The Patella, commonly known as the knee cap, is an essential bone in the knee joint that acts as a fulcrum for our quadriceps, (the thigh muscles), to help gain mechanical advantage for extending your lower leg.  The patella is roughly triangular with the apex of the triangle articulating with the femur bone and it is the largest sesmoid bone in the body.  It is equipped with some of the thickest cartilage on this inferior surface.  The knee cap is stabilized within the grove of the two femoral chondyles with the balance of the musculature and ligaments around it.  This is largely made up of the quadriceps muscles. When there is trauma or a muscular imbalance at the patella, pain occurs.

Symptoms of Patellofemoral Pain Syndrome (PFPS)

PFPS can affect everyone with women and young adult athletes being affected the most. The main symptom of patella-femoral syndrome is pain under or around the knee cap but other symptoms include:

-pain going up and down stairs, (usually more descending stairs)
-pain squatting
-pain kneeling 
-swelling around the knee cap
-knee pain when getting up after sitting for a period of time
-grinding or popping when moving the knee
-increases pain with activities that involve jumping or running

Causes of Patellofemoral Pain Syndrome

Trauma can be a cause of PFPS when  a person falls directly onto the knee and drives the knee cap into the joint.  This causes injury to the cartilage under the patella and joint irritation.  Gradual onset of PFPS is the most common presentation.  There is no one common cause of the condition but often an imbalance of knee cap musculature is at the root of the problem. 

Common aggravating factors to this include:

-Over use of the knee joint when the knee musculature isn't capable of handling the stress
- repetitive exercise that causes an imbalance of musculature around the knee. (example: cycling can build up the lateral leg muscles greater than the medial ones)
- weakness in the hip and back muscles causing an imbalance down the mechanical chain
-Increased pain when playing sports on hard surfaces 
-Certain body types with an increased angle at the knee are more prone to PFPS
-Flat feet or other foot conditions
-improper footwear or changing footwear can flare up PFPS

Treatment of Patellar-Femoral Pain Syndrome

Initial Treatment
Inflammation should be initially managed if you have a flare up around the knee cap that involves pain and swelling.  The classic RICE method should be used:
R- Rest. Decrease or eliminate the aggravating activity
I -Ice. Place ice on the knee in intervals of 15 minutes an hour (don't place directly on skin)
C- Compression. Lightly wrap the knee in a compression bandage, leaving a hole for the knee cap.  Ensure that it doesn't cause more pain when wrapped
E- Elevate.  When you are able, elevate your leg when resting throughout the day.

Medications
Initially, the use of anti-inflammatory medication is appropriate for those who can take them.  They should not be used for over 2 weeks without consulting with your doctor. 
 
Therapy
Conservative care is the appropriate treatment as surgery is rarely needed.  A thorough examination of the leg, hip and back musculature is needed to asses if there are any weakness in the biomechanical chain.  Secondly the feet should be checked to see if there is extra force being placed on the knee due to improper foot mechanics.  
Initial therapy may include modalities such as ultrasound, current, TENS, massage and adjustments to the hips and spine.  It will be determined if you have an imbalance in the musculature and an exercise program will be implemented. 
Common exercises for PFPS include:
a) Stretches
-quad stretch (heal to bum)
-calf stretch (foot up the wall or hang heal over a step)
-hamstring stretch ( sitting toe touches with a straight leg)
- IT band and glute stretch ( sitting with knee bent and pull the leg across the body)

b) Exercises
-shallow wall squats
-glute exercises including clam shell, side leg raises and rear leg extensions
- sitting leg raises with no weight
- lay on your back and lift your leg off the floor 8 inches and hold for 20 seconds
- stand on one leg and slightly bend your leg and hold for 10 seconds

These are some common exercises prescribed and may be different depending on the cause of the imbalance.  Always remember to stop if the exercises hurt, warm up before and cool down after exercising.  

Pay attention to knee pain around the knee cap when it starts.  Listen to your body and get an examination to see if you are starting to develop PFPS.  Find the imbalance and correct it and therefor stop  any progression of chronic knee pain. 

