Patellofemoral Pain Syndrome

Patellofemoral pain syndrome (PFPS) is a common cause of knee pain in athletes, particularly young women and those who are involved in running.  The pain is felt around or behind the kneecap, and is often of gradual onset unless trauma is involved.  There is increased pain with prolonged sitting (knee flexion), stair climbing, squatting, running, kneeling and jumping.  Generally there is no swelling around the knee cap, nor is there any pain in the patella tendon or surrounding ligaments.

PFPS is usually a functional problem rather than a structural one.  It has to be differentiated from another patella condition, chondromalacia, which is the wearing down of the cartilage under the knee cap, and may accompany PFPS.  The causes are multifactorial and can be broken down into three categories:

Biomechanical, or patellar tracking problems, are caused by lower extremity malalignment, which pulls the patella out of its groove.  Factors such as flat feet which cause the knee to internally rotate (knock knees) and wider Q angles of the hip, which are more common in women, contribute to PFPS.  A “J” sign can be seen with lateral patellar tracking, as the knee is extended from 90 degrees of flexion to full extension. 

Muscular imbalance is another factor, with weak quad muscles (particularly the medial quad) and a tight iliotibial band and hamstring, as well as weak hip extensors/abductors and tight hip flexors. Overuse or overload of the patella caused by repeated weight bearing impact, such as with running, is also a contributing factor in PFPS. 

 Conservative treatment is multipronged, based on the underlying reasons for the PFPS.  Relative rest from aggravating activity (running) to another non impact activity (swimming, elliptical); icing after activity; cold laser therapy to reduce pain/inflammation and heal the tissue; taping or a knee brace with a U shaped insert to keep the patella in alignment; orthotics to help support the arch; and specific exercises to strengthen weak muscles (quads and gluts) and stretch tight muscles (TFL ,hams and psoas).  Rarely surgery is indicated, but true chondromalacia may be amenable to arthroscopic surgery to smooth out the cartilage under the knee cap, and lateral retinaculum release if the problem is caused by excessive lateral pulling.

Peripheral Neuropathy

Peripheral neuropathy is nerve damage which is caused by long standing diabetes.  The injury to the blood vessels by elevated blood sugars causes a lack of oxygen and nutrients to the nerves, most commonly in the toes, feet and lower legs, but also in the fingers and hands.

Symptoms include progressive numbness or insensitivity to pain or temperature; tingling, burning, prickling sensation; sharp pain or cramps; or extreme sensitivity to touch.  If symptoms are in the lower limbs, loss of balance or coordination can occur because of the weakened muscles leading to falls.  Blisters or sores may develop in numb areas, resulting in infections which may lead to amputation, making it important to have regular foot exams.

The risk of developing neuropathy increases with age and with those who have uncontrolled blood sugars, elevated blood fat, and high blood pressure.    Other causes include autoimmune factors which lead to inflammation of the nerves and smoking which decreased oxygen to tissues.

Besides keeping the blood sugars in a normal range, treatment for pain includes antidepressants, anticonvulsants or opiods; and topical lidocaine or capsaicin cream.  Some supplements that have shown promise include alpha lipoic acid (50mg/day) and omega 3 oils for inflammation.  Acupuncture may also help with pain control.  A newer therapy, cold laser, has shown in clinical trials to increase blood flow and help regenerate damaged nerves as well as accelerate wound healing for diabetic ulcers.

Sources:

 http://diabetes.niddk.nih.gov/dm/pubs/neuropathies

Diabetic distal symmetric polyneuropathy: effect of low intensity laser therapy; Lasers Med Sci, 2011

A randomized clinical trial on the effect of low level laser therapy on chronic diabetic foot wound healing; Photmed Laser Surg; 2011

Cold Laser in the treatment of carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is caused by the entrapment of the median nerve as it travels through the carpal tunnel in the wrist.  Signs are pain, numbness and paresthesia in the thumb, index, middle and inside ring finger; increased pain and numbness at night due to prolonged wrist flexion; and if long standing, weakness in pinching and grip strength and atrophy of the hand muscles. 

Causes of CTS include inflammatory conditions such as pregnancy, rheumatoid arthritis, hypothyroidism, diabetes, and obesity.  Cumulative trauma from repetitive activities such as typing and guitar playing which puts the wrist into forced flexed positions are also implicated.  History and clinical tests to stress the nerve give a diagnosis, with a nerve conduction study being conclusive. 

Non surgical treatments have included night splints, NSAIDs, cortisone injections, ultrasound and modifying or changing certain activities.  Cold laser, a new treatment now being offered at our clinic, has shown promise in treating CTS to reduce pain and inflammation, as well accelerate healing. Surgical release of the carpal ligament may be indicated if conservative treatment has failed, if so cold laser can also be used post surgically to assist in healing. 

Several recent clinical trials have compared cold laser with sham laser, splinting and ultrasound. Results have shown cold laser to be effective in pain alleviation; reducing the numbness and paresthesia; improving hand grip strength and even improved EMG findings with no side effects, and to be superior to both splinting and ultrasound.   

