Part I of a Three-Part Series on Handling Sports Injuries, Soft Tissue Injuries, and Severe Degeneration. Over the past 25 years. I have seen just about every soft tissue injury imaginable. In fact. I have had most of those injuries, myself; between playing sports and weight training. I say, "had,'" because I really have no pain, or injured joints in my body. At 53, I am more physically fit than ever before. I have realized one thing over the years: Regardless of who you are. you are going to experience a soft tissue injury, sometime! It's just a part of life. Although exercise may help an injury, it can also cause the very same injury, if done incorrectly. So. it will happen: and. when it does, you need to be ready for it. If you are not ready, that joint or body part will make your life a living hell, and the pain and continued degeneration will dramatically impact all aspects of your life. It will consume the majority of your life, the longer you live. I want to spend the majority of this article, and the next two, explaining the necessity of a multi-disciplinary approach when treating soft tissue injuries, especially the chronic degenerative ones. Doctors. I'm not just talking about athletes, but about the patients you see in your offices daily. I'm also talking about the patients you see in your offices daily. They all suffer from some type of soft tissue injury, as well as being subluxated. In tact, why do you think their subluxations persist? Because nobody ever handled the underlying soft tissue injury correctly. Please remember this: "The nervous system controls function, but the mus-culoskelelal system supports the nervous system, allowing it to function". When addressing a sub-luxation, it would behoove you to address the soft tissue element, as well. This all starts with the consultation. The Consultation (Please note that I have listed the procedural codes, along with my fees, which may vary from state to state, so please use these as guidelines only. Procedural codes 99241 focused 15 mins, $125 When consulting with a patient, you must spend time explaining soft tissue injuries to that patient. I use visual aids that show and explain the crippling effects of soft tissue damage. Patients must learn that this type of an injury is worse than a broken bone. It is interesting to note that most people (attorneys, insurance companies) consider soft tissue injuries nuisance claims. If they truly understood what will happen to a patient as a result of soft tissue injury, then maybe—just, maybe—they would get the picture. One of the major concerns with any soft tissue injury is the dramatic loss of strength and flexibility that occurs. Within weeks, injured soft tissue undergoes cellular degeneration, reducing strength by 5()<7r. flexibility by 30-40%, and resulting in excitation of pain from the production of fibrotic tissue. As time continues, this degenerative process exacerbates, causing the condition to worsen. Over time, the joint becomes arthritic, degenerates due to the loss of soft tissue integrity, and one leads a miserable existence. Treating a soft tissue injury, also. requires sacrifice on the pan of the patient, and involves a process. They might be required to lose weight, change their diets, alter their lifestyles, etc. Please, make sure that your patients thoroughly understand this, because, if they do not look at this as a "priority" in their lives, they are never going to get well. Some patients may not be willing to make the sacrifice, whether it be financial, time, or just plain commitment. Let them know that your treatment will give them pain relief, but the condition will return, and with a vengeance! When it does come back, make sure they feel welcome enough to come back. You'll be surprised that many patients will return and follow up on your recommended program. It may take the patient five years to realize what you said five years earlier, but they will remember that you said it and will return to your office. Other patients never learn, have surgeries, take pain medications, and live miserable existences. You cannot save everyone, so do not waste your precious time trying. Just make sure the patients know that it will take time, and will require certain sacrifices on their part. Once they understand, they will be more apt to follow through with your recommendations. Treatment Protocol Phase 1 (1^1 Days; Daily Treatment) The first phase of care for an acute, or acute-on-a-chronic injury would be the typical kind of care using the R.I.C.E. principal. R stands for Rest: I stand's for Ice: C stands for Compression: and E stands for Elevation. Above and beyond the R.I.C.E. principal. I would use some light neuro-muscular reeducation and pulse/continuous ultrasound. Phase 2 (2 YVeeks-3 Months; 3 Visits per Week) The only (.inference between the treatment of an acute or acute-on-a-chronic condition, during phase two. is lime. Acute conditions respond faster than chronic conditions, and usually require much less time. During this phase of care, I use a combination of: Spinal or extremity manipula tion: Procedural code spinal manipulation. 98940-2. $55: procedural code extremity manipulation. 98943. $55. If spinal and extremity manipula tion are performed on the same date, use the -51 modifier with the extremity code: i'.i>.. 98943-51 Neuromuscular reeducation procedural code 97530 neuro muscular reeducation S55 or 97140 manual therapy 15 min. $55. or 97140 manual therapy 30 min $110 Heat or ice Ultrasound: Procedural code 97035.$30 Low volt muscle stimulation: Procedural code 97014. $30 The key to treating sports/soft tissue injuries is the neuromuscular reeducation and the manipulation. Let me preface what I mean, when I say nemo muscular reeducation. This is not massage, or acupressure. It is a hands-on procedure that will use many of the techniques listed below to restore neurological integrity to that region, by breaking neuromuscular reflexes to that area. This technique requires: a through understanding of that joint or body part. how it functions. its nerve supply. origins/insertions/actions of the surrounding musculature, surrounding areas that may affect this particular injury (like a sacroiliac condition affecting a shoulder problem), ranges of motion. etc. The purpose and goal of neuromuscular reeducation is to find the injured soft tissue, treat it and return function back to that area. Through palpation of thai joint and surrounding musculature, determine which muscle groups are creating the problem, and check the spinal levels that feed these areas. For example, if someone were complaining of anterior shoulder pain. I would examine all the musculature surrounding the shoulder, including, but not limited to. the trapezius. deltoids, latisssimus dorsi. biceps/triceps, pec-toralis major/minor, and rhomboids. I would, then, palpate around the joint proper, looking for ligament sprains. I would