Spondylolisthesis

Spondylolisthesis is a spinal condition that in the sports world most commonly affects cricketers and gymnasts, but in reality, can affect anyone! Pronounced ‘spon-di-lo-lice-thee-sis’, it most commonly affects the lowest segments of the lower spine region.

What is spondylolisthesis?

Spondylolisthesis is the slipping forward of one vertebra on another. This most commonly occurs at the L5 segment (the lowest vertebrae in the lumbar spine), which slips forward on the S1 segment of the sacral bone. The runner up? L4, which is also a commonly affected area.

There are a few different causes of this condition, and so it has been classified into different types. There are five categories of spondylolisthesis. These are:

  1. Degenerative: Occurs due to degenerative changes to the spinal facet joints and discs
  2. Isthmic: Occurs due to a bone defect in a part of the vertebrae known as the ‘pars interarticularis’
  3. Traumatic: Occurs following a trauma that results in a fracture of either the spinal facet joints or pars interarticularis.
  4. Dysplastic: Occurs due to a developmental defect of the vertebrae which alters the direction of the spinal facet joints, leaving the segment(s) open to slippage in the area where they are partially held in place by the facet joints.
  5. Pathologic: Occurs secondary to a medical problem such as infection or cancer.

In theory, any process that leads to the weakening of the supportive structures of the spinal segments (i.e. the bones, ligaments, discs, muscles) can lead to abnormal movement of the spine.

 

Grades of spondylolisthesis

Spondylolisthesis is further classified based on the amount of slippage that has occurred:

  • Grade 1: Between 0-25% of the vertebral body has slipped forward on the vertebrae below
  • Grade 2: Between 25-50% has slipped forward
  • Grade 3: Between 50-75% has slipped forward
  • Grade 4: Over 75% of the vertebral body has slipped forward

The most commonly reported grade of this condition is grade one, accounting for approximately 75% of all cases.

 

Signs and symptoms

These vary depending on the cause, but can include any or all of the following:

  • Low back pain, including pain in the buttocks
  • Pain along the back of the thigh which rarely goes lower than the knee
  • Tight hamstring muscles
  • Changes in walking pattern
  • Pins and needles and/or numbness down the legs
  • Bowel and bladder dysfunction (in more severe cases)

If you come to us with low back and/or leg pain, we are trained to work out exactly what is going on based on your symptoms and medical history. We will ask you lots of questions to begin with to dwindle our list of potential diagnoses to just one or two. Then we’ll get you to move and through a thorough movement assessment, will be able to come to a specific diagnosis that we will work with you to treat.

Sometimes we may require the help of imaging to rule in or out spondylolisthesis, depending on the severity of symptoms and how much it is impacting your life. In these cases, we will send you off for an x-ray which can detect this issue.

 

Treatment

Most cases of spondylolisthesis can be managed conservatively, meaning non-surgical options are chosen over a surgical one. When this injury occurs, the instability of the particular spinal segment can lead to many of the signs and symptoms mentioned above. One of the main goals of treatment is to increase stability around the affected area and offload the forces that are acting on the injured area.

We will spend time educating you on the mechanics of the spine. If you understand what is happening to your spine, you will know how to protect it, without adding unnecessary stress to the area. We will also advise on appropriate footwear, as well as standing, seated and sleeping postures. Being obese or overweight is also a risk factor for developing, as well as maintaining this problem. If you need to lose weight, we can help you formulate a plan to get there.

Exercise to increase core stability, as well as flexibility of tight muscles is a very important part of therapy as this will reduce the need for external supports such as braces in the long term. And of course, not forgetting our wonderful hands which will get to work on your muscles and joints to reduce tension and tightness, while increasing range of motion. Our osteopaths can help you manage your spondylolisthesis.

All of the above treatments will help you to manage pain, increase function and get you back to work or sport or gardening… Whatever your goal is! Call us today on (416) 546-4887 or book online at beachealth.janeapp.com if you have low back pain, or even if you already have a diagnosis of spondylolisthesis, and we can help you formulate a recovery plan to get you on the road to better health.

