Is it muscle, joint, ligament, nerve or tendon problem.

Where is the problem coming from? 
    A very common question I am ask, Is it a joint problem? is it a muscle problem? is it a ligament problem? are just some examples. This attempts to clarify the question, and looks at the difficulties in answering it.

Which is more serious?
    Before continuing it is useful to look at which is more serious, a joint problem, muscle problem or ligament. The reason I bring this up is people often have their own idea which they think it is. It is commonly perceived  for instance that a joint is worse than say a muscle problem. This is mistaken belief. In fact they are all equal, mostly it depends on the level of tissue damage.

What is a joint, muscle or ligament problem?
    Unless there is arthritis or some internal derangement of the joint, describing "what is joint a problem" is not always as straight forward as one thinks. Joints are held together by ligaments and moved by muscles and tendons. All these can then be involved. For instance if there is a muscle  imbalance round a joint, the joint can come under strain. The strain then effects the ligaments holding the joint together and produce pain. It is now a ligament and muscle problem as well. This is one reason people can get a "different diagnosis" from different Osteopaths and Physiotherapists. In an attempt to describe the problem in a simple coherent form that a patient can understand Osteopaths and Physiotherapists will often describe either "tissues causing symptoms" (standard diagnosis) or "causal and contributing factors" as the diagnosis. Therefore, it is possible to have two diagnosis from practitioner, and both be right.

Example
     Take for an example a shoulder problem. Give it a medical diagnosis "supraspinatus tendonitis". This is inflammation of the supraspinatus muscle tendon. However, though it may be a "correct diagnosis" it does not tell us any more than the name of the tendon which is inflamed. As such the diagnosis does not in itself help with the formulation of any treatment. The real issue and question is "why is the tendon inflamed in the first place" Once this is worked out a treatment plan can be formulated and the "diagnosis" it self is of little help. In this example it is the tissue causing symptoms (supraspinatus tendon) which is used as the diagnosis.
     If one where to now look at causal factors it get much more varied, as there can be quite a number, often different in each person. If for instance some scapular muscle are weak (lower trapesius, serratus anterior) and some are tight (upper traps, pectorals), the imbalance may result in the shoulder girdle not functioning as it should and this leading to the supraspinatus tendon getting inflamed. The situation could then be correctly described as a "muscle problem". If there was a problem in the neck that had a bearing on the supraspinatus tendon (these can be various but may including nerve supply) one might call it a "nerve irritation". If the spine was stiff (for instance the thoracic spine), because of loss of movement here the shoulder has to move extra resulting in strain at the shoulder joint, one could call it a "spinal problem". If one where to look at  functional problems, such as improper movement patterns, ( initiating reaching the arm forward by lifting the shoulder girdle first) this could also be seen as a diagnosis.
 
    All the above can be a "correct diagnosis" and in fact more helpful than the diagnosis of supraspinatus tendonitis.

Chris Reynolds Osteopathy & Physiotherapy

The best way to stretch hamstrings

Hamstring stretch with one leg on chair 

This looks at at how to stretch the hamstrings in standing putting one leg up on the chair. To do it well there is a lot more to it than most people think. It is important to localize all the different movement components and avoid the "cheating" movements. 

Video for right hamstring stretch

Process

1) The first thing is to be upright, balanced and relaxed before lifting the left leg onto chair.

 Common faults 

- Leaning back in order to get the leg up.

- Tensing shoulders

2) In standing, with right leg on chair, focus where the left pelvis / hip area is. With out moving anything else, keeping shoulders relaxed, move the left hip area forward (toward chair). You may feel the hamstrings tightening at this point. The left hip area comes as far forward as to be level with the other side don,t go further.

 Common faults 

- Just bending forward at the waist in attempt to get a stretch. This cheating movement results in more of a adductor (inside leg ) stretch. By focusing the the left hip area moving forward the stretch is localized to the hamstrings and more important the outside hamstring - biceps femoris. This muscle is usually the tightest in the group, therefore the "cheating" avoids the stretch on this muscle and renders the stretch pointless.

3) This part is often not necessary. It is the bending forward part. Usually bringing the left hip area forward will be enough to create a stretch. However, if it doesn,t (the hamstrings already have good length) one may need to bend forward to get the stretch. This movement must come from the hips (groin area) not the back (waist) 

  Common faults

 - The most frequent problem seen is people starting the whole process by bending forward. The second is they do it from the waist rather than the hips. One of the reasons for tight hamstrings in the first place is initiating movement from the trunk rather than hips. See blog hip movement and back pain.

