I am 43, and was hit at approximately 60-70mph, my car was thrown 117
ft from the sight of impact. I am concerned because I cannot wear my
flight helmet without severe pain in my shoulder and tingling in my left
arm and hand. It has actually spread from the thumb to the entire hand
when lifting patients, bags etc. C5 and 6 reveal old arthritic changes
and a severe narrowing on the left. I am awaiting my MRI.
I am really becoming more and more interested in this subject as I
try to make these changes. This has to be one of the subjects that Tiger
Woods and his staff must have studied a lot. But Tiger has no idea
what it is like to try to make the large swing changes that I have had
to go through. He has always had a solid swing and his muscle memory
changes were small.
My initial take away of the club has been flawed for 20 years. When I
start the club away from the ball my muscles in my hands and arms tense
a little, the club hesitates a little and goes back on a slightly
incorrect path.
I think a lot of this has to do when I was 15, I started working out
with weights a lot and trained > these muscles to do something else.
I also believe that it is partially mental and that when I start the
back swing this is all my mind and muscles know to do. At this age
my game started going down hill and I lost confidence and starting the
club back became hard.
I can stand in front of a mirror or take a practice swing and make
the correct take away and movement easily. This is what makes this
interesting, I can make a perfect take away, just not on an actual shot.
When I look at trying to make a change to this muscle memory, I
wonder how long and how many repetitions would it take me to correct the
muscle memory. It sounds also that how I think and feel will affect the
progress.
There have been some swing corrections that I have successfully
changed and now are fairly ingrained in my muscle memory. I did not log
how long it took me to change this which I wish I did.
The particular take away move I talked about before I would like to
log and record details to see how long it would take to successfully
change. Any ideas on how to go about this?
I started depending on the players about 14 games in the season so we
had some great before and after numbers. The coach got me the stats and
I wrote a case study based upon those findings and the actual work with
the kids. I am sending you via snail mail a copy of the study. The
results were almost unbelievable and probably wouldn't be had it not
been for the actual stats and the letter from the coach detailing the
season. I'd love your feedback and any ideas about getting it published.
A second
trauma could have occurred from a much lesser force, but once you have
a spinal injury, from a second trauma, the disc lesions are more
common (protrusions, herniations).
.....Q
I did not
undergo any chiropractic treatment and I have a pretty sedentary
job--I sit at a desk for 8 hours a day. The only exercise I do is
30 minutes on an inclined treadmill.
Is there any
literature that would explain a time frame of the formation of a
disc herniation following the low impact rear ended accident? I
mean, I was very surprised to learn that a herniation had
developed. I was always under the impression that if it was a very
forceful trauma, then a disc herniation would show up immediately on
the MRI, but all that was noted was a loss of signal three weeks
after the accident.
So I guess
what I also want to know is given the lifestyle I described to you,
this herniation appears to have been very progressive in nature -
correct?
So while I
have back pain I am still able to function close to normal. Was
there any way that I could have prevented this herniation from
developing?
A
You
apparently have two MRI's one following the accident and then one a
few months later as I understand from your email. Trauma will
create a herniation and should be visible on MRI. First thought is
to take both MRI to one center for a comparison reading as
variations occur by radiologist's interpretation. You may discover
that it was present in a milder form on the initial reading and
possibly the second MRI was "over-read". This does happen on rare
occasions.
As I
explained earlier, a cough, sneeze, lift against resistance is
enough force to create a disc lesion. Golf can create herniations.
Occasionally, individuals who can't recall any trauma are discovered
to harbor a disc herniation. All in all it is easier to explain a
herniation associated with force.
I don't
recall if your herniation was in the neck or low back. Each one has
it's own specific reason for herniation.
Sorry I
can't be more helpful as I have not found any literature on the
progression of a herniation.
Q
Your article about golfers and muscle memory
was really unconvincing. You would use the same muscle groups in the
same order to chop down a tree, but how many lumberjacks do you know
that have made the transition from tree felling to professional
golf?
If you want to use your scientific expertise to
explain the perfect golf swing, you would be better advised to look
at the finger and palm print configurations of great golfers.
Right handed people that play a lot of golf,
quickly develop a callous on the second flange of the ring finger of
the left hand. over time the callous develops its own 'finger print'
pattern over an area covering a diameter of about a quarter of an
inch. Non-golfers do not have this area of super-developed finger
print.
I have no doubt that a comprehensive study of the
palm and finger prints of great golfers would reveal a particular
pattern of super developed areas that would shout 'golfer'. These are the areas that tell the brain how to
use particular muscle groups, in a particular order, with a
particular force, to produce a golf shot.
A
Thank you for your question.
I agree with your assessment of specific callous formation in high
level golfers. The ability to develop such callous' deems good muscle
memory. As in the waggle, the sensory input sets off a chain of
neurological signals to prepare the muscles into sequential
movements--a form of muscle memory.
Callous' are sensory epidermal stimuli that initiate a similar
phenomenon. I don't recall any specific research done to map the
callous formation in golfers, but it would be interesting to identify
differences in amateur and professional players. I hope I helped with
your astute observations.
Response: Thank you for
your prompt and very informative reply to my unsolicited and
bothersome e-mail, it was most kind. I had not properly thought of a
callous as providing sensory epidermal stimuli. It would seem by its
nature to be a natural precursor to the more sophisticated finger
print formations.
Thank you again.
Q
I found your muscle memory article interesting and on target for book
research I am doing. Could you recommend some sources for good
information along the line of muscle memory and sports.
A
Thank you for reviewing my web
site. Muscle memory is a relatively new concept and has many
applications. Sports and athletic ability is fascinating for my
work. The resources are recent and not well peer reviewed. Most
research is anectodal and not double blinded. This is a learning
concept which is hard to provide scientific procedures to validate.
Please write back, providing me with more specific needs for your
book, i.e. what sports, what age groups, what conceptual applications,
ect.
.....Q
I am part time professional golfer that is rebuilding my swing with
top instructors. When I say part time, I have a full time career. I am
learning just how hard it is to change muscle memory.
I am writing a book on how I am changing my swing for the better.
It covers a lot of what I have experienced over the last couple of
years. Muscle memory is turning out to be a huge challenge and factor
in these changes. It also appears it is going to be one of my
strengths when I obtain the correct swing. I have achieved great
changes in my swing but it is amazing how the old muscle memory will
still show up when I play, etc.
