Mobility & Flexibility - Joint Movement

For individuals experiencing pelvis pain symptoms and associated problems, can integrating pelvic floor physical therapy exercises help with treatment and prevention?

Pelvic Floor Physical Therapy

• The pelvic floor muscles are located at the base of the pelvis and protect the pelvic organs like the vagina, cervix, uterus, bladder, urethra, and rectum. (U.S. Food and Drug Administration. 2019)
• They provide posture support, aid in orgasm function, facilitate sphincter function, and help pump lymphatic blood. (Dulcegleika Vilas Boas Sartori, et al., 2021) (Varuna Raizada, Ravinder K. Mittal. 2008)

When the muscles fail to function correctly, individuals can experience symptoms like:

1. Painful intercourse
2. Prolapse - when an organ or tissue drops or shifts out of place.
3. Urinary incontinence
4. Constipation problems
5. These conditions are common in pregnant individuals or older women.

These symptoms can be treated with pelvic floor physical therapy to alleviate discomfort. Pelvic floor physical therapy can help women and individuals with vaginas:

• Alleviate issues like painful sex, urinary leakage, and prolapse.
• In physical therapy, individuals work on breathing, relaxation, and lengthening and strengthening techniques to train their muscles to function optimally.

Causes of Pelvic Floor Issues

Pelvic floor dysfunction tends to happen with age, during pregnancy, or in combination with events like the postpartum period and menopause, which can lower hormone levels.

• Individuals who are pregnant are especially prone to pelvic floor issues but might not know they have a problem.
• The pregnancy weight of a uterus can pressure and strain the muscles.
• Vaginal childbirth can also stretch or weaken the muscles. (Ilaria Soave, et al., 2019)

Symptoms

Symptoms can include: (Columbia Surgery. 2022)

• Pain in the pelvis region
• Back pain
• Painful urination
• Constipation
• Urinary leakage or incontinence
• Stool leakage or incontinence
• Painful intercourse
• If left untreated, these symptoms can worsen over time.

Pelvic Floor Physical Therapy

An individual will meet with a specialist to discuss symptoms and undergo a physical examination that includes:

1. Pelvic floor exam.
2. Evaluation of posture, mobility, and core strength.
3. Once the initial exams and evaluation are complete, the practitioner will go over pelvic floor exercises and provide a treatment plan.
4. Recommended exercises vary based on symptoms but focus on relaxing, stretching, and/or strengthening muscles.

Muscle Relaxation

• To relax the muscles, a therapist may recommend breathing exercises.
• For pregnant individuals, this means timing breaths with contractions.
• For individuals experiencing constipation, breathing exercises can help the body relax and reduce strain.

Stretching Muscles

• Stretching can help relieve muscle tightness and stiffness.
• A therapist may help stretch the pelvic floor through various therapy modalities.
• This type of physical therapy can help loosen tight muscles or help gently reset dislocated organs back into place.

Strengthening Muscles

• After the pelvic floor is loose and relaxed, the focus typically switches to strengthening the muscles.
• Strength work may target abdominal muscles or the pelvic floor muscles themselves.

With time, commitment, and targeted treatment, individuals can use pelvic floor physical therapy to loosen tissues, strengthen muscles, and restore function.

Spinal Decompression In Depth

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from various disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research studies or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, don't hesitate to get in touch with Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

U.S. Food and Drug Administration. (2019). Pelvic organ prolapse (pop).

Sartori, D. V. B., Kawano, P. R., Yamamoto, H. A., Guerra, R., Pajolli, P. R., & Amaro, J. L. (2021). Pelvic floor muscle strength is correlated with sexual function. Investigative and clinical urology, 62(1), 79–84. https://doi.org/10.4111/icu.20190248

Raizada, V., & Mittal, R. K. (2008). Pelvic floor anatomy and applied physiology. Gastroenterology clinics of North America, 37(3), 493–vii. https://doi.org/10.1016/j.gtc.2008.06.003

Soave, I., Scarani, S., Mallozzi, M., Nobili, F., Marci, R., & Caserta, D. (2019). Pelvic floor muscle training for prevention and treatment of urinary incontinence during pregnancy and after childbirth and its effect on urinary system and supportive structures assessed by objective measurement techniques. Archives of gynecology and obstetrics, 299(3), 609–623. https://doi.org/10.1007/s00404-018-5036-6

Columbia Surgery. (2022). Pelvic floor disorders: frequently asked questions.

Flexibility is the ability of joint/s to move through an unrestricted range of motion. To maintain joint health, the cartilage and structures within the joint need a constant supply of blood, nutrients, and synovial fluid to move through a full range of motion. The range of motion is influenced by the mobility of the soft tissues that surround the joint. These soft tissues include muscles, ligaments, tendons, joint capsules, and skin. Factors affecting the loss of normal joint flexibility include injury, inactivity, or little to no stretching. Although flexibility varies for everybody, minimum ranges are necessary for maintaining total body health. Injury Medical Chiropractic and Functional Medicine Clinic can create a personalized stretching program to restore joint flexibility.

