The tensor of vastus intermedius is respresented by the "Red 1" in this diagram.
MEDICINE IS STILL AN IMPERFECT SCIENCE, EVEN WITH QUANTIFIABLE
TRUTHS. Anatomy can, and does, change.
The image above is a comparison of a normal Left thigh (quadriceps muscle group) with the newly discovered muscle in RED, the kneecap (patella) is located at the bottom of the image
. Traditionally, there are 4 muscles that compose this group: Vastus Lateralis (2-VL), Vastus Intermedius (3-VI), Rectus Femoris (5-RF) and Vastus Medialis (6-VM). Here is a link to the article by Grob et al (2016), recently submitted to the journal Clinical Anatomy. http://www.ncbi.nlm.nih.gov/pubmed/26732825
Because anatomy rarely changes, it is exciting for the scientific and medical communities when research such as this is released. As I just stated, traditionally the quadriceps consist of 4 distinct muscles on the front (anterior) portion of your thigh. These muscles act mainly as knee extensors (i.e. kicking a ball in front of you) and contribute slightly to hip flexion.
Considering I am currently teaching lower extremity anatomy in my undergrad course
, I will absolutely investigate some cadavers in the upcoming week. Let's see what I can find...What's the big deal?The finding of this muscle, which was identified on 26/26 cadavers in this study, implies that the Vastus Intermedius (3-VI) is impacted by a separate and independent structure. This structure was given the name "tensor of vastus intermedius", as it's contractile fibers apparently pull/tense the larger vastus intermedius muscle. This study also indicates this new structure is supplied by distinct blood vessels and nerves, further contributing to the notion that this is an true muscle. The ramifications of this research would likely impact imaging procedures like MRIs, physical therapy/corrective exercises, massage techniques and certain surgical procedures.
Although our understanding of the human body is quite extensive...nothing is 100% accurate. MEDICINE IS STILL AN IMPERFECT SCIENCE, EVEN WITH QUANTIFIABLE TRUTHS. We as humans are fallible creatures and therefore anything we participate in has fallibility, including the assessment of anatomy. Another Example:
To illustrate this point again, look at the image of a Right knee below.
The Anterolateral Ligament is a recently discovered ligament located on the outer aspect of the knee joint.
The structure labeled the Anterolateral Ligament is a relatively new discovery, the corresponding study
was published in 2013 int he Journal of Anatomy. http://www.ncbi.nlm.nih.gov/pubmed/23906341
The researchers hypothesize that this ligament is responsible for limiting certain rotation forces in the knee joint. Additionally, this ligament may actually be the structure damaged when ACL injuries are thought to occur. This notion may support the relatively high number of unsuccessful ACL repairs.
I hope you share in my excitement as we introduce the world to the tensor of vastus intermedius. Ok, maybe not the whole world, but rather the finite group of anatomy dorks like myself. As always, I value feedback and look forward to hearing from you.
"TO BE HONEST, I DISCOVERED A CAROTID BRUIT IN A PATIENT DURING MY FIRST YEAR OF PRACTICE. IT WAS A COMPLETELY JARRING EXPERIENCE."
Patients everywhere are beginning to question the necessity of a chiropractic manipulation...HERE'S WHAT YOU NEED TO KNOW.
It's all over the news: Model Katie May passed away at the age of 34. Here is just 1 article of many
describing the situation: http://www.nydailynews.com/entertainment/gossip/model-katie-death-fall-photo-shoot-article-1.2521755
This type of story tends to circulate around the media every time a similar situation occurs in our field. Unfortunately, it perpetuates the general public's fear of chiropractors. There is NO DIRECT CAUSE-EFFECT RELATIONSHIP BETWEEN STROKES AND CHIROPRACTIC MANIPULATIONS. HOWEVER, IT IS A VERY REAL RISK FACTOR THAT ALL CLINICIANS AS WELL AS THEIR PATIENTS NEED TO BE AWARE OF.
