Chain Reaction Injuries
Those of you who know me, would agree that I always attempt to make connections, even when those are not visible or “making sense”.
A client can arrive with chronic neck pain that has not been solved with any therapist before, and I would start looking at his legs, arms and lifestyle in order to determine the cause of said pain and not just treat the symptom.
Further to that, as can be seen in the other articles regarding pain, I have stated before that the pain felt, is almost never the cause of the pain, and lower back pain (LBP) would be addressed mostly through the legs, shoulder through the arm, chest, back and neck and so on and so forth. In this article, I would provide evidence of those connections and interrelations using the literature.
I am true believer of the osteopathic approach, which concludes two basic ideas to be based on: the body is one organism where structure and function are intertwined; The body is well able to fight disease supplied with the right environment (Tyreman, 2013).
It has been shown that there is a direct relation between ligamentous injury and reoccurring injury. It has been suggested that a ligamentous injury will be followed by reduced proprioception (body’s ability to determine placement in an environment), leading to decrease in the neuromuscular control, resulting with functional instability which will cause a repetitive injury leading back to ligamentous injury (Lephart and Henry, 1996). The cycle described is not joint specific and can occur within any joint that has experienced an injury.
A research measuring the forces passing through the ankle and the knee while performing a run and while landing from a jump, has shown that during a run the forces transmitted to the knee are equivalent to 1.6 – 3 time the body’s weight, while the same forces in a jump can reach up to 6 times the weight, depending on the type of landing measured (Dufek and Bates, 1991). This is important information we’d circle back to in a moment, but sheds light that from a functional point of view, it is crucial to have appropriate joint stability in order to have proper force transition within the joint.
A few studies that investigated the ankle and knee joints compared stability and proprioception of the joints after injury with those of healthy joints. While comparing the joint stability of an uninjured ankle with the joint stability of a post sprained ankle, it was shown that the ability to hold a single leg stance on the injured joint has decreased. On the same note, while checking injured knees, either from wear and tear due to old age or Anterior Cruciate Ligament (ACL) rupture, the ability to sense the positioning and movement, through a passive examination of the knee, has decreased (Lephart et al. 1998). From those papers, we can conclude that an injury to the ankle would result in problems with the transmission of forces throughout the body, due to the reduced proprioception of the joint, leading to a potential injury to any area of the body and not just the ankle. Furthermore, taking into consideration the body’s need for homeostasis, a dysfunction in any joint may require a different joint to compensate the instability causing it to operate outside of its functional range of motion, which can lead to an injury.
A few studies on the matter have found direct relation between the hip position or muscle strength in different regions.
A review of those studies demonstrates some of the more common characteristics. For instance, Gluteus Medius was found to be more active during sudden ankle inversion motion, with no direct connection to whether or not that ankle is hypermobile.
This supports the theory that the body would recruit different joints to compensate for a dysfunction.
Another example from the review shows that subtalar joint (ankle) pronation, which is also theorized to be connected with ACL injuries, can affect the hip abductors strength and cause imbalance between the adductors and abductors (Reiman et al. 2009). When inspecting the spine, a direct relation to the hip can be made due to the anatomical structure of the joint. The inferior (lower) part of the spine, vertebra L5, is mounted on the Sacrum which creates a joint with the hip. Any change to the structure or function of the hip would affect the Sacrum and therefore affect L5. Reviewing some of the literature on the relation between LBP and hip dysfunctions can shed some light on mechanics leading to LBP.
Spine movement has a direct correlation with our walking pattern. Subjects with degeneration of the hip joint have more movements in their spine and pelvis when having their gait inspected (Mellin, 1988). Having excessive movements in a joint while performing daily routines can lead to an overuse of that joint.
An overused joint may result with a performance dysfunction, and while said dysfunction may not cause direct injury or raise a need to stop a given activity due to an injury, an overused joint may cause an inflammation of the tendons around it (Siewe et al., 2011).
Having that in mind, inspecting the anatomy along with the body’s need for balance through compensation discussed previously, we can infer that a dysfunction due to overuse in the lower regions of the spine can effect the upper regions either by compensation overuse of the segments or by a lower tendon inflammation affecting the muscle and reaching the higher regions of the spine, including but not limited to, the cervical spine (C – spine) also knows as the neck.
Looking into the literature available on the C – spine in relation to shoulder pathologies, a C – spine degeneration may put an individual at risk of getting a rotator cuff tear. Looking at that junction from the other way, a shoulder injury can effect C – spine alignment (Katsuura et al. 2019).
To sum up all of the above, an injury in the foot, whether you feel it or not, may start a chain reaction leading up to your neck, as the placement on the ground would be a bit different, so that you avoid possible pain, and that would change the whole structure of the body along with force transmission, which, as was shown before, can vary according to the activity you partake.
I know this information is a lot to take in, but I am sure that with this bottom line in mind, you may ask your therapist (GP, Physio, Massage, etc.) to try a more holistic approach to your pain instead of treating the same area every time when you present the same symptoms.
Written by Zilber, Medical Massage Therapist.
If you have any questions regarding the article or want to consult me regarding yourself, please feel free to reach out to me and let me know. This was made to high light the connections present in the body between different regions when looking at pain symptoms. Consult a professional before changing anything in your routine to maximize your benefit. Stay Safe!
Dufek, J. and Bates, B. (1991). Biomechanical Factors Associated with Injury During Landing in Jump Sports. Sports Medicine
Katsuura, Y., Bruce, J., Taylor, S., Gullota, L. and Kim, H. (2019). Overlapping, Masquerading, and Causative Cervical Spine and Shoulder Pathology: A Systematic Review. Global Spine Journal
Lephart, S. and Henry, T. (1996). The Physiological Basis for Open and Closed Kinetic Chain Rehabilitation for the Upper Extremity. Journal of Sport Rehabilitation
Lephart, S., Pincivero, D. and Rozzi, S. (1998). Proprioception of the Ankle and Knee. Sports Medicine
Mellin, G. (1988). Correlations of Hip Mobility with Degree of Back Pain and Lumbar Spinal Mobility in Chronic Low-Back Pain Patients. Spine
Reiman, M., Bolgla, L. and Lorenz, D. (2009). Hip Function’s Influence on Knee Dysfunction: A Proximal Link to a Distal Problem. Journal of Sport Rehabilitation
Siewe, J., Rudat, J., Röllinghoff, M., Schlegel, U., Eysel, P. and Michael, J. (2011). Injuries and Overuse Syndromes in Powerlifting. International Journal of Sports Medicine
Tyreman, S. (2013). Re-evaluating ‘osteopathic principles’. International Journal of Osteopathic Medicine