Sometimes you just meet someone whose story stops you in your tracks. A little over a year ago, I met Daniel.
He came in with complaints of wrist and elbow pain that were making it difficult for him to ski. As I worked on him, he told me of his love of the mountains and being outdoors. The feeling of carving tracks in deep powder. The exhilaration of flying down a mountain. His smile grew as he talked about the times he spent skiing with his twelve-year old son.
He told me all of this as he sat in his wheelchair.
We talked little more and I asked him about the accident that caused his paralysis. "It was an avalanche," he said. He had hiked up a mountain in Romania in 1994 to take some pictures when all of a sudden the ground started moving beneath him. The mountain he so revered was about to toss him over the side of a frozen waterfall and into the icy water. He told me about the people who saved him and carried him to safety. He described his unrelenting pursuit to walk again. And he told me about the day he finally came to realize that his efforts might better be spent on something else.
So, he headed back to the mountains. This time with a monoski and two outriggers and figured out how to once again commune with nature the way he was intended to...only his hands were now also his legs.
I've never wanted to fix wrist pain so badly before in my life.
I could tell you about how we normalized his thoracic rotation in attempt to decrease the myofascial tension in his UE. I could tell you how we improved his mobility and UE strength. I could talk to you about how his scapular malpositioning and the tightness in his pec minor were integral in the ongoing pressures in the carpal tunnel. In the end, he ended up having to have carpal tunnel releases, the compression of the median nerve was so advanced.
But this isn't about what we did for Daniel as much as it is about what he did for us.
Sometimes life throws you curveballs. Lord knows, I've fielded a few of those in my day. And sometimes the best laid plans of mice and men...well, you know how that quote ends. And since I'm on a roll with cliche's, here's one more I heard on a recent episode of a TV show. "When men make plans, God laughs."
God laughs. Maybe not because He thinks our plans are funny, but perhaps because He thinks our plans are too small. Or too timid. Or too superficial.
I thought by now (I'm almost 45), that I would have launched a large, successful and self-sustaining clinic. That I'd be retired and independently wealthy. But if that would have happened, maybe I would have never met Daniel. And I wouldn't still be plugging away trying to figure out the puzzle that is the human body to rid people of their pain problems.
Maybe I would have touched less lives...and witnessed fewer miracles...and learned less. Sometimes in the pursuit of our biggest plans, realizing the need to change course is the biggest blessing of all.
So, I don't have a huge clinic. Instead, I have a small practice where I can see from one end of the building to the other. I have a small staff...about half the size it was 5 years ago. I have to defend a lot of what we do because it is unconventional. And I get to teach it, not to university students, but to community college and high school students. Sometimes the days are longer than I would like and my wallet is flatter than I would like. And surprisingly, I wouldn't change a thing.
Because I get to work with some of the most intelligent people I've ever known. I also get to see miracles almost everyday. I get to meet incredible people from all walks of life. And even though it feels like such a small place and a small thing and we don't always fix every person we meet, the work feels important. Somehow it changes the world. And then it changes us.
I think about Daniel this time of year. I imagine he is hitting the slopes with a huge smile on his face, loving the life he never thought he would have to live. I send up a prayer of thanks for his inspiration and the constant reminder that when you come to a fork in the road, take it. And engage it. And don't look back, except to be thankful for where the journey has taken you.
And I send up a prayer of thanks that MY plans were maybe laughed at by the God of the Universe. Because, I when I stop to think about it, I really love my life.
I look forward sharing news from the MIHP Think Tank in 2012. Happy New Year.
I was blog surfing today and saw a link to an interesting article that came out two days ago: http://www.usatoday.com/sports/baseball/2010-11-16-shoulder_N.htm
Evidently, there is a bit of controversy regarding whether or not the biceps tendon is an important part of the throwing shoulder. One thing most can agree on is that chronic biceps tendonitis is often the cause of persistent anterior shoulder pain after a SLAP lesion repair.
Superior Labrum Anterior Posterior (SLAP) is a tear in the labrum, common in overhead athletes. As a student of biomechanics, my first question is, "What position of the humeral head would predispose one to a SLAP lesion?" And then, "What does the biceps tendon have to do with that?"
It is this author's experience that persistent biceps tendon pain occurs when the biceps tendon is placed in a long/weak position. Here are the options:
1. Elevated scapula (due to upper trapezius trigger point or elevated pelvis) - Sagittal Plane
2. Adducted scapula (uncommon) - Frontal Plane
3. Upwardly rotated scapula (due to upper trapezius or infraspinatus trigger points) - Transverse Plane
#1, 3 are the most common scapular positional faults that create overload to the biceps long head tendon. This is clinically confirmed by performing manual muscle test of the biceps pre- and post-treatment of the above trigger points.
