Pain Doc - Ask Dr. P - The Pain Doc

Hamstring muscle strain from running

by Pain Doc | Jun 29, 2012 | Uncategorized

I have a patient who complains of acute pain right under the right butt cheek, and inner part of the thigh. It is a persistent pain that has been bothering him for weeks and also feels stiff. He is in his mid 50s, professional, and in good health other than “high” cholesterol, for which he takes Lipitor.

The pertinent history for this patient is that he is an avid runner, and has been running regularly since his 20s. He is one of those folks who enjoys the feeling of running, during and after. It is a form of stress relief for him. He also does Pilates using the reformer, and enjoys 3-4 glasses of wine on most nights.

The area in question is the biceps femoris tendon, which is part of the “hamstrings” of the leg. It functions as the major knee flexor of the leg (its agonist, opposing muscle is the quadriceps group). The biceps femoris muscle inserts into the ischial tuberosity, which is the bony part of the ischium (half of the pelvis) that we use to sit.

Without the benefit of an MRI or CT scan, and based mostly on the history and lack of other findings that would cause me to think otherwise, I diagnosed myofascial strain of the biceps femoris tendon, with possible tendinopathy (degradation of the tendon from overuse). Basically, something has happened to the muscle and tendon that is resulting in unrelenting pain.

Running is the repetitive, alternating contraction and relaxation of opposing muscles. The most stress occurs at the tendinous attachments to the anchor points on the bone. However, the spot where the tendon attaches to bone is stronger than the breaking point of the tendon itself, so when it is stressed, the body of the tendon will experience tearing (strain) first. It is rare for a tendon to separate from bone at the attachment site. This is the case for this patient, as his pain is described as about 2-3 inches from the attachment point on the ischial tuberosity.

I am treating his injury with a LiteCure deep tissue laser and have given him a nutritional prescription consisting of whey protein to provide the building blocks for repair; high potency fish oil and capsaicin to help reduce the inflammation, and bromelain supplements to serve as an enzyme to soften scar tissue formation. Today, I advised him to drink distilled water for 2-3 weeks. Distilled water may have a chelating-type of effect (binding) on dissolved, inorganic toxins or debris in tissues, which could help with the situation; it is often used for detox programs because of this quality. He was advised to rest, ice and compress the area for 3 days to help suppress the inflammatory reaction.

The case is a very interesting one that will hopefully have a good outcome. We should realize that a muscle is very much like an organ of the body, although it is rarely referred to as one. It has its own unique type of cells, blood supply, and plays an important function. As in all cases of disease of the body, a good strategy is to give it an edge in repairing itself. Diet modification, concentrated, high potency supplements, and non-pharmacological, manual therapy, when used in the right manner can oftentimes hasten recovery.

What Should You Do For Neck Pain?

by Pain Doc | Jan 8, 2012 | Neck Pain

A recent study in the Annals of Internal Medicine compared the effectiveness of chiropractic spinal manipulation, pain medications, and home exercise and advice in treating biomechanical neck pain.

The study participants were 272 people between the ages of 18 and 65 who complained of non-specific neck pain for 2-12 weeks. They were divided into three groups, one of which took medicine only; one which received spinal manipulation to the neck only, and a third group that was just given home exercises and self-care advice. Participants were asked to rate their pain at 2 weeks, 1 month, 2 months, 3 months, 6 months, and one year. The method the study used to grade the pain was subjective rating (probably using a visual pain scale between 0 to 10, with 0 being no pain and 10 being the worst pain) and a Health Status questionnaire asking them their level of ability to engage in certain activities.

The patients treated by a chiropractor experienced the highest rate of success with 32 percent saying they were pain free, compared to 30 percent of those who exercised. Only 13 percent of patients treated with medication said they no longer experienced pain.

The conclusion of the study was that for participants with acute (recent onset) and subacute (usually meaning lasting more than two weeks) neck pain, chiropractic spinal adjustments were more effective than medication in both the short and long term. However, a few instructional sessions of home exercises and advice resulted in similar outcomes at most time points.

My comments:

Biomechanical neck pain can lower the quality of life significantly. Imagine having to struggle to turn your neck all the time, and having to avoid exercise, sports and many recreational activities due to neck pain. According to the researchers, neck pain affects 70% of adults at one point in their lives.