 

References

  1. Chila, AG. et al. 2011. Foundations of Osteopathic Medicine. 3rd ed. Lippincott, Williams & Wilkins: Philadelphia
  2. Tenny, S. and Gillis, C. 2020. Spondylolisthesis. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430767/

Dorsal Scapular Nerve Entrapment

Has one of your shoulders been feeling a bit off lately? Is the neck and mid-back region around the shoulder blade feeling stiff and heavy? If this sounds like you, then you may have a problem with a nerve known as the Dorsal Scapular Nerve (DSN). This is a previously under-diagnosed cause of neck, mid-back and shoulder pain and dysfunction. With advances in technology and the development of knowledge and skills of treating practitioners, it has become apparent that this problem is much more common than originally thought.

Relevant anatomy

The neck is made up of a stack of seven bones known as vertebrae. These are numbered C1-7, where ‘C’ stands for cervical (i.e. the neck region of the spine). The vertebrae are numbered from top (near the skull) to bottom (where the neck meets the back). Between the vertebrae are little holes where nerves run through on their way to provide electrical signals to our muscles and other body parts. Between the 4th and 5th vertebrae, the C5 nerve root lives. The DSN is a little off-shoot of the C5 nerve root which runs from the neck to the back of the shoulder and mid-back.

 

The DSN provides electrical stimulation to three muscles in the neck/shoulder region, all of which attach to the shoulder blade (or ‘scapula’) at one end, and the spine at the other. On its way to these muscles, the nerve pierces through another muscle in the neck (one of the three scalene muscles if you’re really interested!).

 

Muscle function

Two of the three muscles that the DSN supplies help to move the shoulder blade inwards from its resting position, towards the spine. These are the Rhomboid Major and Rhomboid Minor muscles. The other muscle, the Levator Scapulae, as its name suggests, helps to elevate or lift the shoulder blade. The proper functioning of these muscles is important for us to be able to move our shoulder through its full range of motion. Injury or entrapment of the nerve can lead to poor muscle function and subsequently, poor shoulder movement.

 

Signs and symptoms

As previously mentioned, the nerve pierces through one of the neck muscles on its way to innervating the other three muscles. This creates a potential point of entrapment of the nerve and this can lead to signs and symptoms commonly experienced with DSN injury. People with DSN injury may present to the clinic with any or all of the following signs and symptoms:

 

  • Abnormal and/or reduced shoulder movement
  • Pain around the lower neck, upper/mid back and shoulder region
  • Winging of the shoulder blade (i.e. tilting of the blade away from the rib cage)
  • Difficulty with drawing shoulders backwards and together
  • Difficulty with raising the arm upwards to full range
  • Altered resting position of the shoulder blade on the injured side. Due to poor functioning of the rhomboid muscles, the shoulder blade may sit away from the spine compared to the non-injured side.
  • Weakness of the affected shoulder muscles
  • Stiffness in the neck / spine

 

Who does it affect?

DSN injuries are common throughout the general population. People whose occupation puts their posture in a compromising position every day and leaves them open to issues around the neck joints and muscles are particularly susceptible to this issue. It has also been seen in people who lift weights and after car accidents.

 

Treatment

Great news! We can help you get over this issue. Once we’ve been through our assessment and are happy with our diagnosis, we can get to work on you. Yes, this is a problem which primarily affects muscles that drive shoulder movement, but the root of the problem is usually down to poor function of the joints and muscles around the lower neck and upper back. Don’t be surprised if we direct quite a bit of our treatment at the spine. We will provide tight neck muscles with a soothing massage. Stiff neck and back joints will be mobilized and may be manipulated if we feel it is required.

As with most injuries, there is an exercise element to recovery. Poor movement patterns in the spine and shoulder have to be corrected and re-trained over a period of weeks to months. This is to ensure we get to the root cause of the problem and don’t just bandage over the top of it. Strength and stability exercises of the trunk and shoulder will be on your to-do list.

As previously mentioned, your occupation may be driving a lot of these issues. We may suggest changes to your work (i.e. a desk set-up assessment) and other aspects of your lifestyle to ensure you’re hitting this issue from all angles. That way we have more chance that the problem will be resolved permanently.

First and foremost, if you think you have a problem, please get in touch today on (416) 546-4887 or email to daniel@beachealth.com so we can start your journey to recovery.

