Thoughts from the journey… Excerpts from a day in the life of Sherry McLaughlin

12Oct/090

The origins of anterior/lateral meniscal pain

I've seen this three times in the last week, so I'm taking that as a sign that I am supposed to write about it.

Have you ever had a knee patient who complains of anterior knee pain with end range knee extension? They will either describe a pain at the anterior knee joint line or deep inside the knee. This is common, especially in post-surgical knee patients, and will delay healing time or possibly be the reason for a lack of terminal knee extension.

There are two primary scenarios that will create a pinch in the anterior/lateral knee with end range extension:

1. A femur that is internally rotated (check for t.p. in the anterior fibers of gluteus medius and TFL and/or in the medial gastrocnemius)

2. A tibia that is externally rotated (check for t.p. in the bicep femoris tendon and check for a posteriorly displaced fibular head)

Lat men t.p.

The trigger points may be treated with counterstrain and/or deep trigger point massage. The posteriorly displaced fibular head may be treated with MET. All of these aforementioned techniques take less than  two minutes!

Make sure you re-check end range extension after you treat the trigger points you find. Normal extension end-feel should yield a stretching sensation in the BACK of the knee.

Then make sure you address the offending tender point with exercises in the gym:

1. Gluteus medius - try medial reach with contralateral arm at waist level, heel-toe walking or carioca walking

2. Medial gastrocnemius - try gravity drop, downward dog, long strides in the ladder (make sure the toes stay pointed straight ahead) and balance board or foam roll rockers.

3. Bicep femoris - try the revolving triangle, anterior cone touch with the opposite hand or an anterior pulley low row with the opposite hand as the stance leg.

It sounds like a lot to get knee extension, but I assure you, it is the fast track to achieving a normal gait pattern and normal functioning of the lower extremity.

Until next time...

8Oct/092

Let’s Eat!

I started writing a book in January 2005. I never finished it, but lately I've been thinking about it...about the importance of people I come in contact with...about the lessons learned that I might have missed had I rushed by too quickly. About the places I've been and the people I've met.

So, I thought I'd share some excerpts from the book that will hopefully get finished one day. I am going to call it, Lessons from a Life.

Good food ends with good talk. – Geoffrey Neighor

Born and raised in a traditional Filipino home, I realized something at a very young age. Food is a good thing. No matter what the occasion or who the company, sounds of pots and pans clanging in the kitchen was a common occurrence. It seemed whenever friends and relatives came to visit, food was being prepared, or they were bringing food to be prepared or they were coming to prepare the food or prepared food was brought.

If you know anything about Filipinos, they never cook alone – and you can fit about 20 of them in an average sized kitchen. From a social perspective, preparation is just as important as consumption.

My dad’s two favorite words, “Let’s eat!” often spoken in the tone of a victorious battle cry, would result in hordes of smiling faces gathering around the kitchen table. Even then, he knew a secret that I had yet to learn: Food is our common ground. A universal experience. – James Beard

During my high school years, I attended a boarding academy. My parents would come and visit once a week, and with them would come – you guessed it – food. I had an entire drawer dedicated for my weekly stockpile of goodies. You can imagine how quickly the word spread. In fact, my parents were integral in spreading the message and as hungry kids would flock to my room each week, they would be supplied with their very own stockpile. Once the proverbial stores were filled, my dad would round up anyone – and I mean anyone – who wanted to jump in the family van, out for dinner. At times, we commandeered half of the tables at the local pizza parlor. Looking back, I realize how much my father must have spent on food for my high school friends.

“Dad, how many friends can I invite?” I would ask.

“As many as you want,” he would reply.

I graduated from high school and went off to college. My life became more of my own. I would come home on vacations and spend days catching up with my friends—eating out.

I got a job, got married and had a child and in those years, meals were rushed or “fit” into my schedule. I used to have a motto: if it couldn’t be cooked in less than 5 minutes, than we weren’t having it for dinner.

On the occasions I would visit my parent’s house, my dad would say, “Come, sit down and let’s eat.”

“Sorry, Dad.” I would reply, “I already ate and besides that, I’ve gotta go.”

If I wasn’t so busy, I might have caught the look of disappointment in his eye. But he would just smile and say, “OK, thanks for coming to visit. See you later.” I know he knew where I was coming from. His life had been just as busy as mine at one point, rushing from office to office, seeing tons of patients, being involved in extracurricular activities and raising a family. After all, I was the one most like him.

As I look back on the years before he passed away, I realize the countless invitations to the kitchen table I received from him. Some of them I accepted. I wish now I would have accepted them all. Hindsight is 20/20. The moments with my dad at the kitchen table are where I learned some of life’s greatest lessons.

