Jelly Filled Doughnuts

donut

By Emma Maaranen

This slushy morning my dog and I braved the elements and found a beacon of Sunday morning warmth and ritual on our walk – the doughnut shop.  With powdered sugar on my lips, I bit into the pastry and caused the jelly filling to shoot out the back, leaving me with a gooey mess.  Being me, a therapist who sees anatomy everywhere she looks, this reminded me of a disc injury in the back.

The jelly filled doughnut is a great analogy for a spinal disc.  Spinal discs are puck-shaped shock absorbers sandwiched between every vertebrae of the spine.  The vertebrae protect the spinal column and allow spine motion between each segment.  Each vertebra has a pair of nerves that exit the spinal column next to the disc to innervate a specific region of the body.  Discs are made of tough rings of cartilage, called the annulus fibrosus, which look like a cross-section of a tree.  Their layered circular fibers resist compression in all directions.  Discs have a squishy middle, called the nucleus pulposus, which absorbs forces put on the spine.  This is the jelly center of the doughnut.  If too big a force or a constant force is applied, the nucleus pulposus can push into the annulus fibrosus and damage it, much like a big bite into a doughnut causes the filling to escape.

disc anatomy illustrationCommon Disc Injuries

Disc Herniation – This is where the nucleus pulposus tears through the annulus fibrosus and escapes the disc; the jelly filling has exploded out of the pastry.  Pain and numbness are caused by the torn disc or extruded nucleus pulposus pressing on the nerve nearby as it exits the vertebrae.  The body will absorb the nucleus and the torn disc often will mend over time.   If the disc continues to irritate the neighboring nerve, surgical intervention may be required.  However, the nucleus is gone and can never return to the middle of the disc.  This disc will not be able to resist compression in the same fashion in the future, and care (a strong core and good biomechanics) will be needed to keep the disc healthy in the future.

Bulging DiscIn this case, the nucleus pulposus is being squished on one side and is pressing on the opposite side of the rings; the jelly is oozing into the pastry and with a little more force may burst out.  The nucleus pulposus is tearing the inner rings and expanding the disc.  This disc bulge can put pressure on the nerve causing pain and numbness.  By removing the pressure on the disc the nucleus can reabsorb into the middle of the disc and the tears in the disc can repair.  A bulged disc is quite delicate and too much force on the injured disc can cause it to herniate.

Degenerated Disc – Long-term pressure or a history of trauma to the disc can cause the nucleus pulposus to disintegrate and/or the annulus fibrosus may flatten; your doughnut is drying out and the jelly filling is turning to a dense paste.  The disc is no longer able to cushion compression in the spine as it used to.  Pain will generally come from the muscles trying to protect the spine in that location or from the spinal joints (facets) smashing together now that the flattened disk has reduced the space between the affected vertebrae.  Disc degeneration is often accompanied with arthritis of the spine in that area.

You may hear people referring to their disc injury as slipped, ruptured, compressed or prolapsed.  These terms loosely refer to a bulged or herniated disc.

If you have injured your back, there are several things to consider on how to proceed.  It the pain is sudden and is accompanied with numbness down the arm or leg, especially if numbness is present in both limbs, you need to go to the ER!  If pain comes on gradually and is accompanied by numbness down the arm or leg you should see a physician.  If any pain in your back continues or worsens over three days you should see a physician.  Once your doctor has diagnosed your disc injury a plan to heal it can be made.  Surgery is rarely performed on new disc injuries unless there is damage to the vertebrae above and below the disc (such as a displaced fracture) or the spinal column is compromised and paralysis is a concern.  Disc injuries typically heal with therapy, anti-inflammatory medication and time (six months to two years).

Therapy for disc injuries involves changing postural habits such as sitting at a desk and lifting mechanics.  Muscle imbalances will be addressed and joints will be mobilized to restore normal range of motion.  A physical therapist that specializes in spine injuries (we know a few fantastic ones we can recommend) is critical to healing a disc.  Massage therapy will address muscle tension at the injury site and can help with nerve generated pain down limbs.  Acupuncture reduces nerve pain in many people.  Healing from disc injuries is a slow process.  As an athlete it is important to have a team of professionals guiding you in return-to-play parameters and to be creative and open to new activities (like swimming or Pilates) to keep you active while supporting the healing process.