Joint Flexibility

Body Effects

• Not stretching the body can lead to fatigue, weakness, and soft tissue shortening.
• The effect can be particularly noticeable in weight-bearing joints like the hips and knees.
• If the joints become weak, the risk of injury increases.
• Inflexible muscles tire more quickly, causing opposing muscle groups to work harder.
• Muscle fatigue can lead to muscular injuries and the inability to protect the joints from more severe injuries.
• Decreased flexibility can also lead to added stress on structures and tissues in a different body area from the source of the inflexibility.
• An example is tendonitis in the knee can be related to calf tightness.

Stretching Routine Benefits

Research has shown that stretching can help improve flexibility and, as a result, the range of motion of the joints. Benefits include:

• Improved performance in physical activities.
• Improved ability with daily activities.
• Decreased risk of injuries.
• Increase circulation.
• Improved muscle function.

Testing

Flexibility can be measured with functional tests. These tests measure the joint's range within common movement patterns. Using these tests, areas of inflexibility can be identified and addressed. The tests look at the following:

• Neuromuscular coordination.
• How the muscles return to a normal resting state.
• Blood circulation and recirculation.
• Typical assessment areas include the lower back, hips, hamstrings, knees, and feet.

Stretching the Body

Developing a regular stretching routine to be incorporated into a training program is recommended. A stretching routine should cover all the major muscle groups of the body as well as any specific muscle groups. Implementing a physical therapy stretching program can help individuals stay motivated, as gaining flexibility takes time. It can take several weeks of consistent, regular stretching for improvement.

• Stretching with a physical therapist will target the largest areas of inflexibility.
• Stretching sessions can be 20 minutes or more.
• Once these areas have been addressed, the therapist will move on to more specific areas.
• The therapist will train the individual how to stretch at home.

The therapist will provide specific guidelines that should be followed for stretching at home:

• Stretching when muscles are cold could lead to a strain or pull.
• Warming up before stretching is recommended as it increases the blood flow and temperature of the muscles, ligaments, and tendons, improving the elasticity and functioning of the tissues.
• Begin each stretch slowly and gently.
• Maintain the stretch position for 30 seconds, and gradually increase to 1-2 minutes.
• Maintain a regular breathing pattern when stretching.
• Stay relaxed, and do not bounce.
• There should be pulling or tightness but not pain.
• Static stretching should gradually go through the full range of motion until the resistance is felt.
• Stretch to the point of tightness and then just beyond.
• Gradually release the stretch.
• Repeat daily.

A stretching therapy program keeps the body loose and effectively increases the mobility of all soft tissues.

Full Body Stretching

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please contact Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Behm DG. Does stretching affect performance? In: The Science and Physiology of Flexibility and Stretching. Kindle edition. Routledge; 2019.

Berg, K. Stretching fundamentals. In: Prescriptive Stretching. 2nd ed. Kindle edition. Human Kinetics; 2020.

Ghasemi, Cobra, et al. "The effect of soft tissue manipulation and rest on knee extensor muscles fatigue: Do torque parameters and induced perception following muscle fatigue have enough reliability?." Journal of family medicine and primary care vol. 9,2 950-956. 28 Feb. 2020, doi:10.4103/jfmpc.jfmpc_838_19

Gordon BT, et al., eds. Flexibility assessments and exercise programming for apparently healthy participants. In: ACSM's Resources for the Exercise Physiologist. 3rd ed. Kindle Edition. Wolters Kluwer; 2022.

Hui, Alexander Y et al. "A systems biology approach to synovial joint lubrication in health, injury, and disease." Wiley interdisciplinary reviews. Systems biology and medicine vol. 4,1 (2012): 15-37. doi:10.1002/wsbm.157

Lindstedt, Stan L. "Skeletal muscle tissue in movement and health: positives and negatives." The Journal of experimental biology vol. 219, Pt 2 (2016): 183-8. doi:10.1242/jeb.124297

A doctor, chiropractor, or physical therapist could recommend therapeutic stretches along with exercises as part of a sacroiliitis or sacroiliac joint pain treatment plan. Sacroiliitis refers to inflammation in one or both of the sacroiliac joints. This could be caused by:

• Pregnancy
• Injury
• Infection
• Arthritis
• Ankylosing spondylitis

Sacroiliac joint pain is a symptom related to sacroiliac joint dysfunction. The symptoms of sacroiliitis and sacroiliac joint pain can be felt in the lower back, buttocks, hips, and legs. These symptoms can be similar to sciatica and can mimic other lower back disorders.

Some of the stretches and exercises included are common for treatment plans for various low back conditions/problems. Talk with a chiropractor or doctor to get their recommendation prior to starting any exercise or stretching program.

Stretches

Piriformis stretch

The piriformis muscle extends over the hip and can aggravate the sacroiliac joint when it becomes tight. To help stretch the muscle:

• Lie on back with knees bent
• Feet flat on the floor
• Slowly raise the right leg
• Bring the right knee toward chest
• Gently pull the leg in until there is a comfortable stretch in the buttock
• Exhale during the stretch movement
• Hold the stretch for 30 seconds
• Lower leg
• Repeat on the left leg
• Repeat each side 3 times daily, as needed

The stretch helps the muscle fibers to lengthen/elongate and relax.