Activity fact: long-term studies have found that runners have less incidence of knee osteoarthritis. One study that followed runners and nonrunners for 18 years found that, while 20% of the runners developed arthritis during that time, 32% of the nonrunners did!

Whiplash is a term to describe a sprain/strain injury to the neck caused by a significant jarring to the spine and stretching of the tissues.  This term is commonly used when describing a neck injury in an automobile accident but can also be applied when the neck is injured in sports, a fall, or other trauma. The over-extension and/or  flexion of the neck causes the muscles, ligaments, joint capsules, and tendons to be stretched beyond their normal capabilities and tissue injury occurs. 

Symptoms

Whiplash associated disorders (WAD) have  been categorized  into four categories based on the severity of the signs and symptoms:

1. Grade 0- you do not have any symptoms or physical signs
2. Grade 1- you have pain and discomfort  but no physical signs
3. Grade 2- you have pain and discomfort with physical muscle and joint signs
4. Grade 3- you have physical signs and neurological changes
5. Grade 4- You have neck complaints with fracture or dislocation

Often whiplash symptoms to not appear till the next day or sometimes 2-3 days after the injury. The most common symptom is neck pain and the intensity of symptoms vary widely between patients correlating with the severity of the injury.  

Common symptoms can include:

-neck stiffness
-headaches (common at the base of the skull)
-trouble sleeping
-mid back and low back pain
-change in range of motion of the neck
-muscle fatigue (worsening throughout the day)
​ 
More severe symptoms include:
-dizziness
-blurred vision
-ringing in the ears
-Arm pain or numbness
-depression
​-difficulty with concentration or memory
-difficulty swallowing
It is important to seek medical attention if you suffer from any of these more severe symptoms after your injury. 

Treatment of Whiplash

It is important to seek treatment if you suspect you have suffered a whiplash injury. You must seek medical attention if you have endured a significant trauma to your spine or have sustained a head injury.  A medical doctor will examine you and order imaging, such as x-ray, if they feel it is needed. 
Once any serious problems have been ruled out, a proper assessment of the spine and the surrounding structures will ensure a quicker recovery and help to avoid any long term development of a compensation pattern that can lead to osteoarthritis later on.  In grade 2-4 WAD injuries, there is a risk of causing hyper-mobility of the neck joints due to the fact that the stabilizing tissues (ligaments and muscles) are over stretched.  This can cause the muscles of the neck and mid back to tighten up and be chronically irritated as well as the joints to have too much movement.  Over time these problems can lead to arthritis in the spine. 

Initial treatment of whiplash should include applying ice and using over the counter anti-inflammatory medications to help manage the pain and swelling. This should be done over the first 2 or 3 days. It is important to maintain movement and to keep active.  Research shows that prolonged rest or wearing a neck brace to prevent movement can prolong recovery. 
It is important to start regular treatments to the neck and mid back. Most grade 1 and 2 whiplash injuries will resolve within 4 to 6 weeks.  Grade 3 and 4 whiplash injuries, all though rare, can take much longer depending on the structural damage to your neck.  
Treatment guidelines for neck pain due to whiplash  outline that the best practice is to initially seek regular weekly care over a 6 week trial, involving home exercises and stretches.  Multi-modal care has been proven to be the best.  This involves combining therapies including: deep tissue massage, spinal adjustments, short term use of muscle relaxants, yoga, range of motion exercises and stretches. For more information visit: https://www.ccgi-research.com/guidelines.

Keeping Active

Again, it is important to keep moving and doing your normal activities of daily living.
It is not recommended that you sit around and do nothing.  Being active with minor pain will not cause tissue to be damaged. 

