load along the humerus. Although the numbers of patients in their study is insufficient to test the validity of the test, they found that six patients who had positive crank tests all had labral tears, and no patient with a negative crank test had a labral tear.
OBriens Test: O'Brien's active compression test was primarily developed for assessment of Acromioclavicular joint pathology following a patient's demonstration of what reproduced their shoulder pain. O'Brien noted in a series of patients it was also excellent for detecting labral pathology.
The patient is instructed to flex their arm to 90° with the elbow fully extended and then adduct the arm 10-15°medial to sagittal plane. The arm is then maximally internally rotated and the patient resists the examiner's downward force. The procedure is repeated in supination. The O'Brien Test is designed to maximally load and compress the ACJ and superior labrum. For maximal results the authors stress that the patient should resist the examiner's downward force rather than the examiner resisting forward flexion.

The O'Brien and crank tests were not sensitive clinical indicators for detecting glenoid labral tears and other tears of the anterior and posterior labrum. Results were often falsely positive for patients with other shoulder conditions, including impingement or rotator cuff tears (5).

What if the clinician suspects a labrum lesion but could not clinically rely on the clinical test?:
However, lesions of the superior labrum are complex and difficult to both diagnose and treat effectively. The clinical diagnosis is challenging due to the nonspecific history and physical examination. MRI has substantially improved our ability to detect SLAP tears, although experience is necessary to distinguish pathologic findings from normal anatomic variants. Treatment is determined by patient age, functional demands, and the type of lesion identified (1).

1. Bedi A et al; Clin Sports Med. 2008 Oct;27(4):607-30
2. Myers TH et al; Am J Sports Med. 2005 Sep;33(9):1315-20. Epub 2005 Jul 7.
3. Luime JJ et al; JAMA. 2004 Oct 27;292(16):1989-99
4. Rames RD et al; Orthop Clin North Am. 1993 Jan;24(1):45-53.
5. Stetson WB et al; Am J Sports Med. 2002 Nov-Dec;30(6):806-9.

Discussion of Mechanisms Of Maual Therapy

Mechanisms of Manual Therapy:

This article is taken from an article in Manual Therapy by Joel Bialosky and associates from the University of Florida. The article provides a framework of manual therapy that has yet to be previously defined to this degree.

How manual therapy works is more controversial than the procedures. Convictions differ considerably about proposed mechanisms for manual therapy among the clinicians, teachers & peers. However,in generic terms, now a days it is believed that the identification and correction of biomechanical faults within the musculoskeletal system leads to the clinically found effects. The peer reviewed literatures are proving us insights into what really happens when manual therapy is done. However with emerging evidences, it is gradually becoming clearer that manual techniques are more than correcting upslips and stretching joint capsules etc. Bialosky et al has proposed five potential mechanisms reponsible for manual therapy.
Mechanical Stimuli: Our hands are capable of inducing temporary mechanical changes within connective tissue, but the lasting effects are still uncertain. We have seen positive effects from our manual techniques and assumed a mechanical response to our mechanical technique, but it may not be that simple.

Neurophysiological Mechanism: There is clearly an interaction between the peripheral and central nervous systems during manual therapy. Hypoalgesia and changes in sympathetic activity following joint mobilization technique have been consistently documented in recent literature. Notably the changes in pain threshold and sympathetic activity often occur distant to the site of the manual technique. Something within the patient is clearly interested in what we do!

Peripheral Mechanism: Local tissue injury sets off a cascade of events both near and far within the body. Manual therapy has been recently shown to reduce inflammatory chemicals such as cytokines and substance P along with increasing systemic opioid release. The "good feelings" associated with manual therapy have often been attributed to correction of mechanical faults, but peripheral mechanisms may provide a more reasonable description the therapeutic effect.