There really is not much information on muscle memory and any rules
on how many repetitions it takes to learn a new move. This subject
will be at least a chapter or two in my book. Any information or
help would be of great help.
A
So much has been studied in
golf, but little integration with the studies of biomechanics. The
present golf studies of biomechanics have only confirmed what the
researcher was trying to validate.
I on the other hand have no
golf experience and have an open mind to biomechanics. I work with
professional instructors and high speed cameras to observe motion and
muscle function. The golf swing is complex in that three different
swing mechanics are identified based on your biomechanical
make-up.
Some are born natural
swingers, some are born natural hitters and most fall into the middle
group. We have tested the muscles that make each swing unique and are
in the process of building and educational foundation for golf
instructors. Next month we have been invited by the
Japanese LPGA to do a special seminar to bring this information forward.
Our goal is to write a book on biomechanics that is functional and
understandable.
Next, muscle memory. If
you have instructors who tinker with your basic swing and not analyze
your natural movements--you have the phenomenon of trying to provide
wheel alignment to a car with a bent frame--the bent frame being the
historical experience of instruction. Not much will change, as you
need over 20,000 specific movements to encode into muscle memory.
Unfortunately, golf is not
the best suited sport to isolate new and repeatable movement.
Additionally, emotional input plays a major role in muscle
memory--your situational state of learning must mimic playing
conditions to be effective in creating memory.
This is just a short
overview of the complexity of golf. Equipment is extremely
important. You need proper swing weight, frequency. moment of inertia
balancing, loft, lie, and grip to provide you with the proper tool to
execute consistent and successful play. If you lack confidence in
your equipment, how good can your muscle memory be established?
We have spent four years analyzing vibrational engineering for club
making with some golf pros.
Unfortunately, I have held
back the new information and the research that we have "discovered".
It is probably an ego thing, but if I released it earlier in my work,
I would have made some mistaken analysis. Science proves what
athletic training shows to be successful.
If your in the Southwest
Florida area, please let me know and I will try to spend time with you
to give you our input to your re-established career goal.
Q
One year ago I
was in Bosnia as a civilian contractor and I suffered a severe fall
while carrying about 75-80 pounds. The Army doctors said I had a
widening of the Mortis space in my ankle. They put me in a walking
cast and had me on crutches completely for about 8 weeks. Here it is
now a year later and I am back in the states but I still have a lot of
pain when I try to do any kind of jogging or even sometimes when I am
sitting at a desk. Any idea why this should still be giving me so many
problems?
A
The ankle
is a complex compilation of small and medium sized bones arranged in a
precise matrix supported by many thick ligaments that allow for a
sophisticated muscle pulley mechanism for function. Additionally
greater than 500 pounds per square inch of pressure could be applied
through the ankle.
Widening of the Mortis space indicates that you have to some degree
torn the supportive ligamentous attachments that caused a disruption
to this complex structure. As a result, there is a high degree of
probability that the small and medium sized bones may have shifted
ever so slightly out of their functional position, leading to slight
loss of range of motion and resultant pain. Occasionally, minor
swelling can be associated with this problem.
Unfortunately, I don't know anyone who repositions the bones as I have
been fortunate to learn on my own. The ankle repositioning learning
was an extension of my work on the wrist for my son's fractured
wrist. If you haven't read this article, I would encourage you to
read it as the wrist has many similarities to the ankle joint.
I live
in Bradenton/Sarasota area on the Southwest coast of Florida just
south of Tampa. Should your travels take you here, I would be glad to
assist you in reassessing and hopefully providing some solutions to
your problem. Unfortunately, I have not yet written an article on how
to correct ankle malalignments of more specifically what we call in
healthcare as "subluxations".
Q
I am a female age 43 who injured my left wrist in
June2005 in a fall. I had fractures on the distal radius and ulna
styloid process. The doctor inserted fixation pins to stabilize the
fractures and my hand was in a half cast. ( In the x-ray, it would
look like a x-cross of two pins. ) After 4 weeks the fixation pins
were removed and my hand was put in a cast. After 3 weeks this cast
was removed. In total, my hand was in cast for 7 weeks.
Upon removed the cast, x-ray showed that the
distal radius had collapsed by about 1cm and also there was
subluxation of the radial Ulnar joint. My problems were weak grip,
flexing the wrist and turning my palm upwards. The doctor also noted
that I developed Reflex Sympathetic Syndrome. I have been going for
physiotherapy sessions for almost 4 months already. The grip and
flexing has improved but I can only turn my palm slightly. Upon doing
stretching exercises, I can turn more but once rested, my palm cannot
turn much. I also feel restriction at the Ulnar bone when I turn or
flex my wrist. The Ulnar bone (distal) also feels bigger than my
normal right. There's some slight similarity in the 'dinner fork'
deformity.
What is causing me so much problem and
recovery progress in turning my palm ? What does this subluxation of
the radial Ulnar joint meant? What options are available for me to
recover ? Will I have future difficulties or possible to develop
other complications ? I would like to know more so as to be more
informed. I appreciate your professional advice.
A
You
have a serious injury that required surgical stabilization.
Unfortunately, the wrist somewhat collapsed on the radial side. My
real concern was the development of Reflex Sympathetic Dystrophy.
That in itself is quite disabling.
Your
options may be limited. I am not an expert on surgery, thus I don't
have any opinion for further surgery. Surgery can be beneficial,
but comes with substantial risks and no guarantees. After surgery,
the biomechanical function of muscles and ligaments gets distorted
from secondary scarring. The nerves can become irritated and thus
lead to RSD. You may want to find a good manual therapist or
massage therapist that will work with you on trying to release the
tightness and improve range of motion.
My
intuition suggests that because of your age and loss of function,
you may need to attempt a second surgery. However, do you homework
and find a physician at a University teaching hospital, Mayo Clinic
in Rochester Minnesota, Duke University Hospital to see if there is
a specialist in this corrective hand wrist surgeries.
I tried
to answer your question, which has been difficult for me to provide
a more definitive answer.
Q
I read with great interest you article
"Assessment and Treatment of Motor Vehicle Accidents", as it has shed
some light on some of my long-standing problems. Here is my story:
On October 1994 I was involved in a rear end impact MVA. I
was stopped in traffic; I checked my rear view mirror and saw a car
coming at a high rate of speed. I had braced myself both arms "locked"
(for lack of a better word) and hands gripped on steering wheel and
both legs braced right leg "locked" on brake and left leg "locked" on
the floorboard. Head slightly tilted right and up (looking in the rear
view mirror). I was driving a 1980 Monte Carlo.
