38

a chiropractor’s perspective

the knee bone’s connected to the thigh bone…

MARC LEGERE, DC, BS, BA

Editor’s Note: I asked my friend Marc Legere while he was the Phillies’ chiropractor to offer his viewpoint on the core. As you will see, Marc makes complex things simple and fun.

As a physician who specializes in physical pain, I often have patients describe pain throughout different parts of their body. What is often surprising to them is that, more times than not, the pain that they feel in one part of their body is due to a problem or dysfunction coming from another, “unrelated” area.

One thing that you have to keep in mind as we discuss injuries in this section is that your musculature is the true key to proper functional movement. If a muscle is injured, shortened, or doesn’t function properly, you can develop issues in your joints, ligaments, tendons, discs, and nerves locally or at another location in the body. With that said…

Remember that song “Dem Bones”?VID 1 That’s the song that says “The knee bone’s connected to the thigh bone, the thigh bone’s connected to the hip bone, the hip bone’s connected to the back bone…”. As funny as it may sound, that song is more true than you know. This “bone connected to another bone” lyric describes what in medical terms is referred to as the kinematic chain. The word to focus on in the word kinematic is “kine.” Kine is short for kinesiology, which according to the Merriam-Webster Dictionary is “the study of the principles of mechanics and anatomy in relation to human movement.” Now look at what, according to www.thesciencedictionary.com, is the definition of the word kinematic chain. That definition is: “A number of links connected to one another to allow motion to take place in combination. It becomes a mechanism when so constructed as to allow constrained relative motion between its links.” What both of these are saying is that a muscle or bone in one location can affect another muscle or bone at another location because of a chain of related movements.

PROPER EVALUATION

Keeping this in mind, in order for a physician to properly evaluate a patient for the first time, he/she should possess an in-depth knowledge and understanding of how the body works as a unit to properly diagnose what the actual problem is. Most of our clinical knowledge comes from information that isn’t found in many textbooks. While anatomy and injuries are taught in school, the clinical connections that are seen in practice are not. With that said, we need to consider both core and non-core muscles in order to properly fix a core muscle injury. If we simply focus on fixing a painful muscle, we may be setting the patient up for future problems. We need to expand our scope to consider the damaged and causative muscles at the same time.

OK, so you may be saying to yourself, now that I know that I can’t just focus on the core, where else should I look?

During an examination, I always like to focus on all of the non-core muscles first, and then work my way back to the core muscles, ensuring that I don’t miss anything. With that said, let’s take a look at a motion below the pelvis and then one above the pelvis to see how they can affect our core muscles.

THE FOOT, THE BRAIN, AND THE NECK

An improperly functioning foot can wreak havoc on our core muscles. Let’s reference our “Dem Bones” song to help us trace our way up to the pelvis. “The foot bone’s connected to the shin bone, the shin bone’s connected to the knee bone, the knee bone’s connected to the thigh bone, the thigh bone’s connected to the hip bone.” You can see how the domino effect that occurs in the foot can connect to the hip due to these connections.

When the foot collapses inward, “losing your arch,” a stress occurs on the inside portion of the knee. This creates an opening of the inside portion of your knee joint. This opening causes the inner portion of the thigh to move even farther inward. That movement can either pinch the inner muscles of the thigh or cause the muscles that prevent the inner motion of the thigh to have to work harder and therefore become painful or damaged. If we look at a foot that rotates in the opposite direction of the arch, a stress occurs on the outside ankle joint. That stress puts additional pressure on the outside portion of the knee. This leads to either an opening between the pelvis and thigh or an outward rotation of the leg, which causes a shortening of the muscles in the posterior pelvis and hip. In either case, these far away areas create problems in the pelvis.

Now you may be asking yourself, if I have foot problems, why doesn’t it feel like they are working improperly? Well, it’s a pretty simple answer…the brain! Our brains are amazing machines that can adapt to different stimuli or challenges very quickly. The ability to learn a new pattern or motion is called neuroplasticity.¹ Exactly how fast does the brain adapt? Within 24 hours.

What I mean is that your brain has already started making changes to muscular firing patterns as soon as it experiences pain or restricted motion. After approximately 48 hours, the body has made global changes to movement that begin to feel normal. It is the concept of practice makes perfect or learning a new golf swing. If you start to learn a new swing, at first it feels very awkward, but, over time, your body has made the necessary changes to its firing patterns and movements.

With that in mind, we can see how an ankle sprain 2 to 3 years ago set the stage for a core muscle injury today. That improperly moving, normal-feeling ankle has begun the domino effect all the way into the pelvis.

