Thursday, February 27, 2014

"Why won't this Pain go away?"

In the field of physical therapy, there's been a growing trend of two groups of thought regarding pain:

1) the classical "structural" point of view (i.e. poor postural alignment leading to pain)

2) the neuroscience/pain science view where pain is a brain output.

And yet a third group is emerging that is somewhat of a "middle path" that is both #1 & #2.

The middle path isn't as popular, perhaps since being in the middle isn't as charged as polar opposites. Some people need identity (the "charge") through their tightly held beliefs which separates them from any opposing view.

Gratefully, I see the middle path is growing more each day since seeing both sides of a coin allows us to experience the Whole coin.

And this is Understanding.....

Below is a post I made on my personal FB page:

Pain is a brain output. In other words, it's a thought, and like all thoughts, pain is a limiting belief based upon past experiences and conditioning.

Our thoughts separate us from Reality and what we perceive as reality.

In this respect, pain is more of the Messenger.

It's not simply that the pain you experience is "all in your head". It's so much more than this. It can be from that "herniated disc" that an MRI revealed, or it can be related to that "forward head posture" from sitting eight hours a day, and it can also be so much more than a structural "fault".

It's a call to pay Attention. The Messenger is telling us to pay Attention to something that we've neglected or were too distracted to attend to.

But what do we tend to do to the Messenger?

Blame it, kill it, avoid it, or run away from it. In other words, refuse to Listen to It.

What is it that we do not want to hear?

Perhaps the Truth to who we are?

I don't know.

Friday, February 21, 2014

Got ITB issues?

Common gluteus minimus trigger point referral patterns

Often times when someone says they have "ITB issues", it's not so much that the iliotibial band (ITB) is at fault as it is it's a compensation for something else that's going on. And although there can be a lot of other possibilities to why the ITB can be affected, it can be as simple as some stubborn trigger points in the gluteus minimus muscle of the hip joint.

As you can see in the picture, the red areas represent the common referral pattern of a gluteus minimus trigger point (denoted by the "x") which coincides with the full length of the ITB.

Now you can simply treat the trigger point for some temporary relief (if that's what is causing your symptoms), but it's probably a better idea to address the movement pattern impairment that started the trigger point in the first place. One can think of a trigger point as the nervous system's way to create soft tissue stability in an unstable function.

Always a great idea to get assessed ;)

Wednesday, February 5, 2014

My Kneecap Keeps "Popping" Out

Dislocated patella
It's very common when presented with a history of one's kneecaps "popping out" for a doctor to refer the patient for physical therapy with a prescription of "Knee Strengthening/Quadriceps Exercises" and "ITB Stretching".

The medical term for this situation is "patellofemoral instability", where the patella (kneecap) has a tendency to sublux (or even dislocate) as it glides over the femur (thigh bone). I like to explain this to patients as if a train (your kneecap) is coming off of its tracks due to poor alignment.

Your patella derailing off your femur

Why does this happen?

Despite what conventional wisdom would tell you that it's weak muscles around the knee that cause the instability, it's actually a bit more involved. The usual suspects in conventional thinking to "blame" are a "weak" vastus medialis obliquus (VMO) and a "tight" iliotibial band (ITB).


In reality, the cause is more functional in that you can think of the knee joint as the middle man in-between the hip/pelvis above and the foot/ankle below. And like all middle men, they react to what's going on with the opposite ends of the chain.

When the patella subluxes, or "goes out of place", it's usually lateral of the femur. In not so severe cases, because the soft tissue structures involved are still contained, the patella usually glides back into place with a straightening and bending motion of the knee (i.e. it falls back into its track)

When the pelvis is in a less than ideal position, it will affect the function of the hip joint which will affect the function of the knee joint below. Likewise with the positioning of the foot and ankle can affect the knee joint above.

You can think of the pelvis/hips as the steering wheel, the knee and the foot/ankle as the wheels. What happens when your steering wheel is out of alignment? More wear & tear of the wheels.

Here's a typical clinical presentation:

The pelvis on the same side of the involved knee is either rotated too far forward or backward, with either way, there's a compensation at the knee where the femur (thigh bone) either wants to roll inward excessively or can't roll inward enough. Either way, the vastus lateralis (VL) quadricep muscle can be overly worked to maintain  a stable amount of internal rotation of the femur. Because the ITB covers the VL, it commonly is mistaken as the "culprit". And because the VMO wants to do the opposing motion of external rotation of the femur, it is often "out-classed" by the VL.

Can you see now why doctors prescribe "quadriceps strengthening" and "ITB stretching" for patellofemoral situations?

Everything's connected
The moral of the story is that everything is connected and with patellofemoral instability situations, I find what works is addressing what's going on above (more than below) the knee joint. Obviously every case is unique and I could go on about many other possible relationships, but what it comes down to is what is the primary driver, or the "Mother", behind the clinical presentation and the only way to find out is through a thorough clinical evaluation along with a barrage of assessment/reassessments of function.

So the next time you're in the Greenwich Village and/or Union Square neighborhood, consider coming by Michael Jocson Physiotherapy for a check up. You'll be glad you did.....