I should mention that, at the time of my accident I was 33 years
old. I am shorter in stature- measuring 5 feet and 3.5 inches in
height and weighed about 120 lbs. I was undergoing treatment for TMJ
and approximately 9 months prior to the car accident I had undergone
treatment for whiplash and concussion (injuries were not as a
result of MVA). I should mention that, unfortunately, I wore the
soft collar for months on end (not knowing any better) and developed
muscle atrophy.
After the MVA, I was treated for whiplash and soft tissue injuries
for my upper chest, upper back, right shoulder and hip soreness. I
participated in conditioning program with little improvement.
Approximately 1 1/2 months after the accident I started to experience
sharp pains running down my neck along my spine when I turned to look
over my right shoulder.
Finally in August 1998, after worsening of symptoms, right arm
weakness, tingling and pain I had a MRI. The MRI indicated I had 2
herniated discs, with nerve root impingement at the C4/C5 level and
C5/C6 level.
July 1999 I underwent an Anterior Cervical fusion. Approximately 8
months after surgery I started to develop "cold burning spots", first
on my right forearm (about the size of a silver dollar) then on my
right calf. These "spots" have grown in size and spread to my left arm
and leg. At times I have a 3 degree temperature change from my right
hand to left (right being 3 degrees cooler), which had been documented
by a physician. I also burned my right hand on an oven element. I was
putting the lid on a roasting pan and I did not feel the hot element.
These symptoms, cold spots/burning/ sensitivity to hold cold, are
intermittent and appear to be activity dependent. I also experience
occasional burning sensation on my feet.
My right hip/groin and low back area is very painful at times. My
right hip, at times, feels "out of line" and when doing certain leg
exercises my hip snaps. When my right leg is pulled straight back I
feel my hip is back in alignment.
I also experience headaches, migraines, chronic pain, fatigue as I
rarely sleep through the night without waking up 2 or more times per
night.
The above is just a snapshot of what has been happening with me
over the past 11 years since my MVA.
Despite attending 4 Neurologists, 2 Neurosurgeons and 2 Orthopedic
Surgeons, (I might add all referral to these Specialist were done by
my family GP or by the Specialists themselves) I have no clear
diagnosis. I have had one Specialist indicate "Failed neck Surgery
Syndrome".
I am extremely frustrated and frankly feed up! I am tired of being
thought as and treated as a malinger, I have been a hard worker all my
life and continue to work very hard… I should mention that during the
11 years since my MVA, I completed my University Honors Degree, with
Honors, and have worked steadily since 1998 (with the exception of 3
months when I had surgery). And have done this, despite of the pain
and fatigue I experience on a daily basis!
I am really hoping you can help me and shed some more light on my
symptoms….
A Thank
you for your information and reading the article. Let me add more
clarity to your situation.
The
first mistake you made was to brace for impact. The energy of the
impact was then transferred into your musculoskeletal system. With
the arms in a locked extended position, you may experience
subluxation of the wrists, elbow tendonitis, but more importantly
shoulder joint trauma especially in the acromial-clavicular AC joint
that is interconnected with the clavicle bone that attaches at the
sternum or top front of the rib cage.
In the
lower extremity one would mimic similar pattern of biomechanical
forces. Distally, the ankle can malalign, the outer aspect of the
lower and upper leg can absorb the force into the small muscle
called the tensor fascia lata, as well as the sacral-iliac joint can
become subluxed (malaligned).
Additionally the forward and back movement of the spine can result
to deeper disc lesion in the forms of a bulge, a larger bulge called
a protrusion and finally a disruption of the disc into a disc
herniation.
When
the skull moves forward and back rapidly, the gelatinous brain
swells as if jello was thrown about in a metal container leading to
concussions or if forceful enough to loss of consciousness.
When
one experiences pain while asleep, the pain awakens the person to
change positions.
You
have done with diagnostic tests such as the MRI to identify the
major traumatized areas and their causes. My recommendations is to
find an osteopathic physician who performs manipulations or a
chiropractor in your area to realign the minor joint Subluxations
(malalignments). Massage can be added to follow each manipulation.
If you have access to an AIS trained massage therapist AIS Active
Isolated Stretching or the Mattes Method, this technique is quite
good. If you live in the St. Louis area I know of an excellent
therapist with various manual techniques. Mark Frank is his name and
I can forward his contact number if you need it.
I hope
this helps you understand your immediate needs.
Q.. Thank you so much for
writing back and shedding light on my symptoms. It has been a 11
years since my car accident and no one has ever explained things
to me as you have in one email. I realize now that bracing for
the impact was not a very good idea....
I live in Canada, so finding professionals
who are aware and can treat my symptoms are rare if found at all.
I have tried attending a Chiropractor for
adjustments and Massage Therapist, but I do not believe he
specialized in AIS. Besides my Insurance company has advised me
they will no longer reimburse me for either treatments. I can not
afford the $60 per week to attend both treatments.
The massage did help with my pain control and
at times the Chiropractic adjustments helped with the alignment,
but adjustments on my neck, near the fusion, became to painful and
I became fearful. I try to keep active and exercise on a regular
basis, albeit at a much slower and less intense pace than before
the MVA.
No one has ever addressed my shoulder
soreness or why I am unable to work with my arms above shoulder
height. One theory is thoracic outlet syndrome. I do have a
dimished pulse when tested according to my Doctor.
I have also under went needling (deep
muscle), botox treatments, cortisone shots, embrol shots, deep
tissue massage and manipulation. At best, these treatments have
been of limited benefit and provide temporary relief. I typically
attend my doctor on a weekly basis for treatments.
I did forget to mention that the Insurance
experts estimated the force of impact to be 15-18 kilometers per
hour (9 -10.8 miles per hour) forward velocity.
Q
I think I have an upper ankle sprain on my
right leg. I have been icing it and it is still very painful. Is it
worth it to see a doctor or should I just keep icing it and take it
easy until it feels better? What is the exact location of an upper
ankle strain? About a third of the way down from the knee on the
outside part of the leg downwards? I am just curious because I am
leaving for a ski trip in a few weeks and want to be able to ski in
comfort if possible.