Spinal Mechanisms: Renown pain physiotherapist David Butler refers to the spinal cord as an amplifier for sensory modalities. Manual interventions have been recently implicated in modifying both afferent and efferent activity within the spinal column. The bottom line is that the spinal column isn't simply a conduit, but an active participant in determining the effects of manual care.
Supraspinal Mechanisms: Admit it. There have been times where we've thought privately that a condition or response to treatment was "all in the patient's head". Turns out there may be more truth to this statement than we'd previously imagined. Recent animal and human studies implicate specific regions of the brain in mediating the pain experience. Moreover psychosocial factors such as patient expectation and placebo are very likely to affect the outcome of our manual intervention.


The following painful conditions & injuries may happen in bicyclists. The conditions described below are cephalo-caudally (head to toe) on not on prevalence rates.

1. Neck pain
2. Back pain
3. Shoulder pain
4. Wrist pain
5. Handlebar palsy
6. Groin injuries- saddle sore, chafing, pudendal neuropathy, male impotence, female uvula trauma etc
7. Patello-femoral joint pain (knee cap pain)
8. Foot & ankle paresthesia (numbness in foot & ankle)
9. Metatarsalgia (present as toe pain & numbness)
10. Achilles tendonitis (presents as heel cord pain)
11. Planter fasciitis (presents as heel pain)

Friends, in the next part we will discuss how these injuries are caused by riding a bicycle.

Saturday, February 7, 2009

treatment of CRPS

How is Complex Regional Pain Syndrome Treated?

Because there is no cure for complex regional pain syndrome, treatment is aimed at relieving painful symptoms so that people can resume their normal lives. The following therapies are often used: • Physical therapy: A gradually increasing physical therapy or exercise program to keep the painful limb or body part moving may help restore some range of motion and function.
• Psychotherapy: Complex regional pain syndrome often has profound psychological effects on people and their families. Those with complex regional pain syndrome may suffer from depression, anxiety, or post-traumatic stress disorder, all of which heighten the perception of pain and make rehabilitation efforts more difficult.
• Sympathetic nerve block: Some patients will get significant pain relief from sympathetic nerve blocks. Sympathetic blocks can be done in a variety of ways. One technique involves intravenous administration of phentolamine, a drug that blocks sympathetic receptors. Another technique involves placement of an anesthetic next to the spine to directly block the sympathetic nerves.
• Medications: Many different classes of medication are used to treat complex regional pain syndrome, including:
• topical analgesic drugs that act locally on painful nerves, skin, and muscles
• antiseizure drugs
• antidepressants
• corticosteroids
• opioids
However, no single drug or combination of drugs has produced consistent long-lasting improvement in symptoms.
• Surgical sympathectomy: The use of surgical sympathectomy, a technique that destroys the nerves involved in complex regional pain syndrome, is controversial. Some experts think it is unwarranted and makes complex regional pain syndrome worse; others report a favorable outcome. Sympathectomy should be used only in patients whose pain is dramatically relieved (although temporarily) by selective sympathetic blocks.
• Spinal cord stimulation: The placement of stimulating electrodes next to the spinal cord provides a pleasant tingling sensation in the painful area. This technique appears to help many patients with their pain.
• Intrathecal drug pumps: These devices administer drugs directly to the spinal fluid, so that opioids and local anesthetic agents can be delivered to pain-signaling targets in the spinal cord at doses far lower than those required for oral administration. This technique decreases side effects and increases drug effectiveness.
What is the Prognosis of Complex Regional Pain Syndrome?
The prognosis for complex regional pain syndrome varies from person to person. Spontaneous remission from symptoms occurs in certain people. Others can have unremitting pain and crippling, irreversible changes in spite of treatment. Some doctors believe that early treatment is helpful in limiting the disorder, but this belief has not yet been supported by evidence from clinical studies. More research is needed to understand the causes of complex regional pain syndrome, how it progresses, and the role of early treatment.