For my dad, it was never about the food—it had always been about the time. For as busy as we both were, the kitchen table was a sanctuary all its own. A place where we could stop the rollercoaster of life, slow down, catch up and just be in the moment.

Life Lesson #1

The best gift you can give the ones you love

is a good meal at a nice table,

relished with flavor,

time

and great conversation.

It will fill not only fill the stomach,

more importantly…

it will quench the appetite of the soul.

8Oct/091

Adhesive Capsulitis (and a weak shoulder)

For anyone that has ever had a "weak" shoulder, this case might really help you out.

For the lay person, here is the major point: Weakness with lifting your arm up may be due to your shoulders not being the same level (check this in the mirror!) and a trigger point on your infraspinatus muscle (lower angle of your shoulder blade), which you would only notice if someone poked it. The good news is, it's fixable! But it takes some corrections in places nowhere near your shoulder... like your hips and your thoracic spine and maybe even your ankles.

For the clinician: I had the opportunity to evaluate a Marine who had sustained a gunshot wound that pierced his left 6th intercostal space and exited through his right external oblique. After 15 months of multiple surgeries and rehab, he is now complaining of left shoulder weakness and limited range of motion. He had a soft tissue endfeel at approximately 140 degrees of elevation.

Visual observation reveals his R shoulder significantly higher than his L. He stands with his L foot slightly externally rotated. (This is a classic Leaning Tower R scenario, for all of you Missing Link alumni) - R leg more supinated, L leg more pronated.

His range of motion is limited to about 140 degrees of elevation by a soft tissue restriction. Isometric MMT revealed 4 flexion and 4 abduction strength with mild pain noted in the posterior shoulder region with resistance.

Trigger points were palpated in the R upper trapezius, L iliopsoas, L piriformis and L quadratus lumborum.

Here is the assessment of his three key rotational spots:

Hips: Tight hamstrings bilaterally (90/90 test approx. -40 degrees); (+) R FABERs test (hip won't externally rotate); Normal piriformis test bilaterally.

Thoracic spine: 50% rotation bilaterally. R limited primarily due to hip and thoracic spine limitations (restored with piriformis inhibition, ITB release, thoracic NAGs and posterior rib mobilization). L limited primarily due to hip restrictions (restored with piriformis inhibition, ITB release and lateral hip mobilization).

Ankles: L>R tightness on the gravity drop; Severe hypomobility of the L>R subtalar joints into eversion. Incidentally, prior to his injury he had a history of L ITB friction syndrome and has used Brooks Beast shoes (their most stable motion control shoe) for years.

He presented with R SI joint dysfunction. I corrected an inflare and a posterior rotation, L on R sacral torsion.

Following correction of all of the above, his shoulder height was symmetrical. He still had mild pain/weakness with resisted shoulder abduction (4 MMT).

I palpated a significant trigger point on the L infraspinatus (inferior angle of the scapula). After counterstraining that tender point, his MMT was 5/5 and pain-free.

How did that happen?

Well, if you look at a picture of the infraspinatus, you will find that a trigger point in the inferior angle would have to be caused by one or m0re of the following:

1. An upwardly rotated scapula which would put the supraspinatus and deltoid in a long/weak position

2. An abducted scapula (which would put the rhomboid in a weak position

3. Or an elevated scapula (which was not the case here).

Normalization of shoulder strength after counterstrain to the infraspinatus would lead us to believe that the first scenario was the case. The deltoid/supraspinatus were weak because the infraspinatus trigger point was creating upward rotation of the scapula, placing them in a long/weak position.

The manual therapy fixes were mentioned above, primarily to normalize his posture and rotational movement patterns and inhibit the infraspinatus.

The exercise fix:

1. Strengthen the rhomboid in the short position. By they way, this gets compromised with abnormal rotation of the opposite hip.

2. Lower the opposite shoulder by encouraging thoracic rotation: backstroke, prone alternating arm lifts, plyoball throws, prone sky reaches, STEMs, etc.

3. Get that L hip to work! Shoulder flexion drives off of the L hip, which in this case was shown to be a major cause of his postural asymmetry (remember the trigger points in the iliopsoas, quadratus lumborum and piriformis?). Those trigger points will all inhibit the gluteus maximus.

Try some anterior cone reaches, pulley low rows (hip dominant), wall airplanes, the yoga warrior series to wake up that L hip.

4. Normalize ankle dorsiflexion with the gravity drop, downward dog, BOSU or foam roll rockers, Warrior I.

5. THEN put the shoulder to work with all the ways you normally do that.

Well, that's a lot of stuff to work on, so I'll let you get to it.