A The
upper ankle sprain is located above the proper ankle joint. This
implies muscular strain. Muscles that move the ankle, foot and toes
have their upper most attachment in the area. The location of the
attachment helps identify the muscle that a person overstretched and a
biomechanical mechanism of injury can be explained. These upper ankle
strains respond as any other tendonitis, initial ice to reduce the
area of swelling, then rest--which implies not to overuse this muscle,
applying a tension wrap to give a slight support to the muscle, then
after a few days or up to a week later, start to increase its use and
possible address attention of strengthening that muscle group. The
activity of skiing won't be as affected for upper ankle sprains as the
boot provides an excellent "brace" for the lower third of the leg.
You may experience discomfort from keeping the muscle contracted
within the boot, but it is unlikely that you would worsen the
tendonitis. After skiing, you may want to incorporate some isolated
stretching exercises for that specific muscle group. Over the counter
anti-inflammatories may also be beneficial or even aspirin if you can
tolerate aspirin and have no medical conditions that contradict its
use.
Q
Can you tell me if the breaking of an airbag in an auto crash
can cause labored breathing and pain in the chest. I can't seem to be
able to get out of bed without extreme pain. If I cough oh my god
forget it. The pain seems to be like a straight line right across my
chest and after two weeks it has not gotten any better.
A
Chest wall pain, even
difficulty in breathing are common occurrences following a motor
vehicle accident. The ribs are joints that "articulate" or connect in
the spine called the thoracic spine. All twelve ribs insert into
small joints. At impact, the force call shift these ribs slightly out
of position or a term we call in medicine as "subluxation". As a
result of this shift, the muscles that attach to these ribs change
their length and strain or spasm causing chest wall tightness. If the
trauma was more forceful, ribs may break or fracture, but not
displace. X-rays can miss these non-displaced rib fractures and a MRI
of bone scan are more sensitive. Frequently associated with chest
wall/rib injuries are the collar bones on each side called "clavicles"
that can also displace from their insertion into the sternum and cause
upper chest wall tightness and some shoulder pain--notably in the
acromion-clavicular joint (AC Joint). I agree with your plan of an
MRI. For readjustment of the ribs, a chiropractor or a DO (Doctor of
Osteopathic Medicine) be best trained to provide proper manual
adjustment and corrections in the malalignment.
Q
I have a few questions as I have been struggling with pain in
my wrists, hands, and fingers for 7 months now. I have also
experienced tingling in my fingertips and painful clicking and popping
in my fingers and wrists. I have had numerous tests and several
possible medical problems have been discussed, but none decided upon.
I was hoping to get some general information or at least be pointed in
the right direction to have my questions answered.
I am very curious about the volar anatomy of the wrist. I
notice that I have bumps (bilateral) on the volar side of my wrist,
just below my thumbs. These are the areas of my wrists that I have
pain in and the bump is there when my hand is in radial deviation and
then almost appears to shift distally when I move my wrist into ulnar
deviation. The left wrist has a slightly larger bump and they are
just above the most distal wrist crease. I have done a lot of
research, looked at numerous pictures on e-hand.com, and also used
friends and relatives for comparison.
There are similarities in some cases, but the other bumps I have
detected are much smaller in size than mine. I am not sure if this is
normal or if it is some sort of abnormality. My best guess, if this
is a bone, is that it is the scaphoid or lunate. However, I cannot
find a diagram or photo that indicates that there is a volar
protrusion, other than the scaphoid tubercle, of either bone. I have
also seen pictures of ganglion cysts in similar areas, but I am not
sure how likely bilateral and nearly symmetrical ganglion cysts are.
I am a 24 year old male and any problems without a previous history
of trauma or an underlying condition would be out of the ordinary
anyway. Can you give me more details on the volar wrist surface
anatomy or tell me how to find more information? I appreciate your
time, effort, and consideration. I am going to see a hand surgeon
next Thursday and I want to be as prepared as possible. I have a
fairly extensive background in medical research, but finding the
details that I am looking for has proven to be difficult.
A
It appears that you have a
good foundation in human anatomy which helps me explain at a higher
level of understanding.
Your approach to the
problem was very logical. Symmetry of bone protrusions is unusual in
trauma or disease state for your condition. Familial tendency is
more common. I have seen protrusion of the distal ulna and radius
that look like a deformity, but yet most of these variations were
non-painful and functional.
The problem lies in the pain
you experience and the numbness of the fingers. I seriously doubt that
the scaphoid is shifted out of its position. The area at the junction
of the wrist and thumb, the
metacarpalphalangeal
joint is the most common first area of inflammation for an individual
prone to osteoarthritis, especially if they use their fingers and
wrists against repetitive resistance. You may even have a slight
subluxation of this joint, malalignment, that allows the MCP bone to
shift out of the joint proper.
Another problem lies in the
tracking of the tendons that glide over these bony structures. In the
radial aspect, three tendons glide to give movement and strength to
the thumb. If they are inflamed, a condition of DeQuervain's
syndrome develops.
This is the consequence of
the tendons causing friction and resulting tendonitis. I usually try
to shift the carpal bones back into alignment and ensure that the MCP
joint is not subluxed, then myofascial stretching allows the
functional elongation of these muscles and tendons to return back to
their proper position and function.
The numbness of the fingers.
Compression of the sensory nerves in the wrist may lead to two
patterns of numbness. If the large median nerve is irritated by
compression, then the thumb, index and middle fingers become numb.
This is known as carpal tunnel syndrome.
If the ring and little finger
are numb, then the ulnar nerve may be irritated. If only the finger
tips are numb, I don't know, but I know a significant number of my
patients describe this, usually after some neck trauma, but I don't
know how it neurophysiologically is explained, or worse, how to
correct or fix it for them.
If you are a golfer, and you
carpal (wrist) bones have slightly shifted out of position, you will
experience pain with movement and hitting the club. At age 24, it is
doubtful that you have degeneration occurring. Sounds like your
doctors have eliminated or ruled out inflammatory diseases of
the small and medium joints.
Many doctors will give you an
opinion, even if they don't know the answer. Few state the
honest--I Don't Know. Therefore, before you agree to anything
invasive, such as surgery, make sure that is the definitive answer.
Before surgery, get at least one other surgical opinion from a doctor
the initial surgeon may not know. Hand surgery is great for those who
need it, but terrible for those they are "exploring" to find answers.
