Shockwave therapy has been around since the 1970s. It was first used as a treatment for kidney stones called lithotripsy until a German doctor used a shockwave machine on rabbits that he had partially cut through their Achilles tendons. Tendons are very poorly supplied with nutrient rich blood that is why they are white when looked at in the lab. This lack of blood supply means that it is very difficult to repair a tendon or ligament when they have been torn or ruptured.

Shockwave therapy was until recently only used with anaesthesia as it was very painful for the patient. With the new machines now on the market it is a pain free procedure. At Al Biraa arthritis and bone clinic we have the latest model of machine from Switzerland.

Treatment:

The shockwave treatment last no longer than ten minutes and is applied by something that resembles a large pen. The appropriate setting is selected and the procedure commenced. The best outcomes in trials have been achieved with a combination of shockwave therapy and a guided exercise program. This approach has been proven to be the best and quickest way to recover from any tendinopathy. The scope of treatable areas has increased in the last ten years. It was until recently only used on plantar fasciitis (heel pain) and tennis elbow. Now it is used on Achilles problems, rotator cuff tendinitis, patella tendonitis and some low back conditions with great results. The literature states that you will only need three treatments, but in my experience if you have had a condition for years it normally takes months to resolve fully.

How it works:

The shockwaves encourage the body to form new vascular networks called neovascularisation. These new networks of very small arteries carry the blood that contains the proteins needed for repair to the tendons. The rate that the shockwave hits the target area also sends many millions of sensory signals to the brain. The brain interprets these signals and decreases the pain receptors in the target area. This leads to a local anaesthetic effect and less pain. If you have any questions about shockwave therapy and you are not sure if it will help you please feel free to contact the Al Biraa clinic and Dr Peter or the Physiotherapist will talk to you.

The Iliotibial band (ITB) is a fibrous band of tissue that runs down the side of your leg from pelvis to lateral knee. “What is it and what does it do”. The ITB is a stabiliser of the knee, it will aid the lateral collateral ligament to resist lateral (sideways out movement). However its primary role from its anatomy is to resist lateral displacement of the hip. Many authors will tell you it is an overuse injury that occurs when the ITB rubs on the lateral condyle of the knee. This is missing the point, actually the ITB injury is a secondary, compensatory injury. The question is “why is the ITB under more tension, on one side than the other”. The ITB is thick and tough, it was designed many millions of years ago when we were cavemen walking and running for miles. So what are we doing differently to our ancestors? There are a few questions to answer. Why would a ten mile run bring on this very painful condition? Why is the standard treatment rest, massage, stretching? What are we missing?

ANATOMY of the ITB

To consider the anatomy of the ITB we need to introduce the main culprits in the ITB syndrome, that’s the muscles called tensor fasciae latae, glut max and glut medius which we will call glut max, medius and TFL for brevity. TFL is a relatively small muscle that is designed to tension the ITB when the knee is flexed. This is how the ITB works to stabilise the Knee. The ITB is made up of thick collagen fibres which flow from its insertion in TFL and glut max/medius down to the lateral condyle of the knee and interdigital fibres run onto the tibial plateau and the knee cap. The band is thick and broad at the hip end and thins as it progresses down your leg. This thick at the top and thin at the bottom situation should tell you that most of the work goes on at the top. Too much tension in the muscle groups of the pelvis and we develop ITB irritation.

How does it all start? Unfortunately the TFL has a secondary job and that is acting as a synergist (helper) to glut medius . This is the important part to understand. When a person is running or cycling the first muscle to contract is glut medius. This muscle stabilises the pelvis when the leg is off the floor, by contracting the glut medius the pelvis is abducted and this keeps the pelvis level. If we did not have this muscle, every time our foot left the floor we would lurch to the side as our hip would fall down and our hip would turn out. The glut medius is designed for this task; unfortunately it is also a postural muscle and any lower back problems will force it to go into spasm. When it is in spasm we have to call on the synergists to help and it is this recruiting of the TFL that ultimately causes the continuous tension of ITB. This situation goes unnoticed for years but will ultimately manifest itself as pain that “just came on” When we are fit and healthy we have no problems with our TFL/ITB because we are not asking the nervous system to contract any of our muscles to protect any structures.