Trunk rotation

Trunk rotation increases flexibility in the low back and hips. This can help relieve pressure on the sacroiliac joints. To do this stretch:

• Lie on back with knees bent
• Feet flat on the floor
• With knees together
• Slowly rotate to one side
• Feet, hips, and back should stay on the floor
• Hold 3-5 seconds
• Move knees to the opposite side
• Repeat 5-10 times on each side

Bridge

This is a stretch that strengthens the muscles in the lower back, buttocks, and hips.

• Lie on back with arms at side
• Knees should be bent, and feet flat on the floor
• Slowly raise hips while squeezing buttocks and hamstrings
• Hold raised position for 5 seconds
• Repeat 10 times

Water Therapy and Yoga Exercises

Aquatics and yoga are a gentle and natural form of exercise that is recommended for staying active. Talk to a doctor before starting any exercise program. Aquatic therapy, known now as hydrotherapy/water therapy, is one of the gentlest forms of exercise and is highly effective.

Exercising in water creates an almost weightless environment without gravity. Hydrotherapy uses the resistance from the water to improve strength and flexibility without straining the muscles. Regular exercise can cause pain by placing added pressure on the sacroiliac joints. Water therapy conditions the spine and hip muscles without generating muscle stress. Another option for individuals with back pain is yoga. The following poses are recommended and beneficial for the sacroiliac joints:

Child’s pose

This pose stretches the hips and thighs and is a great yoga pose for beginners.

Cobra

Cobra pose can help strengthen and stabilize the sacroiliac joints.

• Lie flat on the stomach
• Hands beneath the shoulders
• Slowly push up as far as the arms extend
• Bring upper body off the ground
• Keep the pelvis and legs on the floor
• When extended, be sure low back and buttocks are relaxed
• Hold for 15 to 30 seconds
• Gently lower to the floor

Triangle pose

Triangle pose helps to strengthen the sacroiliac joints and makes them less susceptible to pain. However, this pose involves twisting, so make sure to do this pose only when the joints are stable and pain-free.

Before stretching and exercise

Before starting any stretching or exercise program, check with a doctor or chiropractor, if the joints are able then the stretching/exercise could begin right away. However, in most cases, a doctor will refer the patient to a physical therapist or chiropractor to create a customized exercise and stretching plan. The therapist will show exactly what activities will strengthen the joints and how to do them properly and safely. These movements can help condition the spinal and abdominal muscles. This can help prevent future episodes of back pain.

If an individual just had surgery for sacroiliac joint pain, the surgeon more than likely prescribed a customized rehabilitation stretching/exercise program. Follow instructions, and get the surgeon’s approval before engaging in anything outside of the plan.

Staying fit safely

When dealing with sacroiliac joint dysfunction or sacroiliitis, physical activity may need to be redefined after treatment. As regular exercise could mean strenuous activity and could do more damage. Exercises like heavy weightlifting, contact sports, and intense biking could place excessive pressure on the joints. A doctor or chiropractor will offer the best stretching and exercises for every individual.

Physical activity combined with gentle stretching and conditioning exercises can effectively reduce low back and hip pain. Talk to a doctor, chiropractor, or physical therapist about incorporating healthy exercise into a daily regimen. For some, the workout might not feel like there's anything going on, but the effects on the pain will be.

Labrum Tear Hip & Chiropractic Treatment

Dr. Alex Jimenez’s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*

Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*

Understanding The Upper Trapezius

Doctor of Chiropractic, Dr. Alex Jimenez explores the relevant anatomy and function of the UT, the role it has in musculoskeletal dysfunction and management ideas in the form of strengthening and loosening.

The upper trapezius (UT) is a major muscle that affects movement and stability of both the scapula and cervical spine. The coordination and interplay between the UT and other scapula muscles such as the lower and middle trapezius, serratus anterior, rhomboids, levator scapulae and pectoralis minor, have a large bearing on how the scapula moves and how stable it can become to allow proper gleno-humeral motion. With this in mind, dysfunction in the UT, either as weakness or hypertonicity, has been implicated in a host of shoulder pathologies and cervical spine syndromes.

Anatomy & Biomechanics

The gross anatomy and function of the UT is comprehensively discussed in a landmark study from the 1990’s(1). Johnson and Bogduk (1994) dissected the individual fascicular anatomy of the UT from the superior nuchal line near the occiput, all the way down to the C7 vertebrae, and also the thoracic portion of the
UT. What they found was that the UT was a multipennate muscle that had no osseous attachments between the occiput to the C7 spinous process. Instead the UT originated from the fascial structure known as the ‘ligamentum nuchae’.

The upper cervical fibres from C1 to C6 passed in a downward direction, and traversed to insert into the clavicle. Fibres from C7 and T1 passed horizontally to reach the acromion and spine of the scapula. Its thoracic fibres converged to the deltoid tubercle of the scapula (see Figure 1).

Figure 1: Anatomy of the upper trapezius

Note the thicker C7 and T1 fibres
The fascicle length of the UT fibres measured around 1cm from the occiput to C3, and from C3 to T12 the fibres were around 7-14cm. These fibres are primarily low-threshold type I fibres, suggesting that their role is not to produce power but instead act as a controller and stabiliser of the scapula.

The findings from the Johnson and Bogduk dissectionstudy paved the way for a different interpretation on the function of the UT in scapula movement. As only the upper fibres showed a vertical orientation, this suggested they may have only a slight role in scapula elevation. These fibres are relatively small compared to the lower fibres; volumetric studies have demonstrated that the fibres from C7, T1, and the lower half of ligamentum nuchae are the largest.