4) Pull the right foot up and down

Comment

  This is a very specific stretch to the hamstring muscle group which gives equal stretch to all of them, including biceps femoris. It is also useful in people with ITB band ( ilio tibial band ) syndome. This is because generally if one muscle is tight on the outside of the leg, others are as well. If tensor fascia lata and ITB are tight and biceps femoris (outside hamstring ) usually is as well. A person who has this type of imbalance is much more likely to do the "cheating" movements - as described above, as it will be easier for them. 

  By doing this stretch correctly an additional benefit is a stretch on the left hip flexors (standing leg). It one has a tight hamstring on the right leg for instance there is frequently tight hip flexors on the left. This can sometimes be part of a twisted pelvis (common in back pain ). This stretch can also be helpful with that problem.

Lying on back using band

This hamstring stretch is done lying on the back with a band under the foot to assist the leg up.

Lying down hamstring stretch video

Process

1) Place the band under the foot.

Bending at the elbow (don,t tense shoulders or neck) assist pulling the leg up

2) Pull the leg up just to the point where the back starts to flatten to the floor. This is important as if you go further the next point in the movement chain is reached and it starts to become a back stretch as well. As relatively neutral pelvis is required. However, don,t be to strict, its ok to allow a little movement

3) Variation.

Pull the foot up towards you (increase stretch an sciatic nerve)

Let the leg drop outwards (increases stretch on adductors)

Let the leg move inward (help stretch TFL tensor fascia lata and ITB Ilio tibial band.

Arch the back slightly - back lifts a little off the floor. (anterior tilt of pelvis)

The knee can also be allowed to bend slightly - Takes stress of back of knee.

The opposite leg can be actively stretched out. This give a stretch to the hip flexors on that side.

Common faults

Tensing neck and shoulders when pulling band.

Back going too flat on the floor.

Comment

This stretch is one of the safest of hamstring stretches. It is not necessary to try and get a strong stretch with this. In fact this will probably pull the pelvis out of neutral. It provided a gentle stretch with modifications. For people who like to feel a strong stretch a word of warning. More does not mean better. Slow gentle stretching and relaxing into it is usually much more effective in the long run. If a muscle is stretched to strongly it will provoke a stretch reflex and the muscle will tighten against you.

Hamstring stretch using door frame
This hamstring stretch uses the side of a door frame for resting one leg against. It is the strongest of all the stretches I show.
Door frame hamstring stretch video



Process
1) Lying on back place one leg (right here) against door frame and other through door space.
2) Allow the knee to be slightly bent.
3) Check the rest of your body is relaxed, tongue, jaw, neck shoulder. (Note: A very common problem with stretching is that on attempting to stretch one body part people will frequently tense other parts at the same time)
4) Push the right heel into door frame - a third of full strength. Hold for 3 breathes. Relax leg. Then check you really have relaxed it! Allow the foot to slide a little further up the door frame.
5) Repeat several times.
6) Variations. Straighten left leg to floor. This stretches psoas major and tilts the pelvis is little more anterior (back lifts a little off floor) increasing pull on right hamstrings.


I,ve picked these three hamstring stretches as they are the most frequent I give. For an detailed look at a wider variety of hamstring stretches see my website page on hamstrings stretching. For information a tight hamstrings and why they may be tight see my website page tight hamstrings.

Trapped nerves

I have a Trapped nerve
"I has a trapped nerve in my shoulder" or "I have got a trapped nerve in my back" are very common phrases I hear in practice. It is a very frequently used "self diagnosis" but what exactly does it mean?

What is a Trapped nerve
Nerves don,t actually get trapped in the way most people image. If a nerve (often nerve root) implicated it is usually because there is something pressing on it (sometimes disc prolapse) or inflammation.

 Its is not trapped as such. If this where the case there would be severe trauma and urgent surgery required. The main problem with the expression "trapped nerve" is it can lead people to the idea that it needs to be "untrapped" by some expert. However, like many acute musculoskeletal problems it will still usually resolve itself in time - though quicker with treatment.


The quality of pain in trapped nerves
Now that I clarified the term trapped nerve I will look at the problem in more detail. All pain is in fact "nerve pain" in the sense it its the sensory nerves that sends the signal of pain to the brain.