 

References
1. Snell, RS. 2012. Clinical Anatomy by Regions. 9th ed. Philadelphia: Lippincott, Williams & Wilkins
2. Muir, B. 2017. Dorsal scapular nerve neuropathy: a narrative review of the literature. The Journal of the Canadian Chiropractic Association. 61 (2). 128-144. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5596970/

Winging of the shoulder blades

Do you have, or have you ever seen someone whose shoulder blades stick out on their back and look a little bit like wings? This condition is aptly named ‘winging’ of the shoulder blades.

SCAPULA bone anatomy x-ray scan

Anatomy

Osteopaths love a bit of anatomy! The shoulder blade or ‘scapula’ is a largely flat bone that sits on the back of the rib cage and is an important ingredient in what makes up the various joints of the shoulder. As well as the larger flat part, a few extra lumps and bumps makes for a very odd shaped bone when looked at in isolation. One of the bony protrusions actually makes up the ‘socket’ part of the ball and socket joint in the shoulder. The ‘ball’ part being made from the head of the upper arm bone (aka the ‘humerus’).

Interesting fact… There are 18 muscle attachments on the shoulder blade. It is through fine balancing of these muscles which keeps the shoulder blade stabilized and flush to the back of rib cage and allows us to move our shoulders through an extremely large range of motion. As you can imagine, keeping all of these muscles in full working order takes a bit of co-ordination and with so many players involved, there is room for dysfunction to creep in and movement to become affected. Sometimes the dysfunction is great enough to cause the shoulder blade to flip outwards from the rib cage, and this is what we refer to as ‘winging’.

 

Causes of winging

The causes of shoulder blade winging can be broadly broken down into:

  • Muscular: As we previously mentioned, lots of muscles are responsible for controlling the position and movement of the shoulder blade. Injury to these muscles, or an imbalance in the strength, length and function of the muscles over a prolonged period may lead to this issue. The main muscles involved here are the Serratus Anterior (a muscle which attaches to the ribs and the underside of the shoulder blade), and the Trapezius (a kite shaped muscle which covers the back of the neck, shoulders and upper back… Aka ‘traps’). It’s more complex and there are more muscles involved, but these are the key players when it comes to winging.
  • Neurological: Muscles require a nerve supply in order to move, so if any of the nerves that supply the key players (i.e. Serratus and Traps) are injured, this can stop the muscles from being able to perform their job. Nerves can be injured through entrapment, where something presses on a nerve as it travels from the spine down to the muscle it supplies. Other causes may be from acute traumas as seen with car or sporting accidents where the shoulder takes a direct blow while the arm or neck are suddenly pulled.

Other ways these injuries may come about include prolonged wearing of a heavy backpack, complications following surgery, or as a result of a viral infection that affects the nerve.

 

Signs and Symptoms

The main sign is a shoulder blade that doesn’t sit snug to the rib cage, particularly when trying to move the arm upwards in front of the body or out to the side. Many people with scapula winging feel no pain whatsoever, but this can be a very painful condition if the cause is from a severe nerve injury. Another key sign is the inability of a person to lift their arm above their head.

 

Treatment

The treatment of shoulder blade winging very much depends on the cause. If the shoulder blades are winging because of a muscular imbalance, these are a little easier and faster to rehab. After careful assessment of your shoulder, neck and other spinal movements, we will aim to restore full functioning of the muscles that control the position and movement of the shoulder blades. This might include techniques which aim to lengthen short or tight muscles which are pulling the shoulder blade out of position. If there is a weakness to a particular muscle or group of muscles, we will also prescribe you strengthening and movement re-training exercises which aim to return the shoulder blade to its functional position.

Winging caused from nerve entrapment or injury is notoriously harder to treat. If entrapment of the nerve is caused by muscular tension in another part of the body, or because you’ve been carrying a heavy backpack for too long, then we will work on the relevant muscles and nerves to release the entrapment and pressure. We might also need to adjust how you wear your backpack and how much weight is inside while we focus on improving your physical impairments. Nerve-related injuries can take much longer to resolve. Winging caused by paralysis of the nerve which supplies the Serratus Anterior muscle has been known to take up to two years to resolve. The good news is, most people will make a full recovery in this time with surgical procedures saved only for more complex or unresolved cases. Which if you ask any Osteo, is always the goal!

