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Non-Surgical Care for Shoulder Instability in Young Adults

12 Nov

Shoulder instability (SI) occurs when the soft tissues (joint capsule, ligaments, and labrum) that hold the humerus in the shallow ball-and-socket glenohumeral joint become stretched, torn, or detached. When these tissues are damaged, the resulting shoulder instability is characterized as structural. If instability is caused by abnormal muscle activity that places too much or too little stress on the shoulder joint, the condition is described as functional instability.

In teenagers and young adults, shoulder instability is typically the functional variety, and it can affect up to 2.6% of this population. The most common variety of functional SI among these individuals is posterior positional functional shoulder instability (PP-FSI).

Patients with PP-FSI experience disabling shoulder pain during mid-range movement of the shoulder joint, caused by a muscle imbalance where the external rotator cuff muscles and the posterior deltoid are under-active and the internal rotator muscles are hyperactive. There is also an altered balance of the periscapular muscles. Using functional MRI, researchers have observed that the brain of a PP-FSI patient may send abnormal signals to the shoulder muscles during movement, similar to an infant who hasn’t developed fine motor skills or a recovering stroke or brain injury patient.

The conservative treatment approach to PP-FSI involves manual therapies to help restore proper motion to the shoulder joint, specific exercises to strengthen the muscles that have become inactive, ice and nutritional recommendations to address inflammation, modalities like electronic muscle stimulation to retrain the muscles, and activity modifications to reduce the risk of re-injury during the initial phase of the healing process. Over time, the patient can begin to resume their normal activities, provided movement doesn’t lead to sharp, lancinating pain in the shoulder.

Other musculoskeletal injuries in the shoulder, arm, neck, or upper back that may have preceding or developed following the PP-FSI injury will also need to be addressed in order to return the patient to their normal activities. While surgical intervention may be advised as a first course of treatment for some PP-FSI patients, treatment guidelines typically recommend utilizing non-surgical methods first, of which chiropractic care is an excellent choice.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Things to Consider Before Knee Joint Replacement

12 Oct

When it comes to a condition like chronic knee pain, there are many treatment options available to reduce pain and improve function, including chiropractic care. However, there are cases when a patient may opt for total knee arthroplasty (TKA). In some instances, they may be able to resume their everyday activities, but a segment of patients may not achieve a satisfying outcome. What can we learn from these patients that can inform us on when to and when not to consider surgery for knee pain?

In one study, researchers examined TKA patients one year after their procedure to assess their progress with respect to knee range of motion and function, as these are important for performing activities of daily living (ADLs) such as the ability to put on shoes and socks, squat down to pick things up off the floor, get up and down from sitting, climb and descend steps, etc. The research team found that patients with poor range of motion before surgery, as well as those with poor knee alignment (the tibial-femoral angle), were less likely to have a satisfactory outcome.

Several studies have demonstrated how hyperpronation of the ankle can affect the alignment of the knee, placing added stress on the joint, as can impaired hip function. These issues should be addressed before considering TKA. This is why it’s important for doctors to assess the whole patient for a musculoskeletal condition because the cause or contributing factors for the issue could be from outside the area of chief complaint. In many cases, a combination of manual therapies and specific exercises provided by a doctor of chiropractic can restore proper motion to the affected hip or ankle, which can then benefit the knee.

Manual therapies can also break up adhesions and scar tissue that may affect knee range of motion. When the knee can move as intended, the pressure from normal movement can help provide nutrients to the remaining cartilaginous tissue, reducing inflammation and pain. 

The take-home message is that there may be a time when a TKA is the only option available to a patient with knee pain, but if the knee is poorly aligned or its range of motion is restricted, then TKA may not be the answer. Luckily, these are issues that can be addressed with chiropractic care, which may delay or even reduce the need for an eventual surgical procedure.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Hip Bursitis and Management Strategies

17 Sep

Hip pain is a common complaint that can arise from many different sources including the spine, pelvis, and the knee. Greater trochanteric bursitis or gluteal tendonitis (GT) is a condition that occurs five-times more often in women than men, affecting one-in-four women over 50 years of age.