Johnson and Bodguk also found that the UT muscle has an angle and orientation, which are too small to be a significant elevator of the scapula when the arm is down by the side. They act primarily as an upward rotator of the scapula when co-ordinated with the lower and middle trapezius fibres.

They also work in a force couple along with serratus anterior to create upward rotation. Without the contribution from the lower trapezius and serratus anterior, the UT cannot create upward rotation in isolation. It needs to work in concert with the other upward rotators.

The mechanism of this force couple is via the action of the serratus anterior, which pulls the scapula into protraction. The lower trapezius contracts isometrically to fixate the middle medial border of the scapula so that the serratus anterior can then upwardly rotate the scapula.

UT then contributes towards upward rotation as the scapula has already begun upward rotation. The UT also elevates the scapula at the top of the shoulder flexion/abduction movement (see Figure 2).

Figure 2: Force couple of UT with middle/lower trapezius and serratus Anterior

Furthermore, the majority of the UT fibres attach onto the distal third of the clavicle, and due to their horizontal arrangement, they also rotate the clavicle medially – this rotation compresses and stabilises the sternoclavicular (SC) joint.

This SC joint compression allows load to be transferred away from the cervical spine and instead is directed towards the sternum and axial skeleton.

Johnson et al argue that the increased EMG activity of the UT does not occur to elevate the scapula but instead exists to draw the clavicle medially and upward at the same time to compress the SC joint(1). Therefore, the UT creates elevation by exerting an upward moment on the clavicle and increases the
compression loads at the sternoclavicular joint. This means that the cervical spine is not taking the load of the UT during shoulder elevation but the SC joint is.

The diagram below shows the angle of orientation of the fascicles, based on the work by Johnston and Boduk(1). A radiograph shows the direction of fibres. In this image the size and cross sectional area of the fibres are also shown based on the thickness of the lines. It can be seen that the fascicles of the lower half of the UT are much larger than the upper fibres.

The largest fibres are the transverse C6 and C7 fascicles.
In summary, the UT works synergistically with the other trapezius muscles (middle and lower) to produce a force couple on the scapula; therefore the UT has both a functional role in movement and stabilisation of the scapula. To highlight the individual and synergistic role of the trapezius muscle, the individual heads work in the following ways;

Figure 3: Orientation of fascicles(1)

UT draws the clavicle backwards, medially and upwards at the sternoclavicular joint. It helps to control the neutral positionof the scapula. It has some potential to produce movement to the cervical spine and contributes to the stability of the cervical spine.

Middle trapezius produces scapula retractionand upward rotation, as well as drawing the clavicle and scapula backwards and medially together with UT allowing scapula upward rotation. It controls or resists scapula protraction, and downward rotation.
Lower trapezius produces scapula upward rotation, external rotation, posterior tilt and depression. It controls or resists scapula elevation, abduction and downward rotation, as well as controlling the neutral position of the scapula.

Finally, the UT working with other cervical muscles can also laterally flex the cervical spine to the same side, rotate the cervical spine contralaterally and extend the cervical spine.

Dysfunction Of The Upper Trapezius

The UT has an important role to play in both scapula position and stability. This in turn will influence the gleno-humeral joint in positions of shoulder elevation, since scapula mobility has been linked with shoulder range of movement(2,3). During arm elevation, the scapula moves toward internal or external rotation, upward rotation, and posterior tilt. These actions are influenced by the upper/middle/lower trapezius and the serratus anterior as a force couple (mentioned above)(4). Lack of control of these muscles will break down the optimal scapula position and stabilisation/orientation of the shoulder joint. This scapula imbalance has been linked to shoulder pain(5). It must not be forgotten that other factors such as thoracic spine posture, capsule tightness in the shoulder and tightness in pectoralis major/ minor and latissimus dorsi may also influence scapula position(6,7).

Figure 4: Classic UT trigger points (from Travel and Simons(21))

Turgot et al (2016) studied the isometric strength of the three heads of the trapezius and linked it to electromagnetic assessment of scapula mechanics(8). They found that shoulders with stronger UT muscles showed greater upward scapular rotation at 30°, 60°, 90°, and 120° of elevation in the frontal plane. Shoulders with stronger middle trapezius had greater scapular upward rotation at 90° of elevation in the frontal plane. Shoulders with stronger lower trapezius showed greater scapular posterior tilt at 90° of elevation in the sagittal plane.
Numerous studies have identified an imbalance in activation between the UT and lower trapezius in patients with painful shoulders. Specifically, the imbalance identifies overactivity of the UT and underactivity in the lower trapezius(9-13). One study found that using a novel taping technique to inhibit the UT, reduced activation patterns of the UT in patients with shoulder pain(14). This aspect will be explained in detail later in the article.

Peat and Grahame investigated trapezius, serratus anterior and deltoid EMG in people with and without shoulder pathology(15). They found that in those with shoulder pathology, UT showed increased activity during arm elevation and lowering (between 40 to 100 degrees of arm elevation). Also, serratus anterior showed decreased activity at some humeral elevation angles (between 70 to 100 degrees) compared to healthy controls. This increase in UT activity has been found in numerous other studies on UT activation and shoulder pathology(9-13,15,16).