The trauma she experienced on a photo shoot that led her to believe she was experiencing a pinched nerve, was likely the injury that resulted in a tearing of her carotid artery. Check out the image
below for the anatomical and pathological significance of this condition.
Essentially, a tear occurs within the artery itself, leading to a blood clot (which is your body's attempt to repair the damaged structure). This blood clot, or fragments, may then become dislodged and travel downstream to important structures in the face and brain. Once the clot (or fragments) reach a small enough blood vessel that is impassable, nutrient deprivation occurs to that area. Certain signs and symptoms should be evident at this point. Unfortunately, prior to this stage of the condition, signs and symptoms may be relatively vague...such as neck pain.
The American Stroke Association
estimates that 10% of strokes occur in people under the age of 45, like May. Most of you probably associate stroke with the elderly population but this is a dangerous misconception
. Now, although I am obviously a chiropractor, I am not going to blindly
support the chiropractor involved in this case. WHY? Because there are necessary questions and procedures to medically rule in or rule out stroke as a diagnosis.
FAST is the acronym regularly advertised by the American Stroke Association now and is a great tool for the general public's recognition
of a medical emergency.FaceArmSpeechTime
More specifically, look for:
Face-drooping or face numbness
Arm weakness or arm numbess
Speech difficulty or slurred speech
Time to call 9-1-1 as these symptoms indicate a medical emergency.
HOWEVER...when a patient presents to a doctors
office with vague neck pain induced by trauma that is not improving, a more thorough clinical investigation should follow. While nothing is 100% accurate, there is a significant likelihood that if your neck pain resulted from an arterial dissection, the following will assist the clinician in determining the cause. If a carotid dissection is expected, the patient should have a doppler ultrasound of the carotid artery
to determine the severity of the clot or plaque build-up.
So here are the steps I take in my office to rule out the possibility of stroke.
Ask the 5 Ds And 3 Ns
in the office for anyone with neck pain or headaches as well as auscultation of carotid arteries
to detect a bruit (an abnormal whooshing sound).
Diplopia (double vision)
Dysphagia (trouble swallowing)
Dysarthria (trouble speaking)
Dizziness (vertigo-like symptoms)
Drop attacks (spontaneous falls)
Ataxia (loss of controlled bodily movements)
Numbness (abnormal sensations)
Nystagmus (repetitive, uncontrolled eye movements)
Nausea (uneasiness of stomach)
Auscultation of carotid artery below:
TO BE HONEST, I DISCOVERED A CAROTID BRUIT IN A PATIENT DURING MY FIRST YEAR OF PRACTICE. IT WAS A COMPLETELY JARRING EXPERIENCE. I am in no way trying to "toot my own horn". It is necessary for those of you reading this to know that I do take the medically necessary steps to determine the cause of your pain and will absolutely refer to other medical providers if indicated.
There are risk factors associated with any and every medical procedure...from a basic blood draw TO chiropractic manipulations TO medications TO surgical interventions.
I hope that you realize that the media has portrayed this inappropriate connection between chiropractors and stroke. If you seek care from ANY MEDICAL PROFESSIONAL: ASK ABOUT POSSIBLE RISKS ASSOCIATED WITH THE PROCEDURE.
As always, I look value feedback and look forward to hearing from you.
The MOST IMPORTANT QUESTION in physical medicine:
WHY DO YOU HAVE PAIN THERE? AND HOW DO WE FIX IT OR MANAGE IT?
Scrolling through Instagram...(yes we all do it)
I came across a great clip demonstrating a complex connection through a basic exercise. Since my last few posts have had little to do with human movement/anatomy, it is about time I share some knowledge of this topic. After all, that's the focus of my practice.Do you know someone with hip, knee, ankle or foot pain?
I'm sure that all of us could think of a friend, family member, co-worker, classmate or colleague that has one of these ailments. Many patients come into my office and assume that because their knee hurts...their knee is the problem. Usually, they're wrong.
