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Sports Chiropractic and Therapeutic
Transcript of Sports Chiropractic and Therapeutic
Sports Chiropractic and Therapeutic
Strategies in Athletes
Tips for Treating Rib Dysfunction:
The Myofasical System
David R. West, D.C., C.C.S.P.
UF Diver All-American 1992-1996
West Family Chiropractic 2002
UF Consultation Staff since 2004
4th Generation Chiropractor
Certified Chiropractic Sports Physician
Approximately 3500 UF athlete patient visits over the last 11 years.
Anatomy, Physiology, Biomechanics, Research
The World Federation on Chiropractic Defines Chiropractic as:
"A Health profession concerned with the diagnosis, treatment
and prevention of mechanical disorders of the musculoskeletal
system and the effects of these disorders on the function of the
nervous system and general health. There is an emphasis on
manual treatments including spinal manipulation or adjustment.
JMPT. Volume 34, Issue 2, Pages 88-97 (February 2011)
In a recent study, asymptomatic subjects with a previous history of neck pain significantly improved their elbow joint position sense immediately following a chiropractic adjustment to the neck. While only the position sense of the elbow was evaluated in this particular study, it's not a stretch to assume other parts of the upper extremity and potentially lower extremity could also be positively affected.
Over 100 techniques
Soft tissue approaches
The expression of the science and philosophy
Cervical Disc Involvement.
Radicular symptoms in single dermatome (burning).
Usually have pain with extension and
radiculpathy usually accompanies neck pain.
Upper cervical spine is usually hypomobile (restricted) while mid to lower cervical spine is usually hypermobile.
Look to Scalenes, Suboccipitals, SCM and Levator Scapulae as major pain producers.
Head Posture is a major player in thoracic spine dysfunction.
Abnormal or decreased GHJ motion promotes scapular dyskinesis.
Evaluate for pectoralis hypertonicity with intrascapular pain or weakness.
Cat/camel or foam roller works well with general stiffness (Motion and therapy help tremendously).
Pain with sitting think disc.
Pain with transitions think S/I.
Pain with standing think facet or muscle imbalance / weakness.
Pain with any movement think protective muscle spasm.
Antalgia “always” means disc involvement.
Following an injury try to get muscle activation and stability ASAP (mobility first!) – Keep activation and exercise pain free.
Always evaluate entire pelvis, lumbar spine, and hips when dealing with pain or dysfunction.
Shifting in frontal plane:
Glut med, TFL and adductors
Shifting in sagittal plane:
Psoas, hamstring and abdominals
Sacroiliac joint dysfunction
Unilateral spasm or hypertrophy
First Rib: usually is anterior and superior at the top of the trap. Make a contact and ELF. Use the back of the head to turn towards and extend gently. Feel for movement and release .
Sprung ribs - This concept is inspired by George Roth's matrix repatterning classes, level two. Dr. Roth talks about how trauma is stored in the body. A sprung rib is sprung outward, and will be posterior in the front and back. This is usually caused by a trauma that came in from the opposite lateral side, causing an expansion of the rib cage on the involved side. This is corrected with simultaneous recoil from both the front and back. The adjustment is very gentle, but the results can be spectacular.
I want to share two different types of corrections that may be new to you. They are both variations on ELF. The first is a two-hand contact surrounding the rib cage, in which you are paying attention to the changes occurring between your hands. You can use this method to simultaneously correct a rib subluxation in the back at the costovertebral joints, and in the front at the sternocostal joints. With the patient supine, find the most restricted anterior sternocostal joint with one hand; with your other hand, reach under the patient and find the same level of rib where it meets the spine. You can test whether you are on the corresponding level in the back by pushing anterior to posterior (AP) with your front hand and feeling for motion in the back. You can use either the tips of your fingers, or your thenar eminence. You will be pushing gently AP on your anterior contact, and gently posterior to anterior (PA) on your posterior contact.
Begin the correction by laterally tractioning both contacts. This begins to disengage the rib. Pay attention to which direction your hands are pulled. Does the rib seem to float posterior or anterior? The direction that the rib floats toward indicates the primary restriction. (If it is not obvious to you, don't worry. You can still effectively do the technique.) Focus on the primary restriction, in either the front or the back, and load this three- dimensionally into the direction of most resistance, i.e., into the barrier. This would involve a superior versus an inferior motion, and a clockwise rotation versus a counterclockwise one.
The rib will usually need lateral motion as the third dimension. Do the same for the second contact; it will usually go in a somewhat opposite direction. This completes the engage portion of the correction; now listen and follow. This means you hold at the elastic aspect of the barrier while the tissues reorganize themselves and release. This will usually take 10 to 60 seconds. If no movement occurs in the tissue, it usually tells me that my contact is too strong, and I need to back off a little. This technique is great for releasing the whole of the rib and addresses both the posterior and anterior components simultaneously.