.....Q
Thank you so much for your response. I know that your time is
incredibly valuable. It answered a couple of my questions, but also
prompted another one. Can the Scaphoid and/or Lunate bone be felt on
the volar surface of the wrist? I have attached a few pictures of my
wrists. I am not sure if you can comment on them or not since we do
not have much of a relationship and you have not conducted an exam.
The pictures of my left wrist have the "mass" circled and there is a
deep crease between it and the thenar muscle nearby. My right wrist
looks very similar, but the mass is not quite as big.
A
Regarding your question. The
lunate bone is the only carpal bone that moves dorsally, whereas the
others are usually palmar shifters. Yes, you can palpate all the
carpal bones if you understand and have experience in anatomical
assessment.
Divers are the most prone to
lunate dislocations. They usually use taping as a measure to
prevent this carpal bone from subluxing. Another test is range
of motion. Do you have full range of motion of the wrist in all
planes? Is it symmetrical to both wrists, assuming that you did not
traumatize, fracture, or had surgery on one wrist?
.....Q
I do not want to bother you, but I came up with a few more
questions. I hope you don't mind, but no hard feelings if this is
asking too much. Where is the approximate location of the
scaphoid bone
on the volar side of the wrist?
Is the carpal tunnel just to the ulnar side of the scaphoid? In
a normal wrist, is there a visible protrusion of the scaphoid bone?
I followed up with my hand surgeon and he told me that he does not
believe that I have carpal tunnel syndrome based on the negative emg/ncv
study from May of 2005. I have had the same tingling in my
fingers for nearly a year now. I have no idea what else it could be.
I was a little upset this week because a co-worker of mine has been
having arthritis like pain in her left wrist for about a week and her
PCP ordered an MRI no questions asked. In 8+ months, I have only been
able to get 1 set of x-rays and some blood tests during a number of
very brief office exams with 4 different physicians. Am I doing
something wrong during my appointments? Would an MRI even be helpful?
A
Yes an MRI
is indicated. It could be the scaphoid bone, or it could be a
ganglion cyst. Symmetrical
on both palms usually a congenital condition rather than a
disease. I did get the pictures finally, but I can't give you a
definitive answer.
.....Q
Thank you for the information. I have an appointment with
my hand surgeon next Wednesday. I pleaded my case on the phone, but
they would not order the test until I go back into the office. What
do I have to say in order to make sure that they don't just say to
continue with NSAID's (which have not helped at all in 10 months) and
splints rather than ordering an MRI?
They also mentioned injections, but I am not willing to settle for
temporary relief and then have to deal with the same issue again in 6
months. I think injections are overused and the doctors do not
consider the possible complications. The injection site cannot be
seen and I know that an undiagnosed infection can lead to sepsis after
an injection. Also, what if a persons anatomy is different for
some reason and the landmarks traditionally used leads to a nerve or
tendon injury?
As always, I really appreciate your help. I want to be prepared for
my visit so that I get the treatment that I think I need. I think
that patients need to be their own advocate, but I do not want to be
threatening or hostile either. After all, this doctor may take a
knife to my hands at some point.
A
Your concerns are valid. The
most important aspect of medicine is the most precise diagnosis. The
MRI provides invaluable information that we as clinicians use to help
us make that diagnosis. To arbitrarily inject a substance into a very
complex area of ligaments, nerves, and tendons just to experiment is
flawed medicine. Additionally, you are paying for insurance for
situations like these. Why shouldn't the doctor utilize the
diagnostics for his benefit, it doesn't cost him anything? In your
visit, provide as concise of a history and also politely request that
other physicians have recommended and MRI. Possibly summarize our
ongoing email discussions. The successful outcome of your doctor's
visit is establishing a diagnosis.
Q
I have recently noticed and felt that my wrist is hurting. I
don't remember falling on it or anything. I don't know if it is just a
sprain or something else. Their is a protrusion of some bone in that
middle of my wrist when i bend it down at a 90 degree angle. I was
wondering what this protrusion was and how to treat it. The Protrusion
is more towards the thumb side of my right wrist but really almost
centered.
A
Your question is a good
example of a wrist bone malalignment. Out of the eight small
wrist (carpal) bones only one of them dislocates dorsally or to the
top of the wrist. This bone is the lunate bone, often seen in divers
(not scuba, but swim divers). As the divers hit the water, the wrist
bone shifts out of position and causes pain and discomfort.
Typically, these divers must use a taping technique to help stabilize
this bone from shifting.
If you were in my office I
would position your wrist in a neutral position an place my thumb at
the top crease of your wrist. Separating the small bones from the
large forearm bones, as I pull (or apply traction) on the hand away
from the forearm and body, my thumb would focus on pushing the
> small lunate bone downward into its anatomical position. You
can't perform this technique on yourself as you tighten up the muscle
and the bones can't shift. You need someone to apply appropriate
amount of traction. If you experience pain at the force of
traction--too much traction is provided.
Q
Can you list the muscles involved in the kinetic chain of
events for a baseball pitcher?
A
Thank you
for your question. It is a great question. Since the mechanics of
pitchers differ and differ for the type of pitch, I shall defer to a
better specialist to address your question. He is the former Cy Young
pitcher Dr. Mike Marshall. He is a PhD in kinesiology and has a great
website that explores many aspects of biomechanical explanation. Dr.
Marshall and I have worked alongside at Univ. of South Florida in the
High Speed Camera Analysis of various pitching motions, but he has a
greater expertise than me. His web site to address your question is
www.drmikemarshall.com
Q
I'm a middle-distance runner. Or rather I was. I have
chronic ITB tightness/pain, with weakness on the lateral aspect of my
knee that has prevented me from running for 18months, despite much
physiotherapy. I eventually found some straps that allowed me to play
basketball without much pain (but still couldn't run long distances).
(I don't know if this is normal?).
In playing this I have now developed what appears to be an equally
debilitating injury. It 'came on' following a new exercise in the gym
- a lunge and a particularly heavy playing week.
I initially thought it was a quad strain, with the middle quad (vastus
intermedius, I think) being the most painful. Then, following the
games, the 'point of pelvis' (anterior rim of wing of the ilium? - my
partner's a vet, trying her best with the human animal anatomy!