Any insult to the musculoskeletal system is registered in the brain and acted on immediately. Something as simple as having a tight lower back from driving too much or sitting in an office chair all day is a symptom of the nervous system responding to a potential threat. To treat this painful condition successfully you need a thorough examination starting with your feet. Hyperpronation is one of the main causes of tibial (shin bone) rotation, this rotation puts strain on the ITB and structures further up the leg. The rotation of the shin bone can cause problems in your hip and low back. After ruling out any foot problems we will look at the hip rotation. Too much rotation of the hip and you will cause the gluts to be tight which will ultimately cause your TFL/ITB to be painful. The sacroiliac joints if strained will cause recruitment of the ITB. At the Al biraa arthritis and bone clinic we have the latest in technologies and can get to the cause of your ITB pain. If you suffer from this condition or similar unexplained pain that is brought on after running, cycling or simply walking, you can call the clinic and you will be seen by Dr Peter a Chiropractor who will be able to diagnose and treat the condition.

As I write this article at my laptop I can feel the tension between my shoulders slowly creeping up my neck and if I carry on working for another twenty minutes I will have a headache for the rest of the day. The average human is not designed to sit at a desk for ten hours a day in a slouched position. There is an imaginary line that passes from the tip of your shoulder through your ear. For every 2.5cm your head travels in front of this line you double the effective weight of your head. The average head weighs 4kg, double it to eight and the muscles of the neck and shoulder are working very hard. As the muscles of the neck contract the small ones at the base of your skull called the sub-occipitals contract, it is postulated that they can restrict the blood supply to the scalp and forehead by squeezing the sub-occipital artery and hay presto you have a headache over the eye and pain in the shoulder.

How to help yourself:

Sitting in the correct position is the absolute minimum a person can do to help themselves, short micro breaks from the computer (40-50 sec) stood up allows the body to reset itself. Sitting with the computer at the right height keep your eyes level and try to retract your chin. You should feel this pulling at the top of your scapular, hold for 30 seconds and relax, try and do this a minimum of five times a day. Look to the left as far as it is comfortable, place your right hand on your face (try not to push on your jaw) breath in and as you breath out relax and push your neck a further 2.5cm repeat for the other side. Try to place your right ear on your right shoulder with your left hand reach over and palace it on the left side of your face, again gently breath in and on breathing out pull the head down towards the shoulder. At no time should this be painful, the old adage of no pain no gain was one of the most stupid statements ever made.

Long term implications:

Over 180 million days lost in the UK annually due to repetitive strain injuries. 100% preventable injuries and with the proper advice and guidance, relatively easy to implement a work based regime. The individual runs the risk of earlier and more debilitating osteoarthritis, as the head travels forwards the muscles are initially used to try to pull you back in line. If this strategy fails the brain will lay new bone at the joints to try to stabilise the area, this is osteoarthritis. Chiropractors are in a unique position to help as we deal with the muscular component and also the bone component of what can be a debilitating condition.

What do celebrated concert artists, amateur musicians, music students, studio players, chamber musicians and orchestral players have in common besides their love of music? They all experience higher rates of back pain than most of the population. The severity may range from vague feelings of discomfort to conditions serious enough to impair their ability to perform. The rate of back pain among cellists is higher than for any other group of musicians, followed by harpists, pianists and bass players, in that order. Over time, those who suffer with these problems tend to accept pain as normal and inevitable. I have treated many different types of musician, but the most common in my home country of Wales is the violin. The violin is used in Welsh country music and in the traditional cultural shows called the national eisteddfod. These violin players will spend many hours a day practicing, they normally suffer from left sided shoulder and neck pain with a repetitive sprain of the right wrist.

Although there are many causes of back pain, much of it is related to the way we sit when we play our musical instruments.Sitting is more complicated than standing. When you stand, you are able to move more freely to maintain good body balance. Standing allows your body weight to shift, naturally, from one foot to the other as you move your arms. The ideal way to sit is in a manner that provides your body the same support and freedom of movement as when you stand. If your body’s natural weight shifts are inhibited, you cannot be completely balanced or free of tension. You may also notice, that when you sit and your feet are not properly placed, your knee and hip joints tend to lock, limiting your mobility. Carl Flesch, the noted violin pedagogue observed that “Even the simplest movements of the arms can be carried out properly only when the position of the legs is correspondingly correct.”