From my experience, biomechanical neck pain typically arises from some type of past trauma, and it doesn’t have to be major. Examples include car accidents, sports injuries/impacts, horseplaying as kids; and hard impact generating activities such as running, horseback riding, parachuting, gymnastics, boxing, martial arts, and cheer leading.

A second, possible cause of biomechanical neck pain is ergonomic in nature; meaning, related to positioning of the body. Long hours of desk work keeps the head relatively stationary (static) in a single position, allowing gravity to pull down on the head, over time altering the weight distribution on the joint surfaces of the bones that make up the neck. Such an “activity” also promotes muscle deconditioning around the neck. The term “deconditioned” means that the muscle is slower to respond to nerve commands, so it loses some ability to support, guard and protect the cervical spine (neck).

The worst combination is someone who has a history of impact trauma to the neck who later gets a job that involves working at a desk for long hours at a time. The trauma history sets the stage for neck pain, and the static positioning of the head accelerates the process over time.

The pain in biomechanical neck pain frequently originates in the joint surfaces of one or several cervical vertebrae, commonly the posterior facet joints (also called the zygapophyseal joints). This is where most of the movement occurs when turning and bending the neck. Orthopedic surgeons sometimes prescribe a facet block for neck pain, which is an injection of pain medications directly into the joint, usually guided by video fluoroscopy. If the patient has degenerative disc disease, pain can emanate from the intervertebral discs, either as a disc herniation or internal tear of the disc. If this is the case, neck surgery is typically the last hope. The disc herniation may be able to be reduced by surgery, but if the surgeon feels that the disc is beyond repair, discectomy (total disc removal) with surgical fusion is usually performed. However, this is like trading one evil for another. Surgeons know that when you fuse two vertebrae together, the vertebrae above and below the fusion bear an increased burden of providing the movement lost by the two fused vertebrae. This will lead to accelerated degenerative changes to those areas as well, over time.

Neck pain can also emanate from the surrounding muscles and fascia. Myofascial trigger points are focal, tender spots along a muscle that are believed to develop from trauma or microtrauma. They may actually be a concentration of nerve endings on the muscle that developed following an injury. These are best handled through manual therapies such as chiropractic, massage, exercises and stretches.

Some people get inexplicable muscle spasms of the neck. This is usually accompanied with a migraine or tension headache. A muscle spasm occurs when the nerves that control the muscle misfire, causing the muscle to maintain a constant state of hypertonus (involuntary contraction). This results in muscle pain, fatigue and low grade inflammation. Sometimes the spasm can be so intense that anti-spasmodic medications, ice, heat, and rest have no effect. In cases like this, botox injections are sometimes used. Botox injections are comprised of a weakened strain of the Botox bacteria, which has the effect of muscle paralysis.

Lastly, it should be mentioned that a poor, nutrient-deficient diet and smoking can make neck pain worse by denying the body critical nutrients needed for repair and maintenance of muscles, ligaments, tendons, nerves and bones.

The study, while emphasizing that chiropractic manipulation was superior to medications in reducing neck pain among participants, also mentions that home exercises and advice were just as effective. It therefore seems natural that a combination of spinal manipulation and home exercises would be a good strategy to reduce or eliminate biomechanical neck pain.

If you are experiencing non-specific neck pain (don’t really know what caused it) for over two weeks and desire to try chiropractic, it’s important to choose a good, qualified chiropractor. Some of the signs of a good, reputable chiropractor are:

1. Doesn’t try to convince you to purchase a long-term treatment program involving multiple adjustments per week.

2. Asks you about your complaint: the nature of your symptoms, how they started, how long you’ve had these symptoms, how they affect your ability to do certain things; and questions regarding your general health.

3. Gives you his/her diagnosis and uses standard orthopedic terminology that is consistent with what you are coming in for (doesn’t go off subject). It meshes with the information you provided in #2 above. You feel that the chiropractor listened to you, and responded with a meaningful solution that is clear to you.

4. Gives you a treatment recommendation the same day: the type of treatment and a brief description of it (spinal adjustments, modalities, supports); what to expect from the treatment, and approximately how long it will take. The chiropractor should also disclose potential risks and side effects of the treatment. In my opinion, six treatments followed by a re-evaluation is a sensible treatment approach for most cases of subacute, musculoskeletal pain.