This finding may be associated with the increase in clavicular elevation or scapular elevation found in several clinical and kinematic studies(17).

The increased UT activation may be viewed as a common compensatory strategy used by people with shoulder pain and pathology to elevate their arm. However, the subsequent increase in clavicle elevation at the SC joint that may be produced by increased UT activity will result in scapular anterior tilt. This offsets the scapular posterior tilt produced at the AC joint by the lower trapezius, reducing the overall posterior tilt of the scapula on the thorax, which may be viewed as a potential mechanism to either cause or aggravate impingement symptoms.

Other authors have suggested that excess UT activity may attempt to compensate for a weak serratus anterior, and is believed to contribute to impingement through abnormal rotation
of the scapula(13). Evidence of increased UT activation combined with reduced SA activation (as well as evidence of increased superior translation of the scapula) has been demonstrated in persons with shoulder pain(13,15,18). Imbalances of force production of the serratus anterior and UT can result in a scapula elevation motion (or early shoulder shrugging).

This may cause excess superior translation of the scapula, with less efficient upward rotation and reduced posterior tilting. Clinical consequences of these alterations can include subacromial impingement, subacromial bursitis, and rotator cuff or biceps tendinitis, which can progress to rotator cuff tears. There may also be altered acromioclavicular joint forces and possible predisposition to degenerative changes(19).
In a study by Leong et al (2016) (20) it was shown that athletes with rotator cuff tendinopathy exhibited higher UT shear modulus during active arm holding than the asymptomatic athletes(20) (higher shear modulus suggests an increase in active and/or passive muscle tension measured on a specialised ultrasound). UT shear modulus was also higher in athletes with rotator cuff tendinopathy than in the asymptomatic athletes during the resting arm position at 0°of shoulder abduction.

The findings from such a study cannot however be used to determine whether the increased tension in UT is a result of rotator cuff tendinopathy or if it is a cause of the problem. It is clinically appreciated that athletes with painful rotator cuff may have a scapula at rest that appears downwardly rotated and anterior tilted, and often this is attributed to an overactive pectoralis minor. This position would place extra ‘stretch’ on the UT thus creating a situation whereby the UT had to counterbalance the drag effect of the scapula position.

Upper Trapezius Myofascial Trigger Points
 
Figure 5: UT shrug exercise (note the wide hand placement)

1. Wide Grip Shrug

In a study performed in Brazil, researchers attempted to correlate the anatomy of the trapezius and the accessory nerve entry points into the muscle with clinical locations of myofascial trigger points(21,22). What they found was that of the classic seven clinical points of myofascial trigger points, four correlated well to the actual anatomy of the accessory nerve and the trapezius muscle. These seven points with their characteristic referral patterns are shown in Figure 4.

Upper Trapezius, Neck Pain, Headaches & Nerve Pain
It was suggested in a study by Australian researchers that tightness in the UT is correlated to limited neural extensibility in the brachial plexus(23). Although it is difficult to prove causation, the suggestion is made that those with sensitised neural tissue may have reactive muscle tone in the UT. The weight of the arm at rest would provide a reasonable traction force to the brachial plexus, and the UT may react to protect the brachial plexus by increasing tone and lifting the scapula in order to reduce the traction effect on the nerves.
Figure 6: Single-arm overhead shrug start position (note angle of abduction)

2. Single-arm overhead shrug

What is also interesting are the morphological changes in the UT in the presence of neck pain and dysfunction.
The muscle fibre type changes from type I to type II, with fatty infiltration and higher percentage of grossly hypertrophied type I muscle mega-fibres, along with poor capillarisation(24-26). Finally, the famous ‘Janda’s Upper Crossed Syndrome’ has been implicated as a causative factor in cervicogenic headaches and patients; this condition is often present with tightness of the sternocleidomastoid, UT, levator, scalenes, suboccipitals, pectoralis minor, and pectoralis major(27-30).

Management Of Trapezius Dysfunction

*Strengthening

A group of Australian researchers investigated the use of a standard shoulder shrug (scapular elevation) at 0 degrees compared to a modified shrug performed with the arm elevated to 30 degrees (with the scapula in slight upward rotation). They found that the arm-elevated position elicited greater activation in the lower and upper trapezius. Therefore, traditional shrug exercises are not as effective as the 30-degree abduction position(31). Below are shown some exercises that may be used to retrain the UT in the presence of weakness and dysfunction.
Hold a barbell with the hand placed as far away as comfortably possible. This will place the arm in some abduction and the scapula in upward rotation. Slowly elevate the scapula towards the ear. Perform three sets of 20 slow repetitions with a hold. This is a great starter exercise for a patient with shoulder pathology because the arm is in relative neutral abduction.
Holding a dumbbell above the head and the body in a side sit position (this position opens up the shoulder and avoids impingement of the shoulder). Slowly elevate the scapula and rotate the dumbbell from internal to external rotation.
Perform three sets of 20 reps.

Hold two dumbbells overhead with the arm fully elevated (you need good shoulders for this). This is the same process as exercise 2 above but the exercise is performed bilaterally, and with more abduction of the shoulder.