If you are a musician and suffer from any of the problems talked about please feel free to contact me at the Al biraa arthritis and bone clinic. Were we can show you the best possible position for your particular instrument and we will also give you a complete set of exercises to perform that will help you maintain your musical career.

Plantar Fasciitis

Having moved to Dubai recently, I thought it about time I got back into running. Running is a sport of passion; why else would we torture our bodies with miles of punishment every day? Running injuries are an unfortunate, but all too common, occurrence. Understanding a running injury is the key to effective treatment. From my three weeks of running I can discuss a common injury, plantar fasciitis, commonly called runners foot.

I have, for a number of years needed to have orthotics for my shoes. Being a little heavier than the average person, I have a tendency to hyperpronate my ankle (turn my heel in). Unfortunately I was not wear my insteps in my training shoes as I started to run bear foot on Jumiera beach. The joy soon wore off after two runs my ankle and sole of my foot were very painful. What is the cause and what is the treatment?

Plantar fasciitis is the medical term for pain in the sole of the foot, normally spreading from the heel to the underside of the instep. This condition is thought to be caused by an inability of the transverse ligaments to hold the heel bone and the bone next to it the navicular in the correct position. This is only one theory and it is a little flawed in that it only subscribes plantar fasciitis to ankle/foot problems. An injury further up the chain can lead to this condition.

Low back/pelvic pain can cause plantar fasciitis.

I have treated literally hundreds of patients with plantar fasciitis and the vast majority of them did not need to have an expensive pair of orthotics. The latest research has a figure of only 8% of patients with plantar fasciitis actually need insteps. Why do we get given them then? They are a great generator of revenue for the people giving them to you, and that’s just the way they have been taught to think. Most people with this condition will suffer more in the morning when they place their foot on the floor? Strange as we are not hyperpronating when we are in bed asleep. Our lower back however is in a slightly forward flexed position and our hamstrings will be tighter if we have a back condition. The hamstrings have a common insertion point with the calf muscles. As we point our toes down at night the pain goes away as the calf`s are not under tension. As we stretch the calf we experience pain the calf is tight only because it is being recruited to help stabilise an injury further up the leg/ body. If you are getting any of these symptoms don`t be mislead into buying a set of expensive orthotics without having your lower back and pelvis looked at by your Chiropractor. If you would like more information feel free to call the Al biraa clinic.

Dr Peter Jarvis (Chiro) Dc MSc BSc (Hon)

Most of us, sometime in our lives will suffer from a headache. These headaches can range from debilitating to mildly annoying. The first thing to understand about headaches is that most of them are not caused by a brain tumour. In fact brain tumours are relatively rear and generally come with a multitude of other symptoms. Another myth is that high blood pressure is the cause. High blood pressure can cause a headache, but it has to be very high something like 200/120 and if your blood pressure is that high the headache is the least of your concerns.

Before treating anybody with a headache you should be given a truncated cardiovascular and neurological examination to rule out any of the above. When we have discovered that you, in fact, do not have any life threatening illnesses, we need to look at the type of headache you are suffering with. The majority of people are diagnosed with migraine headache. This is mostly not the case, migraine headaches are classed as aura or non-aura, meaning you have visual disturbances (zig zag line and strange colours across your visual field) photophobia is common (Light hurts the eyes a lot) sound or taste disturbances can also occur before onset of pain. Migraines are generally one sided and last no more than twenty four hours. They respond well to medication and can be alleviated by discovering the triggers. The triggers can be caffeine, chocolate, alcohol or strong cheeses, these are just some of the triggers reported and you need to have a systematic look at your lifestyle to discover your own personal triggers. As it stands, today science still has not discovered the cause of migraines. Some believe it is vascular occlusion and some believe it is neurological. The jury is still out on the cause, I personally think there is more than one type of migraine and our classification system has to catch up. As a Chiropractor I have a 50% success rate treating migraines. Are these really migraines that I am treating successfully?