In short, correct scapular position and the biceps irritation goes away. Interestingly enough, the elevated, upwardly rotated and protracted scapula is also a culprit in rotator cuff tendonitis and tears. And the position of the scapula is often a result of dysfunction somewhere else in the biomechanical chain.
It isn't surprising then that SLAP lesions, rotator cuff tendonitis and persistent biceps tendon pain are commonly associated. According the to article, if you just move the bicep tendon and affix it to the humerus, then you remove the offending tendon and the pain goes away. One study even sites that there was no change in performance. (Maybe it's because these guys actually are throwing from the hip).
I suspect we will find out the ramifications of moving or removing body parts that are part of our intricate design. Kind of like rebuilding an engine only to have a box of leftover parts. It might seem like everything works, but it always makes me a little bit nervous.
For those of you non-professional athletes out there suffering from chronic anterior shoulder pain, here is great news! There is a fix! And it doesn't include a knife or moving body parts around. I assure you these shoulders weren't injured because the bicep was in the wrong place. Moving it, at best, avoids the problem. It doesn't fix it.
For the clinicians out there, remember, the biceps tendon wasn't designed to work in a long/weak position. Fix it's starting length (i.e. fix scapular position) and restore normal functional rotational movement patterns (that means check the thoracic spine, the hip and the subtalar joint).
To quote Dr. James Andrews: The rotator cuff "is still the granddad of the problems" in pitchers' shoulders, but surgeons aren't satisfied with the success rate on SLAP repairs. We're all trying to figure it out — how to fix the damn thing.
My advice, put your ears to the shoulder and take your eyes and look elsewhere. There are real world solutions to this problem. It's our job to exercise those solutions and let the consumers at large know about their options. I promise you, when you solve one of these for yourself, you won't ever forget it--and neither will your patient.
And just when you thought all letters were created equally...
I have had the opportunity to see some rotator cuff tendonitis and biceps tendonitis patient recently who reminded me of the importance of that first statement. A quick on-line search of the "T", "Y" and "W" exercises commonly prescribed for shoulder pathology confirmed that many clinicians use these exercises more as a general means of fixing scapular instability rather than for a targeted purpose.
I've made that mistake before. And when the patient returned with equal or worse pain, it sent me back to the drawing board to figure out why. Collectively, these exercises appear to all strengthen scapular muscles. But let's take a closer look at each one:
The "Y" - This is a strong activator of the lower trapezius muscle (also a functional antagonist to the over active upper trapezius). Remember, the lower trapezius muscle is activated with arm elevation past 90˚. One of the best ways to shut it off? Adopt a thoracic kyphosis or limit rotation to one side and this muscle will become neurologically insufficient (or what we call neurologically lazy).
The "W" - This exercise incorporates retraction with external rotation, so is a strong activator of the shoulder external rotators (infraspinatus and teres minor). Here is the caveat. If a patient has a trigger point in the infraspinatus or teres minor, doing this exercise can actually increase a person's pain! These muscles are not only external rotators, but relative upward rotators of the scapula (just take a look at a picture of them).
So, there you have it. I have seen biceps tenosynovitis and rotator cuff impingement patients gain pain-free status after doing the T, and then immediately have their pain return with resisted flexion or ER after doing the W. There are specific reasons to do specific exercises. Know the "Y" behind what you do. Your patients will thank you for it.
Until next time...
You know what they say, when life hands you lemons...
I had been training for months for a spring half marathon. Normally, I do the Martian Half Marathon, but since they moved it a weekend up this year and put it on a Saturday, that took me out of the running (no pun intended). So, I decided to enter the Trail Half Marathon that was held this past weekend.
My crazy schedule and lack of immediate attention to detail left me high and dry when I tried to sign up three weeks ago, only to find out that all 1,100 slots had been taken. Now, if you know me, you know that I don't particularly enjoy running. I do it as a matter of discipline and so that when I take part in my yearly Olympic Distance Triathlon, I'm not dying running the 10K at the end of it.
So, with all of this crazy training behind me, I decided to run my own half marathon. That's right...just me. As the vision became clearer in my head, a smile grew on my face. Not only would I take the top spot in my age bracket, but I would also win the overall prize! Never before in my wildest dreams did I think I could ever win a half marathon and now, in just a few short days, I could be crowned champion of my own race.