Complex Regional Pain Syndrome- CRPS

What is Complex Regional Pain Syndrome (CRPS)?
Complex regional pain syndrome (CRPS) is a chronic pain condition that is believed to be the result of dysfunction in the central or peripheral nervous systems. Older terms used to describe complex regional pain syndrome are:
• reflex sympathetic dystrophy syndrome (RSDS)
• causalgia

Causalgia was a term first used during the Civil War to describe the intense, hot pain felt by some veterans long after their wounds had healed.

Typical features of complex regional pain syndrome include dramatic changes in the color and temperature of the skin over the affected limb or body part, accompanied by:
• intense burning pain
• skin sensitivity
• sweating
• swelling
CRPS I is frequently triggered by tissue injury; the term describes all patients with the above symptoms but with no underlying nerve injury.

Patients with CRPS II experience the same symptoms but their cases are clearly associated with a nerve injury.
Complex regional pain syndrome can strike at any age and affects both men and women, although most experts agree that it is more common in young women.
What are the Symptoms of Complex Regional Pain Syndrome (CRPS)?
The key symptom of complex regional pain syndrome is continuous, intense pain out of proportion to the severity of the injury (if an injury has occurred), which gets worse rather than better over time. Complex regional pain syndrome most often affects one of the extremities such as:
• arms
• legs
• hands
• feet Complex regional pain syndrome is also often accompanied by:
• "burning" pain
• increased skin sensitivity
• changes in skin temperature: warmer or cooler compared to the opposite extremity
• changes in skin color: often blotchy, purple, pale, or red
• changes in skin texture: shiny and thin, and sometimes excessively sweaty
• changes in nail and hair growth patterns
• swelling and stiffness in affected joints
• motor disability, with decreased ability to move the affected body part
Often the pain spreads to include the entire arm or leg, even though the initiating injury might have been only to a finger or toe. Pain can sometimes even travel to the opposite extremity. It may be heightened by emotional stress.
The symptoms of complex regional pain syndrome vary in severity and length. Some experts believe there are three stages associated with complex regional pain syndrome, marked by progressive changes in the skin, muscles, joints, ligaments, and bones of the affected area, although this progression has not yet been validated by clinical research studies.

Stage one is thought to last from 1 to 3 months and is characterized by severe, burning pain, along with muscle spasm, joint stiffness, rapid hair growth, and alterations in the blood vessels that cause the skin to change color and temperature.
Stage two lasts from 3 to 6 months and is characterized by intensifying pain, swelling, decreased hair growth, cracked, brittle, grooved, or spotty nails, softened bones, stiff joints, and weak muscle tone.
• In stage three the syndrome progresses to the point where changes in the skin and bone are no longer reversible. Pain becomes unyielding and may involve the entire limb or affected area. There may be marked muscle loss (atrophy), severely limited mobility, and involuntary contractions of the muscles and tendons that flex the joints. Limbs may become contorted.
What Causes Complex Regional Pain Syndrome (CRPS)?
Researchers aren’t sure what causes complex regional pain syndrome. In some cases the sympathetic nervous system plays an important role in sustaining the pain. The most recent theories suggest that pain receptors in the affected part of the body become responsive to a family of nervous system messengers known as catecholamines.
Animal studies indicate that norepinephrine, a catecholamine released from sympathetic nerves, acquires the capacity to activate pain pathways after tissue or nerve injury. The incidence of sympathetically maintained pain in complex regional pain syndrome is not known. Some experts believe that the importance of the sympathetic nervous system depends on the stage of the disease.
Another theory is that post-injury complex regional pain syndrome (CRPS II) is caused by a triggering of the immune response, which leads to the characteristic inflammatory symptoms of redness, warmth, and swelling in the affected area. Complex regional pain syndrome may therefore represent a disruption of the healing process. In all likelihood, complex regional pain syndrome does not have a single cause, but is rather the result of multiple causes that produce similar symptoms.
How is Complex Regional Pain Syndrome Diagnosed?
Complex regional pain syndrome (CRPS) is diagnosed primarily through observation of the signs and symptoms. But because many other conditions have similar symptoms, it can be difficult for doctors to make a firm diagnosis of complex regional pain syndrome early in the course of the disorder when symptoms are few or mild. Or, for example, a simple nerve entrapment can sometimes cause pain severe enough to resemble complex regional pain syndrome.
Diagnosis is further complicated by the fact that some people will improve gradually over time without treatment.
Since there is no specific diagnostic test for complex regional pain syndrome, the most important role for testing is to help rule out other conditions. Some clinicians apply a stimulus to the area to see if it causes pain such as:
• touch
• pinpricks
• heat
• cold
Clinicians also use triple-phase bone scans to identify changes in the bone and in blood circulation.