If you notice winging of the shoulder blades, or difficulty with achieving full shoulder range of motion, then get in touch today on 416-546-4887. We would love to chat to you about your issue in a phone or video consult and get you on the road to recovery as soon as possible.

 

References

  1. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw Hill Education
  2. Snell, R. 2012. Clinical Anatomy by Regions. 9th ed. USA: Lippincott Williams & Wilkins
  3. Magee, D. 2008. Orthopaedic Physical Assessment. 5th ed. USA: Saunders Elsevier

Numbness Or Tingling In Your Arms And Legs, What Does It Mean?

Numbness and tingling are abnormal sensations that can occur anywhere in your body however, numbness and tingling in the arms and legs are the most common association and complaint.

Sensations related to numbness and tingling in the arms and legs are often caused by an interruption in proper nerve flow. Activities like sitting or standing in one position for a long period of time can cause a temporary pinch on the nerve thereby interrupting its conduction. Continuous pressure on a nerve can cause lasting damage to the layers of the nerve known as myelin sheaths.

Causes of Numbness of Tingling

There are many common causes of numbness and tingling in arms and legs. Some common causes include:

  • Disc Herniation’s
  • Carpal Tunnel
  • Diabetes
  • Multiple Sclerosis
  • Stroke
  • Transient Ischemic Attack
  • Raynaud ’s phenomenon
  • Vitamin B12 Deficiency

How Your Osteopath Can Relieve Numbness and Tingling in Arms and Legs

In the case of prolonged numbness and tingling in arms and legs, early detection and proper diagnosis by an Osteopath, is of the utmost importance. Most causes of numbness and tingling are not serious and we can resolve quickly.  By examining your spine & joints, lifestyle, daily activities, diet and exercise we are able to not only identify the symptoms causing your arm and leg discomfort, but also the causes. This integrated approach helps determine the best and quickest treatment protocol for your arm and leg discomfort.

Treatment may include activity modification, anti-inflammatory medications and joint mobilizations’. The Osteopath will be able to provide you with a series of stretching and strengthening exercises designed to return you back to participation and to reduce the chances of the injury re-occurring.

Joint mobilisations can help restore alignment, improve mobility, and relieve arm and leg pain, swelling and stiffness. Osteopathy may apply a variety of therapeutic modalities in conjunction with the adjustments which may include but not be limited to dry needling, massage, traction, stretching and strengthening exercises.

Make an Osteopathic appointment with Beachealth today and relieve yourself from numbness and tingling in the arms and legs.

Carpel Tunnel Syndrome

The carpal tunnel is a narrow passageway in the wrist, which opens into the hand. It is enclosed by the bones of the wrist (underneath) and the transverse carpal ligament (across the top).

Many structures pass through the carpal tunnel, including:

The carpal tunnel and its contents

The median nerve, which gives feeling to the thumb, forefinger, middle finger and half of the ring finger. The muscles of the thumb are also innervated by the median nerve. A person with advanced carpal tunnel syndrome may find weakness in thumb movements and difficulty grasping objects.

Many tendons also pass through the carpal tunnel – the long flexor tendons from the forearm run through the carpal tunnel into the hand. These tendons are covered by a smooth membrane called the tenosynovium and allow hand movement.

Signs and symptoms

The symptoms of carpal tunnel syndrome include:

  • Numbness
  • Pins and needles
  • Pain, particularly at night
  • Darting pains from the wrist
  • Radiated or referred pain into the arm and shoulder
  • Weakness of the hand
  • The little finger and half of the ring finger are unaffected.