IN MY WORLD OF HUMAN ANATOMY, THE SITE OF PAIN AND THE CAUSE OF PAIN IS OFTEN NOT THE SAME. ( a previous post of mine on this topic, http://dynamicphysicalhealth.com/2/post/2015/07/it-hurts-righthere.html
Check out the photo below, then I'll explain.
Let's look at the image on the LEFT (with posterior at the top).
I am going to attempt to explain this in non-medical terms, as well as anatomical/medical terms.
Tilt your butt backwards OR tuck it underneath...
-this leads to your hip joint rotating outward slightly
-this leads to torque on the knee joint, force is outward
-this leads to your lower leg rotating outward slightly
-this leads to a slightly higher arch in your foot
Posterior pelvic tilt...
-leads to hip external rotation
-leads to external rotation torque at tibiofemoral joint
-leads to tibial external rotation
-leads to supinated foot position
I tried to coordinate the 2 sides to make it easy for the visual learners reading this post. Actually try this at home...perform a posterior pelvic tilt (or tuck your butt underneath yourself) and see what happens.
DO YOU FEEL THE MOVEMENTS I DESCRIBED?
If you do...great! If you do not...you may lack adequate gluteal activation or have other issues along this entire kinetic chain (which also extends well above your hip by the way). Next time you have pain anywhere along this chain, think of this basic movement and how all of these areas are SYNCHRONOUSLY CONNECTED. So, if you seek care from a movement professional like myself and they start evaluating a different area of your body, realize this is fairly normal in our world. By the way, this kinetic chain is just one example of the many bio-mechanical connections throughout the body. Yes, the shoulder blade not moving properly can effect the wrist...crazy, I know. Yes, the neck can effect the feet...crazy, I know.
The reason for this post is 2 fold----
1. To demonstrate I actually understand and apply my physical medicine knowledge (other than write about doctor-patient relationships)
2. To illustrate that although helping people "get out of pain" seems rather straightforward, it's not.
Clinicians like myself have a whole host of observations to make, questions to ask and tests to perform to answer the most important question in physical medicine...
WHY DO YOU HAVE PAIN THERE? AND HOW DO WE FIX IT OR MANAGE IT?
I have included a brief video demonstrating this movement, hopefully this helps. Notice the movement at my feet (although minimal). And please...TRY THIS AT HOME. As always, I value feedback and look forward to hearing from you.
THE DISTINCTION I WANT TO MAKE IS THAT BOTH QUANTITATIVE AND QUALITATIVE INFORMATION NEED TO BE GIVEN EQUAL ATTENTION. DO NOT PLACE QUANTITATIVE INFORMATION ON A PEDESTAL ABOVE QUALITATIVE.
This past weekend I attended a continuing education seminar through the McKenzie Institute, an amazing assessment and treatment method. As I was standing in the back of the room (yes, I'm that person because sitting too long drives me crazy) watching the instructor assess a patient, it hit me... One of the reasons this method works so well is because although it utilizes quantitative information, THE QUALITATIVE INFORMATION DOES NOT GET OVERLOOKED.
The world of science and much of the world outside of science rely on quantitative information. Measurements, recordings and tangible evidence are the focus of research studies. People discuss game scores, pounds they lost, horsepower in cars, number of emails in their inbox, length of time they worked and the list could go on. But let's apply this thinking to the world of medicine.
Being an evidence-informed doctor, I absolutely agree with using quantitative information to progress healthcare.
Here's the problem: WE FORGET ABOUT QUALITY.
What about the description of interactions? As opposed to attempting to quantify everything, we should absorb the environment around us. Describe (mentally, not aloud) how engaged your doctor is in your visit or how thorough of a physical exam is performed or how educated you are on your condition....
The qualitative description suddenly becomes immensely important.
Consider someone with years of education and "alphabet soup" behind their name indicating many, many credentials. Does the number of their credentials indicate they will provide quality care? It could, but not always. We must consider the quality of situations.
Although qualitative information does not hold as prestigious a position as quantitative information in research... there is still significant validity. Especially in medicine, quantitative information is the "gold standard". We know for a fact how many milligrams of a drug to administer, how deep an incision needs to be, how much motion occurs at a joint and how much time it takes for a procedure (medical coding is sometimes based on this). What about the rest of the picture? This quantifiable information provides only some insight into a much more complex organism.