Friday, February 6, 2009

An Manual therapy prospective of the Occipitoatlantal Joint

Occipitoatlantal (OA) joint is the most superior weight-bearing synovial joint in the body. Because the OA articulation is one of the final locations at which the body can adapt to asymmetry or dysfunction below, hence this joint requires evaluation in the context of the entire body. The Atlanto-occipital joint (articulation between the atlas and the occipital bone) consists of a pair of condyloid joints.The ligaments connecting the bones are:

* Two Articular capsules
* Posterior atlantoöccipital membrane
* Anterior atlantoöccipital membrane
* Lateral atlantoöccipital

The movements permitted in this joint are:

* (a) flexion and extension, which give rise to the ordinary forward and backward nodding of the head.

* (b) slight lateral motion to one or other side.

Flexion is produced mainly by the action of the Longi capitis and Recti capitis anteriores; extension by the Recti capitis posteriores major and minor, the Obliquus superior, the Semispinalis capitis, Splenius capitis, Sternocleidomastoideus, and upper fibers of the Trapezius.

The Recti laterales are concerned in the lateral movement, assisted by the Trapezius, Splenius capitis, Semispinalis capitis, and the Sternocleidomastoideus of the same side, all acting together.

The Atlanto-occipital joint features predominantly in the symptoms of tension-like headaches as a result of prolonged inappropriate posture from poor ergonomic adaptation.

In such cases, patients typically report cracking of the neck, discomfort when sitting, continuous migraine-like headaches, dullness, dizziness, tingling in the fingers, sensitivity to light and a feeling the head is expanding.
There must be a concise physical evaluation process for the OA joint complex with reference to prominent clinical findings indicative of dynsfunction. Further manual therapy is planned particularly in a fashion of "integrated manual care" approach. Evaluation procedures include:

* postural assessment;

* muscle and joint manual palpation techniques;

* range-of-motion testing; and

* anterior-posterior and lateral gliding tests.

Treatment methods upon finding OA dysfunction are organized around clinical findings of the examination. The suggested treatments are:

* positional release;

* direct methods (low velocity, muscle energy, high velocity);

* myofascial release; and

* general techniques (ischemic compression, isometric contractions, deep stroking massage, friction, etc.).
1. Manual care of the occipitoatlantal joint. Chiropractic Technique, August 1999:11(3), pp116-124.
2. gray's anatomy
3. Physiology of joints-Kapandji

Treatment Hyiod Dysfunctions

Introduction: The hyoid bone and related myofascial connections of the neck often are not evaluated as possible causes of head and neck pain or dysfunction. Hyoid bone syndrome involves nonspecific cervical pain and pain while swallowing, with radiating pain to the face, neck and shoulders.
This article provides information on hyoid dysfunction, anatomy, evaluation and manual treatment methods.

Examination: The working understanding of the anatomy of the anterior structures of the neck is necessary to evaluate patients for this syndrome (a review of that anatomy is provided). Patients with anterior neck symptoms or tension and reduced extension of the neck should be checked for hyoid dysfunction, using palpation on the supine patient. Once the hyoid is located, it is tested for mobility, asymmetry, discomfort and muscle tenderness in the anterior cervical triangles. Bimanual palpation of the suprahyoid muscles is also performed.

