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Interventional Chronic Pain Management Treatments | Central Chiropractor

Chronic pain is known as pain that persists for 12 weeks or even longer, even after pain is no longer acute (short-term, acute pain) or the injury has healed. Of course there are many causes of chronic pain that can influence any level of the spine, cervical (neck), mid back (thoracic), lower spine (lumbar), sacral (sacrum) or some combination of levels.

What treatments do interventional pain management specialists perform?
Oftentimes, early and aggressive therapy of chronic neck or back pain can earn a difference that is life-changing. But remember that knowledge is power: Be certain that you know your choices. There are various treatment procedures and treatments available for chronic pain, each completed by a treatment specialists. Interventional pain management specialist treatments may be a fantastic solution for some people with chronic pain symptoms.

Interventional Pain Management Specialists
Interventional pain management (IPM) is a special field of medicine that uses injecti…

Athletes with Pectoralis Major Ruptures from Sports

Athletes with Pectoralis Major Ruptures from Sports - El Paso Chiropractor

Pectoralis major ruptures are considered to be significantly rare types of sports injuries. These specifically occur on contact, caused by a sudden, violent contraction of the muscle, usually with particular stretching positions, such as during the bottom of a bench press or during tackling in rugby or football. Although pectoralis major ruptures are believed to be uncommon injuries, these have become more frequent with the growing popularity of contact sports, such as body combat sports and weight training.

Anatomy and Biomechanics

The pectoralis major muscle is made up of two recognizable heads; the clavicular head and the costosternal head. The clavicular head emerges from the medial clavicle and the upper sternum while the costosternal head on the sternum emerges from the aponeurosis of the external oblique and the first six costal cartilages of the rib cage. They both incorporate to form the anterior wall and fold of the axilla, extending across the shoulder and inserting onto the proximal humerus.
The clavicular and upper sternal portion of the muscle precisely inserts on the humerus below the introduction of the lower sternal and external oblique fibres. Each distinct tendon divides onto each other approximately 90 to 180 degrees before being introduced on the humerus. Through a study utilizing fine wire gauges, research determined that the sternocostal head and its tendon stretch unevenly in the last 30 degrees of humeral extension in comparison with the clavicular head. Because of this, the sternocostal head has a higher risk of injury and rupture as it is most exposed to intense stretches. In addition, this also shows that partial ruptures of the tendon are more common than the complete rupture of both heads.
The pectoralis major is a powerful internal rotator, adductor and flexor of the shoulder. It acts to support the shoulder in contact sport conditions. Researchers demonstrated, however, that the pectoralis major is not as essential towards normal shoulder function as other shoulder muscles. It is necessary though for strenuous physical activities which indicates that some athletes may require surgical repair while others may respond well to conservative treatments.
Injuries to the pectoralis major include contusions or sprains, partial tears, complete tears, muscle origin tears, muscle belly tears or the development of musculotendinous junction, or MTJ. Most frequently, ruptures of both heads are not seen where only the inferior fibres of the sternocostal head has ruptured, giving an incorrect perception that the entire tendon still remains intact. Complete ruptures almost always include an avulsion of the humeral enthuses.

Pectoralis Major Anatomy Diagram - El Paso Chiropractor

Demographics

Pectoralis major ruptures have become more prevalent in the last few decades, now more common among athletes ranging from the ages of 20 to 40, which suggests that athletic behavior may be the main underlying risk factor for tendon injury. Moreover, pectoralis major ruptures appear to affects males much more than females.
A study found that 50 percent of individuals were initially misdiagnosed. The presenting signs and symptoms of an injury are essential when dealing with acute soft tissue trauma, particularly in athletes. It’s been demonstrated that delaying treatment as a result of misdiagnosis can result with improper functional outcomes.

Mechanism of Injury

Pectoralis major ruptures are generally caused by a sudden forceful overload of the muscle in a maximally contracted position or due to direct contact with the muscle while it is in a stretched position. Stretch and load type injuries often result in injuries to the insertion and musculotendinous junction whereas direct blows tend to injure the muscle belly.
Exemplary mechanisms of injury include: tackling in contact sports such as rugby and football; bench pressing, specifically at the bottom or if the weight is suddenly bounced off the chest or if the lifter arches the spine; water skiing or windsurfing, specifically if the arm is externally rotated, extended and a sudden stretch is applied due to a fall or jolt; and wrestling, specifically if the arm is caught in an abnormal position.
It has been proposed that a normal, healthy tendon can be resistant to rupture and that degeneration must be present in order for the tendon to suffer injury. Constant weight training may expose the tendon to multiple loads of pressure and stress which may lead to the start of tendon degeneration and the occurrence of pectoralis major ruptures can usually follow tendon degeneration.

