Conservative Orthopedics and Wellness -COW

09/01/2023

https://conservativeorthopedics.com/2023/08/shoulder-pain-very-effective-exercise-for-a-variety-of-patients-athletes/

Visit the post for more.

08/23/2023

https://conservativeorthopedics.com/2023/08/neck-isometrics-easy-and-effective/

Visit the post for more.

01/27/2023

https://conservativeorthopedics.com/2023/01/disc-related-low-back-pain-sciatica-what-should-you-do/

Visit the post for more.

12/25/2022

Happy Holidays

04/16/2021

Continuing education time

McKenzie Mechanical Diagnosis and Therapy  Advanced Cervical Thoracic and Upper Extremity refresher course, M&M version with Medcalf and Miller instructing, super pumped to learn from the masters

Fine tuning the diagnostic classification of whether an issue is a neck problem, arm problem, both or something else, without a full examination of neurological status, spinal mechanics and the whole upper body, things are going to be missed. If only seen as a muscle or a joint or a flexibility or strength issue, assumptions will generate errors.

Friendly reminder that McKenzie is a diagnostic system, not a set of exercises or protocol, frustrating to see how many patients have been told they were given mckenzie when it was just a few random stretches without an initial diagnosis or reassessment, we do a full comprehensive exam and start getting results with an open ear and attention to detail.

Never stop learning

04/08/2021

Continuing with our belated, boisterous and borderline blasphemous briefs on bird dog blunders series, we look at the elbow, not usually the center of attention with this exercise, but can have a big impact on where we feel it working.

This is of particular interest for bendy people, the ability to hyperextend the elbow gives a different option for loadbearing during a bird dog exercise, which can drastically change which muscle groups are working.

As we hold the bird dog or any other exercise which has our weight going through our hands into the ground, there are different muscle chains we can use to hold ourselves up, This can be directed by our hand pressure, elbow angle and shoulder/scapula position, whole body, its all connected yadda yadda, anyways today we are focusing on the elbow.

If we over straighten the elbow, we can shift the tension more into the front of the shoulder, anterior delt, long head of the bicep, upper shoulder blade muscles, etc along with the ligaments and stacked bony structure of the elbow. This can be an issue if those areas are painful or overworked, when we are still bracing through them, we're burning calories, but not having a real therapeutic effect.

If we keep the elbow neutral or slightly bent if required, we tend to activate more triceps, the long head inserts into the shoulder blade, and this ties into more the lower scapular muscles into the abdominal slings, connecting an arch from the hand on the table to the opposite knee. 

The key here is the load passing into the ground without a detour through the head and neck, our elbow and upper extremity position will determine the road we take, so needs to be observed and modified as needed. This can expose a lack of strength or endurance which needs to be built up, or its possible that we have the nuts and bolt but just aren't using that pathway preferentially.

Hope this helps, thanks for reading

Pete

                 

04/05/2021

For this month's mckenzie minute for moderately motivated musculoskeletal menders minute, we crossover some techniques to get into more of the creative side of mechanical testing.  

I like SOT blocks, they add some interesting forces into the therapeutic toolbox and are easy to teach a patient for self treatment.  

They can create a useful translation force of the pelvis relative to the rib cage depending on the depth of the blocks under the pelvis. Prone CAT 3 or 1 blocking causing a posterior translation or shear of the pelvis relative to the rib cage and CAT 2 supine blocking anteriorly translating the pelvis relative to the rib cage. This creates a shear force across the lower back which can be a good or bad thing depending on the mechanical response to range of motion and provocative testing.

We can put sagittal plane translation into our MDT assessment as a variable, we sideglide in frontal plane, so why not in sagittal also? Similar to traction vs compression with motions also, some patients need pulled apart while other need extra compression of sitting to get a full treatment effect.

Would be similar to the hands across the lower back with extension or leaning backward over a table to extend, extra pivot point and shear which can change the movement.  

Advantage of blocking would be the fine adjustment and ability to prolong the duration of the force, especially when it needs time for a small shift to take effect. Can utilize breathing to help relax further into the position while blocked, I've heard it described as a form of positional release from time to time. Can also be helpful with derotating certain patients for repeated extension prone, in scoliotic patients notably.