Treatment: The author discusses five common treatment methods: 1) sustained compression over trigger points until softening occurs; 2) deep massage stroking distal to proximal; 3) positional release to slacken hypertonic tissue; 4) direct myofascial release on the whole complex; and 5) indirect myofascial release. The author’s preferred treatment method follows this method, in order: find tender points on the suprasternal notch and treat; treat muscle hypertonicity with massage; and stretch the hyoid using direct myofascial release. He emphasizes minimizing repetitions and limiting methods to 1-2 treatments.

Note: This article delves directly into the practical aspects of evaluating and managing patients. Active practitioners will find it useful in day-to-day practice.

Such GW. Manual care of the hyoid complex. Topics in Clinical Chiropractic 2002:9(3), pp. 54-62. Reprints:

Thursday, February 5, 2009

Rotator cuff muscles that causes shoulder pain

(1) Supraspinatus: This is one of the three rotator cuff muscles infamously known for giving rise to shoulder pain. It arises from the fossa above the spine of the shoulder blade bone known as supraspinous fossa. It inserts into the upper facet of the greater tuberosity of the arm bone and from the capsule of the shoulder joint.
It assists the deltoid in moving the arm away from the side of the body (abduction). It also helps to roll the arm outward (external rotation). It is supplied by the suprascapular nerve from the upper trunk of the brachial plexus. The suprascapular nerve carries the C5 and C6 nerve nerve root fibers (especially the C5 nerve root fibers) to this muscle.
The tendon of this muscle is commonly involved in degenerative processes and may rupture. It can also be entrapped under the acromion.
(2) Infraspinatus: Shoulder pain symptoms are commonly associated with a rotator cuff problem. The infraspinatus is the largest of the three muscles comprising the rotator cuff, the other two being supraspinatus and teres minor muscles.
The infraspinatus muscle arises from the infraspinous depression (fossa) of the shoulder blade bone and attaches to the middle portion of the greater tuberosity on the arm bone (humerus). It also arises from the capsule of the shoulder joint.
It functions primarily to roll the arm outward as in turning the palm forward so that the thumb is away from the midline of the body (external rotation). It is supplied by the suprascapular nerve from the upper trunk of the brachial plexus which carries the fibers of the C5 and C6 nerve roots, primarily the C6 nerve root.

Points to focus on:

a. Rotator cuff injuries occur because there is power mismatch between the muscles that roll the arm inward as in turning palm backward so that the thumb is toward the midline of the body (internal rotation).

b. There are very few muscles that can perform external rotation, namely the three rotator cuff muscles (supraspinatus, infraspinatus and teres minor) and the posterior deltoid muscle.

c. In contrast, there are many internal rotator muscles and they are large and powerful. These include the latissimus dorsi, teres major, pectoralis major and subscapularis muscles. Most of the activities that we do daily are performed with the shoulder in internal rotation. Therefore the internal rotators become extremely strong and tight.

d. The external rotator muscles are used in lengthening contraction to stabilize the shoulder joint when it is internally rotated. Also, it is prone to attrition when caught under the acromion especially with the shoulder in internal rotation. As a result, the external rotators consisting of the rotator cuff gradually fail to the point that it can even rupture.

Internal rotation resistance strength test (IRRST)

One study introduces a new sign to differentiate between outlet impingement and non-outlet (intra-articular) causes of shoulder pain in patients with positive impingement sign: the internal rotation resistance strength test (IRRST).

It was hypothesized that positive test results are predictive of non-outlet impingement, whereas negative test results confirm outlet impingement.

A prospective comparison between IRRST and arthroscopic findings of 115 consecutive patients showed the test to be highly accurate in differentiating between these two diagnoses (positive predictive value 88%, negative predictive value 96%, sensitivity 88%, specificity 96%, and accuracy 94.5%).

The IRRST, in conjunction with impingement and apprehension signs, adds to our armamentarium of tests that distinguish between subacromial outlet impingement and intra-articular forms of pathology.

