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It's Time to Create a Strong Acupuncture Footprint
Footprints in the sand. Footprints in the snow. Where do these footprints go? Some are big, some are small, but footprints are made by all.
Online Efforts That Convert Traffic Into Patients
Most chiropractors are using "dinner with the doc," "refer a friend," customer appreciation days, grand openings, health fairs, chamber of commerce meetings, and other networking events to get new patients.
Adjusting the Occiput on the Atlas
You may never see a particular set of patients in your office – the ones who are either afraid of neck adjustments or have had a bad experience. A vast majority of those who had a bad experience did not have a life-threatening vascular event.
Joint Supplements for Athletes (Part 1)
Maintaining joint health should be a daily focus for athletes. Joint health is a complex issue for everyone, but for athletes it poses a greater concern.
Put the Social Back Into Social Media
Social media is more than a passing fad, it is definitely here to stay. Social media apps and channels of distribution may evolve, but the concept of social media is now big business and a part of all our lives.
What's Triggering That Point?
An orthopedic friend recently saw a patient of mine. He felt an injection of a trigger point (TP) at the upper trapezius and surrounding areas was necessary, since that was the patient's area of chief complaint and there was a tender, radiating nodule.
Finding Balance in the Clinic
This past December, I celebrated 11 years in practice. I seriously don't know where the time went. I feel beyond blessed and grateful to be practicing our profound and beautiful medicine and to be helping guide my patients restore a state of optimal health.
It might have been a miserable start to the day in the heart of downtown San Diego. A heavy rain had soaked the large homeless population congregating near the intersection of Third Avenue and Ash Street as they waited for a free breakfast to be served at the First Lutheran Church on the corner.
Are You Really a Healthy Eater?
I always giggle a little bit (to myself) when someone comes into my office and informs me that they are a healthy eater. What exactly does that mean? Does that mean they eat sugar in moderation? And what's that, exactly?
Old TCM Sayings: Treat the Front to Treat the Back
Chinese medicine college was, and always will be, a memorable time. It was a time of massive personal and professional growth.
The Conscious Evolution of Healing, Part 2
The idea of transmission is very important in the Chinese medical classics. According to author Claude Larre, the ancient Chinese were highly interested in the connection between things. Nothing was looked at as an isolated entity.
Connections Worth Making
"If most doctors are like me, [they are] isolated physically and professionally. I do not make the time to connect with other doctors and also a lot of doctors do not want to be connected for a lot of reasons. Dynamic Chiropractic keeps me grounded and connected.
The Easy Way to Learn How to Document ICD-10
The 2015 Work Plan for the Office of the Inspector General (OIG) includes a focus on chiropractic services. This means chiropractors can expect to see more audits and reviews in the coming year because private payers pay attention to the OIG's focus as well.
Leg Length and Pelvic Fixations
A common component of low back pain is sacroiliac joint dysfunction. Signs of SIJ dysfunction can include fixation with reduced range of motion, and localized pain or joint laxity and inflammation.
Case Histories from Bali: Treating Balinese Chidren with TCB and Shonishin
When I moved to the island of Bali in 2005, I offered my services in Bumi Sehat, which means Healthy Mother Earth, a free birthing center for poor and disadvantaged local women located in Ubud.
We Get Letters & E-Mail
We Have Come a Long Way – But There's a Long Way to Go; Grounded and Connected.
The Top Seven Website Mistakes Clinics Make
The majority of acupuncture clinics finally have a website for their business. Having a website is crucial for being found online through Google, Facebook and review sites like Yelp.
A New Era of Injury Awareness Means a New Focus on Prevention
Despite a dramatic Super Bowl last month, the National Football League has taken quite a few hits lately concerning player injuries, particularly concussions.
Reflections: The Art of Teaching Asian Medicine
Over the past three decades, my global workshops have been translated into German, Swiss German, French, Romansch, Spanish, Lithuanian and Xhosa. Time to offer you new teachers a few tips!
Acupuncture and Homeopathy: Bioenergetic Brothers
Acupuncture and homeopathy share an important healing principle: bioenergetics. "Bio" means "life," so bioenergetics is literally "life energy."
Exploring Elusive Knee Pain
Massage is great for many soft-tissue pathologies. However, sometimes various conditions exist that seem like a common pathology, but then don't respond to the treatment. In some cases, an undiscovered problem may exist. Let's take a look at the synovial plica, a cause of knee pain that can easily mimic other common knee conditions.
What Is a Plica?
During embryologic development tissues gradually change state as they develop into their fully formed structures. Early in fetal development, bands of tissue separate the knee into different compartments. These bands of tissue gradually shrink as the knee joint fully forms and is eventually surrounded by a synovial capsule. However, in some people, these bands of embryonic tissue persist into adulthood and become sleeves or folds of tissue called synovial folds or plica.1
The medial side of the knee is one of the most common locations for a plica to develop. When it develops in this region, it is called medial plica syndrome and may cause pain and discomfort during various movements and is often mistaken for other knee pathologies.
While the plica will have existed for the person's entire life, it may become problematic only later as a result of overuse. The plica becomes swollen and fibrotic for several different reasons. The most common reason for plica irritation is chronic overuse. Repetitive motions of the knee cause friction on the plica and it becomes fibrotic and far less flexible. Depending on its location it can become bowstrung across a bony prominence in the knee.
