Sports medicine, unlike other specialties today, is in its fetal stages of development.
Pre-season exams performed on athletes are medical exams, despite the fact that most sports injuries are structurally based injuries.
No one ever looks at the athlete from a structural point of view. Top college and pro athletes have strength coaches, who work on strength and conditioning, but no one ever evaluates an athlete structurally, before, during or after an injury. Until all athletes are structurally evaluated, injuries will never fully be understood, prevented or treated.
Current sports medicine system
Injured athletes are typically treated symptomatically. Whether the athlete sees a medical doctor, orthopedist, chiropractor, or physical therapist. Care is usually given to remove the symptoms. Once the symptoms are gone, we live under this misconception that the athlete is stable. This protocol has become commonplace in the sports medicine community, as the insurance guidelines will generally only allow for care with a diagnosis.
This equates to drawing a circle around the sight of pain, and doing whatever is necessary to relieve the pain (within the time frame the insurance company allows). Although this defines the standards that most doctors practice by, it is thoroughly inadequate care for the athletic population. Athletes deserve better, and no one is better qualified than the chiropractor to provide this advanced care.
Athletes have become so accustomed to poor quality sports medical care that they self-treat more often than not, knowing that in many cases their doctors are unable to help. And the thought of “stop exercising” as an effective recommendation is out of the question. In most cases, there is no need for the athlete to consider stopping their exercise, unless it’s part of the rehab plan. But as a treatment unto itself, it more often than not is a clear indication the doctor is in the wrong specialty.
Three categories of athletes
All athletes fall into one of three categories.
- Injured with symptoms
- Injured without symptoms
- Not injured without symptoms.
Regardless of which category a patient is in, we should be able to dramatically help every athlete today. We’ve got to stop thinking that the only athletes who need our help are those in category 1. Our collective goal is to educate our athletic communities and to begin seeing athletes in categories 2 and 3.
Every athlete lives with structural defects. Every athlete has had prior injuries, has hereditary weaknesses, conditioning problems, dietary problems, physical, emotional, chemical and thermal stresses, equipment deficiencies, etc. that contribute to structural defects. Every athlete lives with deferred structural maintenance, as most have never been fully examined to locate individual structural defects, nor treated to correct them.
Chiropractors are the most qualified to make the biggest advancement in sports medicine history by standardizing the tests performed and re-educating athletes as to the necessary structural corrections that need to be made. This effort will dramatically reduce the likelihood of injury in an athlete’s career, improve the capacity for conditioning and performance and heal an injured athlete much quicker and more effectively.
The Structural Fingerprint exam
This structural exam looks at the athlete as an architectural structure, from foot to head. All defects, imbalances, fixations and distortion patterns are noted. Once performed, the objectives are to reduce or eliminate symptoms and then restore balance and mobility back to the structure. Objective testing and re-testing guide a doctor along the way. The thought that a patient needs only 12-15 visits per year is ludicrous, especially if you’re talking about correction of structural problems.
Tests begin with an examination of the feet, with the athlete in the standing position. Five tests are performed(See Figure 1).
- Noting any flaring out of the toes upon standing,
- Checking the medial arches for height and symmetry,
- Checking the Achilles tendons for bowing (either in or out),
- Checking shoes for even wear patterns and
- Checking the patellas for abnormal internal or external rotation. In most cases, the athlete will structurally benefit from custom orthotics, especially if any of the above is positive.
The testing then involves range of motion, leg length checks , deep tendon reflexes, basic orthopedic tests, muscle compliance tests, muscle strength, and flexibility tests and neutral postural observations.
The majority of the information used comes from the standing X-rays. An A-P Open Mouth , Lateral Cervical (fig. 4), A-P L-S (fig. 5) and Lateral L-S (fig. 6) are taken. After ruling out pathologies, a variety of structural information is measured and noted. Once all data is collected, a 6-8 month structural correction program begins.
A case study
Sally Stibinger came into my office in May 2002. She was a patient of another chiropractor, however, the chiropractor could not provide relief nor did they do a thorough examination or X-rays on Sally. Her complaints were rather simple; right medial knee pain following a lengthy period of left medial knee pain. For the left knee pain, Sally saw her orthopedist, who X-rayed the knees, did an MRI, and concluded nothing was wrong.
Sally also suffered with long term low back pain. These combinations of symptoms were preventing Sally from beginning her quest to become a triathlete at the age of 64.
