Login to view Shoulder & Elbow Pain videosRock Climbing with Shoulder Pain
November 9, 2010
Rock climbing is a tough sport, made 10 times tougher if your shoulders aren't working well. I just began working with a climber with shoulder pain that's been getting worse over the last few months. Turns out the scapulae are not elevating and rotating properly. This has led to a hypermobile (excessively moving) shoulder joint. Any of you who have read my books know that hypermobility typically leads to pain.
We've been re-training his humeral and scapular movements as well as strengthening key scapular muscles. He's done quite well with these exercises. We then advanced him to an upper extremity workout to help him understand how these principles play out in the gym. While working out, we realized his forearms lacked adequate rotation. This was significant because it was another stressor to his hypermobile shoulder joint. Because his forearms would not rotate adequately, he had to internally rotate his humerus more than usual to reach out or up. This caused pain. We gave him forearm stretching exercises and his pain decreased.
This is a great example how two issues at both ends can come together to feed a third site of pain. Poor scapular movement stressed the shoulder joint. Poor forearm rotation also stressed the shoulder joint. I think it's interesting to note that the two issues feeding his pain are both hypomobile areas which have created a hypermobile painful area. Fixing these two problems will fix his pain and make him a better rock climber.
Plantar Fasciitis, Heel Spur, and Bunion Treatment
October 27, 2010
I've been experimenting with a new concept in treating plantar fasciitis based on foot-strike patterns and have been very successful with it. I'm doing the research for my next book, Fixing You: Foot & Ankle Pain (which won't be out for quite some time!). The one thing I've noticed, however, is that all the feet I've seen for this issue have been pronated (flat feet). This works perfectly with my theory of how foot-strike patterns create this as well as other problems in the feet, however I'd like to see some supinated feet with plantar fasciitis to learn the nuances of working with this foot type.
The heel spur treatment has also gone well, although I haven't seen as many of these patients as I'd like. Treatment for this group is a little trickier because of the contact stress on the spur which contributes to constant irritation. But, so far, it seems the conditions and patterns creating heel spurs, seem to be identical to those that are creating plantar fasciitis.
No news to report on my treatment for bunions yet. Although I think my reasoning is theoretically sound, I've learned a long time ago that the human body has its own way of doing things and that sometimes it takes time to figure out the logic of it. I am very excited though to see how this treatment approach works (or doesn't work). I can't seem to get out of my mind that bunions must be a mechanical issue and that correcting the mechanics, corrects the bunion. We'll just have to see.
There are some inherent problems with my treatment approach, namely that I cannot determine how often and for how long my patients are adhering to the protocol. Changing the way we walk takes time and practice and involves some fine-tuning for each person. I can't be there to coach them through this so I must leave it in their hands to figure some of this out. This makes the treatment a little less precise. But this also underscores my hope that exact precision is not required to correct these issues. A general idea of how we should be walking should be enough. Thankfully the results have been dramatic enough so the patients know exactly when they are not doing enough--because their pain returns.
Overall I'm heartened by my results!
Dry Needling Hurdles
October 21, 2010
My last two posts have been about trying dry needling on a patient with carpal tunnel syndrome and using this modality for bunion correction. I'm disappointed to say I'm running into some hurdles. The first deals with the bunions and is that most people don't feel comfortable having needles inserted into their feet. Imagine that! Therefore I'm using fewer needles and going shallower than I think I need to target the muscles I'd like to target--that's if they let me needle at all! So I'm developing an alternative strategy to correct this which should work better, actually.
Second, regarding my carpal tunnel patient, his sensitivity to the needles has unfortunately increased so we've had to discontinue this intervention. Now we are focussing on other issues I believe are contributing to his condition. This turns out to be a positive step because I believe if we can change the motor planning issues associated with his problems, then that will have a more lasting effect on his symptoms. The problem is there is a variety of issues requiring much of his attention. Thankfully he is committed and motivated to make these changes. We'll see.
So all in all, I'm not having much success with the dry needling, although I still believe it will have a place in treatment of some of my more difficult cases. This is what I love about medicine; when you run into a hurdle, you must find a way to go around it. Thinking creatively is key, as well as not giving up. I expect my outcomes will be even better because of the hurdles.
Dry Needling Carpal Tunnel Syndrome
September 30, 2010
I've just had my second visit with a patient with 20+ years of carpal tunnel syndrome for which we are trying dry needling (an anatomically based approach to using acupuncture needles). I must say, I've run into an issue in which the needles are either meeting with resistance or the patient is hypersensitive to the needle. This was unexpected as his hands have been numb for at least the last 20 years and he has even burned his hands a couple times due to an inability to feel heat.
Nevertheless we continued with his second treatment today and found him less sensitive to the needles. We were, therefore, able to go deeper into the key forearm and hand muscles I believe may be contributing to his carpal tunnel syndrome. We've stayed away from his neck area thus far but I intend to work my way up there once the forearm area is desensitized.
In addition to the dry needles I am also using vacuum cup therapy on his forearm muscles. This uses bell-shaped cups to create a vacuum within and draw the skin and fascia away from the bone according to Dr. Yun-Tao Ma, my instructor in dry needling and vacuum therapy. I'm using an electric motor to generate the vacuum. This is apparently 4x the strength of traditional cup therapy which uses a flame to create the vacuum. My goal here is to loosen fascia around the muscles to help allow the needles to penetrate.
Finally I stretched his deep forearm rotator muscles into pronation and supination according to my book, Fixing You: Shoulder & Elbow Pain. I believe tightness in these muscles creates stress to the finger and wrist extensors and flexors causing tennis elbow, golfers' elbow, and perhaps my patient's carpal tunnel syndrome.
My hope is that by combining corrective exercises for his functional deficits with dry needling and vacuum therapy, we can obtain a better result. This is because I treated him a few years ago using my approach and generated some very positive results which then plateaued. Although we were able to obtain some feeling in the tips of his thumb, first, and third fingers, we could progress no further in our results. I'm hoping that combining these three treatment modalities, we can achieve broader and deeper changes.
After his first treatment, the sharp electric shocks in his hand have dramatically reduced in frequency and intensity. I'm heartened by this and am remaining cautiously optimistic. We will continue with treatment for a few weeks to see where this takes us.
Bunions, Biomechanics, and Dry Needling?
September 16, 2010
I've been experimenting with the effects of reduced heel strike and increased mid- or forefoot strike patterns on issues such as plantar fasciitis, heel spurs, bunions, and other foot maladies for my sixth book in the Fixing You series. It's been very interesting and I believe this should be an integral part of treating these conditions. But in many people, something more is needed, either because they are not being vigilant enough in changing their foot strike patterns or their issue is complicated by years of adaptations in the foot musculature and ligaments. I've begun addressing more specific soft tissue issues and my results are now even better.
In every person I've seen with bunions, however, I believe this extra attention to the soft tissues should apply specifically to the abductor hallucis and medial head of the flexor hallucis brevis muscles in addition to the transverse and oblique heads of the adductor hallucis muscle. I won't get too technical here but I believe these muscles, as well as ligament changes, must adapt over time to hold the bunion deformation in place. So even if the mechanics of the foot are restored, these muscles may not "release" the bones to return where they need to go.
I've just taken a dry needling course and will take the advanced course in the next couple of days to become certified in Colorado. Dry needling, among other things, is meant to relax needled muscles and promote healing. Regarding bunions, I wonder if I needled the muscles mentioned above, together with changing the foot strike mechanics, whether this would reduce the size and pain of bunions. It's just a thought but I'll be experimenting with this over the next few months to test my ideas. We'll see how it goes!
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