Anyway, it's the bony point at the front) was also painful. In 6
weeks the pain in the pubic area and quad has not gone away,
stretching makes it worse, and swimming/walking don't improve it,
situps and pushups exacerbates the pain. Worryingly, the quad area
has also been numb, even during exercise, for the six weeks. The
numbness is focused in the middle quad, but extends down to the
lateral side of the knee joint, and sometimes includes the whole quad
muscle and ITB.
I have seen an osteopath, who diagnosed and treated uneven leg
length and malaligned spine. This has improved the ITB problem, but
not the pain, weakness and numbness of the quad.
Any suggestions you can offer would be wonderful.
A
Lunges
are questionable, as they can create more problems than benefit.
The attachments in the area where you describe is either the bony
landmark of insertion of the quadriceps or the sartorius muscle.
Both flex the hip, but the sartorius attaches below the knee. The
numbness most likely-may be an entrapment of a superficial
sensory nerve and not of significant clinical concern.
To
obtain diagnostic certainty to your problem, start with a plain
X-ray looking for an "avulsion fracture" of the anterior iliac
spine. This is the bony landmark that these muscles insert into.
Soccer players are most often affected with this as they kick
against resistance. The plain x-ray may not be conclusive, then a
bone scan may help. CT is usually better for bone problems over an
MRI.
Recommend that you find out what the problem is and not aggravate
it. Should avoid lunges and other plyometric work until you have a
diagnosis.
Q
I had a spinal fusion
L5-S1 from an injury. I do stretching exercises and go to physical
therapy 3x week. I work part time. I am very healthy. My problem is :
The muscles in my buttocks are like knots and are very painful. PT
helps temporarily, but the muscles tighten up a day later. I am
considering Botox injections to help. If this is possible, how many
injections will it take?
A
I don't know the history of your problem. Botox will paralyze these
muscles, but doesn't solve the problem. It could be that you may have
a sacral-iliac malalignment and a chiropractor may be of help. If you
would write a bit more on how old you are, what transpired, what was
the basis of the surgery and diagnostics X-rays, I could be more
specific to your needs.
.....Q
I fell down on 2/1/03 and sustained an injury. I had
spondylolithesis. Spondylolysis with the slippage. I was in severe
pain. I had the surgery June 21, 2004. I returned to work July 2005. I
have been in and out of work since then (depression, pain, adjustments
etc.) I still have pain from the affected muscles. Since the pain
isn't as severe as it was before the surgery, I have been told that I
should be grateful.
I have finally adjusted to this and I am back to work and happy and
healthy. I can not accept that nothing further can be done. It is a
muscle problem. The massage helps. The muscles are knotted and I was
hoping to unknot them with the Botox.
I am a 38 year old female. I am active. Today I walked 1.5 miles. I
eat healthy. I am approximately 20lbs overweight.
The pain stops me from exercising and leading the life I want to
lead.
A
I think you should try a
consultation with an Osteopathic Doctor or Chiropractor which can
provide adjustments for malalignments followed by massage therapy and
stretching.
Q
I'm having a
big problem hooking my irons. What is the problem?
A
I
apologize in my delay for replying to your question, as I tried to
contact some golf pro instructors to help me. As I assumed, they need
much more information about your swing mechanics and club specs. I
will direct you to Frankie Costa who I feel can help you with your
question. He can be reached at
fcfsu@aol.com
Q
I am finally going to get the MRI that I have been
wanting. I saw my PCP today and explained my symptoms again along
with my experience with the hand surgeon he referred me to. He
actually applauded me for learning as much as I have about medical
conditions in the last few months. I told him I felt like I caught
the hand surgeon off guard with my questions, but I was able to
confront him when his answers did not make sense to me. Anyway, after
reviewing everything he
recommended an MRI. I have to schedule the appointment, but I will
keep you updated. I only have 1 questions at this point - I bet you
are pleased about that. It is - will the MRI show the problem no
matter what it is e.g. Carpal Tunnel Syndrome, Tendinitis,
Tenosynovitis, nerve lesion, circulation problem etc?
A
I am
pleased with your persistence. MRI show tendonitis is prominent, not
nerve lesions nor circulation problems. CTS is a clinical
manifestation of increased pressure in the canal where the median
nerve and tendons lie.
Q
My
son who pitches has just been diagnosed by an orthopedic doctor as
having posterior capsular tightness. He will be going to physical
therapist in next couple of days for stretching exercises. For the
moment, the doctor has told him to stop pitching.
What’s the prognosis for a
condition like this? Is it likely that he will be able to pitch later
this year? Will be able to bounce back and pitch well again?
A
The question remains--why a
tightness of the posterior capsule? Is there a posterior capsule
micro tear and the muscles are tightened to protect it? Are the
supporting ligaments been sprained and secondary protective
tightness? Are any of the individual four rotator cuff muscles
strained, thus shortened, causing a tightness? Are any of the top
thoracic vertebrae out of alignment leading to strain of the
supraspinatus of upper trapezial muscles? Are there any strains in
the neck that lead to a protective tightness? Are any of the internal
or external rotators of the shoulder girdle affected? Does the
shoulder joint show swelling indicating a problem with internal
derangement? Any acromial joint problems such as a partial AC
separation? Does the shoulder capsule tighten with repetitive overuse
or is it always present? Any bone spurs in the shoulder and AC joint
complex? Any over strengthening of the pectorals or latissimus muscle
that will restrict range of motion? Any diagnostic tests, i.e. plain
X-rays, MRI's? Once an exact diagnosis is made and confirmed
clinically, then a solution is most often found. If you are in the
Southwest Florida area, I would be glad to see your son and offer you
an opinion. Hope this helps. If you have further questions, please
responds with them and I will do my best to address them as best as I
can.
Q
I'm a truck driver who has had sciatica running down my
left buttock and leg. Recently I have had a burning condition
in my right side as well as my left and mid abdominal wall. I
have had a CT scan, bloodwork, urinalysis, and even a MRI of my
lower back. I have not been able to work in the last 5 weeks because
of the burning pain in my right side, as well as the sciatica in now
both legs. My doctor is at a loss and seeking the neurologist
for help. My chiropractor thinks it could be the psoas muscle
causing all the nerve pain. I really need your help and Dr's
opinion.