(J Shoulder Elbow Surg 2001;10:23-7.)

Clinical test for DD of Labral tears and acromioclavicular joint abnormalities

Labral tears and acromioclavicular joint abnormalities were differentiated on physical examination using a new diagnostic test.

Step 1. The standing patient forward flexed the arm to 90° with the elbow in full extension and then adducted the arm 10° to 15° medial to the sagittal plane of the body and internally rotated it so that the thumb pointed downward.

Step 2. The examiner, standing behind the patient, applied a uniform downward force to the arm. With the arm in the same position, the palm was then fully supinated and the maneuver was repeated.

The test was considered positive if pain was elicited during the first maneuver, and was reduced or eliminated with the second.

Pain localized to the acromioclavicular joint or “on top” was diagnostic of acromioclavicular joint abnormality, whereas pain or painful clicking described as “inside” the shoulder was considered indicative of labral abnormality.


Stephen J. O’Brien et al

Diagnostic implications of CSF in Lumbar Disc Herniation

1. Cerebrospinal fluid protein concentrations in patients with sciatica caused by lumbar disc herniation.

The increase of the CSF total protein concentration in sciatica without spinal block is assumed to be due to leak of plasma proteins into the CSF from the nerve root. A relationship between CSF protein concentrations and certain clinical parameters has been found.

Skouen JS et al studied 180 adult patients admitted to the Neurological Department, Haukeland Hospital in Bergen, Norway, for a period of 5 years from 1984 to 1988. One hundred fifty-seven patients were followed up 3.9-9.0 years after admittance to the Neurological Department.

The purpose of this study was to find out if the total cerebrospinal fluid (CSF) protein concentration could predict the outcome of lumbar disc surgery or conservative treatment in patients with sciatica.
Elevated CSF total protein concentration was related to chronic leg pain, leg pain, and subjective physical disability at follow-up. Hence the authors advocated, CSF total protein concentration can be regarded as an indicator of the functional status of the nerve root and a prognostic factor in patients with sciatica.

Procedure for the study:
At myelography, 10 ml of CSF was collected for analysis. The patients were evaluated for involvement of the nerve root and/or the dural sac, respectively. The neurologic parameters investigated were: straight leg raising tests, paresis, disturbances of sensibility, and altered reflexes.

At follow-up, the patients were asked to fill in questionnaires concerning job function, sick leave or disability pension, subjective physical disability and pain perception, and a clinical examination with the same neurologic parameters was performed.

Markers of nerve tissue injury can be analyzed in the cerebrospinal fluid, allowing characterization of the cell types involved and the degree of disease in patients with neurologic disorders. Researchers Brisby H et al went little further to investigate specific proteins in CSF for analysis in lumbar disc herniation and sciatica.

2. Markers of nerve tissue injury in the cerebrospinal fluid in patients with lumbar disc herniation and sciatica.

The light subunit of neurofilament protein, S-100 protein, neuron-specific enolase, and glial fibrillary acidic protein were determined in the cerebrospinal fluid in patients with lumbar disc herniation and in control patients by Brisby H et al to determine whether nerve root injury caused by disc herniation increases the levels of nerve and glial cell injury markers in the cerebrospinal fluid.

The findings suggested patients with disc herniation and sciatica have increased concentrations of neurofilament protein and S-100 in the cerebrospinal fluid, which indicates damage of axons and Schwann cells in the affected nerve root.

Procedure for the study:
Cerebrospinal fluid samples were obtained by preoperative lumbar puncture in patients who underwent surgery for lumbar disc herniation and in patients who underwent lower extremity surgery (control group), neurofilament protein (light subunit) and glial fibrillary acidic protein were analyzed by enzyme-linked immunosorbent assay and S-100 protein and neuron-specific enolase by radioimmunoassay and luminescence immunoassay, respectively. In the disc herniation group the concentrations of the four markers were evaluated regarding possible correlation to patient history, computed tomographic findings, and clinical findings.