 This tells us where the pain is located. When a nerve is implicated itself ie there is direct pressure on it, the quality and distribution of symptoms as somewhat different from other types as muscloskeletal symptoms such a shoulder problems, elbow or knee pain. This will often include pain, pin and needles sensation and or numbness with loss of sensation or sometimes muscle weakness. Not all these symptoms need to be present at one time. What is particular about the distribution of symptoms from a trapped nerve is that they will usually go down a leg or arm. When pain is present in the limb, it is very often of an "unpleasant nature" (I know all pain is unpleasant) and create the sensation of "I don,t know were to put my arm" or " I don,t know where to put my leg"


Trapped nerve in neck and shoulder
With the neck this usually means a nerve root is being effected where it passed out between the vertebra in the neck. This can be due to inflammation of a facet joint, disc prolapse (not so common in neck) or soft tissues. The result is pain, pin and needles, numbness in the arm and / or hand. Often there is pin and needles in a few fingers or the thumb. The fingers in which someone feels numbness or pin and needle give a rough idea about where in the neck the problem is coming from.

 The thumb being higher up and the little finger lower down. Which arm pain coming from a "trapped nerve" in the neck it is common for a person to obtain relief by having their arm above the head (usually in lying). This is because the brachial plexus (nerves from neck) are under less traction. One should however do this with caution, as the pain can come back worse after.

   Another problem that effects nerves in the region (shoulder) is thoracic outlet syndrome.

 This can involve blood vessels  as well. The bundle of nerve and blood vessel can get pressed on as they pass from the shoulder to arm. Usually, if this is the case symptoms are more in the little finger. See Thoracic outlet syndrome on my website.

Trapped nerve in back
When nerve is involved with back pain there is pain, pins and needles and numbness (not necessary all) down the leg. Often there is pain in the calf, hamstring or foot. With the sciatic nerve being involve this can lead to the mistaken belief there is a tight hamstring. One should never (unless by a qualified practitioner) attempt to stretch it in these circumstances.
  Often this leg pain is called sciatica

 and can be linked to a disc prolapse .

Other areas of trapped nerves
 These can include the elbow cubital tunnel  and carpal tunnel .

The treatment of trapped nerves
These kind of problems are very frequently seen and successfully treated by Osteopath and Physiotherapists. Each treatment will need to be tailored to the individual. Often where a nerve root is involved its the areas above and below that area, that are real source of the problem being stiff.


For more information on trapped nerves
Chris Reynolds Osteopathy & Physiotherapy trapped nerves.

Alexander technique or Osteopathy for back pain

A question that is frequently ask to by me is "who is the best to person to see for my back pain, an Alexander Technique teacher or an Osteopath?". The most straightforward answer is that if there is something you are doing to yourself, that is causing your problem, then the Alexander Technique is the better choice. If there is a "structural problem", or a recent injury then Osteopathy is a better first choice.
  However, it is not always that straight forward. For instance someone may have a injury or structural problem requiring Osteopathic treatment. Due to this though, they may develop compensatory movement habits to get round the problem or pain. These movement habits may be continued when the original problem is gone. In time this can in itself start to cause problems. A common example is with back pain. Because the back is painful the person will "push with their arms on legs" to help themselves get up. When the pain is gone they may continue to do this. Another example is holding the back stiff and being scared to bend it. This is were the Alexander technique may help along side Osteopathic treatment.

Chronic or Acute Back pain
A chronic problem is one that been around a longer time (over 6 months) whereas a Acute is recent onset. Usually the Acute is more painful. If someone has an Acute back problem (they may be in muscle spasm) it is better to see an Osteopath at that stage. In chronic back pain the Alexander Technique come more into its own. With chronic back problems there is usually, in my experience a combination of structural (osteopathy) and functional (Alexander technique problems).

Car analogy - Structure and function
Sometimes a Car analogy is useful (the car is your body). The Alexander Technique will teach you how to teach yourself to improve your driving. If it is constantly driven "badly" damage will occur to parts. On the other hand, if say for example the tacking is out, it doesn,t matter how well you drive the tires will wear.

I have chosen the Alexander technique here as an example but the same principles apply to Pilates or the Feldenkrias method.

Chris Reynolds Osteopathy & Physiotherapy

Hip joint movement and back pain

Can a lack of free moment at he hips lead to back pain? 
 My answer is yes. In fact with some people it can actually mean the difference between chronic back  pain and being pain free.

Why does good hip movement get lost?
There are quite a number of reasons, but one of the most important is "people are completely unaware where the hip joint is located on their body".