Causes/Risk factors

Any risk factor that causes a reduction in the amount of space inside the carpal tunnel can cause carpal tunnel syndrome. If left unchecked, the median nerve is squashed against the transverse carpal ligament until the nerve cannot function properly. Numbness and pain are the result. It can affect one or both hands. Many factors can increase your risk of developing carpal tunnel syndrome.  These include:

 

  • Anatomic factors: A wrist fracture or dislocation that alters the space within the carpal tunnel can create pressure on the median nerve.  Carpal tunnel syndrome is generally more common in women. This may be because the carpal tunnel area is relatively smaller than in men and there’s less room for error. Women who have carpal tunnel syndrome may also have smaller carpal tunnels than women who don’t have the condition.
  • Nerve-damaging conditions: Some chronic illnesses, such as diabetes and alcoholism, increase your risk of nerve damage, including damage to your median nerve.
  • Inflammatory conditions: Illnesses that are characterized by inflammation, such as rheumatoid arthritis or an infection, can affect the tendons in your wrist, exerting pressure on your median nerve.
  • Alterations in the balance of body fluids: Certain conditions — such as pregnancy, menopause, obesity, thyroid disorders and kidney failure, among others — can affect the level of fluids in your body. Fluid retention may increase the pressure within your carpal tunnel, irritating the median nerve. Carpal tunnel syndrome associated with pregnancy generally resolves on its own after the pregnancy is over.
  • Workplace factors: It’s possible that working with vibrating tools or on an assembly line that requires prolonged or repetitive flexing of the wrist may create harmful pressure on the median nerve, or worsen existing nerve damage. There is little evidence to support extensive computer use as a risk factor for carpal tunnel syndrome, although it may cause a different form of hand pain.

 

Diagnosis

Early diagnosis and treatment are important to avoid permanent damage to the median nerve. An Osteopath will perform a physical examination of the hands, arms, shoulders, and neck which can help determine if your complaints are related to daily activities or to an underlying disorder, and can rule out other painful conditions that mimic carpal tunnel syndrome. The wrist is examined for tenderness, swelling, warmth, and discoloration. Each finger is tested for sensation, and the muscles at the base of the hand are examined for strength and signs of muscle wasting.

Occasionally it is necessary to confirm the diagnosis by use of electrodiagnostic tests:

  • Nerve conduction study: electrodes are placed on the hand and wrist to measure the speed with which nerves transmit impulses.
  • Electromyography: electrical activity can be viewed on a screen to determine the severity of damage to the median nerve.
  • Ultrasound imaging: may show impaired movement of the median nerve.

 

Conservative Treatment

Initial treatment of carpal tunnel syndrome generally involved resting the affected hand and wrist for at least two weeks – avoiding all activities that might aggravate the symptoms.  If there is inflammation, applying a cool pack can help to reduce swelling.

Osteopathic management consists of ensuring optimal hand, wrist, elbow, shoulder and neck biomechanics with techniques such as joint articulations, manipulations, and soft tissue therapies.  Identifying and removing the aggravating or underlying causative factor is important for a long term resolution.

Stretching and strengthening exercises are often helpful once the severity of the initial symptoms have reduced. Yoga has also been shown to reduce pain and improve grip strength among some patients with carpal tunnel syndrome.

 

Medication: Nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, and other on-prescription pain relievers, may ease symptoms that have been present for a short time or have been caused by strenuous activity. Orally administered diuretics may help to decrease swelling. Corticosteroids* can be injected directly into the wrist or taken by mouth to relieve pressure on the median nerve and provide immediate, temporary relief to persons with mild or intermittent symptoms. Additionally, some studies show that vitamin B6 (pyridoxine) supplements may ease the symptoms of carpal tunnel syndrome.

*Corticosterioids should not be taken without a doctor’s prescription.

 

Surgical Treatment

Occasionally carpal tunnel symptoms do not resolve with conservative treatment alone. Carpal tunnel release is one of the most common surgical procedures and is generally considered if symptoms last for 6 months. Surgery involves severing the band of tissue across the wrist (transverse carpal ligament) to reduce pressure on the median nerve.

Although symptoms may be relieved immediately after surgery, full recovery from carpal tunnel surgery can take months. Some patients may have infection, nerve damage, stiffness, and pain at the scar. Occasionally the wrist loses strength because the carpal ligament is cut. After surgery, an Osteopath will assist to restore wrist strength and mobility.

Recurrence of carpal tunnel syndrome following treatment is rare. The majority of patients recover completely.

 

If you are suffering from any type of hand or wrist pain, contact us for an appointment.