A
Having read your symptoms and
your diagnostic work-up, the good news is that there is no need for
surgery or other invasive procedures. However, sciatica does not
always have to be a problem of the spinal nerves. Based on your
information and symptoms, I would have your chiropractor evaluate you
for a piriformis syndrome. The piriformis muscle allows the sciatic
nerve to pass through it. If this muscle is strained, it places
pressure on the sciatic nerve causing symptoms of referred pain down
the leg. Piriformis muscle problems occur when one falls on directly
on their buttocks. Another condition that can lead to a piriformis
syndrome is a malalignment of the sacral-iliac area causing strain of
the gluteal muscles with the piriformis muscle.
If the
sacral-iliac bones are malaligned, one experiences pain with sitting,
and most intense pain in the sacral notch. The sacral notch is
located on the medial superior aspect of where your back pocket of
your pants would be located. Again your chiropractor would be best to
correct this problem. Bring this summary to your chiropractor and let
him evaluate you for this possible piriformis syndrome. The other
condition is the iliopsoas, and you can read about it in my clinical
article. The release technique is unique and we have developed an
effective one in our clinic. Should you be in the Southwest Florida
area, I would be glad to see you and provide you with this release of
this deep muscle. I hope this helps you.
Q
How many repetions are necessary for
a particular movement to be considered part of your muscle memory?
A
Muscle memory is conceptually
modeled to explain reproducibility of movement. I believe there is no
one number for it, although some claim that 20,000 is the standard.
Let me explain, a child learning a task may master is it with
significantly less attempts with precise muscle memory, a golfer may
practice twice as much and never fine tune it. The learning
environment plays a factor, emotional and physical preparation.
Avoidance of chemical stimulants and reduction of external
distractions also play a role. In short, one number for muscle memory
can't be established without evaluating all the other circumstances.
Q
I have a 14 year old boy who is a lefty pitcher. He
complained of hurting elbow and we had a bone scan and all was normal.
They told us hot and cold and pills to take and cream. It never swells
and when he pitches it gets to a pain point and goes no further. He
rested it for a week but still is bothered with it. Is this something
he has to work thru and keep on pitching or what. So many stories I am
at a lost what to do.
A
Thank you
for your inquiry. Elbow pain in adolescent years have historically been
ignored. We now recognize that tiny stress fractures can and do occur.
Bone scan is a sensitive tool, but may miss very subtle stress
fractures. At 14 years old, boys start their growth spurt and the
triceps muscles are elongating to the growth of bone. Secondary triceps
tendonitis occurs with a causes extension pain. Furthermore certain
pitches such as a curve ball may create increase torque or forces across
the elbow leading to strains and stress fractures. I follow Dr. Mike
Marshall's work on biomechanics and his theories are sound and he can
provide more detail for you. He welcomes questions at his web site,
www.drmikemarshall.com I hope
this helps, but biomechanically or over repetitions may be the problem.
If you have further questions, please get back with me.
Q
On December 14, 2004 my daughter, who is now 16,
dislocated her right shoulder as a result of diving for a volleyball
during a high school tournament. She was taken to a local hospital were
it was "popped" back into place. The arm was isolated for three weeks
and then she began some minor rehab. On May 13, 2005 while playing
in a varsity fastpitch softball game she attempted to fake a throw and
her shoulder popped out again. She had shoulder surgery on June 16,
2005.
The "anchored" the shoulder during orthoscopic procedure. The arm was
isolated for six weeks and then she went through two months of rehab. I
am happy to say that she is doing great. My question is this. How
do we get her throwing velocity back to at least where it was prior to
the injury? She is very fit and has no pain, discomfort or lack of
flexibility in the shoulder. She is 5'4" and weighs 122 lbs. She
currently can do 50 men's push-ups in strict form and can do 3 reps of
100lbs in lat pull downs. Any help or advice you can give is
greatly appreciated.
A
Fortunately, the surgeons were
successful in stabilizing your daughter's shoulder. With this surgical
correction, tightening of the shoulder complex occurs and range of
motion and/or strength may be jeopardized. You first need to have a
good physical therapist assess all the ranges of the shoulder, i.e.
flexion abduction, adduction, extension, internal and external
rotation. Then the therapist may assess functional strength by manual
testing or by specialized machines. We need more information, but it is
dependent on mechanical performance of flexibility, range of motion and
strength. This may be a good start.
Q
When we are conditioning our arm, we usually do long toss
followed by about 5 sets of surgical tubing resistance (we call it
green tube).
Is it better for our arms if we throw
first & then green tube or should we green tube first & then do our
long toss?
Any advisement is appreciated.
A
Warm up is most important.
How you partake in warm-up could be the long toss of the tube
resistance. Either way as you prepare the arm to more extreme forces
of throwing. The warm-up increases blood flow and range of motion
flexibility in your throwing motion. Try both ways and look at the
outcomes as well as how your arm feels and your performance. Whatever
works best, then continue.
Q
I have been experiencing constant leg
pain, both legs, not a numbness but an ache that actually hurts at
times. It occurs at all times of the day but usually in the
afternoon and evening.
I am not sure how to alleviate this
pain...sitting and laying down do not help.
Any advice you can give would be greatly
appreciated. (I am 35 years old, not overweight)
A
Honestly, I would need more
information about your clinical history. First are you taking any
cholesterol lowering medications that can cause muscle pain?
Secondly, have you had an injury to your low back? Any history of
circulation problems from childhood, occasionally we have
constrictions in the blood vessels that cause lack of blood flow or
ischemia to our extremities? Any other symptoms, such as double
vision, numbness in any part of the body, dizziness or vertigo which
may suggest multiple sclerosis? I'll try to guide you with an
approach to helping identify the possible causes as I understand more
about your situation.
.....Q
As for my history, thankfully there
really is none. No childhood problems or high cholesterol. No
injuries to my back either.
The pain is concentrated in my legs and once in
a while it is mainly in my lower leg below the knee. The pain is a
throbbing pain to that part of my leg. I do occasionally experience
low back pain and once in a while it radiates into my left leg.
I also (less frequently) experience dizziness
and was tested (an ear test if I remember correctly) for vertigo.
That was about 5 years ago. I sometimes get dizzy spells but they
are not frequent, I would say maybe once every other month or so.
Again I appreciate any guidance you can give
me...I assume I will need to get a physical exam from my physician
soon.
A
Well you have eliminated the
more obvious problems. Questions: Do you have pain in your sacral
notch, especially when you sit? Are your hamstrings tight and prone
to strain? The pain behind the knee, is it below the knee and to both
sides of midline? Do you have pain in crossing your leg into a figure
four? If this is similar, then you have a shifted sacro-iliac pelvic
positioning that would best be suited for a physician of osteopathy or
a chiropractor to re-align and manually adjust. If not, provide me
with more information.