Symptoms of Pectoralis Major Ruptures

Individuals with pectoralis major ruptures generally describe symptoms of sudden, sharp pain in the region of the upper chest along the shoulder, typically reported when the arm is caught in a stretched and powerfully contracted position. This can be usually associated with a ripping or popping sensation.
Because of the pain, many affected individuals may refuse to move their injured shoulder, causing a discoloration of the skin in the region of the axilla and upper bicep.
An evaluation may display a thin, axillary fold, a sulcus or a groove in the area where the deltoid and pectoral muscle cross. Active contractions of the muscle often show bulging in the anterior chest wall. The examination can be performed by having the affected individual press their hands together in front of the body, producing an isometric contraction of the muscles.
Range of motion shoulder movements into abduction and external rotations may be greatly limited by symptoms of pain, however, the individual’s range of movement may recover quickly. In other instances, weakness during internal rotations may be present, particularly when internal rotation is evaluated with the arm in a neutral rotation.

Treatments

Only utilizing X-rays may be inconclusive when determining the presence of pectoralis major ruptures, but, it’s been hypothesized that a missing pectoral shadow displayed on X-ray results may suggest a rupture of the pectoral tendon. Ultrasounds can help visualize the tear, showing a thinning of the muscle. Computerized tomography, or CT, scans may show a disruption of the muscle tendon. MRI is the most accurate imaging modality, with axial T2 weighted images being most effective for acute injuries and T1 weighted images being most recommended for chronic injuries. MRI may also display muscle belly hematoma, also used to confirm which individuals will benefit from surgical treatments.  
Surgery has been a preferred method of treatment among the athletic population. For those who’ve chosen conservative treatment options, there’s been a reported peak force production reduction in their work capacity when measured on isokinetic devices. Partial tears of the belly muscle or distal partial tears in non-athletic individuals may experience a positive outcome when treated conservatively. It’s also been suggested that longer periods of delayed treatment can make rehabilitation of a torn tendon difficult. It’s recommended to treat an injury as soon as possible.
Surgery for this type of injury involves a 5 to 8 cm incision in the deltopectoral crease line. The tendon should be properly examined during surgery with the arm carefully abducted and externally rotated since costosternal head tears are often hidden by the clavicular head if the arm is by the side. The full length of the tendon and musculotendinous junction, or MTJ, must be properly analyzed to determine the precise site of the tear. MTJ injuries are repaired using permanent sutures.
In the case the tendon ruptures at the attachment of the bone, then, the lateral lip of the bicipital groove is uncovered and cleared of soft tissue. Suture anchors and drill holes are utilized to re-attach the tendon onto the bone. Frequently, full tendon tears may need up to four suture anchors.

Post-Surgery Rehabilitation

After surgery, the individual may be recommended to rest their arm in a sling for up to four to six weeks, using either a sling immobilizer or a basic sling. Ruptures within the soft tissues may need longer period of immobilization in comparison with direct tendon into bone ruptures. It’s believed that direct tendon into bone attachments are more stable than within soft tissue repairs. Post-surgery rehabilitation goals include: maintaining the integrity of soft-tissues post repair; restoring full range of movement; restoring muscle control and regaining strength; and return to full, unrestricted athletic participation.  

Range of Motion Progressions

The fundamental purpose of rehabilitation involves tissue protection to allow the sutured tendon fibres to heal accordingly. The individual will be immobilized in a sling and no passive or active movements should be allowed for the first 2 weeks. After 3 weeks, gentle, passive range of motion procedures into external rotation, flexion and abduction can be utilized.
From weeks 2 to 3 onwards, the passive range of movement progressions are slowly opened into external rotation, abduction and flexion. Once the individual achieves the desired range of movement for that week, they may be allowed to participate actively within gravity-assisted/resisted positions. At first, the individual’s range of motion exercises can be guided by a therapist, or in many cases, with the help of a chiropractor or other soft tissue specialist, to avoid the risk of further injury. Once the individual achieves a desired passive range, they may carefully use that range actively. The aim is to have full active/passive movements by the 12th post-operative week.

Chiropractic and Physiotherapy Interventions

Since the surgical procedure is introduced into the shoulder joint itself, the procedure is considered to be extra-capsular, therefore, shoulder joint effusion and intraarticular adhesions are not present. As the surgical technique involves significant excision of the soft tissues to access the torn pectoralis tendon, adhesions are common in the fascia and surrounding soft tissues. Safe mobilizations are encouraged to prevent excessive adhesion formations that would otherwise result in complete immobilization. Gentle, passive movements are believed to promote collagen repair and allow the scar tissue to heal.
Gentle scar tissue massages through the pectoral muscle can initiate at week 3 to regulate post-surgery muscle tone and to mobilize the scar tissue. Initially, this may be considerably painful due to the trauma, however, this can also progressively become more aggressive in the form of deep cross friction, continuous ultrasound and tooling used by specialists, even chiropractors or physical therapists may utilize these procedures.  
Deep soft tissue procedures to the pectoralis major can be gradually added along with regular massage, to all other shoulder/scapular muscles that may become shortened as a result of the limited mobility, including the pectoralis minor, latissimus dorsi, upper trapezius, infraspinatus and the subscapularis.
When the individual’s range of movement begins to improve, it may be required by the chiropractor to begin direct glenohumeral joint accessory mobilizations to improve the health of the surrounding structures. It may be further required to mobilize the cervical and thoracic spine with the articulations of the rib as these may also become tightened and restricted as a result of early mobility.
In more advanced stages, once the individual’s strength and original range of motion has been established, the therapist or chiropractor may be required to use manual strengthening procedures.