When a disc has healed it is important to continue thoughtful training and biomechanics forever!  Honestly, anyone who would like to reduce their chances of disc injuries should do this.  Discs are the most vulnerable when the spine is in flexion (forward folding) and a twisting action is done; such as sitting in a slouched position and twisting the legs to the side to get up from a workstation.  This is made more tenuous by adding a heavy object into the equation; such as bending over at the waist to pick up a backpack and twisting while straightening the spine.  It has been said over and over, but it is true – a strong core will support the spine and make it more resilient!  There are many methods to do this: Pilates, specific weight training programs, personal training, home videos, kettle bell, etc.  I’ve even seen a “spin your core strong” class advertised!  Find something you enjoy and add it to your weekly routine.  Even two minutes of targeted dynamic core strengthen exercises as part of a warm-up routine will yield excellent results.  With a strong core, you may even indulge in a doughnut now and then.

Now That Summer Has Arrived, It’s Time for Ribs!

BBQ ribs

By Emma Maaranen

Ribs – not the barbequed ones, yours!  At Focus Bodywork we have seen many rib injuries lately, and I have my own handlebar-induced one as well.  Rib injuries come in many flavors: bruised, separated, cracked, broken, and even collapsed.  These injuries are common in athletes participating in sports where contact or crashing occurs.  You may have heard a friend talking about one of these (hopefully you have not had one of these injuries yourself), but few people actually know what these terms mean and what a rib injury really is.  Let’s clarify.

Your ribs surround your torso, protecting vital organs.  With the assistance of several muscles, ribs help our lungs expand and contract so we can breathe; two very important jobs!  Each of your twelve thorasic vertebrae (the part of your spine between your neck and low back) has a pair of ribs attached to it that wrap around your torso, and all but the bottom two attach to your sternum (also called your breast-bone) on the front of your body.  When your ribs experience a serious blow, they can be injured.  They are designed to displace or crack to absorb a serious force so your organs below are not damaged.  They are not invincible, and sometimes lungs can be punctured,  or other organs experience trauma despite the ribs’ aid.  Here are the common rib injuries:

Bruised Ribs – The muscles and connective tissue around the rib were injured, but the rib bone is ok.  The area will be sensitive to touch, and moving the torso (looking over your shoulder, bending forward) will be painful.  Discomfort from sneezing and laughing are common.  Rest, avoiding jostling activities, and icing the painful area should resolve bruised ribs in a few weeks.

rib-fractureSeparated Ribs – The rib has sprung free from its attachment on the sternum.  The site of impact will feel deeply bruised, any torso movement will be uncomfortable and it will be very touch sensitive at the sternum where the rib attaches.  A separation is a joint injury where the ligaments that hold the rib in place are injured, similar to a sprain.  This will take about six weeks of rest to heal.  Many athletes get frustrated with the healing time of this injury and return to play too soon. Separated ribs can progress to a chronic inflammatory condition that is very painful and will require ongoing medical care, do it’s best to see the rest period through.

Cracked Ribs – This is where the rib is cracked, but does not actually break.  It will be extremely sensitive to touch, and any torso movement (including breathing) is very painful.  Rest and minimal activity for 6-8 weeks is the typical protocol for healing a cracked rib.  Athletes that return to play too early risk the cracked rib progressing to a displaced fracture (where the bone breaks into two or more pieces).

Broken Ribs – This is a displaced fracture, the jagged edges of the broken rib may shred the muscles around it and can puncture the lung.  This is an extremely painful injury where moving or even breathe is excruciating.  It will be extremely sensitive to touch, may be visibly deformed and will likely bruise severely.  Six to eight weeks of rest are needed to heal, but athletes with broken ribs are typically in so much pain they won’t return to play too early!

Flail Chest – This is where several ribs are broken, and the rib cage is no longer able to assist the lungs to breathe.  This is a medical emergency.

Pneumothorax – This is where a broken rib punctures the lung.  This is a medical emergency! Fortunately there are two lungs, so breathing is sort of possible before a medical team can intervene.  Again, six to eight weeks of well-deserved rest are the norm.