Sources: The effectiveness of conservative treatment of carpal tunnel syndrome: splinting, ultrasound, and low level laser therapies; Photomed Laser Surg, Feb 2009 and The effects of low level laser in clinical outcome and neurophysiological results of carpal tunnel syndrome; Electromyogr Clin Neurophysiol; June 2008                                              

Sports Supplements that are Clinically Proven to Work

Athletes may ask about the value of certain supplements to enhance performance or gain muscle strength, but many supplements have more hype than science to support their use. While whey protein in shakes to replace protein loss during workouts is common, creatine, L-glutamine, ornithine and arginine also top the list of legitimate sports supplements. 

Creatine leads to an increase in muscle mass which is thought to occur from increased protein synthesis, this allows athletes to train harder as there is increased energy available for muscle contraction, promoting strength gain.  Creatine can also preserve strength as athletes age, keeping them functional longer. A loading dose of creatine monohydrate crystals is 20-25 grams per day for the first week, and than 10 grams per day for maintenance. 

 L-glutamine has been shown to decrease muscle breakdown during workouts and also reduce the incidence of upper respiratory infections by providing fuel for immune cells.  Optimal dosage of L-glutamine is 1,000 – 2,000 mg per day.

Ornithine and arginine are amino acids that have been shown to increase the release of growth hormone.  As we age, growth hormone declines, facilitating breakdown of lean muscle and bone mass.  Supplementing with arginine and ornithine may not only enhance muscle mass and strength gains, but as it elevates metabolism, it can help reduce body fat too.  Recommended dosage is 500 mg twice a day for five days a week.

So to maximize your athletic performance, consider using creatine monohydrate, L-glutamine, ornithine and arginine at these clinically proven dosages stirred into a glass of juice on an empty stomach.  Happy training!

Author:  James Meschino, DC, MS, ND; Dynamic Chiropractic

Laser Therapy for Shoulder Impingement

A 2011 study published in Clinical Rheumatology compared the traditional treatment of exercise for impingement syndrome of the shoulder to exercise with the addition of low level laser therapy.  Research has shown low level laser therapy to be beneficial in accelerating tissue repair by increasing fibroblast formation and circulation, while also decreasing inflammation and pain.

80 patients were divided into two groups; with neither the participant nor therapist knowing which patients were receiving laser therapy or sham laser.  Treatment consisted of 10 sessions over two weeks.  The intervention group showed significant improvement in both pain and increased range of motion than the exercise group alone.  The results were further strengthened as the same therapist performed all the treatment, eliminating practitioner bias. 

One weakness of the study was that the study did not differentiate only impingement syndrome, but rather lumped it with biceps tendonitis and other rotator cuff pathologies as they commonly occur together.   Strengths of the study were not only the large research group and “gold standard” of being double blinded and randomized, but that the low level laser improved the pain and range of motion, regardless of the underlying musculoskeletal condition. 

 

Manipulation or Exercise for Low Back Pain?

Low back pain affects 80% of the population at some point in their life, costing billions of dollars in lost productivity and health care.  There are many different treatment options available as individual response to care is unique.  A 2011 clinical trial reported in The Spine Journal compared two proven conservative care therapies, spinal manipulation and exercise, in chronic low back pain.

 

300 participants were divided into three groups: supervised exercise; spinal manipulation and home exercise with advice for a 12 week program.  There were equally improved outcomes in all groups, with a 40-50% reduction in pain and disability.  As would be expected, endurance and strength improved in the exercise groups more than the manipulation group.   

Results parallel the 2004 UK BEAM study comparing spinal manipulation and exercise, which found that manipulation and exercise were equally successful in treating low back pain, but that spinal manipulation combined with exercise did better than manipulation or exercise alone.  This supports what chiropractors have been doing for years, keeping the spines of patients functional through manipulation and providing exercise advice and encouragement to strengthen the core to stabilize the spine. 

Managing Pain with Acupuncture

Inflammation is the first phase of healing, but the pain associated with this inflammation may predispose some patients to chronic pain and disability.  If the initial pain experience is severe and continues, central pain hypersensitivity may develop.  Early intervention and prevention remain the best treatment, with rapid pain relief being the key. 

Acupuncture reduces pain via two different mechanisms.  It decreases the stimulation of nerve signals that lead to pain and it also reduces the expression of inflammatory chemicals that stimulate nerve endings that cause pain. 

Acupuncture may provide an analgesic effect by encouraging release of opiate based chemicals in the body and release of serotonin in the central nervous system.  It may also inhibit stimulation of the sympathetic nervous system to regulate inflammation and pain.  Acupuncture also seems to suppress Cox-2 in the spinal cord; Cox inhibitors are commonly used with some NSAIDs. 

If the patient’s pain is desensitized and there is increase tolerance to painful activities and therapy, the patient will hopefully avoid chronic pain syndrome and recover function faster to get their life back!