Patients with GT experience pain in the region from the side of their hip toward the buttocks, which can make finding a comfortable sleeping position difficult. This condition can be as painful and disabling as an osteoarthritic or a worn-out hip joint.

The traditional medical approach for GT is a cortisone injection. However, the results are not impressive in the medium-term, and the long-term results are similar to patients who took a wait-and-see approach. More recently, a treatment regimen that includes specific exercise programs with load-management and education to reduce the load on the injured tendon during sustained postures and activities has gained attention due to its significant medium- and long-term benefits. Better still, it’s non-invasive.

A 2018 study found that GT patients treated with a combination of exercise with education and load management experienced a higher success rate after one year (78.6%) than those given a cortisone injection (58.3%) and those who received no treatment at all (51.9%).

The education, load management, and exercise treatment protocol consisted of fourteen sessions over eight weeks plus a daily home exercise program that included four to six exercises, while keeping a weekly diary. Advice on tendon care was included and exercises included functional retraining, targeted strengthening (especially the hip abductors), and dynamic control during function. A pain-guided approach was used that allowed up to a 5/10 pain intensity level when exercising, provided the pain promptly stopped if activity ceased.

Exercises included the following (partial list):

Static hip abduction: a) Supine: place a belt around the lower thighs with feet slightly wider than hip width, put a pillow behind the knees and gently and slowly push outward while tightening the belt. b) “Imaginary splits”: stand, feet slightly wider than hip width, and pretend you’re doing the splits (sideways)—again, slowly and gently.  

Supine Bridges: a) Double leg bridge: bend knees, feet flat, draw in the abdominal muscles, press the heels into the floor and lift the buttocks SLIGHTLY—only as high as comfortable. b) Offset Bridge: bring one foot closer to the buttocks and lift buttocks up using mostly that leg slowly (three to four seconds up then, three to four seconds down). Another bridge includes lifting one leg up and straightening the knee. These can be held statically or with movement up/down to the floor. Additional exercises included partial squats, step-ups, and sideways floor slides.

If you have been diagnosed with or suspect you have GT, your doctor of chiropractic can guide you in how to perform these exercises and provide additional care to aid in the recovery process.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Common Shoulder Sports Injuries

10 Aug

With many sports requiring overhead movements that can place the shoulder at the extreme end of its range of motion, it’s not surprising that shoulder injuries are so common among athletes. For instance, up to 50% of NCAA college football players have some history of shoulder injury, which comprises about 10-20% of total injuries in the sport. When looking at collegiate quarterbacks, one study found that shoulder injuries accounted for more than half of injuries among players in the position. When it comes to sport-related shoulder injuries, these are the three most common (and to complicate matters, they often co-occur):

1) SLAP (or labrum) tears: Superior (top) Labral tear from Anterior (front) to Posterior (back) tear is a term used to describe a torn piece of cartilage located along the rim of the socket. The labrum adds depth to the cup, which helps to stabilize the ball in the socket. Individuals with a SLAP tear will often report a loss of motion and power, a feeling like their shoulder could pop out of socket, and a deep ache that is hard to pinpoint when attempting overhead movements.

2) Shoulder instability or dislocation: With contact sports, there’s the opportunity for a collision that can dislocate the ball of the shoulder joint (the end of the humerus bone) from the shoulder socket. Because the muscles in the front of the shoulder tend to be larger and stronger, the dislocation will more often occur in that direction. Symptoms can include a severe, sudden initial pain followed by short bursts of pain as well as swelling and a noticeable deformity in the appearance of the shoulder.

3) Rotator cuff tears (RCTs): This is common in sports that require repetitive overhead motion like baseball (especially among pitchers), swimming, and tennis. Symptoms include a deep, hard to locate ache, weakness, and reduced range of motion (especially overhead or to the back).