Evidence for shoulder girdle dystonia in selected patients with cervical disc prolapse.

Some patients with cervical disc herniation suffer from persistent nuchal pain and muscle spasms after decompressive surgery despite the lack of clinical and radiological signs for actual spinal root compression. Sonographic examination of the brain in some of these patients showed increased echogenicity of the lentiform nuclei as described in patients with idiopathic dystonia. This has been linked to an altered Menkes protein level and copper metabolism.

The authors have suggested a relationship between persistent nuchal pain after adequate cervical disc surgery and dystonic movement disorders.

Thirteen patients with persistent nonradicular nuchal pain after at least one cervical disc surgery and without evidence of continuing spinal root compression and 13 age-matched controls were included. All patients had a complete neurological examination, ultrasound, and MRI scan of the brain. In addition, Menkes protein mRNA levels of leucocytes were analyzed in patients and controls.
All patients with persistent nuchal pain exhibited a constant tonic unilateral shoulder elevation associated with an ipsilateral hypertrophy of the trapezius muscle. Ultrasound examination showed an increased echogenicity of the lentiform nucleus in one patient unilaterally and in 10 patients bilaterally but in none of the controls. On MRI the T2-values of the lentiform nuclei were found to be higher in patients exhibiting a hyperechogenicity of the lentiform nuclei compared to controls (P = 0.01). In addition, Menkes protein mRNA levels were decreased in patients with cervical disc herniation (P = 0.03). Clinical, neuroimaging, and biochemical findings of this selected patient sample with chronic nuchal pain and muscle spasms after cervical disc surgery resemble alterations in patients with idiopathic cervical dystonia.

This suggests a link between both disorders. A peripheral trauma to the nerve roots may precipitate dystonic movements in susceptible patients and chronic dystonic muscle contraction would account for the persistent nuchal pain.

word meanings:

1. Nuchal:Referring to the back of the neck (nape).From the Latin "nucha" meaning nape. Pronounced "nu·kal" with the accent on the first syllable.
2. Dystonia: It is a neurological movement disorder in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures.


Becker G, Berg D, Kruse N, Schröder U, Warmuth-Metz M, Rieckmann P,
Naumann M, Reiners K.

line of management of cervical herniated disc related pain syndromes- for general followers of this blog

Neck pain is common. Conservative treatment is usually successful. Cervical radiculopaty is usually caused by a disc herniation. Conservative treatment is generally successful, however surgery is indicated if radicular pain is severe and persistent for more than 6 to 12 wk. Spinal cord compression and long-tract symptoms may be caused by a central cervical disc herniation, treatment is by anterior disc excision, bone grafting or metal fusion cages. Confirmation of the clinical level of disc herniation must be made by imaging (CT and (or) MRI). With proper patient selection, surgery for cervical disc herniation can be expected to lead to excellent results in the majority of patients (80-90%).

reference & authors:
Management of pain syndroms related to cervical herniated disc

Nowakowski A, Kubaszewski L, Kaczmarczyk J.

Pathophysiology of cervical myelopathy-Literature review

Myelopathy is a group of closely related disorders usually caused by spondylosis or by ossification of the posterior longitudinal ligament and is characterized by compression of the cervical spinal cord or nerve roots by varying degrees and number of levels. The decrease in diameter of the vertebral canal secondary to disc degeneration and osteophytic spurs compresses the spinal cord and nerve roots at one or several levels, producing direct damage and often secondary ischemic changes.

The pathophysiology of cervical myelopathy involves static factors, which result in acquired or developmental stenosis of the cervical canal and dynamic factors, which involve repetitive injury to the cervical cord. These mechanical factors in turn result in direct injury to neurons and glia as well as a secondary cascade of events including ischemia, excitotoxicity, and apoptosis; a pathobiology similar to that occurring in traumatic spinal cord injury.

Reference & Authors:
Baptiste DC, Fehlings MG (2006, journal-spine).