Q
I am looking for a profession opinion regarding my lower
back problem.
In the past, while suffering from lower back pain as a result from a
fall, on occasion, I experienced sharp pain to the lower left side
of my stomach.
The pain was extremely intense when I sat up or lift something.
My question is, could their be a connection with my lower back pain
and these sudden lower stomach muscle pains?
A
Your history of a fall seems
to have created this problem. Two clinical opinions come to mind.
The first is referred pain from the spine, notably lumbar 1 and 2
vertebrae. You may have had a stress fracture, compression fracture
of protrusion of a disc that impinges a nerve that refers pain into
the abdominal region. The second opinion is that with the fall, you
may have strained the upper abdominal muscle groups, the obliques or
externals that cause muscle referred pain symptoms. If your pain is
reproduced by pushing on the abdominal wall muscles, then a muscular
strain is suggestive of your problem. Otherwise a plain X-ray may
find a compression fracture, or a MRI is needed to visualize the disc
and nerve structures. I hope this is a start to you discovering the
source of your problem.
Q
I am looking for a profession opinion regarding my
lower back problem.
In the past, while suffering from lower back pain as a result from a
fall, on occasion, I experienced sharp pain to the lower left side
of my stomach.
The pain was extremely intense when I sat up or lift something.
My question is, could there be a connection with my lower back pain
and these sudden lower stomach muscle pains?
Any assistance you provide will be greatly appreciated.
I am a self proclaimed disabled Veteran working with the US Army
overseas, and am trying to justify a compensation for disability
claim for lower back pain and headaches and want to get a
professional opinion on how my abdomen muscles pain could be
related to the constant back pain that is a result of my fall.
Is it ok to use your opinion to submit as evidence to justify my
claim. The federal activity the was the custodian of my medical
records that showed treatment of my back says that they cannot
locate them (fighting to get the records for the last ten years).
The stomach and back muscles have caused me problems since the
injury occurred in the early eighties. Can't do sit ups, can't
stand up to quick after setting down ( for years).
However, its been an uphill battle with snow trying to convince
the VA that the injury is service connected. The only medical
records that I have for treatment that is service connected is for
the strained muscle treatment. I was directed by the treatment
doctor to not lifting anything over 10 lbs and limited sitting for
approximately 2 weeks.
I just received the records that shows the strained muscles this
week and am trying to get the appropriate language to convince
them that the abdomen pain was in fact, caused as a result of the
constant pain that is from the back injury.
A
One
establish how you fell as specifically as possible and where the
level of the injury occurred. Any bruise or bleeding. Any ER visit
and X-ray taken? Then you need an MRI to view the upper lumbar
spine levels. A nerve conduction study and electromyopathic study
of the nerves and muscles can be done to see any neurologic injury
from the spine or corresponding nerve. Thermography is a vague test
but may show area of injury. This should prepare you to make a
clinical diagnosis. You need a good neurologist to summarize the
findings. Hope this helps you.
Q
I suffered an injury to my posterior cruciate
ligament which I believe is a sprain, after a week of no exercise my
walking got much better but the problem is that I cant squat more
than 3/4 of the way before I feel pain. I tried running on it again
and it felt fine. my question is , should I keep resting it longer
or would I cause any damage by running on it even though there is no
pain while I run ? the pain only occurs while I bend my knee
completely or when I squat on it.
A Clinically,
you have difficulty squatting past 3/4 range in your knee. Running
doesn't cause you discomfort. You feel that you strained your
posterior cruciate ligament, which may be the situation, but
possibly you may have torn the posterior lateral horn of your
meniscus (cartilage). To determine the extent of this type of
presentation, an MRI is needed for diagnostic certainty. An
orthopedic surgeon specializing in sports injuries can assess the
type of injury and extent of the problem. The MRI will show him
diagnostically what physical damage you have and treatment
options can be offered. In the short term avoid aggravating
factors, consider a non-restrictive soft knee support, and use ice
for swelling and over the counter anti-inflammatories for comfort.
If you would provide more information on how old you are, what
activity caused the injury and symptoms that were immediate and now,
this would help me. Also, how did you determine that it was a
posterior cruciate ligament that was your specific problem.
Q
My son is a right handed
pitcher he says he gets sore or has pain on his right elbow not
quite on the inner part but like the middle of the elbow is there a
tendon there and what can we do to get him better he is 17 years
old.
A
The
pitching elbow of a competitive baseball player is very vulnerable
to injury, especially in adolescence. The medial and lateral elbow
attachments are for the wrist and forearm flexors and extensors.
The more middle aspect of the elbow attaches the pronator and
supinator muscles. These muscles rotate the elbow allowing the
forearm to turn in and out. The middle muscle that extends from the
elbow to the wrist and hand is the plantaris muscle. Any one of
these can strain and lead to chronic inflammation and pain. To find
the specific muscle, either use google.com of in the bookstore there
is a good simple anatomy book by Yancey that provides a description
of the anatomy and stretching/strengthening program for the specific
muscle. In the meantime, pace his number of pitches, look at his
biomechanics by digital filming and slow motion viewing. For pain
and discomfort use over the counter anti-inflammatories, ice, a
compression sleeve and rest if needed. Hope this helps. If you
would be more specific to the muscle involved, I may be able to
provide more guidance.
Q
Would having been an avid
guitarist from age 10-30 have an effect on range of motion in my
wrists? I became a devoted golfer and student of the swing at age
34.
I would like to be able to create and hold
more of an angle between my arms and the clubshaft but my wrists
simply will not allow it. It seems to me that the thousands of
hours spent playing guitar placed the wrists in the opposite
position of what I would like to achieve in a golf swing.
A
A
physical examination would be optimal to make an informed opinion,
but I'll try my best. If you have either medial or lateral
epicondylitis ( tennis or golf elbow) then your problem is at the
wrist with a shift in the small bones of the wrist. The alignments
of the tendons across these bones affects tension and impedes range
of motion. If don't have this problem then you should see swelling
in the wrist area that limits range of motion by inflammation or
edema. This edema or inflammation occurs from repetitive motions
and overuse. These are the two most common causes other than the
obvious fracture in the wrist or around the wrist. Hope this helps
you get started in determining the cause of your problem.