Rib injuries are frustrating.  Your arms and legs work just fine, but you can’t bend, twist, lift, breath hard, laugh, sneeze and I hope you don’t get a cold with cough!  There is little you can do to speed  the healing ; it just takes rest.  Ice and anti-inflammatory drugs can help with the pain. Increasing your protein intake will ensure you have the building blocks needed for tissue repair and taking a calcium/magnesium/phosphorus supplement will aid in bone repair.  An acupuncturist can help with the pain and stimulate your body to put a lot of effort into healing the injury.  In the past, rib injuries were taped or supported with an ace bandage.  This is no longer recommended because the limited rib motion from the brace can lead to pneumonia.  The last thing you want is to have more problems breathing with a rib injury, and coughing may make you more miserable and lengthen healing time.  When the rib injury has healed to where it is not very touch sensitive and any broken bones have knit back together, massage therapy can help to restore normal rib motion.  When rib injuries heal, it is common for the intercostal muscles (the ones between ribs that pull two ribs together) to develop scar tissue and adhesions.  These muscle restrictions can limit  torso motion and the ability to breathe deeply.  Often the diaphragm (the muscle at the bottom of your lungs that helps the lungs expand and contract) has developed adhesions as well.  Using neuromuscular therapy and myofascial release, your massage therapist can resolve these tension sites, which helps you return to pain-free activity quickly.

I sincerely hope you do not have a rib injury this summer; but if you do at least it’s BBQ season.  While gnawing on some baby back’s and resting in a lounge chair, you can share some rib injury trivia with your friends.

ITBS (Illio Tibial Band Syndrome) is not IBS (Irritable Bowel Syndrome), but it is Irritable

By Emma Maaranen

ITBS is a repetitive stress injury common to both runners and cyclists.  If you participate in either of these sports, either you or your training partners have likely experienced this injury.  ITBS is characterized by pain on the outside of the knee.  Unless you have experienced knee trauma recently, ITBS is most likely the sports injury you are dealing with, not a torn meniscus or knee ligament.

What is the ITB?

ITB anatomyThe ITB (Illio Tibial Band) is a long tendon (rubber-band like structure that connects muscle to bone) that runs on the outside of the thigh from the hip the knee.  The Gluteus Maximus and Tensor Fascia Latta are the muscles that connect to the ITB.  These muscles make a fan shape between the outside top of your pelvis (if you put your hands on your hips, they span from your index finger to thumb), and they narrow to the bony spot at the top outside of your thigh.  (Insert image here) The ITB starts at the bottom of this fan shape and travels down the outside of the thigh.  It then crosses the knee and inserts just below the knee on the outside of the tibia (lower leg bone). The ITB separates the quadriceps (front thigh muscles) from the hamstrings (back of thigh muscles).  If you have ITBS, pain is felt just above the outside of the knee.

How did this happen?

Most of us do sports that move forward and have little side-to-side motion with the legs.  Over time forward only motion weakens the muscles of the ITB.  To walk, run or to pedal these muscles work in a small range of motion, which trains the muscles to be strong only in a small zone and causes a loss of flexibility.  Sudden increases in training distance or intensity, as well as adding steep hills into run training, can overtax these muscles and tighten them.  This creates excessive tension in the ITB and begins to cause friction at the lateral epicondyle (the bony knob at the outside bottom of the thigh bone).  When you bend your knee about 30 degrees the ITB normally glides over this bony knob, but if it is too tight the ITB grates over it and gets irritated.  Once inflamed, the ITB becomes swollen and will grind over the lateral epicondyle more, making the condition worse as you push through the pain!

You have pain at the outside of your knee; what do you do?

The first time you experience pain at the outside of the knee it is important to end your workout.  Go home and ice the painful area.  Rest and ice for three days (no running/hiking/biking; avoid stairs and other activities that involve repetitive bending of the knee).  After three days, see how it feels.  A minor one-time irritation of the ITB should recover after this rest period, but be on notice that you need to strengthen and lengthen the muscles of the ITB.

If, however, three days of gentle care for your inflamed ITB does not alleviate the pain, you most likely have ITBS.  ITBS is a fancy tendonitis.  For it to heal, you will not only have to address the inflamed tendon, but you will have to address the cause of the excessive tension in the ITB as well.  The cause is often a combination of weak/tight ITB muscles, adhesions along the ITB to the quads and hamstrings, muscular or structural imbalances in the pelvis/hip complex, and foot/ankle biomechanics. Cyclists need to make sure they are not in excessive toe-in position when clipped in and runners should replace their running shoes if they have over 250 miles on them.

At Focus Bodywork we can help you sleuth the factors in your ITBS, address adhesions in the ITB, treat the associated muscles and recommend self-care practices.  Occasionally ITBS is stubborn and needs a physician’s care.  In these cases you may need a cortisone injection, orthotics or a regiment prescribed by a physical therapist.  We are happy to recommend some fantastic practitioners for you to work with and be a part of your return-to-play team.

In our next post we will cover self-care for ITB health.