In general, early/prompt care yields the best results. While there are instances when a prompt surgical procedure is warranted, treatment guidelines typically emphasize non-surgical therapies first with surgery only after all other options have been exhausted. Chiropractic management of these conditions will often involve a multi-modal management approach that includes manual manipulation and mobilization to the shoulder’s multiple joints, the neck, and the mid back; specific shoulder exercise instruction; physical therapy modalities (ice, electrical stim, ultrasound, laser, pulsed magnetic field, and more); and nutritional recommendations.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Footwear Changes for the Knee Osteoarthritis Patient

20 Jul

Osteoarthritis (OA) is the leading cause of knee pain and disability in the elderly population. While treatment to address knee OA will often focus on the knee itself, a patient may also need to change their footwear. Why is that?

During normal walking, joint loading is NOT evenly distributed, and the distribution most often greatest on the medial (inner) side of the knee. This greater load can cause  wear and tear over time and lead to thinning of the smooth, slippery cartilage surfaces on the medial side of the joint, which eventually leads to bone-on-bone contact, the end-stage of OA. By changing where joint loading occurs on the knee, it’s possible to slow this process and potentially delay or even prevent the need for a knee joint replacement.

This can be accomplished through either a change in footwear or adding an insole or orthotic to an existing shoe. On the footwear front, an OA patient may need to avoid clogs, barefoot shoes, high heels, and extra-rigid/stiff shoes. Rather, walking or running shoes or, for more formal occasions, a shoe with a shock-absorbing sole and padded collars that’s not too rigid may be a better choice. A well-trained employee at a specialty shoe store can help identify which shoes will work best for your situation.

One study investigated the use of lateral wedges both with and without custom arch supports for people with medial knee osteoarthritis (OA) and pronation (rolled in feet). Each of the 26 participants wore one or the other for two months and switched to the other option after a two-month “washout” or rest period. The researchers concluded that the lateral heel wedge WITH foot orthotic/arch supports provided the best benefit to the participants with respect to performance on a timed stair climb test. Another study found that adding a mobility shoe reduced medial joint loading to an even greater degree.

For the knee OA patient, chiropractic treatment may also include specific exercise training, weight management/nutrition, manual therapies, modality use (electrical stim, magnetic field, laser, ultrasound, and more), and the use of a knee brace—all in the effort to reduce pain and improve mobility.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Non-Surgical Care for Rotator Cuff Tears

17 Feb

While the anatomy of the shoulder allows for a wide range of motion and movement, it comes at the cost of a less stable joint, especially for those who routinely perform activities that require lifting the arms. This is likely why shoulder pain is one of the leading reasons patients seek chiropractic care, trailing behind low back and neck pain. The most common cause of shoulder pain is from tearing of the rotator cuff muscles (RCMs), particularly muscles that rotate the shoulder outward.

The “typical” rotator cuff tear patient is typically over 50 years of age with shoulder pain that has slowly worsened over time. A 2018 study found that as many as 96% of people over age 50 have RCM abnormalities, of which MANY are asymptomatic or non-painful. The study also reported that 24% of a random sample of 46 young people with an average age of 23 years old with no symptoms and no history of past injury, had degenerative changes in the RCMs. This finding supports the notion that rotator cuff injuries may occur early in adulthood and progress slowly until the symptoms drive a patient to seek care.

In a study involving 167 patients with rotator cuff tears, researchers observed no difference in outcomes one year after participants received either conservative care or surgery. This led the authors to recommend that non-surgical care, such as chiropractic care, should be considered as the PRIMARY method of treatment for rotator cuff tears of non-traumatic origin.

One study looked at impingement syndrome in a case series of four patients who received multimodal chiropractic care that included shoulder manipulation, shoulder girdle exercises, and ultrasound. In all four cases, the patients reported complete resolution of their shoulder pain and disability with five treatments. When researchers followed up with the patients four to eight weeks later, the participant’s symptoms had not returned.

A systematic review of data from 200 articles found evidence for the following non-surgical treatment options—which are commonly provided in chiropractic clinics—for shoulder pain: exercise training (specific favored over general), manual therapy, laser, extracorporeal shockwave, pulsed electromagnetic field (PEMF), transcutaneous electrical nerve stimulation (TENS), myofascial trigger point therapy, acupuncture, and microwave and light therapy. For a patient with a rotator cuff tear, conservative chiropractic care is an excellent option for reducing pain and improving function in the affected shoulder!

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.