QuestionWhile I was at work, I was lifting several beer cases into a cooler. I was in a hurry, and I felt a popping sensation in my mid back, followed by a burning sensation. <y employer sent me to a chiropractor, that would not touch me and he sent me to the ER. Anyway to make a long story shorter, My DX was a pulled/strained muscle. I have done exaclty what my orthopedist said and rested my back, took the proper RX and nothing is helping, the pain is right underneath my bra strap in my back, I can barely move somedays, the only thing the physician did was take a plain AP/LAT xray of my thoracic spine...do you have any idea of what this might be?...please help I want to return to work ASAP.
Thank you for your time,
Tina C.
AnswerDear Tina,
There are a few possibilities in your case. The first assessment by the orthopedist is correct, but I also believe you have an associated problems. By the way, I don't know why the chiropractor would not touch you, the examination process should have given him a working diagnosis, and x-rays and a possible MRI would have given him all the information needed to validate safe treatment. I would have treated you.
The popping noise you heard is likely due to the actual tearing of muscle tissue. Athletes often report hearing a pop when someone has a muscle tear. Now the normal healing time of a muscular tear is in the range of 6 to 8 weeks, so it is normal to have lingering pain and dysfunction for up to a month. The key is that you should be showing signs of improvement, if not then you need to look into this a bit further.
In addition to the muscular problem, it is also likely that you have strained and possibly torn part of the Facet joint capsule. This is a bilateral structure found between every vertebra in the spine and allows for the normal movements. This DX is a clinical one, and can be validated by specific MRI views, but MRI are not commonly ordered for this type of problem. If the facet capsule has been damaged it can only heal with the formation of scar tissue, but it must maintain its mobility and continual movement during the healing phase for the best scar formation. Ligamentous structures do not heal as quickly as muscular structures and can be a source of continued pain for months. (See below for a more thorough description)
Conversely, your body position and description of the events point to possible disk disruption. The thoracic spine is not a high percentage area for disk injuries, as a matter of fact it is rare but still possible. Patients with traumatic disk disruption often report hearing a pop and burning pain immediately after injury, and the most common position for injuring the disk is in a flexed position with or without rotation. Clinical research has proven that repetitive motions such as repeated lifting, stacking etc... predispose the disk tissue to injury.
If this is a disk problem, there are orthopedic tests that help to make the diagnosis, and they should have been performed by both of the doctors you saw. Question: Does taking a bowel movement, or coughing increase your pain around the bra strap? IF so this is an indication of disk disruption. To test, take a deep breath, hold it in and bear down like you are straining to relieve the bowels....if this creates increased pain, probably sharp, this is an indication of disk disruption. An MRI of the area of complaint is the only definitive diagnostic tool for confirmation. For more information on disk and spinal injuries I have provided a link to 2 specific pages on my website.
http://www.suncoasthealthcare.net/sa.htm
http://www.suncoasthealthcare.net/dsc.htm
What I would recommend in your case is to find another chiropractor that will treat you, monitor your progress and refer you for an MRI if further examination warrants. Unfortunately, pain medication might help the pain, but it will never address the problem. If there is disruption of the muscle/ligamentous systems, you will likely need some physical rehabilitation to help facilitate proper healing and scar formation, which is important for reducing the likelihood of continued damage or further injury. Remember not all doctors are created equally, some will do what it takes to find an answer to the problem and render an effective treatment, some will not. Make sure that you get a second opinion about this.
Below you will find a more detailed description of muscle/and ligament injury. I have formulated this research for car crash patients of mine because they often come in with disk, muscle and ligament tears after injury. I submit it to you so that you may have a better understanding of the tissues.
