Pain from Ligaments & Tendons
Torn or tethered ligaments and tendons can cause chronic, severe and incapacitating pain. This can result from accidents, falls, or, as in the case of muscle pain, from prolonged stretching due to poor posture and ergonomics. Acute sprains can heal, though sometimes the ligament may not return to its previous length and strength. Chronic ligament and tendon pathology have significantly reduced ability for self-repair. Particularly in the case of recurrent ligament sprains, the joint affected will be less stable and predisposed to further sprains. In addition, these injuries are capable of generating pain. An injury severe enough to cause a fracture is certainly severe enough to cause damage to a ligament. A very common example is chronic pain and dysfunction after a fractured ankle, invariably associated with chronic ankle sprains. Many motor vehicle accidents and work accidents produce ligament sprain and dysfunction which may causes chronic pain.
Often patients are not given a correct diagnosis of these problems and may be left untreated for years. A particularly common area of pain occurs in the lower back or sacro-iliac(SI) joints and ligaments.
Many people suffer from SI ligament laxity resulting from:
- traffic accidents
- chronic strain due to poor posture
- improper lifting techniques
- pathological muscle recruitment syndromes
The pelvic, or sacro-iliac ligaments (see figure 1), are especially vulnerable to such insults because they absorb the shock coming from walking/running impacts from the ground which would otherwise be transmitted undiminished to the spine. These ligaments lie around the joint but span from the lower level of the lumbar spine all the way down to the ischial tuberosity which is the bone that we sit on at the lower end of our buttock, and attaches to the hamstrings tendon. These ligaments are capable of referring pain down the lower limb even as far as the ankle (see figure 2).
Some interesting facts about the SI joints:
- The SI joint moves between 2-4mm on average during walking
- The SI joint locks during various stages of the walking cycle
- An exaggerated military posture or at the other extreme, the sway back causes stress/ strain on the SI ligaments
- Weak SI ligaments inhibit activity of the gluteal (buttock) muscles
- Spinal fusion/ spinal stenosis places excess stress on the ligaments above and below
It is assumed by many that because the SI joint moves very little then its movement is insignificant in causing pathology. Quite the opposite- if the normal movement is between 2 to 4mm, then a movement of only 1mm means that the person has only 25-50% of normal movement, even though it is only 1mm less than normal. In fact, the SI ligaments rely on a reduced range of movement in order to gain stability (as compared to the shoulder girdle) but are often sprained in trauma and accidents. With SI dysfunction, patients may feel that the hip or leg gives way when they walk. Structures in the SI joint and ligament may refer pain locally and to the buttock, and may also refer pain down the lower limb, as far as the ankle. Pain may thus be mistaken to be due to lumbar disc pathology (HACKETT 1991). In fact, as is usually the case, patients will walk into the office saying that they have disc prolapses and hand me their CT or MRI. Neither CT or MRI imaging can diagnose the SI joint in movement!!! Nothing replaces a good and thorough clinical examination! (see section on investigating the source of the pain). These ligament dysfunctions often go hand in hand with muscle trigger points within the gluteus medius and minimis (in the buttock) and the quadratus lumborum (in the loin) muscles described above. Furthermore, the muscle will never regain its full strength as long as SI dysfunction is present. Therefore, sometimes the prescription of appropriate exercises will only work once these ligaments have been strengthened. The above exemplifies why it is often important to employ more than one treatment strategy when treating prolonged pain.
Rotator Cuff Tears
Tears of the shoulder tendons may cause not only severe pain but lad to mechanical dysfunction and failure of the shoulder muscles and eventually cartilage damage. There are several biomechanical causes of these tears, and all of these must be addressed in order to avoid relapse of the problem once treated (even after surgery). Faulty posture muscle imbalances may lead to excess strain on the rotator cuff muscle such that these will develop tethering and eventually tearing. Shoulder pain can be excruciatingly painful, and has a tendency to be more severe at night due to increases in hydrostatic pressures within the bursa.
Treatment should include several methods which complement each other in order to achieve optimal results and prevent a relapse of the problem.
Knee and Ankle injuries
Ligament disruption and sprains may cause persistent pain and dysfunction. It is very common for people who have fractured bones in the ankle or knee to continue suffering pain. In most cases the bones heal, however if the injury was severe enough to result in a fracture, it was severe enough to sprain or partially tear a ligament supporting the joint. The resulting pain can linger on for months or years if not treated, and lead to compensations in nearby joints leading to further dysfunction.
Whiplash injuries result from excessive forces placed upon the neck muscles and ligaments, typically as a result of involvement in a rear end car collision.
In such cases, the impact of the aggressor car from behind causes a fast acceleration of the body to the front. Often the head is “left behind” due to it’s inertia. Once this fast forward motion ceases, the head continues to move forward.
The high velocity movements of the head relative to the body can cause subtle tears in the muscle and ligament fibres of both the front and the back of the neck. Trigger points often develop on these muscles. Both sorts of tears can cause pain to linger on for prolonged periods of time.
Both dry needling as well as prolotherapy are effective methods in treating this injury. Whatever method chosen, care must be taken to avoid faulty posture so as not to stretch already damaged muscles and ligaments and enable healing to occur after the treatment.
In addition, assuming that no fractures were incurred, it is vital to mobilise the neck and not wear a collar, as this may encourage excessive scar tissue formation within the muscles and reduce mobility in the long term
Often a patient comes into the office and says I have inflammation. I find no diagnosis less scientific than “inflammation”. Tendinitis (inflammation of the tendon) is usually a misnomer because, unless in the very acute stage, there is no inflammation but rather a degeneration of the tendon or a tendinosis, either due to an acute injury or due to prolonged wear and tear. Very common conditions are those related to the rotator cuff of the shoulder, tennis elbow, patellar tendinitis of the knee, and Achilles tendinitis at the ankle.
Since, as said above, ligaments and tendons have a reduced ability for self-repair, we inject them with solutions which cause the human body to start the self-repair process – see section on prolotherapy and platelet rich plasma.
Briuta (Mevasseret Zion): 02-585-2300
Sharap (Hadassah): 02-677-8899