Hope that helps, little different today, but something to consider

03/29/2021

Continuing with our belated, boisterous and borderline blasphemous briefs on bird dog blunders series, we look at the stance width of our hands and knees.  Their position will determine if we draw more from the outer or inner arms and legs, this has an impact on which muscle links/fascial lines we utilize during the exercise.  This is important to consider what result we are looking for, if we are seeking abdominal challenge and are hanging on out outer arm and leg, not gonna get the results we need.  That said, not necessarily a right or wrong way to do it, narrow stance for outer extremity challenge and balance, wider stance for the abdominal arch connecting the hand and knee on the floor, all depends on what we want.  Sorry internet, no demonizing exercise positions today, just explaining the value of each modification in a specific situation.

Anyways, simple thing to monitor, can turn an exercise into a test, everything is potentially diagnostic when we switch our lenses

03/23/2021

Zoom fatigue, many contributing factors, personally have used an ancient 2nd laptop for just video to at least get 2 screens to bounce between

https://news.stanford.edu/2021/02/23/four-causes-zoom-fatigue-solutions/

It’s not just Zoom. Popular video chat platforms have design flaws that exhaust the human mind and body. But there are easy ways to mitigate their effects.

03/22/2021

In the wide world of abdominal cylinder training, we have many options to achieve our desired training effect and results.  Along the spectrum of abdominal prompts and feedback tools we have here one of the cheapest ones, a weight.

When we're monitoring the different corners/areas of our abdominal cylinder, getting some feedback can be helpful, when we transition to positions where our arms are needed for different variations/challenges, sometimes a little sensor to make sure our abdominal wall is keeping up with the rest of us is required.  This high tech solution of making sure you're maintaining a wall in your abdomen by keeping a weight from sagging into your stomach is one of our better options.  Gravity is usually available, and most things have mass, so finding the ingredients for this one should be pretty easy.  Starting with a lighter object is usually better, only enough pressure to monitor the abdominal wall during exercise.

When working with a more detailed assessment of your abdominal wall, we can find some spots might have less activation than others.  This can be due to pain inhibition from the spine or pelvis, scar tissue pain, visceral/organ pain and other things requiring clinical assessment and treatment.  This comes more into play with DNS (Dynamic Neuromsucular Stabilization) and Schroth Scoliosis assessment.  Anyways, we can vary the placement of the weight to match the less active area of the abdomen, the little details can matter.

More on the qualitative side of things but can be the difference maker especially when working on overuse injury big picture retraining and balancing tension in the body.

03/16/2021

Popliteus, connecting into things like the fibula and lateral meniscus, often ignored but can have a big effect on knee tracking and arch control

from previous post

I like the popliteus, keeping it in consideration with lower extremity pain, especially posteriolateral and lateral knee pain, is crucial for effective treatment.

http://www.jospt.org/doi/pdf/10.2519/jospt.2005.35.3.165

I take particular interest in musculotendinous structures which tie into joints more than others, this would include the iliocapsularis and re**us femoris into the hip. One of the key visualizations in the jospt paper is the possible connection of the popliteus into the lateral meniscus, not on a large percentage, but more than zero, which is relevant when dealing with an outlier knee pain presentation.

From a kinetic chain perspective, in open chain it functions as a tibial internal rotator, which means with a fixed leg in closed chain it will function as a femoral external rotator. This opens the possibility for overload of the popliteus in weightbearing to control rotation of the lower extremity, when other external rotators such as the hip(too much to list) and foot arch complex, requiring assessment of the whole limb to sniff out an overload mechanism when those areas are dysfunctional but nonpainful, the coveted DNP of big picture treatment planning.

Topic for another post, but the PFL, or popliteofibular ligament is also intriguing, the fibula is more active than would be assumed and its link to ankle rocker at the other side of the tibia is a whole discussion in itself, we’ll save that for another day

A closer look at those lateral structures that keep you in line.. the posterolateral corner (PLC) is comprised of the popliteus tendon, the popliteofibular ligament, and the lateral collateral ligament (LCL, sometimes called the FCL 😉)

03/10/2021

Some reading this week, well traveled/fairly abused copy of Schroth Therapy for scoliosis patients.  Schroth Best Practice has been a great addition to the treatment toolbox, customizing exercise positions to the curve and drawing out the weak spots. 

Schroth's emphasis on breathing to balance the curves and abdominal activation is the missing ingredient in many cases, no matter what the age of the patient.  There is a fairly typical pattern of weakness/tightness associated with the curve which can persist throughout life, requiring some extra attention to detail during exercise to get a real therapeutic effect.