Respectfully,
Dr. J. Shawn Leatherman
CHIROPRACTIC E/M COUNSELING RECORD: SUPPLEMENTAL INFORMATION
Risks and Benefits of Management Options: There is a risk that chiropractic treatment will have a temporary increase in the pain experienced by the patient due to mobilization of inflammatory mediators that are present in injured and inflamed tissues such as; cytokines, proteolytic enzymes elastase, trypsin, chymotrypsin, plasmin, cathepsins & collagenase, growth factors (PDGF & TGF-?, chemotactic agents for neutrophils (12-HETE, PF-4, & PAF), enzyme inhibitors (alpha-1- antitrypsin, alpha-2-macroglobulin), clotting factors, serotonin, thromboxane A-2, platelet activating factor, platelet factor-4, interlukin-1-? thromboglobulin-? tumor necrosis factor (TNF), and substance P. (2,4,6,12,14,16,17,25,28,30,31,32,38,40,44,56,61,68) All of these mediators are released in the acute inflammatory process and persist into the secondary phase of inflammation. Many have been connected to nociceptive (pain promoting) input to the tissues. TNF and IL-1 have also been shown to contribute to joint injury and bone resorption. (56) They may also act as pyrogens similar to prostaglandins/eicosanoids. (16)
Benefits of care are that with passive modalities, controlled early mobilization of injured tissues through chiropractic adjustments, and proper nutritional supplementation; aberrant processes can be limited and sometimes reversed by supplying increased oxygen and blood supply to the tissues. Therefore, pathways are established inducing proper nutrient delivery for repair, stimulated lymphatic channels pull inflammatory mediators away from injured tissues, and normal neurological input is instituted to the brain for improved proprioception through the dorsal columns. Pain control is modulated locally due to the gate theory reflexes. Activation of the opiate receptors, stimulate the descending inhibitory pathways of the peri-aquaductal grey regions in the reticular formation of the lower brain. The nucleus raphe magnus is stimulated and serotonergic projections extend down the cord, synapse with interneurons in the superficial dorsal horn, which release enkephalins and result in inhibition of the nociceptive system. (22,23) According to Wyke, these are the same inhibitory neurons that are stimulated as joint mechanoreceptor afferents are depolarized from a chiropractic adjustment. (66)
揝oft tissue injuries?encompass anything that is not bone including organ systems, nervous tissue, cartilage, musculature, ligaments, tendons, and fascial tissue. Muscle has a high reparative capacity and sufficient regenerative capacity, but extensive damage results in scarring and atrophy of the fiber bundles. (17) In contrast, tendons and ligaments are notably slow to heal! Even after forty weeks, collagen may still not be present in normal concentration and organization. (21) Articular cartilage, which is found in every zygapophyseal joint in the spine, has a notoriously limited potential for either healing or regeneration. (48) The ability of articular cartilage to heal will depend on the severity of injury. Patients requiring surgery are the least likely to heal. (48) In relation to acceleration/deceleration type trauma from vehicular crashes, the cartilaginous surfaces of the facet, (a.k.a. the synovial folds), are exposed to tremendous loading moments with sheer, compression, tensile, and torsional forces. Major cartilaginous damage is probable throughout the spine along with ligament disruption and is responsible for sclerotogenous pain patterns experienced by patients.
Regarding patient care, immobility is a main factor that promotes degeneration. The restoration of mobility seems to curtail degeneration. Previous research has demonstrated that the tensile strength of ligaments and tendons respond to changes in physiologic stress and motion that aid the healing process. Improving mobility can even enhance cartilage healing after traumatic injuries as well as the strength and stiffness of ligamentous structures. Furthermore, after trauma, healing occurs by an unspecified form of collagen, scar tissue, which frequently causes adhesions and fibrotic changes that must be dealt with therapeutically. Chiropractic adjustments improve and restore motion and movement patterns in the zygapophyseal joint at the facet articulations which include the ligamentous, myotendinous, and fascial complexes. With the addition of carefully progressed passive and active rehabilitation programs, further mobility can be achieved due to increased stretch and flexibility.