The idea was brilliant and so I started telling people about it. If you know anything about my life, you realize it is far from private. And, yes, I know much of that is my own doing. As the story spread, I heard a client say, "I think I might want to join Sherry on that run." All of a sudden, what could be the best race of my life could turn into my worst. After all, with only two people running the race, coming in second also means I would be finishing dead last! This woman had never run a half marathon before, though she was certainly a runner.
Oh, the dilemma. But as one of my other patients said, "It might be like that tree in the woods scenario. If you win a race and nobody is around to witness it, did you really run the race at all?" Point taken.
So, the invitation was extended and the time set. 7:30 a.m. sharp, the starting "gun" would go off. We would leave from my house and follow a carefully mapped out route through Birmingham/Bloomfield, ending up at the Starbucks on Old Woodward in Downtown Birmingham.
Just so you know, I was taking this thing very seriously. I got up at 4 a.m. to eat my pre-race bowl of oatmeal with walnuts, then back to bed for a few more hours of sleep before getting up to down my pre-race supplements, Advocare Spark, O2 Gold and Catalyst. Marilyn arrived a little bit before 7:30 and we did final potty stops and took our pre-race photo (see below) before heading to the starting line.
The starting gun went off...well, there was no gun, but we said, "Go!" and started running. The day was gray and damp, threatening rain and with a bite in the air. The route went down tree-lined streets and on dirt roads. We navigated mud and pot holes and ran by some of the most beautiful homes in Oakland County. At mile 6, there was a torrential downpour that lasted for about 10 minutes. We were soaked to the skin. We ran past the Cranbrook Art Museum and through the campus. We negotiated some long hills and enjoyed the downhills that inevitably came. We talked about life and running as we paced each other mile after mile. And as the minutes ticked by and the miles were conquered, my competitor became my friend.
At mile 9, this guy jumped out of his car and ran past us and then turned around to take our picture. He cheered us on and then showed up a few blocks later to shoot more photos. "See you at Starbucks!" he said. Our race came complete with a fan and a photographer... (Thanks, Greg!)
At mile 11, we made a left hand turn to begin our run around Quarton Lake. At mile 12, we faced the long hill into downtown Birmingham. And on the final turn, as my legs were aching and my heart was pounding, I made a run for the finish. It was a slight uphill battle, but nothing could stop me now! My legs were churning and I could see the finish line just ahead. As I crossed the proverbial line, I stopped my watch. Marilyn crossed just 7 seconds behind me to complete her first half marathon. The winning time was 2:11:46. The Kenyans might laugh at that, but I was smiling. And as I hugged Marilyn after she crossed the finish line, I just knew in my heart that this was exactly the race I was meant to run this spring.
There were no crowds. No finishing medals. No speaker announcing our names. But at the end, there was our number one fan at Starbucks, reading the paper and waiting to take our picture. And two women who were now friends...bound by 13.1 miles of mud, rain, potholes, long hills and some great conversation.
Thanks, Marilyn, for coming out very early on a Saturday morning to take part in this inaugural race with me and thanks for letting me win. Thanks to our number one fan and race photographer, Greg. I'll see you guys next year...and maybe a few more of you will join us. But for now, please allow me to bask in the fact that I currently hold the course record.
Until next time...
OK, I've been sitting on this one for a while now just to make sure that what I'm seeing is actually happening.
I have a fair number of patients who exhibit functional quadricep weakness during squatting activities, and not all of these folks have knee pain. I regularly do a squat test during my initial evaluation on most of my out-patient orthopedic clients. Ironically, I have also observed a pelvic rotation (in the transverse plane) on these folks.
So, to cut to the chase, try this test:
3 repetitions of a single leg squat using the TRX or other strap to allow them to use their upper extremities to assist. Don't worry. Even if the "cheat" this a bit, it will be evident which leg is weaker.
Perform 3 x 12 of the kneeling tubing punch using the opposite hand of the weak quad. Here are the specific instructions:
1. Hold the tubing (must be strong resistance) in one hand and allow it to pull the body into rotation to that side.
2. SQUEEZE THE GLUTEUS MAXIMUS on that side to drive the ASIS forward and correct the pelvic rotation.
3. While maintaining this squeeze, have the person perform 12 repetitions of a punch while maintaining that pelvic position and gluteal squeeze. Rest. Reset the gluteus maximus and perform for a total of 3 sets of 12 repetitions.
THEN, repeat the squat test. You just might be amazed at what happens. The quadricep often displays marked improvement following correction of a pelvic rotation.
Give this a try and let me know if it works for you and your patients. Then stay tuned for a little "add on" bonus on how this exercise can improve gluteus medius strength.
Until next time...