A chiropractor like this may or may not have a lot of reviews on the internet. Use your judgement, ask friends and co-workers for referrals, and by all means, don’t be afraid to change chiropractors if your first choice turned out to be bad.

Regarding home exercises and advice for treating biomechanical neck pain, stay tuned! I will be putting up an information-packed neck pain relief video on this topic shortly.

Questions to Ask Your Doctor About Neck Pain (everydayhealth.com)
Why Do I Have Neck Pain? (everydayhealth.com)

Can Custom Foot Orthotics Help Back Pain?

by Pain Doc | Dec 25, 2011 | Foot and Ankle Pain

Shoe orthotics are custom made shoe inserts that doctors (podiatrists, chiropractors and orthopedic MDs) use to help patients suffering from foot, ankle, knee, hip, or back pain. The concept is that, since the feet are literally the foundation of a standing human body, any problems in the foundation will translate to problems further up the body.

If you stop to consider this, it makes a lot of sense. You don’t have to have any special training to realize the connection. For example, if the foot rolls inwards when walking (called prontation) it can place twisting forces in the knee and hip. This will require more effort from the locomotor muscles, which are not only your leg muscles, but also your gluteus (buttock) muscles and psoas muscle (major hip flexor) which attaches itself to the lumbar (lower back) spine. This happens subconsciously behind the scenes, but you will definitely notice the effects: pain in the weight bearing joints, back stiffness, reduced mobility/agilitiy, and fatigue.

Take a moment to look at the soles of your shoes (find an old, heavy-used pair in your closet). Are they worn out a lot more on the inner edges? If so, chances are you are over-pronating. This is common with people who have flat feet, or “fallen arches.” If this is the case, a pair of shoe orthotics shaped in a way to counter the rolling-in action can be prescribed. They may be rigid or semi-rigid, depending on what the doctor thinks is more appropriate. If the rolling in can be minimized by the shoe orthotic, then there will be less twisting forces to the knee and hip, resulting in a more efficient gait (walking motion) and less strain to the lower back.

A May 2011 study in the Journal of Manipulative Physiological Therapeutics studied the effects of custom shoe orthotics on a test group of 50 people experiencing lower back pain. Some were treated for 12 weeks with the orthotics, some had no treatment, and some were treated for 6 weeks. It found that from 0-6 weeks of treatment, there was improvement in subjective scores for pain. From weeks 6-12, improvement was maintained, but did not continue to improve. The people who did not use orthotics continued to experience the same level of pain.

These findings suggest that there is a relationship between foot biomechanics and lower back pain, and that improvements can be effected by correcting imbalances in the foot. However, it also suggests that more studies are needed. What I take from it is that orthotics prescription is appropriate when indicated for treating lower back pain, but must be complemented with other types of interventions, depending on the case. This may include exercise rehabilitation, somatic exercises, nutrition, and spinal manipulation.

If you desire to get custom made foot orthotics, you can seek out the services of a podiatrist. Some chiropractors can prescribe orthotics as well. Two of the main brands chiropractors use are Amfit and FootLevelers. An off the shelf brand that I have found success with is the WalkFit orthotics. These come with a gel cushion for the heel and acupressure massage surfaces to help with blood circulation. If you wear sandals, which can pose a problem for traditional, doctor-prescribed orthotics, the come with sandal attachments. Plus, they are a lot less expensive; less than $20.

To Run Barefoot or Not?

by Pain Doc | Dec 9, 2011 | Foot and Ankle Pain

If you suffer from foot pain, knee pain, or lower back pain of unknown origin, then it might be related to your shoes: Scientists recently held a conference in England to debate shoe running vs. barefoot running. Over the last five years, the barefoot movement has gained a lot of recognition among runners and experts in human biomechanics. I wrote about the merits of going barefoot last year. The movement was apparently started by the book “Born to Run” by Christopher McDougall. In it, he tells of time spent with members of Mexico’s indigent Tarahumara tribe, who routinely run long distances barefoot, often very fast, apparently without suffering the injuries that plague many avid runners in the developed world.

The issue is whether or not putting on a pair of running shoes implicitly causes the person to run in an unnatural way; a way that goes against nature’s design, due to a “false sense of security” offered by the thick cushioning of the shoes, especially in the heel and arch.