Other possible factors that can lead to a fibrotic plica, include a direct blow or trauma to the tissue, excessive twisting motions applied to the knee, or intraarticular bleeding or effusion secondary to another injury. Secondary dysfunction, like meniscal damage, may go undetected or misidentified as some other pathology. In rare cases, the plica can become calcified, which causes much greater pain and disrupts tissue mechanics around the knee.2
Once the plica becomes stiff and fibrotic, it can get pinched between the femur and patella during knee extension. The medial side of the knee is the most common site prone to irritation of the plica (Figure 1). The medial patellar plica runs underneath the distal portion of the vastus medialis, called the Vastus Medialis Obliquus (VMO). Pain in the VMO is frequently associated with patellar tracking disorders and tracking disorders are another potential issue that can mask involvement of a synovial plica in the region.1
The fibrotic changes in the joint can eventually lead to softening and degeneration of the cartilage at the patellofemoral complex. As a result, there may be a cause-effect relationship between the synovial plica and development of chondromalacia patella.1
Evaluating the Plica
Identifying the presence of a synovial plica is not easy because it can be so easily ascribed to some other pathology. However, there are key characteristics that show up when a plica is present. The primary complaint is intermittent dull aching pain medial to the patella. The pain is usually increased with activity and tends to be more evident during forceful knee extension, such as standing up from a squatting position.
Sustained flexion usually increases the pain as the plica tissue is pulled taut. Plica pain generally appears during extension motions, but once the knee is static and held in a position of full extension, such as standing, the pain usually decreases. Additional symptoms may include feelings of giving way, snapping, and popping or clicking sounds especially when moving the knee from 90 degrees of flexion into extension (Figure 2).
During palpation, it is common to find general tightness in the knee region, especially within the quadriceps group. The fibers of the quadriceps retinaculum are also likely to be tender. There are deep fascial connections between the distal retinacular quadriceps fibers and the synovial capsule of the knee, so reducing quadriceps tightness is a key treatment goal.
One of the more common findings with many knee injuries is atrophy in the quadriceps group and this is common with plica syndrome as well. The quadriceps, as an anti-gravity muscle group, is prone to rapid atrophy when there is pain or dysfunction at the knee. Evaluate quadriceps atrophy by using a soft tape measure to measure the circumference of the muscle group just superior to the patella and comparing it with the unaffected side.
In some cases there is a distinct taut and palpable band on the medial aspect of the knee that can be rolled under the fingers during palpation of the medial knee. It is not always easily palpable, so this method is not a highly reliant means of determining the presence of a plica.
Another method that may be helpful in identifying the plica is a pain provocation test. This can be performed by holding the knee in about 300 of flexion and pushing the patella in a medial direction. Medial movement of the patella reproduces pain as the plica is pinched between the femur and patella.3 Physical examination of the knee alone is not considered highly reliable to identify the plica, so high-tech diagnostic studies such as MRI may be used.
Treatment of Plica
The synovial plica is usually treated first with conservative treatments such as physical therapy, which will include stretching and strengthening exercises. Stretching helps encourage pliability of all the soft tissues. Strengthening of knee extensor fibers is an initial treatment because they have fascial connections into the capsular tissues, which helps pull the plica tissue out of the way during extension and prevent it from being pinched.4 It is also very important for the person to reduce offending activities, such as repetitive flexion and extension movements of the knee.
Nonsteroidial anti-inflammatory drugs (NSAIDS) are commonly used to address inflammatory activity in the knee. Iontophoresis (anti-inflammatory medication applied with electrical stimulation) and phonophoresis (anti-inflammatory medication applied with ultrasound) can also be used to reduce swelling and manage fibrosis. If these more conservative methods are not effective, intraarticular corticosteroid injections might be used. Surgery is considered the last resort to remove plica tissue.
Role Of the Massage Therapist
There is currently no research regarding massage treatment for plica syndrome. However, a lack of study does not indicate a lack of a role for massage. To determine the effectiveness of massage for any pathology requires considering whether some form of massage would provide a helpful intervention.
We do know that massage is effective in reducing dysfunctional soft-tissue fibrosis in many conditions, and plica syndrome is fibrosis that develops within the synovial fold of the knee joint capsule. It would stand to reason that massage might be helpful in addressing medial plica syndrome by encouraging mobility within the fibrotic or calcified plica. If the plica is caught between the femur and patella, you can push the patella slightly laterally and friction the medial side of the tibiofemoral joint and the area just under the patella.
You might also provide some deep friction along other regions of the medial side of the knee.
Massage would be generally helpful for maintaining proper muscle tone and biomechanical balance of the VMO and distal quadriceps group so that inappropriate tension levels on the knee capsule fiber do not develop.
A critical part of evaluating the appropriateness of massage is to determine if there might be contraindications. In treating plica syndrome, as long as massage is performed within normal pressure levels, there does not seem to be any contraindications to using massage. In fact, massage is more likely beneficial and might reduce the need for surgical intervention.
Conservative treatments like stretching and exercise have some degree of effectiveness. Massage may be a useful adjunct for these treatments. This syndrome offers a good opportunity for further research into a new application for massage.
Author's Note: Receive 1 hour of continuing education credit related to this article by visiting www.academyofclinicalmassage.com. Whitney Lowe is a premier authority on pain and injury treatment with massage therapy. He is the author of Orthopedic Assessment in Massage Therapy and Orthopedic Massage: Theory and Techniques. Lowe's texts and programs have benefited massage professionals for more than 25 years. Learn about Whitney Lowe's innovative and engaging online courses and products by visiting his website, www.academyofclinicalmassage.com.