A pearl of wisdom:

I have a friend who is a GP in the UK and she suffered with migraines to such an extent that she referred herself to the national headache institute in London. I asked her some months later what they had done, she said they talked to her for two hours and after that she suffered 90% less headaches. Impressed by this new wisdom I asked what she was told, and it was simply identify the triggers before you have the migraine. For her it was twenty four hour before the attack she would be terrible to her reception staff, husband, dog, children and anybody close. When she identified this behaviour she would take her imigrane tablets and 90% of the time it never developed into a full blown attack. Another common prodroma seems to be excessive yawning when you are not tired. I’m not suggesting you take medication every time you yawn, but just keep an eye on the yawning and see if it correlates to a headache the next day. Cravings are another early warning sign, the sudden need for chocolate or cheese is a sign not to ignore. Keep a headache diary and log down what you felt like twenty four hour prior to an attack.

Ten tips:

• Keep a headache diary, log what time of day it started, what you had eaten 24 hours prior, what work you were doing, stresses in your life, arguments, sex. All daily life activities.
• Look at your work station, is the top of the computer screen in line with your eyes.
• Stretch your neck on a daily basis.
• Cut down on alcohol and stop smoking.
• Have regular rest at work.
• Go to bed at a reasonable time.
• No caffeine at least two hours before bed time.
• Stop picking up toddlers.
• Exercise regularly.
• Seek advice from your doctor if you are worried that it may be more serious

If you want more to make an appointment to see if we can help your headaches please feel free to call the clinic.

Dr Peter Jarvis (Chiro) Dc MSc BSc (Hon)

Understanding what is causing your knee pain may be a simple task, or more complicated. Your Chiropractor will use clues from your case history to try to work out the most likely diagnosis some of these clues have to do with you ( How old are you? any recent injury? how long has it been going on? does it hurt at a particular time of the day? what activity makes it worse?). Here are some of the more common and a few less common knee conditions.

Condromalacia patella: is a very common condition where the underside of the knee cap becomes soft and torn. This is normally an overuse injury. The pain is felt on the knee cap and grinding noises can be felt and heard. Normally worse when going downhill/stairs. The treatment is relative rest, ice/elevation and try to work out what you are doing wrong in your exercise program. As a last resort this condition responds well to arthroscopic surgery but tends to come back if the cause is not discovered.

Patellofemoral tracking syndrome: very common condition not to be confused with Condromalacia. PFTS is a distinct injury in its own right. It is caused by the boat shaped patella not travelling in the groove created by the femur. All of the muscle of the upper leg exerts some pull on the patella, so a thorough examination by your Chiropractor is needed to discover what is pulling the knee cap around. The misconception that the knee cap only moves up and down is wrong, it moves around in a rotary fashion and from side to side. The lower limb can also cause this condition. Pronation of the feet will cause the tibial bone to rotate inwards this will create more pull on the knee cap. The first treatment of choice is physical therapy with quad strengthening and Chiropractic adjustments. It takes a long time to respond and needs self help treatment on a daily basis.

Osgood Schlatters disease: This is the most common cause of knee pain in the adolescent child. Average age 9-16, no difference in the sex of the child but it is always associated with a growth spurt and physical activity, running, football, jumping. It is a self limiting condition that completely resolves as the skeleton matures. The pain is felt over the front of the knee on what is called the tibial tubercle (the bump in the front of your knee) this is a growth plate of cartilage that has not yet fused. As the child is using their muscles a lot while participating in their sporting activity, the pull from the muscles causes a local, painful inflammation of the knee. The treatment is rest, ice, elevation and a compressive bandage. It is advisable to have your child checked by your Chiropractor who will ensure that the hip/feet are functioning properly and it is just an overuse injury. The knee in an adolescent is a common site for more serious pathology so make sure you have seen your Chiropractor who will take an x-ray to rule anything serious out.

Bursitis: A bursa is a fluid filled fibrous bag that lies between tendons. They are designed to stop surfaces rubbing together they act like bearings in a car. There are 14 bursas in the knee and any of them can swell and be painful if irritated. The three most common one are pre-patella bursa (Commonly called housemaids knee) as the name suggests compressive loads can cause this condition such as kneeling down for a long time scrubbing floors or in the Middle East, praying, changing nappies is also a common cause of patella bursitis. Any excessive pull from the quads can cause tension so a lower back or pelvic problem can cause this condition. The Ansurine bursa which is situated on the inside of your knee, this area is where a lot of the hamstring group of muscles and the long muscles of the leg insert. Any abnormal pull from your hamstrings/ pelvis can cause this to swell. By far the most common is the poplitial bursa (Bakers cyst) at the back of the knee; this swelling can be as big as a tennis ball and very painful. The treatment is aimed at discovering the cause of the abnormal pull on the ligament in question. Your Chiropractor will do a thorough examination and aim the treatment at the cause rather than the painful area. This does not mean that the bursa will not be treated with Physiotherapy; rather the cause will be treated at the same time as the pain. It is important to see your Chiropractor to rule any pathology out as the back of the knee/calf can be the site of deep vein thrombosis.