In a study published in the scientific journal Nature last year, Daniel Lieberman, an evolutionary biology professor at Harvard University, sought to find out how our ancestors, who ran and hunted for millions of years in bare feet or simple moccasins, coped with the impact of the foot hitting the ground.

Lieberman and colleagues from Britain and Kenya studied runners who had always run barefoot, those who had always worn shoes, and runners who had abandoned shoes.

They found that barefoot endurance runners often land on the fore-foot (the ball of the foot) before bringing down the heel, while shoe runners mostly rear-foot (heel) strike, prompted by the raised and cushioned heels of modern running shoes.

The study further discovered that barefoot runners incur less collision forces on their feet compared to shoe runners, despite the heel cushioning of the shoe, and that they use their calf muscles more efficiently.

As of this date, there isn’t a large scale study that gives definitive data on what is better for the human body, going barefoot or wearing shoes. People are taking sides based on their beliefs, biases and experiences. Major athletic shoe companies generally are against the barefoot running idea, for obvious reasons; but some are experimenting with “minimalist” shoes to capture this growing market. These are shoes that offer protection to the feet but with the least amount of restriction.

My take on this: it makes a lot of sense to walk and run barefoot. It is a natural act, and it’s tough to argue against nature because it has its ways of cancelling out bad traits. Our human ancestors walked and ran barefoot for millions of years, and were fine. I believe that walking barefoot exercises the muscles and small joints of the foot and takes more of the load off the knees, hips and pelvis in doing so. On the contrary, wearing shoes binds the feet, prevents the foot joints from doing their job of distributing the body weight and cushioning the shock, and makes the leg and back muscles work in a less efficient manner. It is easy to see how this can result in lower back problems. So, walk barefoot more than you currently do– not just in the house, but on pavement, hilly terrain, and the nearest park. Then, when you feel that your feet have acclimated to the new sensations, give barefoot running a try!

Laser Therapy for Chronic and Acute Musculoskeletal Pain

by Pain Doc | Sep 20, 2011 | Uncategorized

Low level laser therapy, or LLLT is the application of low-powered lasers or light emitting diodes for the purpose of pain relief and/or injury repair. The therapy is typically done transdermal; meaning through the skin into the target tissue, such as a sore shoulder joint (no surgical incisions). While some research studies show that LLLT can result in immediate pain reduction in rheumatoid arthritis, osteoarthritis, tendinopathies, acute and chronic neck pain, temporomandibular joint (TMJ) pain and other joint disorders there is currently a lack of consensus on the best parameters to use; i.e. power, dosage, time, pulsing, and type of laser. The therapeutic wavelength appears to be between 800-1,000 nm; and dose to be around 6-10 joules/cm2.

LLLT may reduce pain related to inflammation by lowering levels of COX-2 and tumor necrosis factor-alpha (enzymes associated with inflammation); oxidative stress, edema, and bleeding. It is also believed to cause cellular mitochondria to produce more ATP– a cell’s basic energy unit, resulting in increased metabolic activity.

Low level laser therapy is offered by some chiropractors, sports physicians, and acupuncturists. Lasers are classified according to how much damage they can do to the eye, which basically means how powerful they are in terms of wattage. The wattage rating of a laser determines how long it takes to deliver a dose, and how deep the light penetrates tissue (important if you are treating thick areas of the body such as the hip or knee joint). At 10 watts max output, the LiteCure and K-Laser are two of the strongest lasers in the market for this purpose. Lasers with output of 500mW or less will not penetrate as deeply, and will require a longer treatment time to administer a therapeutic dose.

A typical treatment regimen will be 10-15 minutes of laser; six to eight sessions. Sometimes that is all it takes to take care of an acute or chronic problem. Many practitioners including myself incorporate soft tissue therapy, joint mobilization and rehab exercises to fully deal with the painful condition.

So if you are experiencing a recent injury such as a sports injury; or have chronic pain such as tendinitis, sciatica, plantar fascitis, rotator cuff tear, or knee pain, consider trying low level laser therapy. It is generally safe, and faster-acting than manual therapies alone (chiropractic, PT, occupational therapy). Be cautious and tell your practitioner if you are taking photosensitive medications, or have light sensitive skin, as the treatment can be uncomfortable and may even cause pigmentation.

UPDATE ON THIS TOPIC: Can Red Light Heal Injuries and Lessen Pain?

Dr. Dan