Some interesting crossover with Dynamic Neuromuscular Stabilization and some Vojta Reflex Locomotion influences.  Varying the bases to fit each patient's starting point along with any shoulder, knee, ankle or hip etc limitations. More options to get the best results from our exercise program.

03/08/2021

Nice interview on DNS training and rehabilitation with Michael Rintala. Taking the DNS exercise and clinical education series is a game changer, helps create a framework of which exercise and when for designing a rehabilitation program or workout, filling in the gaps of a training program

https://www.youtube.com/watch?v=y6OALVlNgqI

Michael Rintala is a sports medicine chiropractor and one of only 18 international instructors teaching dynamic neuromuscular stabilization (DNS) for the Pra...

03/08/2021

For this month's mckenzie minute for moderately motivated musculoskeletal menders, we'll go over a weightbearing knee extension with tibial external rotation pattern. This can apply to a derangement or dysfunction classification, recalling derangemnt can have a short or long duration of symptoms, while dysfunction requires some time to develop.  For this example, the knee is post operative several months with a persistent range of motion restriction, we would have identified a produce/no worse pattern of tissue loading with partial improvement loading extension and external rotation in nonweightbearing, leading us to progress forces and exhaust the current combination.

When dealing with a restricted knee, particularly in , in this case not getting that last bit of extension, sometimes have to vary the degree of weightbearing, rotation and muscular force to get full range of motion back.  In this case we had a positive response with tibial external rotation in extension, but needed to increase the load to exhaust the direction which we had uncovered.  We progressed to full weightbearing with a quadricep contraction to get at that last bit of extension, varying the ankle position for gastrocnemius contribution to see if any change in response.  Overall fit more of a dysfunction classification with duration of injury and symptom response.

This matches up with the screw home mechanism of the knee and some of the gait issues the patient was dealing with, missing that external rotation in extension was throwing off knee tracking during gait.  Also looked into and function controlling tibial rotation for more of the stability/motor control side of things for a complete rehabilitation program.

02/24/2021

Continuing with our belated, boisterous and borderline blasphemous briefs on bird dog blunders series, we look at how we are driving out  the non weightbearing leg, first question is are we going more through the wall behind us or more up to the ceiling? For most people, I tend to prompt driving heel through the wall, if going too much upward to ceiling, tend to recruit more of a hamstring curl or anteriorly tilt the pelvis with lower back muscles to raise the leg rather than pure hip extension.  Speaking of anterior tilt, another reason we might see a bit too much knee flexion during a bird dog is the hamstring acting as a posterior pelvic tilt control compensator rather than using the abdominal cylinder, fixing that is another post, probably need to go back to 3-6 month supine and prone postures for that assessment through a DNS lens, save that for another day

This fits into the classic lower cross patterns, we want to get abdominal cylinder and glute drive, and must be diligent to observe when the goal of the exercise is being lost, we're still burning calories, but not getting the control and improvements that are needed for continued gains and improvements in pain and function

Anyways, the little things can make the difference and need to be correlated with a full examination and other patterns observed during exercise and rehabilitation, diagnosis never stops

02/17/2021

For this months McKenzie minute for moderately motivated musculoskeletal menders, we will go over fine tuning the sideglide extension in standing

Depending on the person, sometimes have to vary the degree of sideglide to match the patient, sort of like tuning the radio to get the right frequency, this can match up.with imaging of more lateral vs more posterior/anterior presentation depending on the patient

Too far over can also jam a facet, throwing off the symptom response

02/14/2021

One of the things we look for in persistent neck pain and headaches is eye tracking issues, article on eye health with increased screen time, the eyes direct our head and eye movement in some interesting ways, keep it tuned up

https://www.bbc.com/news/uk-55933168

In lockdown, days on end can be spent staring at a screen, which is taking its toll on peoples' eyes.

02/11/2021

Interesting commentary on long covid symptom patterns and treatment from a respiratory physiotherapist

https://www.thebreathingpt.co.uk/post/managing-long-covid-a-respiratory-physiotherapist-s-perspective

The first thing I learned in physio school was “prepare the area” – in other words get everything you need for your treatment session and make sure the space is clear and safe for you and your patient. The second thing I learned was “treat what you find” – which basically means do your a...