Strengthening Progressions

To avoid further injury of the sutured muscle/tendon/bone tissues, no direct pectoralis major contractions should be allowed for the first six weeks following a surgery. Isometrics may be initiated for other surrounding muscles as long as the arm remains in a stable range for that week. Isometric scapular setting, shoulder abduction, extension, external rotation will manage tone in the surrounding shoulder muscles.
From week 6 onwards, the individual can initiate isometric pectoralis major contractions while in a shortened position, also utilizing muscle stimulators. The strength of the contraction can be progressed almost daily. Scapular exercises may be added through all scapular ranges of protraction/retraction, upward/downward rotation and depression/elevation. Weight may also be gradually increased for the external rotation, abduction and extension activities, as long as the arm does not exceed the allowed range for that week.
By week 8, the introduction of careful Thera band exercises for the pectoralis major can be implemented, such as internal rotation, adduction and flexion. From week 8, the affected individual may also begin gentle proprioceptive-type exercises to maintain a safe range of movement for the arms. These can be simple eyes-closed reach-and-feel type drills that retrain position awareness.
From week 12, light exercises using a dumbbell may be utilized to apply careful weight into the planes of movement. The arrangement of strength recovery in strength training which can allow a safe adaptation of all shoulder muscles and protect the pectoralis major would be: horizontal pulling, such as rowing, one arm row and prone flies; horizontal pushing, such as shoulder press and dumbbell raises; vertical pulling, such as chin ups and pulldowns; and horizontal pressing, such as bench press and all the variations. High load pectoralis exercises under long levers should be avoided for six months.
Additionally, at week 12, the individual will be required to begin more advanced proprioceptive-type shoulder exercises. These may include holding specific positions on BOSU balls and alphabet writing with the hand on a SWISS ball.
Plyometric-type drills can initiate with light weights or loads at week 13 and more aggressive plyometrics would need to be delayed until the affected individual has reasonable bench press strength. These would include explosive push-ups, and bench throws with a Smith machine bar.
By week 14, PNF repeat contractions may start as long as the individual has full movement into abduction, external rotation.
Following these from week 18, the individual will start with therapies of light resistance and progress to maximum resistance. The PNF pattern starts with the individual’s arm in flexion/abduction/external rotation. The therapist, or chiropractor, can then apply pressure in the individual’s hand and on the arm. The patient then actively contracts into adduction and internal rotation. This movement is gently resisted by the therapist, or chiropractor. The common program consists of 3 sets of 10 contractions. The chiropractor can increase their manual resistance as a progression.

F/ABD/ER into E/ADD/IR Exercise



Shoulder Strengthening with Weights


After the athlete has followed the series of rehabilitation procedures throughout each week, a specialist, or other healthcare professional including chiropractors, may recommend an additional series of shoulder strengthening exercises to improve the function of the structures and tissues surround an athlete’s pectoralis major ruptures. The use of a dumbbell should be carefully considered and only utilized under the direct instruction of a specialist.

Cross Training

As for cross training exercises following surgery for pectoralis major ruptures, in the early stages, cardio exercises which do not require the use of the arms can be started, such as the utilization of a stationary bike and water running with the arm kept against the stomach.  
Cardio movements that require arm motion should be below the 90-degree shoulder plane by around week 10.
More direct arm cardio exercises, such as grinder, can be started by week 12, swimming, can be started by week 14 and boxing, which can be started by week 16, may be delayed until the end.

Return to Sport

According to the type of sport or physical activity the athlete participates in, this phase can be essential, most frequently because most pectoralis major ruptures can occur in individuals whom participate in rugby or football.
The key times and dates to implement return to sport procedures are: week 8, treadmill running with the arm in a protected posture; week 10, treadmill running with a short arm swing; week 12, unrestricted field running, not sprints; week 14, non-contact catch/pass drills and sprinting; week 16, initiating controlled contact training with 4 week progressions; and week 20 to 24, return to play if all other objectives have been met.
Pectoralis major ruptures are uncommon injuries, however, they do occur during sports and physical activities, such as wrestling, skiing, rugby and bench pressing. The greater part of complete and even incomplete ruptures typically need surgery. Rehabilitation procedures are comprehensive, involving the recovery of the individual’s original range of movement, strength and function. Rehabilitation and return to sport can generally take up to 4 to 6 months for the active athletic population.

By Dr. Alex Jimenez

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