Let's take joint motion as an example: I can move your shoulder complex through various motions and take measurements to determine exact degrees occurring in a particular direction (quantitative). However, even if you can achieve full shoulder extension (reaching behind) what does the movement look like? Do you experience grinding/clicking or cold sensation in your hand? Does your scapula move appropriately in relation to your thoracic cage and neck? Are you compensating with inappropriate muscles to achieve the full range of motion? These are obviously all qualitative observations and ones that I make on a daily basis.
At the end of the day, our society places too great an emphasis on quantity and too little emphasis on quality. The quality of: our work, our interactions with others and our overall life. Life is not simply measured in the number of years you have lived but in the experiences you have had (it sounds a little corny, but it is true).
IF WE ALL FOCUSED MORE ON THE QUALITY OF OUR EXPERIENCES, EVERYONE WOULD BENEFIT, ESPECIALLY IN HEALTHCARE.
Recently, I met with a colleague who informed me of a rather unimpressive appointment with a surgeon that resulted in seeking a second opinion. As the research on other qualified surgeons began, one with an appealing section on their website titled "4 questions to ask your doctor" caught her attention.
Ordinarily I would not have given this a second thought. But, something about the excitement in her voice and the light in her eyes forced me to re-consider.
I then made my mind alternate between 2 viewpoints, the doctor's and the patient's.
From the patient's perspective, why is a list of "4 questions to ask your doctor" so enticing? What makes this different from other websites she had seen? Why did she decide to stop searching and schedule an appointment with this doctor?
From the doctor's perspective, why is a list of "4 questions to ask your doctor" so enticing? (I know, same question as before, just from a different character's view) What would make me decide to post this on my site? Why would a patient stop searching and decide to schedule an appointment with me?
As we continued discussing my colleague's medical options, it became extremely apparent that what she was seeking was a connection. She wanted to feel that she could connect with this surgeon, rather than just simply agreeing to a procedure because the doctor had experience and determined it was necessary. Although this surgeon did have past experience, it was this doctor's ability to remain real and humble that sparked my colleagues interest.
In medicine, as well as life, I think we all seek connections. The ability to connect with another person is an inherent trait we all possess. (this can occur on many different levels)
Look at how social media allows us to connect with others all over the globe (you can even quantify how many people you've connected with). Look at how 2 friends meet over breakfast. Look at how a father and son play a game together.
It's all about connections, the HUMAN-NESS of our lives.
After thinking about this situation from the doctor and patient standpoint, it is apparent that we yearn to connect with others. Even if the other is standing at the OR table while we are under anesthesia....
So, let's get to the:
4 Questions to Ask Your Chiropractor
1. How do adjustments work?
2.What will my first visit look like?
3. Are you willing to co-manage with another clinician?
4. What are the risks/benefits/alternatives to your treatment?
Next time you interact with a chiropractor or another healthcare professional, think about asking similar questions. You already know the WHY.
My colleague's appointment with this doctor was not a disappointment; there was a connection, a human-ness to the interaction.
In the first week of the new year, I wanted to contribute to the whirlwind of New Years resolution articles on the web.
As we begin 2016, everyone will be discussing their goals for this year. Whether these are the always popular "I'm losing weight." goal OR the "I want to learn a new language this year." goal OR the "I'm giving up caffeine and alcohol." goal, there is that little voice in our minds telling us how unrealistic our goals are.
(I'm borrowing that from my church's recent sermon series, but I know they won't mind)
FEAR NOT. If you are truly determined to lose weight or learn a new language or give up a vice, then DO IT. But, do it properly.
"What do you mean by that?", you ask. This is what I mean:
Set realistic goals, research appropriate benchmarks and methods that others may have employed, find a support person/group to lift you up when you're feeling down, document short-term goals that are progressing you towards your overall goal.