Some tips to help with this are:

-Avoid prolonged sitting postures with anterior head positioning
-Avoid contact sports
-Avoid long rides in a vehicle
-Periodically stretch and move around throughout the day
-Avoid lifting heavy objects, such as groceries 
-Adjust your pillow to maximally support your neck during sleep
-Make sure you focus on your recovery not the whiplash
-Make sure you seek care if you feel your mental health has been affected by the injury
-Choose low impact exercises such as walking, swimming, or biking
​-Shorten exercise routines as muscles will fatigue faster

The rotator cuff of the shoulder is made of four muscles that attach onto the humerous from the scapula, (the shoulder blade).  Their main purpose is to stabilize the shoulder joint and scapula and help you move your arm at the shoulder joint. This group of muscles is often injured at its insertion on the arm where they join together.   Cuff tears are the most common shoulder disease in patients with shoulder problems and is prevalent in 21% of the general population and estimated to affect 50% of people over 50 years old.  These statistics make cuff injuries a very common presentation in my office. 

Rotator Cuff Tendinitis and Tears

Tendinitis:

A Tendinitis injury is due to overuse of the muscle, repetitive micro injuries, or secondary to trauma. The junction of the muscle tendon to the humerous bone gets inflamed and irritated causing stiffness, pain, loss of joint motion, and joint crepitus. 

Tears:
​
There are two types of rotator cuff tears: full thickness and a partial thickness tear.  A partial tear occurs when one of the muscle is partially torn and a full thickness tear occurs when a tear occurs through the whole muscle attachment or it gets pulled off of the bone. Acute tears most commonly are caused when a fall occurs with an outstretched arm, and the ball of the humerous forcefully stretches the rotator cuff.  Chronic tears come from repetitive actions like throwing a ball, rotation of the arm, and overhead work that can cause fraying and damage to the muscle overtime.  Often inactivity and age leads to muscle wasting and the odds of injury increases.  

Symptoms of a Cuff Injury

Symptoms of a rotator cuff injury include:

1. Trouble lifting your arm forward or to the side
2. Give away weakness when using the arm
3. Pain around the shoulder joint, mainly on the side 
4. Clicking or popping when moving your arm
5. Trouble sleeping on your shoulder
6. Pain stretching your arm across your chest
7. Acute pain and swelling

Diagnosis 

A thorough physical exam involving muscle testing, range of motion testing, and examination of your neck and mid-back will be performed.  The doctor is looking for weakness, muscle activation pain, decreased range of motion, and muscle tenderness.  Another common symptom is the impingement sign.  This occurs when tissue is pinched between the  ball of the humerus and the roof of the shoulder joint. A pinching feeling occurs when lifting your arm to 90 degrees.  The cuff muscle is responsible for helping the ball of the humerus move through the shoulder socket.  When the cuff is damaged or inflamed, there is an improper movement pattern and an impingement occurs. 
If an exam reveals suspicion of a tear, diagnostic imaging is needed. Ultrasound can be used to compare both shoulders but most often an MRI is the test of choice. 
 

Treatment

​Treatment of a rotator cuff injury always starts with managing the inflammation and irritation at the injury site.  The use of ice and anti-inflammatory medication is your first line of treatment. The second goal is to regain proper range of motion of the joint and thirdly strength work is needed.  

Manual Therapy:
Conservative, manual therapy is appropriate for partial tears or tendonopathies of the rotator cuff.  Conservative care with the use of manual therapies including massage, ultrasound, current, acupuncture, chiropractic care, and strength training. The proper stretches and exercises will be given so that you can  decrease inflammation and gain proper movement back. Rotator cuff injuries can result in compensatory movement patterns where the muscle of the neck and mid back are engaged to help move the shoulder.  This results in neck and back pain that can be treated with chiropractic care. 
​
Injections:
Sometimes your medical doctor might suggest a steroid injection to help reduce chronic inflammation.  This is often suggested if the injury is interfering with  sleep and causing a lot of pain.  The research shows that often injections provide temporary relief and should be used conservatively as they can contribute to weakening of the tendon. 

Surgery:
Full thickness tears and some partial tears require surgery. There are three main surgical procedures including: open repair, arthroscopic repair, and mini-open repair.  The choice of surgery largely depends on  degree of the tear and the structural integrity of the joint.  Your surgeon will discuss what option is best for you. 
Surgery is usually a quick procedure and you will be home the same day. 