3. Monkey Shrug

*Loosening

1. Upper trapezius stretch

The action of the UT is to upwardly rotate and retract the scapula; its role in elevation is questionable. The effect on the cervical spine is to laterally flex towards the same side, rotate away and finally to extend the cervical spine. Therefore, the best stretch position is one that encourages a combination of:

2. Upper trapezius trigger points

Scapula downward rotation, protraction, depression
Cervical contralateral flexion, flexion and ipsilateral rotation.
Above is an example of stretch to target the UT in a stretch and also ball placement for trigger point releases.

Hold the arm behind the back. This will create downward rotation of the scapula. Protract the scapula and depress the scapula actively. Pull the head to the opposite side and look over the same shoulder. Hold for ten seconds and repeat five times.

Place a ball (tennis, spikey, trigger ball) into any of the seven mentioned trigger points. Hold against the trigger for 30 seconds, move off and find another spot.

Conclusion

The UT is an important muscle of the scapula, which has a major role in scapulohumeral rhythm. Its key roles are scapula upward rotation, elevation and retraction. Its role as a scapula elevator is not as important. It is a muscle that may become either tight and hypertonic as a compensatory mechanism for other scapula imbalances, or it may become weak as it is dragged into a stretch position by poor scapula posture. Exercises have been presented that are designed to either strengthen the muscle or to release tightness and hypertonicity.
 
References
1. Clin Biomech (Bristol, Avon). ;9(1): 1994. 44-50
2. Am J Sports Med, 1998, 26: 325–337
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Joints are the musculoskeletal areas where two bones connect. The joints have soft tissues around them, like cartilage, tendons, and ligaments. Cartilage is the flexible tissue that covers the ends of the bones at a joint. The tendons are bands between the muscles and bones that connect everything to initiate joint movement. And the ligaments are a kind of bridge that connects the bones of the joints to keep the body stable when in motion. After an injury, the joints need to be worked out, stretched, and massaged to return to proper function and support. A chiropractic personalized rehabilitation program will include exercises that target joint stability.

Joint Injury Rehabilitation

The shoulders, elbows, wrists, knuckles, hips, knees, and ankles are joints. The spine is also made up of joints. The first step for achieving joint stability after a lower-body injury is to assess the joints for:

• Local strength
• Control
• Structural defects

A physician, chiropractor, or therapist will check the joint and test for weakness or deficits in soft tissues, tendons, ligaments, and cartilage.

• Individuals can have conditions, diseases, or injuries that affect the joints, causing dysfunction.
• Correcting deficits may require taping, bracing, exercises, or surgery.
• Joint stability is attained through specific exercises that target balance, proprioception, range of motion, flexibility, strength, and endurance.
• Individuals must participate in their rehabilitation program to fully recover from their injuries.

Proprioception and Neuromuscular Training 

Neuromuscular training and proprioception are essential to joint stability.

• Neuromuscular control is an unconscious response to joint motions without awareness.
• It is how workers or athletes adjust to uneven pavement or shift their weight to stay balanced on an incline or stairs.
• Proprioception is the ability to sense the body's orientation in the environment.
• It allows body movement and responds without consciously thinking about where the body is in space.
• The information signals detect joint position, limb movement, direction, and speed.
• A joint with a high level of neuromuscular control and a trained proprioceptive system can respond appropriately to various forces placed upon it during activity, decreasing the risk of injury.
• Proprioceptive exercises train joint proprioceptors to adapt before initiating a potentially damaging/injurious movement.

Targeted Training

• Specific to the individual's injury, specific exercises are incorporated to regain/relearn skill sets and reset automatic movement patterns.
• Skills training improves the ability to make adjustments quickly and decreases the potential for worsening or creating another injury.
• Research has found that individuals who participate in neuromuscular retraining have improved muscular activation and reaction to changes compared to those who do not incorporate retraining exercises.
• Trainers and therapists use neuromuscular exercises to prevent and rehabilitate ACL injuries.

Lower Extremities Rehabilitation Exercises Therapy

The following example of an exercise rehabilitation program can be used to rehabilitate the lower extremities. The exercises should be done slowly over several weeks. Therapeutic exercises should be combined with an appropriate and gradual range of motion and strengthening program. Individuals should always work with a chiropractor and physical therapist to develop the most suitable program for specific injuries and limitations.

One-Leg Balance

• Try to stand on one leg for 10 to 30 seconds.

One-Leg Balance with Eyes Closed

•  Stand on one leg for 10 to 30 seconds with your eyes closed.

Balance Board with Half-Squats

• Balance on a wobble board. 
• Perform ten slow, controlled half-squats.

Step-Ups

• Step up onto a balance board.
• Place a balance board, soft pillow, or foam pad 6 to 8 inches above the starting point.
• Step up ten times.

Step Downs

• Step down onto the balance board.
• Place a balance board, soft pillow, or foam pad 6 to 8 inches lower than the starting point.
• Step down ten times.

Single-Leg Hops

• Hop forward and focus on landing properly.

Single-Leg Spot Jumps

• Hop from one spot to another spot on the floor.