Most important of all...FEAR NOT. Do not let setbacks become permanent roadblocks to your end goal. If you stumble, learn from it and continuing moving forward; always with your goal in focus.
Stay FOCUSED. Stay POSITIVE. Stay HUNGRY. (for your goal, not food if you are looking to lose weight) These tips are just a few things I've learned along the way and I hope they provide some support on your journey into 2016.
Another important idea for this whole "New Year, New You" trend is that some of you may not have a ground-breaking goal for this year. Many of us tend to have less dramatic, less evident goals for our lives.
Maybe your goal is to just walk your dog 3 times per day instead of once. Maybe your goal is to have 1 cup of coffee per day instead of 4 cups. Maybe your goal is to run a 5k once per month. Whatever your goal, BIG or SMALL, utilize support tools and FEAR NOT.
(By the way, although this is based-off of a Christian concept -- ALL of us can rally around this idea of 'Fear Not' to better ourselves, regardless of beliefs)
HAPPY NEW YEAR (of NO FEAR)!!
As a doctor I sometimes find myself thinking about things from the patient's perspective. I know that may seem strange and maybe I am just being over-intuitive, but I truly want to understand my patient's situation. This includes not only the medical aspect of their condition but how does this effect their daily life, their social interactions, their psychological and emotional health.
Now I know some of you may be saying to yourselves..."This sounds a little too 'holistic' and idealistic for me." While I agree with you on a certain level, there really is a bio-psycho-social aspect to PAIN. For me to understand this (because every patient is different) I always try to be as empathetic as possible. This means I am attempting to understand your situation.
Patients that seek care from me are spread across the spectrum of activity levels...there are patients in their 30s that exercise intensely 5-6 days per week, then there are patients in their 70s-80s that find it difficult to simply walk from the store to the car. I hear many different complaints from patients, as far as how their pain impacts their lives, and it is crucial that I have empathy.
Next time your doctor spends time asking questions that seem to be unrelated, put yourself in the doctors shoes who's trying to put themselves in your shoes... (terribly confusing, I know)
Ask yourself, "Is this really for me? Will this be helpful if I tell my doctor about this?" YES! It is important to share details that you may think are insignificant or unrelated, they can often unlock important factors related to your health, bio-psycho-social factors included.
Enjoy the day and be blessed!
Please Consult your doctor before beginning an exercise program.
Check out this quick, bodyweight, no-equipment-needed workout on this Thanksgiving holiday. Maybe you can indulge and enjoy that extra slice of pie. On this Thanksgiving Day: BE BLESSED!
That is what we need to say to the active duty and veterans of the military. Regardless of whether or not you agree with the reason they were deployed, as a citizen of this country you need to as least support the individuals fighting for this nation.
One of the ways I can say thank you is through this organization…..The Patriot Project.
I look forward to sharing more information and progressing my profession.
I recently saw a patient that felt unsure, confused, lost and perplexed by a medical decision. Essentially, the decision this patient has to make is to have shoulder surgery or not. Taking all of your own health history into account, you ask yourself, SHOULD I GET SURGERY OR NOT?
Between medical specialists, imaging reports, surgical consults and the world wide web....the decision-making process can be rather troublesome. So how do you (as a patient) account for all of these differing viewpoints and make a reasonable decision?
This patient I'm using as an example is not the first (and will not be the last) that I will encounter in a predicament such as this...
What we need in our healthcare system is SOMEONE to put all the pieces together, sit down, take the time and explain things in simple terms. Years ago, this SOMEONE would have been your family (or primary care) doctor. And typically, this doctor would have a good overview of your entire health history and would have the time to discuss options regarding a treatment such as this shoulder surgery.
Unfortunately, our current healthcare system lacks the human-ness of the doctor-patient relationship, leaving MANY PATIENTS FEELING LOST.
So if you find yourself feeling LOST regarding a medical decision, my biggest recommendation is to consult as many properly trained providers as possible. AND try to find a doctor that can truly connect with you and understand your needs and concerns.
Don't feel lost...reach out to a trusted healthcare provider.