palpate the shoulder, not only in a static position but. also, through its normal ranges of motion, noting range of motion loss. pain, and aberrant mobility. I would be looking for musculature that palpated stringy, nodulated, hard, spastic, painful, swollen, or puffy. Once these areas were located, I would perform any of the procedures listed below: Muscle Spindle Techniques: Muscle spindle techniques are techniques where you apply direct pressure to the belly of the muscle, causing inhibition/relaxation of the muscle spindle. The muscle spindle is a simple cord level reflex, which causes a contraction of the belly of the muscle when it is stretched suddenly and uncontrollably. as in a fall, accident or trauma. To break this neurologic cord level reflex, you hold direct pressure over a painful point on the belly of this muscle, while the patient breaths slowly, and deeply, thus breaking this neurologic cord level reflex. This causes the belly of the muscle to relax. You can use thumbs, fingers (tips and pads), knuckles, distal phalangeal joints, palms and elbows, holding deep pressure over the belly of any muscle for 5-8 respiratory cycles. Then repeat, if necessary. Pain and muscle contraction should be reduced, if the application is sue- cessful. It may. and usually does, take awhile (5-10 minutes) for the spasm and pain to decrease. Please note that this is a deep contact, so make sure that your "angle of drive" is right. The angle of drive is where you palpate muscle, tendons, ligaments, or bone from different angles, which you must challenge from different directions. Palpating any point from the wrong direction may not elicit a response. If this happens, then you missed the line of attack, and challenged it from the wrong line of drive, in this case, making a palpatory error. These anatomical points are '■three-dimensional structures", so our palpation, and challenge should also be "three-dimensional". Make sure that the patient is able to relax the area that you are contacting. Patients usually describe the feeling of the contact as. "It hurts good." Origin Insertion Techniques: Origin insertion techniques are those in which you apply pressure to the origin, or insertion of the muscle/tendon, which causes a relaxation of the golgi organ tendon reflex. This reflex is also a neurological cord level reflex that occurs when a muscle/tendon is trac-tioned/pulled or stretched. The tendon, in response to the sudden stretch via the cord level reflex, contracts, tight- ens. and nodulatcs the tendon ot a muscle at its origin or insertion. This reflex is usually associated with a muscle spindle reflex, since it's that part of the reflex that protects the tendon from ripping away from the bone during a muscle spindle contraction This contact inhibits the neurological cord reflex, and relaxes the tendon portion of the origin or insertion. Your contact points are at the origin, or insertion, or both at the same time, applying deep pressure as the patient is breathing deeply (6-8 seconds inhalation. 8-10 exhalation) to the patient's absolute tolerance, and locus. I often communicate continuously with the patient, and learn what the patient's tolerance is to pain. But. using deep breathing techniques, and explaining, and coaching the patient to relax the painful area is a must. If this is not done, you may not have a happy camper on your side. Also, explain what you are doing. Nothing relaxes a patient faster than a doctor who knows what she or he is doing. Using the SlOO-words impresses the patient, even if they cannot totally grasp what you are saying. They know "you do", and that's all that matters, anyway. Going with the Grain Fascia) Release Techniques, and Cross Friction Procedures Going with the grain procedures (fascial release) means that your contact strips the muscle fiber down (milking it. if you will, from the insertion to its origin or vise versa). This procedure, also, stretches the fascia which surrounds and encases the muscle, allowing it to move independently of the muscle fiber, rather than adhering to the muscle fiber, affecting contraction and relaxation of that muscle. Cross friction procedures mean that you work the muscle perpendicularly, or at an angle to the length of a muscle fiber/bundle. This also frees and affects the fascia. Using deep breathing contacts are a must. Any-hand or elbow contact works just fine. Ligament Correction: Ligament problems are treated a little differently. Most ligaments of major joints can be palpated through muscle, or by getting the muscles to relax, or by moving the joint through its ranges of motion, as well as by going between the muscle fibers with your fingers. When a traumatized ligament is encountered, hold mild-to-moderate pressure on that point, as the patient breathes deeply for 5-8 respirations. Where applicable, the bones that make up the joint can be put through ranges of motion, lightly tractioned. or jiggled back into place (such as the bones of the ankle and wrist), or moved (like the elbow, and shoulder). Spinal/L\tremitv Manipulation: Spinal or extremity manipulation should also be performed to rearticu-late that joint, thus taking the ligamen-tous duress off that articulation. If this isn't done, correction will not take place. So, spinal or joint manipulation is a must in correcting soft tis- sue/ligamentous conditions. Muscle Joint Challenging Procedures: Muscle Joint Challenging Procedures put the joint through each range-of-motion. testing the various muscles, as well as the ligaments surrounding the joint. This is the acid test tor joint, and muscle functional ability. Most doctors miss this important step, and usually give up on treating the patient. For example, the hip. and pelvic joint are challenged from a side posture position. The patient would be asked, possibly, to turn on his right side, with the left leg flexed, and right leg straight, as in the side posture position for a lumbar manipulation. The cervical spine, upper/mid thoracic spine, and shoulder girdle with surrounding musculature, can be challenged in the seated position, or while having the patient rotate his head to the side, while supine. Through the use of the above procedures you will prepare the soft tissue injury for rehabilitation. In Part II of this series. I will explain tips and techniques using free weights, machines, cables, stretching, and repetitive stamina exercises to strengthen, increase flexibility, improve stamina. and reduce pain. In Part III. then. I will address the nutritional support that will be required to successfully treat the soft tissue injury. Dr. James Ciina has been teaching, and writing on this subject for 20 years. Dr. Ciina also teaches seminars and has created a software package for the doctors to help them assess their patients' needs. For more information, call toll free 1-877-627-2770 or fax 561-624-3871, or e-mail Dr. Ciina at [email protected]. o