The second new technique uses a long lever, which will release fascial restrictions found in the rib cage at the midaxillary line or anywhere along the rib. Most chiropractic adjustments use a short lever - a direct contact on the locked vertebrae. This adjustment starts with a direct contact on the fixated part of the rib. The long lever is a controlled movement of the arm designed to release the fascia connecting the arm and the whole of the axilla to the rib. This two-hand, long-lever contact addresses many more of the tissue restrictions. In some ways, this is similar to Active Release of Patrick Leahy,DC, or Integrated Fascial Release of Warren Hammer,DC; in other ways, it is substantially different. The main differences are that the arm does not go through a full range of motion, and that the patient does not control the arm. The doctor takes the arm and lifts it just until he begins to feel the tension build, then uses the ELF concept to feel the slow release of the tissue. Again, we are using the concepts of "just enough" and working at the feather edge of the barrier.
Our primary contact here is a thenar contact on the rib near the midaxillary line. I first assess whether the rib is more restricted moving in an inferior direction (the common finding), or more restricted moving superior. I then contact the rib and engage it in a three-dimensional way. Does it resist going in an anterior or posterior direction? Is there a torque component? Once I have engaged the rib, I begin to lift the homolateral arm. I have maximal control of the arm if I contact just above the elbow. I test and see if either abduction or flexion of the arm maximizes the fascial pull. The common error is to take the arm too far, going right past the barrier. I'll often need only 20 degrees or less of abduction or flexion. Find the new barrier, then fine-tune the arm position, adding slight internal or external rotation.
This completes the engage portion. Now I just listen and follow, and let the tissues release. You can use this same technique on myofascial restrictions in this area. Contact the subscapularis and/or to the pectoralis minor with one hand, and use the arm as a long lever.
Janice K Loudon1, Michael P Reiman2, Jonathan Sylvain2
1Department of Physical Therapy Education, Rockhurst University, Overland Park, Kansas, USA
2Department of Physical Therapy, Duke University Medical Center, Durham, North Carolina, USA
Dr Janice Kaye Loudon, Department of Physical Therapy Education, Rockhurst University, 10121 Delmar, Overland Park, KS 66207, USA; janice.loudon@Rockhurst.edu
Accepted 5 August 2013
Published Online First 26 August 2013
Background Lateral ankle sprains are common and can have detrimental consequences to the athlete. Joint mobilisation/manipulation may limit these outcomes.
Objective Systematically summarise the effectiveness of manual joint techniques in treatment of lateral ankle sprains.
Methods This review employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-assisted literature search of MEDLINE, CINHAL, EMBASE, OVID and Physiotherapy Evidence Database (PEDro) (January 1966 to March 2013) was used with the following keywords alone and in combination ‘ankle’, ‘sprain’, ‘injuries’, 'lateral’, ‘manual therapy’, and ‘joint mobilisation’. The methodological quality of individual studies was assessed using the PEDro scale.
Results After screening of titles, abstracts and full articles, eight articles were kept for examination. Three articles achieved a score of 10 of 11 total points; one achieved a score of 9; two articles scored 8; one article scored a 7 and the remaining article scored a 5. Three articles examined joint techniques for acute sprains and the remainder examined subacute/chronic ankle sprains. Outcome measures included were pain level, ankle range of motion, swelling, functional score, stabilometry and gait parameters. The majority of the articles only assessed these outcome measures immediately after treatment. No detrimental effects from the joint techniques were revealed in any of the studies reviewed.
Conclusions For acute ankle sprains, manual joint mobilisation diminished pain and increased dorsiflexion range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of-motion, decreased pain and improved function.
In the U.S. alone, 23,000 people sprain their ankle each day, resulting in 1.6 million doctor office visits annually.1
To make matters worse, these numbers do not take into account the long-term disability often associated with ankle sprains. In a 10-year follow-up of patients suffering ankle sprains, 72 percent showed signs of arthritis in the ankle joint. 3
overweight athletes with a prior history of ankle sprain are 19 times more likely to suffer another ankle sprain.4
The combination of rehabilitative and proprioceptive exercises has been shown to decrease the chance of recurrent ankle sprains as well as reduce the chance of reinjury in a functionally stable ankle.
The majority of research indicates that proprioceptive training is effective at developing better balance and reducing the chance of further injury.5-8,10-13 Studies have shown that balance and coordination training reduce the chance of recurrent ankle sprains.6-8,10,11 However, other studies indicate that proprioceptive exercise may not be effective at reducing the chance of an ankle sprain.3,9
Despite the strong connection between prior sprain and future sprain, there is a counterintuitive inverse relationship between the severity of ligament damage and the potential for reinjury. In a two-year follow-up of 202 elite runners presenting with inversion ankle sprains, researchers determined that patients with the worst ligament tears rarely suffered reinjury (reinjury rates in this group were 0-5 percent), while individuals with less severe ankle sprains suffered significantly higher rates of re-sprain (18 percent of patients with moderate sprains were reinjured during this two-year period). 6
Perhaps the best way to restore proprioception is with manipulation of the calcaneocuboid and talocrural joints. The importance of incorporating manipulation into a protocol for managing ankle inversion sprain is supported with research by Lopez-Rodriguez, et al.,13 in which manipulation resulted in an improved progression of forces throughout the foot during stance phase. In performing a placebo-controlled study of 52 athletes presenting with grade 2 ankle sprains, these authors determined that ankle adjustments produced a clinically significant redistribution of load throughout the foot, as measured with stabilometric and baropodometric techniques.In addition to decreased proprioception from ligament and nerve damage following sprain, altered proprioception may also be the result of a damaged retinaculum.