Sally’s first chiropractor adjusted her each time she went in to relieve pain, but Sally needed much more than this. No structural evaluation was performed, and the “shot in the dark” adjustments provided no relief. In addition to the knee pains, Sally stated her shoes always wore out on the outside very quickly. She had a history of low back pain with sciatica in the left leg. Her new goal was to run her first triathlon, and her visit to me was to find out if it was ever possible.
I told Sally that after we performed our Structural Fingerprint exam on her, we’d be able to give her a reason for the knee pain and a status report on her structure to then have an educated opinion on her attempt to run this triathlon. Sally’s medial arches were neutral, her patellas were aligned normally, her shoe wear was excessive externally on both shoes and her Achilles appeared normal.
There was pain and restriction on L-S lateral flexion bilaterally. Cervical range of motion showed restriction bilaterally. There were multiple sights of tenderness on palpation due to trigger point involvement. Palpation of the medial proximal tibia produced severe pain, more pronounced on the left than the right.
On x-ray evaluation, Sally had multiple issues. Keep in mind we’re looking at this athlete from an engineering and architectural point of view. On the lateral cervical view, Sally had an anterior gravity line, suggesting the weight of the head (10 percent of the body’s weight) was anterior to the part of the spine designed to handle the weight. This weight distribution problem contributes to the straightening of the lower cervical spine and the degenerative changes in C4/5, 5/6 and 6/7 disc spaces. The abnormal weight distribution increases the likelihood of joint fixation, reduced circulation to the disc and ultimate joint degeneration.
On the A-P L-S , Sally’s pelvis is dropped on the right side approximately 1/8”. The spine doesn’t align with the pubic symphisis as a result of the drop of the right pelvis. This increases the need for custom orthotics, as the foot imbalances are seen both passive and active, and balance in the feet will help to level and stabilize the pelvis.
On the Lateral L-S, there are a variety of structural problems that further magnify the need for corrective work to be done on Sally. Her history of low back pain and sciatica is more than enough information to encourage rehabilitation. Sally had a 35° sacral base angle (normal is 36°-42°). L3 has moved anteriorly on L4, and the L5 disc space has gone through degenerative changes suggesting a lack of normal motion in that joint for many years.
Again, looking at this athlete as an architectural structure, we know the low back has had to function abnormally for many years to get to the point it’s at. With custom orthotics and a proper rehabilitation program, dramatic improvements can occur.
Recommendations
We made three specific recommendations to Sally; get fitted for custom orthotics, begin our Muscle Management program and begin our Advanced Conditioning Program.
- Custom Orthotics-These should be fitted in the standing, weight-bearing position. Rigid orthotics should be avoided as they inhibit the normal mobility of the foot, which is obviously bad for an athlete. Sally purchased both custom orthotics as well as sandals with her orthotics built right in.
- The Maggs Muscle Management Program-This program uses the principles of M.D.’s Travell and Simon’s trigger point work and applies them to the athlete for advanced warm-up of the muscles, accelerated recovery of the muscles and a more efficient treatment for muscle injuries.
- The Advanced Conditioning Program-This program is one we’ve designed to allow us the necessary time to make structural changes in patients. Limited treatment provides minimal and temporary benefits, while a 6-month time frame can help to make permanent changes
Once we’ve determined the specific structural defects present in an athlete, they begin our ACP program. This is a 6-month program that combines 40 adjustments with an individualized exercise program designed by a personal trainer who works in our office. The exercise program is based on 3 things; the patients structural needs, their athletic/fitness goals and the progression of exercises our personal trainer has developed.
At the time this article was written, Sally had completed just over two months of adjustments and exercise. Her knee pain has been resolved for over six weeks now, primarily due to the custom orthotics, and she has had no back pain or sciatic pain. Sally’s training consists of running, cycling, and swimming each week.
At the appropriate time, re-X-rays will be taken on Sally to record the structural changes that were made. Once Sally has completed her 6-month program, she will then enter our Lifetime Structural Management Program. This program will encourage Sally to continue necessary care and exercise/habit program that will help keep her in triathlon shape.
Conclusion
This approach to the athlete allows us to truly screen athletes and teams prior to or during a season. It separates us all other sports medicine providers who compete only for the injured athlete. We will become the specialist at predicting injuries and correcting structural defects. With all chiropractors incorporating this Structural Management Program into their offices, chiropractic will guide sports medicine to new and exciting possibilities in the sports world.
Tim Maggs, DC, specializes in sports medicine and industrial medicine. He is a graduate of the National College of Chiropractic. In addition to his practice, Maggs likes to spread the word on biomechanics by authoring numerous columns, producing a talk radio show on sports medicine, and speaking at numerous engagements. You can contact him at 518.393.6566, or visit CPOYA.com.