Cartilage tear: There are two types of cartilage in the knee the shiny hyaline cartilage that is on the surface of the bone. This is one of the pain generators when you have arthritis. As you get older or suffer any trauma to the knee, the hyaline cartilage will degenerate and fray, this causes the body to start laying down new bone to try to spread the weight and relieve the cartilage. It is this laying down of new bone that gives arthritic knees their characteristic shape. The other type of cartilage is fibrocartilage; this is found in the meniscus of knees. The meniscuses are rounded horseshoe shaped cartilages that keep the forces on the knee evenly distributed. This type of cartilage can tear and be trapped between the bones of the knee. Many people have torn cartilages without knowing it, they will only find out if they stress the area over and beyond its limits. The treatment should start with conservative management as a lot of the less active amongst us can simply live with the condition and if this fails arthroscopic surgery is very effective. Before any definitive diagnosis/surgery is contemplated you should have an MRI scan to make sure of the correct diagnosis.

Ligament tear: The knee is surrounded by a large fibrous bag called the joint capsule. This capsule is highly innervated by nerves and has massive amounts of pain receptors. The ligaments are either inside this bag or outside, so we refer to them as intra-articular or extra-articular. The ligaments inside are the cruciates which stop the knee from travelling from front to back and back to front. The transverse ligament crosses the meniscus and aids in stabilising these structures. The coronary ligament is a small ligament that gives the lateral meniscus extra stability. If a person has an intracapsular injury the swelling is generally massive and immobilising. The ligaments are poorly supplied with blood so the repair process is all but zero. The average person, who is not an athlete, can normally live with a ruptured ACL/PCL without having to resort to surgery. The problems arise when the person is a fit athlete who wants to continue his sporting career. Then the choice is surgery. Who you go to and what type of surgery will have a massive bearing on the result, consult your Chiropractor for advice on possible surgical interventions and who they would recommend.

Arthritis: Arthritis simply means inflammation of the joint. There are processes that can inflame the knee, the most common is osteoarthritis. This term means damage to the articular surface (the shiny surface) of the joint due to age, altered mechanics of the joint, or injury. Osteoarthritis can be managed by your Chiropractor with good success. Osteoarthritis has a defined cause which can be identified and hopefully removed. The cause may be mechanical for instance; if the persons feet are pronating (turning in) or supernating (turning out) over a long period of time the stresses will pull on the knee, the knee will be under abnormal stress and the cartilage will slowly be damaged. Another very common way to start arthritic changes is post-arthroscopy. After arthroscopic surgery (the magic eye) it has been proven that the knee will degenerate quicker than the general population. Weight or being overweight has a direct bearing on the level and age with which you will suffer with osteoarthritis. The heavier the person, the younger the knee will degenerate.

Another common arthritis is rheumatoid arthritis. This is a systemic disease that can affect most of the organs of the body. 1% of the population will get this disease with smokers being more susceptible. This disease causes destruction of the joint surfaces by compression. The body starts to see the joints as non-self. This causes the body to try to protect itself from attack by producing various chemicals that attack the joint. The joint fluid is produced at a massive rate and the joint surface is squashed down. Your Chiropractor can help you with this condition but only if it is not in an active phase of inflammation. The treatment of choice from the allopathic doctors is Disease modifying medication such as methotrexate, gold sulphate and anti inflammatories. Steroid injections are given if the patient is having a flare up. The steroids can mask the effect so should only be given if you have consulted a rheumatologist. The second line of attack is anti TNF medication which stands for tumour necrotic factor, a fairly new but effective treatment with limited side effects compared with methotrexate. At the Al Biraa Arthritis clinic I have the good fortune to work with some of the best Rheumatologist in the UAE and I can refer directly to them if I have any concern about rheumatoid arthritis.