 This may sound incredible but it is true. When I ask patients who come to me where their hips are, I get all kinds of answers many of which include putting hands on outside of pelvis or half way up the back. A long way from the hip joint.

Why is this important?
Though this may seem like a small point, it is in fact crucially important. People will generally try and move where they think a joint is located on them. In relation to the hip and back, this results in a bending at the waist rather than, the more efficient movement, of moving at the hips. Examples of this include getting out of a chair. The individual, instead of initiating moment through their psoas muscle (hip flexor) in order to hing at the hips (until the weight of the body is over the feet), will in fact stiffen their hips and attempt to bend the trunk forward (through rectus abominus ). This means the back is now doing the work of the hips. Over time this results in increasing strain on the back. If you think this is not going to affect your back just think how many times a day you get in and out of a chair
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Getting out of a chair using the hips

Where are the hip joints and where should the movement occur?

The hip joint is in fact located in the groin area. If someone leans forward in a chair (ie to get up), or lifts a leg (ie going up stairs) the movement should pivot here.

What can be done about it?
Unless there is some intrinsic structural problem with the hips, this cause of back pain can be changed. Just understanding where the hips are and where the movement takes place can help.

  Various models such as Alexander technique , Pilates or Feldenkrias can be useful for dealing with this problem. Though Pilates have specific exercises for "hip differentiation" one will find all the above will also have the tendency toward "general" rather than just "specific". The reason for this is specific movement patterns at the hip may be part of, and linked with, more general of movement patterns involving other parts of the body.

Understanding where our hip joints are located and where this movement take place, can be a key to solving many long term and chronic back problem.

A useful video looking at the hip joints from a Alexander technique point of view is Alexander Technique: Understanding the Hip Joints

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Tight muscles and stretching

It is often assumed that if a muscle "feels tight" then the most obvious thing to do is to stretch it. Though stretching can sometimes be the right thing to do, it is not always. This article examines some to the reasons behind this.

Why is this
The feeling of tightness in a muscle is a subjective feeling. The brain cannot tell you if a muscle is in fact short or not. What you are feeling is the body telling you something is wrong, and this is interpreted as "a feeling tight" sensation. Often if a tendon or muscle is over stretched it can "feel tight". In this situation vigorous stretching may not be the right thing to. 
Which muscles do people most commonly feel are tight
Some frequent  areas are tight hamstrings, calf muscles and gluteals (buttock). Because they are all slightly different I will deal with each one in turn.
Tight hamstrings
Feeling tight in the hamstrings is a very frequent complaint and has nothing to do with whether they are in fact physically short or not. This is so important I will repeat it. Hamstrings that "feel tight" have nothing to do with them being tight. The importance of this cannot be over emphasized and it is one of the most frequent mistakes I see in patients coming to me.
  The person on feeling their hamstrings are "tight" will proceed to stretch them. Then despite all their best efforts the hamstrings will go on continuing to feel tight. This is because the sensation of tightness in the hamstrings is either due to a problem in the back (and there may be no symptoms there) or a local problem in the hamstring muscles themselves, such as scar tissue and nothing to do with their overall length. If it dominates in one leg there is a possibility that the sciatic nerve may be involve.
Gluteal muscles
These muscles can also often feel tight when the problems is something else. For example if the sacroilaic joint on that side is moving to much, the gluteal and piriformis muscles can tense in a attempt to stabilize it. The problems then is stretching the gluteal or pirformis muscles can put added strain on the sacroilaic joint and potentially making it worse in the long run.
Calf muscles
These often are problems area in runner. With the achilles tendon (TA), this is usually overstretched though the calf muscle itself may be tight in places. A common mistake is for athletes with TA problem to do calf stretches. Often what happens here is the area that moves to much (normally the TA) will be stretched more and the tight areas remain tight.
What is the solution?
The important point here is that it necessary it identify that a muscle is actually short, rather than " feeling tight". Stretching is very important and can be an essential part of solving a problem. However one should not stretch muscles on the basis they "feel tight". It may be that more "muscle strength" is required to stabilize the areas moving to much or something else needs to be stretched (not the area that feels tight). For example I have had people come to me complaining of one hamstring feeling tight, which they have be stretching in order to get rid of it. I have then advised them to stop stretching that hamstring and to stretch the tight hip flexor on the other side (which I have found to be tight, but feels normal to them). The symptom of the tight hamstring then goes. Of course this is just one example, there are main others.

Flexibility and stretching

Chris Reynolds Osteopathy & Physiotherapy