In an interesting MRI study of ankle sprains, Stecco, et al., 14 determined that the ankle retinaculum is injured in more than 80 percent of ankle sprains, and that the damaged retinaculum may be responsible for lessened proprioception. The authors demonstrated that manual intervention in the form of fascial release resulted in long-term reductions in pain and improved balance, as measured on stabilometric platforms.
In a study done by Suter et al. (2000) He investigated the effects of sacroiliac (SI) joint manipulative treatment on knee extensor inhibition in patients with anterior knee pain (AKP). Based on the clinical observation that patients that presented with AKP also presented with signs and symptoms of SI mechanical joint dysfunction. He put 28 patients with AKP into a randomized, controlled, double-blind study and determined that after adjustment of the SI joint in the treatment group he had a 7.5% decrease in knee extensor muscle inhibition.
Chronic ankle instability, usually a result of recurrent sprains, is an ongoing problem, especially among active individuals. According to Holme et al,1 lateral ankle sprains are common and account for nearly 15% of all sports injuries.
Main cause of continuing symptoms following an ankle sprain are functional instability, joint stiffness due to loss of joint motion, scar tissue, and incomplete or absent rehabilitation.
The efficacy of manual joint mobilization/manipulation in treatment of lateral ankle sprains:
a systematic review
Finding Rib Dysfunction:
Patient should be side-lying with hips and shoulders stacked. Use a cervical spine support to maintain a
comfortable line with a "packed (neutral) neck." Too much lateral flexion will put the patient in a high
threshold protective strategy and they will be unable to relax.
Flex your top leg up to 90 degrees and hold onto it with your bottom hand. Place a support underneath
the knee to prevent excessive lumbar spine rotation. Remember, you want to
isolate thoracic spine rotation, not transition into lumbar compensation.
Bottom hand rests on the top thigh; bottom leg remains straight.
Once in the position, contract the glutes (butt muscles) in the bottom leg to activate extension
The top hand goes underneath the bottom rib cage to assist in end-range stretch.
Lightly press the top leg into the support (adduction) to engage the core.
Look in the direction you will be turning and then let the head follow. Go full cervical rotation to
Cue leading with the posterior shoulder. Almost like trying to touch the top posterior deltoid to the
floor. Great movement for activation of the notoriously weak extensor and posterior chain muscles of the
upper torso. Activate the latissimus dorsi at end range.
At end range, assist with bottom hand, pulling torso farther into the stretch.
Exhale on the rotation and inhale on the return to starting position.
Complete four more rotations by exhaling and at the end range, maintain stretch for four seconds,
breathing through your diaphragm.
Alterations in fascial movement due to increase viscosity or adhesions distort information sent by spindles to the CNS and can interfere with proper movement.
Most injuries occur when connective tissue is stretched faster than it can respond. The less hydrated, the less elastic response it has in it.
Enhance the fascial elasticity essential to systemic resilience.
Responds better to variation than to a repetitive program.
10x more innervated than muscle and responds to proprioceptive training. (rehab)
Training the Neurofascial Web:
Fascial Anatomy Concepts
Fascia connects everything to everything else and is a neuro-myofacial web system. (connects everything!)
It is a net in which muscles and bones float.
It remodels itself in response to direct signaling from cells.
The fascial system is more innervated than muscle, so proprioception, kinesthesia and posture are primarily fascial, not muscular. (think of Fascia as a sensory organ!)
Things to Ponder
Mobility = lack of stiffness or restriction.
Stability = Motor Control = Controlled movement through normal ROM.
Mobility must precede stability.
Loss of mobility is the bodies way to create an artificial stability: stiffness and inflexibility. It is engineered dysfunction at a local level to provide continued physical performance on a global level.
If the body can't move through something, it moves around it.
Mobility problems are movement dysfunctions.
Instrument Assisted Soft-Tissue Release
Use the instruments to feel
Angle, pressure, and speed all matter!
Know your anatomy!
Acute vs. Chronic
Passive vs. Active
Early Joint Mobilization:
Restores ROM more quickly
Reduces PAIN more quickly
Increases STRENGTH more quickly
Returns the joint to NORMAL FUNCTIONAL CAPACITY more quickly!
The American Journal of Sports Medicine
Journal of the America Physical Therapy Association
The Journal of Family Practice
The Rib Roll Stretch:
(352) 359-3755 (cell)
Joint dysfunction alters nerve input and output. Whenever there is a system containing many movable parts, a complex balance is necessary between those parts to function optimally. Normalized joint function promotes maximal function from the neuromuscular system.
The nervous system controls every living tissue in the body. The spine encases the central nervous system and can irritate the spinal nerves as they exit the spine and alter nerve expression. Optimal function of the nervous system allows for optimum function of all the systems of the body.