The rotator cuff is a common muscle group to get injured.   Overuse or trauma can cause damage to the muscles and result in a lot of shoulder pain.  If you are worried about a rotator cuff injury, visit our office for an evaluation and a receive a treatment plan that will help your shoulder.  We will be able to determine if you need a surgical consult or if you are a candidate for conservative care. 

Activity fact:  Factors that increase your chances of having a rotator cuff tear include: being male, having a job that requires repetitive physical work, age and if you have arthritis in your shoulder.  Get active and keep your shoulders strong to avoid injury!!

Stiff back?, Spasms in your spine, Pain going down your leg?   Low back pain is in the top three causes of disability in the world.  An acute low back pain episode will affect about 80% of us sometime in our lives and is one of the top reasons of time loss at work.  According to the Canadian Chiropractic Association, it is estimated that the medical costs in Canada related to  low back pain  ranges between 6 and 12 billion dollars annually!

Causes of Low Back Pain
Low back pain is a complicated, multi factorial problem that often involves a trauma or long term additive stressors.   There is a strong correlation between sedentary lifestyle and increased risk of low back pain.  Most people are sitting over 7 hours a day and this leads to deconditioning of the muscles of the spine. Sitting is the new smoking according to some health experts.  Our abdominal and hip flexors shorten and weaken with prolonged sitting and our back muscles stretch with the loss of the lumbar curve. With this and the weakening of the legs and core due to not using them, you will end up with a back injury.  
Sedentary lifestyles lead to obesity and this also has a strong correlation with low back pain risk.
Thirdly, heavy or repetitive physical labor increases your risk of back injury. Years of performing repetitive physical tasks cause strengthening of some muscle groups and eventually an imbalance on joints. 
Lumbar instability can also be a common cause of back pain and can occur after injury, repetitive micro-traumas,  pregnancy, or due to arthritic changes in the spine. 

Treatment of Low Back Pain

Acute and Sub Acute Low Back Pain

The most important thing to do when you have back pain is not to ignore it!  Your spine is giving you a signal that something isn't moving properly.  Would you keep driving your car when the "Service Engine Soon" light comes on?  The longer you leave it the more your body compensates and the harder it is for your body to heal itself.  Chiropractors are trained as spinal care practitioners that can perform a thorough examination and diagnose and treat your problem. 

Low back pain treatment guidelines are developed from the best clinical research evidence available and they all show it is important to:
1. Ice and/or heat your back
2. Use pain medications to lessen pain
3. Spinal adjustments or mobilizations 
4. Keep active with your normal daily activities, including work, and use the level of pain as your guide to your limitations. 
5. Other therapies can help including, massage, spinal exercises, stretching, and acupuncture

Chronic Back Pain
Chronic back pain is described as pain lasting more than 3 months. Research shows that multi-modal care including different treatments, and the patient being active, is the most effective treatment. Clinical guidelines are similar to that of acute low back pain but also include the following:
1. Yoga
2. Regular exercise to tolerance
3.Spinal strengthening exercises
4. massage and acupuncture
5. Chiropractic care (2 times a week for 4 weeks)  
6. non-steroidal medications, spinal injections, and muscle relaxants in some cases
 
Prevention of Back Pain

The only well researched treatment to prevent the re-occurrence of back pain is exercises.  It is important to have a professional examine your spine and determine if there is any imbalance or weakness in your spine or extremities that could lead to pain.  Exercises should start with stretching and a warm up and then lead into working the core area of the back. The intensity of your exercises should depend on your strength level. A progression should occur over time with this including the addition of an unstable platform, by using a gym ball or half gym ball.  Then the addition of weights should be the next progression. Six common key low back exercises include:
1. Planking (front and side)

​2. Pelvic Tilts

Back pain will affect almost all of us at some point in our lives. Visit our office and get a thorough exam of your spine and learn what you can do to eliminate and prevent your back pain.  Our Chiropractic and Massage therapy teams are trained to evaluate and treat low back pain conditions. ​