To examine another muscle group far from the core, that still affects the core, let’s look at the neck. Our “Dem Bones” connection here is: “The neck bone’s connected to the back bone, the back bone’s connected to the hip bone.” If you have bad posture, you usually hold your head forward of where it should be. This is common for people who work at desk jobs because their monitor is too low or because their chair is too high in relationship to their keyboard. When the head moves forward, the mid-back arches forward to compensate. Because the mid-back arches forward, the low back increases its arch, which in turn pulls on the core muscles in both the front and back of the pelvis, similar to pelvic tilt discussed in Chapter 28. In the front side of the body, the abdominal muscles are stretched and the thigh muscles are shortened. In the posterior portion of the body, the joints in the back are compressed, and the hamstrings are stretched out.

LET’S TALK SPECIFICS

So now that we are on the same page about how our core muscles are truly global muscles, let’s talk specifics. Once we can diagnose the true cause of our pain, we then need to look at all of the methods of treatment that can be utilized to either prevent injuries or to recover from injuries in the fastest way possible. If we look at all of the medical specialists that can help prevent or recover from core muscle injury, the list can be long. In my interactions with professional athletes, they use one or all of the following specialties to help with an injury:

• Surgeon
  
• Chiropractor (modern)
  
• Physical therapist
  
• Yoga instructor
  
• Primary care physician
  
• Sports medicine physician
  
• Pain management physician
  
• Massage therapist
  
• Athletic trainer
  
• Nutritionist
  
• Strength and conditioning specialist

The list of specialists is quite long and can be overwhelming if you do not know where to start. This is where an integrated institute comes into play. The Vincera Institute has developed a truly unique team of specialists who look at a patient’s injury from a global point of view. By working as a team, they can all focus on what we do best with one goal in mind, patient injury prevention and recovery.

For this chapter, I am focusing on how a modern-day chiropractor should address your physical injuries. I am not sure what first pops (Get it? “…pops”?) into your head when you think of chiropractors, but the first thoughts can be negative and rightfully so. Chiropractic has needed to evolve, and has finally begun to evolve in recent years. A much better term for what a chiropractor is should be manual (meaning hands on, nonsurgical) physician. Having said that, let’s stick with the title of chiropractor or chiropractic for the chapter just to keep things simple.

ADJUSTMENTS

Before I get going, I want to address 2 topics: (1) what an adjustment or manipulation actually is and (2) what happens during one? First, to me and the rest of the medical world, an adjustment is, in its most simple sense, a stretch. Yup, that’s it…just a stretch. Now, there is nothing wrong with that, and as we all see or feel it throughout our lives, a stretch can be really beneficial. But to claim that it does anything more than restore motion in a fixed or improperly moving joint is difficult; unless you can prove it, don’t claim it. There is research on adjustments/manipulations that show that an adjustment can help with nonmuscular conditions, but where we can make our biggest impact on our patients is when there is physical pain.

Second, let’s address the infamous “pop” that happens during an adjustment. The popping that occurs during an adjustment is one of two things:

1. The sound of a pop is air escaping a restricted or stuck joint (Figure 38-1). The bone is never out of place and a manipulation does not put a bone back into place. We know through our study of the kinematic chain that muscles are the movers of joints and if a muscle is restricted in its motion, the joint is restricted in its motion as well.
   

   Muscles on one side of a joint need to move well enough so that muscles on the opposite side of a joint can pull the bone through a specific range of motion. If the antagonistic, opposite muscle of a pulling muscle is tight, the joint cannot easily move through its normal range. Imagine a tug of war between 2 teams pulling on a rope or in our case a bone. The stronger one side pulls, the harder the other side has to pull in order to get movement.

   
   

   During normal movement of a joint, air moves in and is released out of a joint. In an improperly functioning joint, the air moves into a joint but does not have enough movement to leave the joint. This creates an accumulation of air in a joint until an adjustment/manipulation or stretch comes along. By creating a movement that opens up the joint, the air finally has enough space to release and then the infamous “pop” is heard. Think of opening a bottle of soda. When you give the air inside the bottle a place or way to escape, it makes a popping sound.

   
   
2. The second time that you hear a pop is when you have created enough movement in a joint where a tight or shortened muscle that is caught or stuck behind a bony growth or bump finally gets stretched enough to pass over the bump and slaps down onto the bone (Figure 38-2).

Related posts:

Putting It All Together—A Patient’s Perspective on the Core Nerves in the Core—A “Fifth Dimension” The Final Stage of Rehab—Getting All the Way Back The Other Muscles—Hip and Core Stability Biomechanics Presenting…the Core!

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