Have a great day.

Filed under: MIHP Think Tank 1 Comment
5Oct/092

Have a Little Faith

I had to travel this weekend at the end of a long work week to work a little more. I was scheduled to deliver the Missing Link Seminar to a group of therapists at Onslow Memorial Hospital in Jacksonville, NC - home of Marine Corp Base Camp Lejeune. And even as I was grumbling about being exhausted, I knew there was a reason I was meant to go this particular weekend. Long story short, I have received many blessings from the weekend, one of which was the opportunity to sit down and read Mitch Albom's new book, Have a Little Faith.

I read it in its entirety on my flight from Detroit to Atlanta, and it held timeless messages, many of which I needed to hear that night on the plane.

I hope you stop and take time to pick up a copy and read it. It will remind you of the importance of family, tradition and believing in something that is unchangeable and unshaking. These times call for something just like that.

Like I said, there were many blessings in the weekend. I had the opportunity to meet with a group  of therapists who sacrificed their weekend to learn about a new way of solving orthopedic problems. I got to evaluate a marine who was wounded in action, recovering from a bullet that pierced his left rib cage and tore up his organs on its way out of his right lower abdominal area. (Stay tuned for his case study) I got to see the looks of understanding and enlightenment of the therapists as we discussed the design of the human body and a better way of doing things. I saw how young our military is as they were out and about on the town, having just gotten paid the day before. They are young and bold...they drive big pick-up trucks and Corvettes...they have young wives and girlfriends and kids...and they protect our freedom.

I was reminded of the goodness of human kind, the sacrifices that our soldiers make in protecting our freedom and the big job those PT's have in restoring people back to health. I was reminded of how important our diligence is as therapists, because many times, we represent the only hope for the people we work with. I was reminded of how much we've learned in the last 10 years and how it doesn't matter how tired I am or how frustrating things get...the discoveries we make here need to get out there.

At one point, the marine looked at me and said, "Are you a faith healer?" I smiled and said, "I have faith..." and in my mind I thought to myself how looking at his wounds and thinking about all he had been through had restored my faith. I am so grateful to have met you, I wanted to say. You have no idea how much you've healed me. Thank you for what you do.

It was a long trip after a long week... intermixed with some great conversation, a good book and a lot of time to think.

Like I said, it turns out the weekend of work after a long week at work...was exactly what I needed.

5Oct/091

FAI and Hip Labral Tears

I frequent a running site where I get to hear about injuries that plague this group of athletes. There has been a recent increase in people complaining of hip pain, femoroacetabular impingement and labral tears. Some have had success with surgery, while many remain frustrated and have not been able to return to running.

The question that has to be asked is how did this happen to begin with? If the hip is sitting funny in the socket, then that is what ultimately causes a labral tear or wearing away of the femoral head.

For you people suffering with hip pain, know that there is a fix and it doesn't necessarily include a knife. We have had people contact us via email, receive a few exercises based on their answers to a few questions and they have become significantly pain-free in 1-2 weeks. It started out as my little pilot study and has yielded some really great results.

For you clinicians out there, there is a biomechanical fix.

Here are the things you want to check first:

1. Pelvic alignment - innominate inflares/outflares or anterior/posterior rotations will cause the hip to bind or pinch with IR/ER.

2. 90/90 hamstring test - if this is tight, check to see if they have a posteriorly displaced fibular head. You can fix that with a muscle energy technique or mobilization and it should improve hamstring length.

3. FABER's test - if this is (+) or limited on one side, the things to check are - latissimus dorsi flexibility (do the lat squeeze for those of you familiar with our techniques), correct inflare/outflares and mobilize the hip (this should be done last). If that doesn't work, check the opposite iliopsoas for a trigger point and if you find one, counterstrain it. Your goal is to normalize this motion as activating the glute is more difficult if this is restricted.

4. Piriformis test- If the patient gets a pinch in the groin with passive internal rotation, this also will impair the ability of the gluteal muscles to be activated during weight bearing activities. Common causes for this are inflares/outflares, a sacral torsion, trigger points in the iliopsoas or piriformis. Check these out on these patients and "fix what you find".

Remember, it's almost always about the butt... FAI and labral tears occur in hips where the gluteus medius and maximus were not functioning properly and more times than not it is due to a muscle imbalance or pelvic malalignment.

As for exercise intervention, once you determine why the glute muscles have taken a vacation, there are very specific ways to wake it back up. Stay tuned for more on this part.

Until next time...

Filed under: MIHP Think Tank 1 Comment