Instructions/Explanations for Treatment: Acute phase-emphasis is placed on limiting the inflammatory response and reducing pain. The use of interferential current aids this process by increasing lymphatic drainage as well as increasing blood flow, oxygenation and nutrient delivery to the injured tissues. We use specific nutraceuticals in the early phase of treatment such as pro-enzymes; malic acid, magnesium, omega III fatty acids, bromelain, tumeric, and zinc. These agents have been proven to inhibit and reduce inflammation, maximize the bioavailablity of repair materials for soft tissue healing, and provide neurological support. (6,7,8,9,10,11,18,19,26,29,33,34,35,37,39,43,46,47,49,51,52,54,56,62) Cryotherapy is an important part of this early phase for its analgesic and anti-inflammatory effects. Passive techniques are used mostly in this phase of care. Massage may be utilized as well to facilitate the relaxation of myospasm, mobilize fascial slings and bands, and inhibit trigger points with Nimmo technique. (13)
Sub-acute phase-emphasis is on the incorporation of active participation of the patient in their care. Home exercises and stretches are taught in this phase and are to be performed either three times weekly or daily depending on patient progress and tolerance. (31) This will facilitate increases in the mobility of injured tissues while limiting the formation of adhesions and abnormal scar tissue. (5,20,53,64)) Nutritional supplementation continues throughout this stage as well as chiropractic adjustive techniques. Ultrasound techniques may be used to increase the microcirculation, break up deeper adhesions and/or trigger points and muscle spasms that are becoming chronic, promote increased oxygen uptake, and increase the plasticity of collagen. (42,67) Patients will generally have their first re-evaluation in this stage of care to ensure that they are ready for active rehabilitation.
Physical rehabilitation phase-emphasis in this stage is to continue with reduction of pain, actively stimulate joint mechanoreceptors, Golgi tendon organ and muscle spindle cells to increase proprioceptive information as well as focusing on building strength, stability, and increasing active functional ranges of motion. (31) Substantial evidence exists confirming that ligaments serve important roles as signal sources for the reflex systems of the locomotor apparatus, (63) therefore effort should be made to normalize and mimic normal function after trauma. The introduction of significant amounts of proprioceptive training in the rehabilitation process is paramount, and aids in the reorganization of the tissue. (65) Reorganization of collagenous scar tissue is important. It creates increased tensile strength as well as promoting the break down of the abnormal cross bridges, aligning the scar along the physiological action of the muscle, tendon or ligamentous complex. (27,41,45,55,57) Healing times for intra-articular collagen are such that it may take up to 3 months to achieve 50 percent of the normal strength and 6 months before a functional strength of 70 percent is reached. (15,69) Essentially, collagen forms 70 percent of the dry weight of the ligament, turning over slowly with a half-life of 300 to 500 days. (24) Maximum functional improvements may take over 2 years for resolution.
Chiropractic adjustive techniques remain the cornerstone of the program to ensure that the zygapophyseal joint biomechanics are proper as facets continue to articulate correctly and send mechanoreceptive information to higher brain centers, and to reduce the neoneuralization of scar tissue. Neoneuralization increases pain transmission to the brain via nociceptive input from the synaptic arborization of c-afferent fibers. The goal is to limit and inhibit this process so that neurological wind-up does not occur and lead to chronic pain and residual disability. Stretching/AROM, resistance training incorporating bands and weights, physioball training, dynamic spinal traction and postural exercises are utilized for maximum benefit.
Dynamic spinal traction for structural remodeling and rehabilitation is utilized to maximize the physiological anisotrophic effects of creep, hysteresis, and set that occur in viscoelastic tissues such as ligaments. (64) The ligamentous complex is the limiting factor in effective rehabilitation. (36,53) Only sustained incremental loading of the ligamentous tissues with low force of long duration, in a consistently applied manner, will have the desired structural viscoelastic effect of plastic changes. (31,59,60) Chiropractic Biophysics traction protocols are substantially researched and documented. There are over 80 clinical papers in the index medicus, and are too bulky to be listed in this document. (**) Cryotherapy is utilized in traction and post-traction due to research indicating that tissues stretched under heating conditions and then allowed to cool under tensile conditions maintain a greater proportion of their plastic deformation than do structures allowed to cool in the unloaded state. Cooling under load may allow the collagenous microstructure to stabilize at new stretched lengths. (36,60)
**Our office protocols have been established to facilitate application of the above techniques, nutrition/ supplementation and information; therefore maximizing injury repair, pain suppression, and patient recovery. Specific treatment differences will exist from patient to patient in relation to their individual injuries, severity of injuries, as well as tolerance to rehabilitation.**
J. Shawn Leatherman, BA, BS, DC, CCST, CCSP?
Director of Clinical Rehabilitation
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** Pubmed/Medline桽earch: Chiropractic Biophysics, Harrison, Calliet, Haas, Ferrantelli, Calloca, Keller, & Meyer.