Transform Your Body

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from various disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, don't hesitate to get in touch with Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Akbar, Saddam, et al. "Effects of neuromuscular training on athletes' physical fitness in sports: A systematic review." Frontiers in physiology vol. 13 939042. 23 Sep. 2022, doi:10.3389/fphys.2022.939042

Borrelli, Joseph Jr et al. "Understanding Articular Cartilage Injury and Potential Treatments." Journal of orthopedic trauma vol. 33 Suppl 6 (2019): S6-S12. doi:10.1097/BOT.0000000000001472

Cote, Mark P, et al. "Rehabilitation of acromioclavicular joint separations: operative and nonoperative considerations." Clinics in sports medicine vol. 29,2 (2010): 213-28, vii. doi:10.1016/j.csm.2009.12.002

Jeong, Jiyoung, et al. "Core Strength Training Can Alter Neuromuscular and Biomechanical Risk Factors for Anterior Cruciate Ligament Injury." The American Journal of sports medicine vol. 49,1 (2021): 183-192. doi:10.1177/0363546520972990

Porschke, Felix, et al. "Return to work after acromioclavicular joint stabilization: a retrospective case-control study." Journal of orthopedic surgery and Research vol. 14,1 45. 12 Feb. 2019, doi:10.1186/s13018-019-1071-7

Vařeka, I, and R Vařeková. “Kontinuální pasivní pohyb v rehabilitaci kloubů po úrazech a operacích” [Continuous passive motion in joint rehabilitation after injury and surgery]. Acta Chirurgie orthopaedicae et traumatologiae Cechoslovaca vol. 82,3 (2015): 186-91.

Flexibility and range of motion are essential elements for an individual's overall health, physical fitness, and quality of life. Healthy flexibility helps the body:

• Maintain a physically active lifestyle.
• Maintain strength.
• Improve endurance.
• Prevent injury.

Flexibility and Range of Motion

Joint stiffness and pain can make it challenging to engage in everyday activities and maintain mobile, physical, emotional, and internal health. To keep the body flexible and moving, individuals need to use their entire body and range of movement. Becoming sedentary affects the body's flexibility, leading to slowed/blocked blood circulation, nerve energy signal disruption, and sickness. To improve flexibility and range of motion, it is recommended to include:

• Stretching the body
• Regular exercise and physical activity
• Yoga
• Healthy diet
• Healthy weight
• Proper sleep

For individuals with stiffened muscles and joints, chiropractic medicine can increase the body's flexibility, improving the range of motion in the joints. Chiropractic optimizes the function of the joints, improving mobility with less pain. When living with arthritis, chiropractic is an excellent therapy to decrease pain and activate the body's natural healing abilities. Chiropractic adjustments align the spine and improve nervous system function.

Nerve Pressure

Nerve pressure can cause pain or tingling sensations that can become difficult to manage. A shifted misaligned spine can compress nerve endings, causing pain that presents with or without movement. Getting the body in motion and moving around is essential to treat stiffness and joint pain. The objective of chiropractic is to align the spine and body and relieve pressure on the nerves helping the body gain back its flexibility and range of motion. Once the body is adjusted, the nerve endings are no longer irritated, relieving the pain. Chiropractic uses various techniques to deal with areas of compression, including stretching, percussive massage, low-laser therapy, ultrasound, and strengthening exercises.

• Chiropractic adjustments relieve pain and improve mobility.
• Strengthening exercises to keep the spine in proper alignment.
• Exercising keeps the adjustments in place.

A careful assessment of the condition will determine the cause of stiffness and joint immobility. Chiropractic can treat the joints, bones, and muscles to improve flexibility manage muscle spasms and soft tissue tenderness to alleviate symptoms restoring and improving range of motion. Chiropractic adjustments are combined with therapeutically designed stretches and exercises to perform at home, along with an anti-inflammation diet and supplements.

Body Composition

Zinc

Zinc is an essential nutrient that provides overall immune function. It is a powerful antioxidant that helps prevent and reduce oxidative stress and inflammation responses. Various bodily chemical reactions require Zinc. Zinc is necessary for muscle protein synthesis and hormone regulation. Zinc deficiency is common in older individuals and has been connected with degenerative diseases that include:

• Rheumatoid arthritis
• Atherosclerosis
• Age-related macular degeneration
• Weight loss
• Muscle atrophy

Sources of Zinc include:

• Nuts
• Legumes
• Chicken
• Red meat
• Oysters

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Green, S et al. "Physiotherapy interventions for shoulder pain." The Cochrane database of systematic reviews vol. 2003,2 (2003): CD004258. doi:10.1002/14651858.CD004258

Hartvigsen, Jan et al. "What low back pain is and why we need to pay attention." Lancet (London, England) vol. 391,10137 (2018): 2356-2367. doi:10.1016/S0140-6736(18)30480-X

Kavuncu, Vural, and Deniz Evcik. "Physiotherapy in rheumatoid arthritis." MedGenMed: Medscape general medicine vol. 6,2 3. 17 May. 2004

Page, Carolyn J et al. "Physiotherapy management of knee osteoarthritis." International journal of rheumatic diseases vol. 14,2 (2011): 145-51. doi:10.1111/j.1756-185X.2011.01612.x

Wessels, Inga et al. "Zinc as a Gatekeeper of Immune Function." Nutrients vol. 9,12 1286. 25 Nov. 2017, doi:10.3390/nu9121286

Neck pain prevention can go a long way as long as you take proper care of your body, exercise, and practice healthy habits. Here are a few tips to help prevent neck pain before it begins. Neck mobility is a marvelous thing. The neck can move the head in various directions:

• 90° of flexion forward motion
• 90° of extension backward motion
• 180° of rotation side to side
• Almost 120° of tilt to each shoulder

A lot of us are very familiar with a stiff neck or a crick in the neck. This stiffness prevents us from moving comfortably. A crick in the neck can cause the neck part of the spine to feel stiff, rigid and immobile. Fortunately, prevention and various treatments can help.