The relatively rare knee complaints: There are too many conditions of the knee to consider in a relatively short article like this, but here are a few you may come across.
Pellegrini-Stieda syndrome: Simply calcification of the lateral collateral ligament found on x-ray and easily treated by your Chiropractor.
Plica syndrome: Easily mis-diagnosed as patella-femoral tracking syndrome. Plica is a very fine’ tissue that is a remnant of the foetal knee, this tissue has failed to be reabsorbed in utero. It is very fine as stated and can be hard to see even on MR scan. It can be trap between the femoral condyles mimicking meniscal tears. Treatment is anti inflammatory therapy, physical therapy and if all else fails surgery.

A rare condition that occurs when the blood supply to the knee is interrupted and a small fragment of bone can break off causing pain and swelling of the joint.

Osteomyelitis Osteochondritis Dissicans: Bacterial infection of the knee. This condition is serious and need referral straight away. The joint is very swollen and hot.

Osteosarcoma: Malignant cancer of the knee joint. Immediate referral is required.

Ewing’s Sarcoma: malignant cancer of the knee in the young child/adolescent. Immediate referral is required.

If you have any questions about knee pain please feel free to call me at the Al Biraa arthritis and bone clinic and I will be happy to discuss your condition.

Dr Peter Jarvis DC MSc BSc (Hon)

Acceleration/deceleration injury to give it it`s proper name. The commonest cause of a whiplash type injury in Dubai will be an automobile accident. This is not always the case however. Many sports will involve acceleration/deceleration injuries, you only have to see a game of rugby to appreciate this fact, also soccer when heading a ball, diving when hitting the water from any height and boxing/martial arts are just a few of the sports that will give a person whiplash.

The head weighs approximately 4kg in an adult male and it sits on top of a relatively small structure, the neck. The neck muscles are designed to keep the head in a neutral position as much as possible. When we have a whiplash the injury occurs not so much in the forward movement of the head, although a lot of the soft tissue e.g. muscles, ligaments, and tendons will be damaged. It is in the backwards or extension movement that causes most damage. The muscles in the front of the neck are much smaller than the ones on the back of our neck and so cannot resist the rapid movement as well as the muscles in the back of neck. The joints of the neck are at a 45 degree angle to the horizontal plane. The joints of our neck like all joints have a fine fibrous bag surrounding them called the joint capsule. This bag is designed to keep and make the oil of the joint; it also has sensors that tell the brain just how far apart the joint is. As our neck moves backwards at a rapid rate, the joint capsule is telling the brain that there is a potential for damage. The only reaction the brain has available to it is to use the muscles of the neck to try to splint the area by going into spasm. This is why we have a stiff neck many hours after an accident, coupled with soft tissue sprain/tearing and local inflammation.

Grades of whiplash injuries are very arbitrary and are based more on the compensation from an insurance company than what you see in the individual. They are broken down into three main types depending on initial symptoms.

Grade one: pain felt in the neck between 6-24 hours after the accident. No arm or hand disturbances are reported. This has the best prognosis for full recovery and an aggressive rehabilitation program started three days post accident is recommended.

Grade two: pain felt immediately after the accident but with no arm or hand involvement. A more serious injury and a longer recovery period is to be expected. The person who has suffered this injury will always be left with a minor stiffness and a slight degree of pain.

Grade three: Immediate pain with referral down one or both arms and into the hands. Major structural damage has occurred and the rehabilitation can take years. This patient in my experience will never achieve full function or pain relief. The treatment is the same but over a longer period. This person needs to have strategies to deal with the pain and a life time of medication, a joint medical Chiropractic approach is best for these people.

Treatment of a whiplash injury has to deal with all aspects of the injury not just the muscles. If we only get the muscles and ligaments repaired the brain will still be getting signals from our joints that we are in danger of damaging the joints. These signals are what cause the neck to still be painful many years after an accident. This is often put down to scar tissues, ligament damage, but even in a minor accident with minimum damage we have chronic pain still affecting the patient. As Chiropractors we are able to manipulate the joints open and decrease the signals to the brain. With time and a good rehabilitation program most people can be at least 90% better from a minor whiplash injury. At Al biraa arthritis and bone clinic we can offer full Chiropractic and rehabilitation services to the individual who has suffered a whiplash. If you would like any further information on whiplash injuries please feel free to call the clinic for an informal chat with Dr Peter.

Dr Peter Jarvis (Chiro) Dc MSc BSc(Hon)