Prevention:

• Standing and sitting properly maintains proper posture and keeps muscles working/healthy. If you begin to hunch over, correct it immediately as it can quickly lead to pain in the neck. Pay attention to how you stand and sit and the more you do this it will become a healthy habit.
• Do neck and body exercises regularly and try for a 30-minute cardio workout 3-5 times week.
• Staying within a healthy weight-range will keep your spine in top form as it carries the weight of your body, and not overstrain it, which can lead to all kinds of pain.
• With healthy weight comes a healthy meal plan, not just for proper weight but to strengthen muscles, bones, enriching the blood and getting to optimal health.
• Smoking can affect the bones and muscles in your cervical/neck area of the spine, as well as all the other areas of the body. Therefore it is time to quit.
• Sleep with correct head and neck posture. Sleeping with your head in an awkward position is an easy set-up for a strain and pain.
• Stress and tension reduction. Tense muscles in the neck and shoulder often lead to pain in the neck. A few effective ways to reduce stress can be writing, talking to friends, exercising, walking, listening/playing music, art/crafts, cooking, reading,  and turn to these when the stress begins to build.
• Driving safely and wearing seat belts can help prevent whiplash.
• Using the proper equipment to protect your neck while participating in sports that can lead to neck injuries like football, skateboarding, wrestling, soccer is a must.

Taking care of your body is a complex process. Lifestyle changes pave the way to wellness and making these changes will benefit more than just the neck.

Don't worry about the list and try to check everything off. Look at the things that apply to you and try to implement a few of these tips one at a time. Keep the bigger changes like quitting smoking/losing weight in the foreseeable future. It takes time, patience and commitment. With a little hard work, it will pay off, and you should have a healthier life with less neck pain episodes and remember prevention is key.

Massage

This is a popular therapy that relieves:

• Aches
• Fluid retention
• Inflammation
• Muscle tension
• Pain
• Spasms
• Stiffness

Other benefits include improved blood and lymph circulation, flexibility, range of motion, and increased tissue elasticity. While increasing circulation the muscles are warmed along with other soft tissues like tendons and ligaments.

Swedish

It is one of the most popular massage types in the US. Usually, therapeutic muscle lotion or oil is used to reduce friction and relax the area/muscles as the therapist performs light stroking in one direction with deep pressure in another to relax and loosen the muscles and surrounding ligaments/tissues.

This takes the blood flow and flushes lactic acid, uric acid, and other waste products from the muscles. The ligaments and tendons get stretched, which increases their soft but firm/strong feel. The nerves are stimulated and relaxed, with any stress in the muscles taken away. Relaxing the muscles is the overall goal.

Deep Tissue

This technique aims at chronic muscle tension. The strokes are slower, using more intense direct pressure to release the built-up stress, knots, and tightness. Depending on how deep the muscle and tissue stress maybe, the therapist will adjust their hand positions, strokes, and intensity periodically to work the tissues releasing tension.

Relaxing the Muscles

The therapist using their hands or tools to rhythmically knead, rub, and stroke muscles, circulation begins muscle stimulation. This blood flow brings needed oxygen and nutrients and helps the muscles eliminate waste products, like lactic acid, that can collect in the muscles brought on by spasms, which cause pain.

El Paso, TX Chiropractic Neck Pain Treatment

As a part of chiropractic care treatment, it’s essential for individuals who frequently suffer from joint and/or muscle pain due to direct trauma from an injury or an underlying condition to continue keeping their bodies as flexible as possible. People who often workout to maintain or improve their flexibility are actually at a lower risk of experiencing an injury or aggravating a condition. According to chiropractic, the best way for an individual to control their flexibility is to stretch before starting any physical activity.

Before stretching however, its also important to note that each individual should warm up their muscles prior to stretching. Stretching first can often result in further injury because the joints and muscles are pushed beyond their limit while the tissues are stiff and not yet loosened. Participating in a few low or no impact workouts, such as a simple walk, can be enough to warm up the body lightly. A chiropractor can also recommend an appropriate series of stretches and exercises according to each individual’s level of symptoms or injury.

Once you’ve made sure to warm up your body properly, you can begin stretching. There are two basic forms of stretching: static stretching and dynamic stretching.

Static stretching, is defined as focused stretches of the muscles used while the body is at rest that loosen up the muscles by holding a certain position for a determined amount of time. Dynamic stretching, is defined as focused stretches of the muscles used by building momentum to move parts of the body by pushing the muscles to extend their range of motion while making sure not to exceed the individuals normal stretching capacity. Both types of stretches are important towards enhancing one’s flexibility although a majority of people often use static stretching over dynamic stretching.

Many of the most effective stretches for correcting symptoms of back pain among others, can be practiced at home.